autism and related disorders

Autism now affects

1 in 68 (autismspeaks.org) children and 1 in 42 boys and 1 in 189 girls Prevalence figures are growing and it is the fastest growing developmental disability in the US Receives less than 5% of research funding No medical detection (no medical test) or cure for autism

History of Autism and what is it

First described in 1943 by Leo Kanner (psychiatrist) Common childhood disorder with neurological (brain disorder with a genetic basis) and developmental components - Core deficits in socialization, communication, play, and behavior

Amygdala & Hippocampus

Parts of limbic system Amygdala Determines what memories are stored, based on emotional response Hippocampus - Sends memories out to the cerebral hemisphere for long term storage & retrieves them when necessary

what are the cognition foundations? and the variables

Attention- must be attentive to learn, especially (bottom bracket) learning language Memory- Organization Problem Solving and Reasoning Skills variables too help you have better cognitiion= Audio Processing Skills Image Processing Skills Speed of Processing Executive Functions Theory of Mind

Prerequisites to Language

Attention-be viable and present enough to learn language -have to be available Eye contact, joint attention- very hard to look at someone and not pay attention thats why we want eye-contact Turn Taking (It's the dance!) Cause-effect understanding Beginning and ending an activity Mirror conversation without verbalizations Praise and reinforcement

Symptoms in autism

Autism affects child's perception of the world making communication and social interaction difficult Heterogeneous but within same categories Communication, Social, Repetitive Behaviors Symptoms last throughout lifetime (mild to extreme) EI treats and can lessen symptoms but has to be caught early. THERE IS A CRITICAL PERIOD -lack of joint attention, smiling, pointing, gestures, preferring isolation, self-sutlers, lack of facial expressions, not providing any insight

Structural Brain Anatomy & Autism

Bauman & Kemper (2005) Large head circumference (macrocephaly) Increased white matter (cerebral & cerebellar) Reduced size of amygdala and hippocampus Possible limbic system lesions Abnormalities of neuronal density Most evidence around limbic system and cerebellar circuitry

Pervasive Developmental Disorder

The DSM-IV proposed concept of spectrum disorders under this general heading for disorders including: Autism Rett's disorder (removed from DSM-5) Childhood Disintegrative Disorder Asperger's syndrome PDD-NOS 3-5 now subsumed under one ASD category

swearing

in basil ganglia- subcortical cortex

what are some types of discourse

procedures, explaining, narrative, conversational -but have rules that are harder to defined

informal questions

questions relate to these types of skills of early signs of autism

Cognition what it means

- to know how you know things, learning rules about patterns and the environment and start learning things ex.) ball under a blanket still exists this has to come first, observant of your environment, also represented by IQ, us verbal task and non-verbal tasks -early cognitive skills don't teach them they just learn them -have underlying rules like language does

Language-

-ability to express yourself and understand, formulate ideas, express your self and understand other ideas - has underlying rules like morphology, semantics, phonology, syntax not pragmatics left- analysis and look back in past, present and future right- allows you to live in the present

autism cognition

-autistic kids can attend but sometimes its not language based and have really good memories but for things that are not useful for interaction, can be really organized but limited to what they are attended too can problem solve for things they have experienced, break down where there is abstract you can't experience it= judgement, imagining, reasoning -can get competency but don't get performance right -have attention- not joint attention

Qualitative impairments in communication

1-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). 2- In individuals with adequate speech, marked impairment in the ability to sustain a conversation with others. 3-Stereotyped and repetitive use of language or idiosyncratic language. (ecohliaia, not novel) 4-Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level -building of learning is play and setting up opportunities that is not reality 5-Restricted repetitive and stereotyped patterns of behavior, interests and restricted patterns of interest that is abnormal either in intensity or focus. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. 6-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. - have soothing things to help feel comfortable, autistic kids usually hit themselves and do to make them feel comfortable ex.) hitting their head, sucking thumb 1- have to be aware 2- have to act on awareness

lack of social interaction with autism (social interactions)

1-behvaioral 2- lack of interest 3- turn-taking 4- lack of pointing 5- eye-contact 6- not using social language (waving bye, wanting to get picked up, don't respond to name) 7-lack of facial expressions, not showing emotions ex.) not getting upset when they should be upset

what are 3 categories that you look for autism

1-communication 2-social interaction 3-repetitive behavior

Attention

A child's ability to attend to the information that is presented. It is the ability of the child to grasp all the information.

Logic and Reasoning Skills

A child's ability to logically find a solution to a problem or reasoning to find the best solution out of the available solutions. Logical and Reasoning skills helps a child to formulate concepts, solve puzzles, build structures etc. These skills are very critical for developing a child's thinking and imagination. Children with poor logical and reasoning skills generally struggle with mathematics and solving puzzles. -if they experienced it, they will know how to problem solve -have to be taught how to do it or experience it themselves

Memory

A child's ability to remember information. These skills can be sub-divided into: Long Term Memory: It is the ability of a child to remember and recall a piece of information for a substantial amount of time. Long Term Memory is critical for child's overall development. Short Term (Working) Memory: It is the ability of the child to grasp information, process it and use it for a short interval of time. Very good example is a child writing the words being dictated to him. He will hear the words, remember them, and write them down and then move ahead to hear the next word. -primitive part of brain- when they swear there is an emotional feeling tied to it, less experience you have to have the emotional part of it -put a way to access it efficiently

Other changes to childhood disorders

ADHD symptoms are largely unchanged but age of onset has changed from age 7 to 12. Specifiers have replaced sub-types (inattentive, hyperactive, and mixed). Comorbid diagnosis with Autism is now permitted. Communication disorders have new names: language disorder (combines expressive and mixed receptive-expressive language disorders); speech sound disorder (previously phonological disorder); childhood onset fluency disorder (previously stuttering); and a new disorder has been added called social communication disorder. Motor disorders are largely unchanged. Stereotypic movement disorder has been more clearly differentiated from the repetitive behavior of autism and obsessive-compulsive disorders. Oppositional defiant disorder and conduct disorder have been reclassified and moved into a new group of disorders called Disruptive, Impulse-Control, and Conduct Disorders. This category of disorders will be discussed in future newsletters. Separation anxiety and selective mutism have been reclassified and moved into Anxiety Disorders. However, the new Anxiety Disorder group does not resemble the DSM-IV. It no longer contains obsessive-compulsive disorder or PTSD. These disorders are classified elsewhere and will be discussed in upcoming newsletters. Pica-eating things that are not food (for sensory reasons) and rumination disorders have been reclassified and moved into Feeding and Eating Disorders. Enuresis and Encopresis disorders have been reclassified and moved into a new group of disorders called Elimination Disorders. Reactive attachment disorder has been reclassified moved into a new group of disorders called Trauma and Stressor-Related Disorders. PTSD and adjustment disorder are also a part of this new group. -all of these you will see in autism!! but the new dsm wants us to identify it with a communication disorder and motor disorder instead of saying autism some can appear together but often you have autism

Neurodevelopmental Disorders

ASD Specific Learning Disorder (replaced reading disorder, mathematics disorder, and disorder of written expression) Intellectual Disabilities (replaced Mental Retardation)

New Criteria

ASD must meet criteria A, B, C, and D Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following. Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing and maintaining relationships appropriate to developmental level Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following. Stereotyped or repetitive speech, motor movements, or use of objects. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behaviors, or excessive resistance to change. Highly restricted, fixated interests that are abnormal in intensity or focus. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment. (is new) Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities. Symptoms together limit and impair everyday functioning.

Alternating Attention:

Ability to switch or immediately transfer your focus or concentration from one activity to another.

Limbic System & Autism

All parts of limbic system with noted abnormalities are important for memory, learning, emotion, and behavior Variation in extent of areas involved determines severity (continuum/spectrum) -fight or flight! Includes amygdala, hippocampus, part of forebrain (i.e., diencephalon) Primitive brain structure Top of brain stem Under cortex Responsible for emotions & motivations related to survival (e.g., fear, anger, sexual behavior, feelings of pleasure) Memory -establishing your learning style, emotions what you react too and spontaneous behaviors

Early Indicators of ASD

Children can show signs of autism before 1 Parents must understand typical milestones REDFLAGS No smile or other joyful expressions by 6 m No back and forth sounds by 9 m No babbling by 12 m No pointing, showing or waving by 12 m No words by 16 m No 2 word phrases by 24 m Any loss of speech or babbling or social skills -Less likely to orient to name Early sensory processing concerns Difficult to soothe Lack of joint attention may be earliest indicator Early screens are better at determining child is somewhere on the spectrum -RED FLAGS EARLY INDICATORS OF AUTISM-lack of joint attention, expressions, no eye contact, lack of babbling and difficult to suth (fussy kids), lack of attachment (security), especially people they are not familiar with -picky eaters, digestion problems

Social Symptoms

Early lack of socialization may include: lack of eye gaze at people, turning to voices, grasping a finger, smile. May avoid eye contact Prefer isolation, resist attention Fail to seek comfort or respond to anger or affection Limited facial expression-they are not receiving it from others either and because of that can't interpret other peoples feeling THEORY OF MIND- pick up what others are saying no they have the background stories, knowing what you have to say cause you presume that you don't have to state it -monotone speech (awk pausing) Slow interpretation of others feelings Pragmatic impairments Limited theory of mind (misses the cues) -able to be independent learners- cause you form really good foundation and learn it yourself -going to get things they want by using words that are high frequency and get them what they need

PDD-NOS

Described individuals who did not fully meet criteria for autism or Asperger's "Subthreshold" autism Pervasive impairment in social interaction Pervasive impairment in communication skills Did not meet criteria for Autism because of late onset, atypical symptoms, or not severe enough symptoms May be 3 items from the core areas rather than 6

How is Autism Diagnosed?

Diagnosed based on observation of behaviors as well as educational and psychological testing (subjectivity so you might get over or under diagnosing) Diagnosis is often delayed and mistreated as developmental delay MDs are now frequently screening at 2 ½ and may be given screening checklist (determines referral) May be diagnosed by MD or team of specialists; According to ASHA, it can also be diagnosed by SLP but very controversial -based on criteria -pediatrician usually makes diagnosis unless you are an expert in autism then you can make the diagnosis, you would say "I want to rule out some problems so lets refer __ to a pediatrician"

Asperger's Syndrome Dx

Difficult to differentially dx individuals with high functioning ASD (normal cognitive abilities, no significant LD) and Asperger's. (treated similarly) Lot to do with social component and what typical language development means Asperger's said to have non significant delays in language development Other symptoms include: one-sided conversation, lack of eye contact, above average verbal communication, repetitive speech, awkward mannerisms. Inability to understand the actions, words or behaviors of others (theory of mind)

Screening Parameters - Level 2

For children who fail level 1 Diagnosis by experiences clinician or developmental MD Examination of familial prevalence, head circumference, cognitive, and verbal skills Observation of verbal and nonverbal communication, sensorimotor challenges, motor deficits, speech-language deficits Further testing including: genetic testing, sleep study, metabolic testing, brain scans (more like an evaluation)

Screening Parameters - Level 1

Formal hearing test Lead testing Further evaluation if: No babbling, gesturing at 12 m, no single words at 16 m, or no phrases at 24 m Monitoring of siblings Use of formal screening tool for autism (more like a screening)

Neurobiologic Considerations

Genetic vs. environmental Twin evidence and familial dominance Vaccines (MMR) have been associated with autism but research does not support Food allergies have not been supported by research What may be the connection?

Five Neuropathologies

Increased brain weight & white matter Reduced neuronal size in limbic system Reduced cells in cerebellum Age related changes in cell size and number in Broca's area Malformation of the cerebral cortex & brainstem

Joint Attention

Joint attention does not just mean two people looking at he same thing at the same time. Nor it is just one person looking on while another engages with an object , nor is it the child alternating her attention between two phenomena (person and object) of equal interest". Tomasello, 1995 -must look at this with client -can have hyper attention -most children want joint attention from adults and peers -usually occurs in a social context- discourse involves being able to take turns recognize someone else input

Communication Disorders- own category of neurodevelopment disorders

Language Disorder Speech Sound Disorder Childhood Onset Fluency Disorder Social Communication Disorder

Diencephalon

Made up of the thalamus and hypothalamus Thalamus Sensory perception and regulation of motor function (i.e., movement) Connects areas of cortex involved in sensory perception & movement with other parts of brain & spinal cord Hypothalmus - Regulates hormones, pituitary glad, body temp., adrenal gland, & other vital activities

Repetitive Behaviors

May be extreme or subtle (e.g., arm flapping, toe walking, lining cars up) Tremendously upset when order is disrupted Consistency in environment Also called stims - persistent, intense preoccupation (seems like an obsession) May be hyper focus on basic skills -make sure client accounts for each of the skills

Communication Difficulties

May remain nonverbal May only have holistic language May need to learn alternative modes of communication May have concomitant apraxia- most non-verbal kids have apraxia Echolalia Inability to understand body language, tone of voice or formulaic language May use odd pitch or other pragmatically inappropriate forms -have problem with questions that require abstract parts -little kids with autism avoid interaction b/c the learning component of it, the older kids want to interact with other on their terms because they are seemed as awkward they have a hard time with friendship where there is give and take, have to not be self-centered- autistic kids are self centered they want it to always be their turn have others like what they like , can't be good friends -autistic kids have trouble being with children their own age (older kids follow around, younger kids help them feel dominate) peers are problems can't except

Current Status of the DSM-V

Need to have repetitive behaviors and perseverations as features of autism ASD is highly comorbid with other dx including intellectual disability (50%+), learning disabilities (30-50%), ADHD, OCD (20-30%), and anxiety disorder.

Role of Practitioners in Dx

Need to support observations with data (quantitative measures) Usually interdisciplinary team approach Formal diagnosis is made by a pediatrician, developmental pediatrician, or neurologist (possibly psychologist) SLP generally makes the referral to MD for diagnosis or conformation of dx

Changes in DSM-V criteria

New manual published in July 2013 Category - Neurodevelopmental Disorder not Pervasive Developmental Disorder ASD is the catch-all diagnosis proposed for the new DSM5 ASD will be included under the category of Neurodevelopmental Disorders A new subcategory of Social Communication Disorders is now included No longer using PDD-NOS, or Asperger syndrome

Social Communication Disorder

Persistent difficulties in pragmatic or the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social reciprocity and social relationships that cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability Persistent difficulties in the acquisition and use of spoken language, written language, and other modalities of language for narrative, expository, and conversational discourse Rule out ASD . Symptoms must be present in early childhood. E. The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement, or occupational performance.

Speech Disorder

Persistent difficulties in speech production that can affect the domains of speech sound production, speech fluency, voice, or resonance. Speech production that is atypical for the child's age or symptomatic of abnormal oral-motor structure or function, based on multiple sources of information. Speech disorders occur as a primary impairment or co-exist with other disorders or congenital or acquired conditions (e.g., CP, DS, deafness, TBI, Cleft Palate) Symptoms must be present in childhood. E. Difficulties with speech production result in functional limitations in effective communication because of interference with speech intelligibility and distract from effective communication of messages.

Language Disorder

Persistent difficulties in the acquisition and use of spoken language, written language, and other modalities of language that are likely to endure into adolescence and adulthood, although the symptoms, domains, and modalities involved may shift with age. Language abilities that are below age expectations in one or more language domains and that manifest persistent difficulties evident by multiple sources of information. Language disorders occur as a primary impairment or co-exist with other disorders (e.g., ASD, Learning Disorder, Selective Mutism). Symptoms must be present in early childhood. The difficulties with language result in functional limitations in effective communication, social participation, academic achievement, and occupational performance.

So what happens in autism?

Predisposition for misdirected sensory processing Impacts Learning Style: Learning is motivated by self-directed/independent stimuli, not interaction The dance is between stimuli and child, not caregiver and child Repetitive play is the turn taking with toy and not people. Learn what you are focused on (e.g., many overlearn basic skills) Autism = SPD (genetic/constiutional) and attention misdirection (self-directed/precipitory) come together

Asperger's Disorder/Syndrome

Previously characterized by repetitive routines or rituals Peculiarities in speech and language (pragmatic deficits) Socially and emotionally inappropriate Problems with nonverbal communication Clumsy and uncoordinated motor movements Intelligence appears normal -immature, don't take figurative language correctly, very knowledgable about certain things-very rigged way of thinking

Qualitative impairments in social interactions

Qualitative impairment in social interaction, as manifested by at least two of the following: 1-Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze. 2- Facial expression, body posture, and gestures to regulate social interaction. 3-Failure to develop peer relationships appropriate to developmental level. 4- 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 to other people). 5-A lack of social or emotional reciprocity, lack of empathy

Sensory Processing Concerns

Reportedly often have sensory processing concerns" Also referred to as sensory integration disorder, sensory processing disorder (SPD). May be key underlying factor to deficits Hypo and hyper sensitivity across senses including, vision, hearing, tactile, taste, smell, proprioceptive, vestibular

Brain Specialization for Language

Rule based versus holistic language learning Role of the right and left hemisphere Emotional language learning- up till age 2 or 2 ½ (memorized learning) Loosing language at 2? Vaccine controversy-miss allocating it due to the vaccine, they think people with autism are reacting to vaccine but they were born with it Similarity to reading (sight words vs. phonics) -talk freely about any situation that you want by using your rules -formulaic language/ holistic language- not creative language learned from experience, emotionality, relevance to it, more automatic, less control over it (right) -higher functioning in terms of analysis (left)

Diagnostic Assessment Tools

Screening and diagnostic instruments are available to help determine if criteria in DSM-IV are met More formal measures can be used to differentiate severity on spectrum Most involve family report or interview as well as interaction with child May determine whether child should be seen further by developmental pediatrician -guillam- screening tool (some need parents involvement its parent report) some isn't all observable you need caregivers input

Physical and Medical Issues

Seizure disorders Genetic disorders Gastrointestinal disorders- has to do with their sensory system, picky eaters don't like textures Sleep dysfunction Sensory integration dysfunction Apraxia Pica-eating objects that they shouldn't

Differential Diagnosis From NON-spectrum Disorders

Specific language impairment Learning disabilities Mental retardation Obsessive-compulsive disorder Attention-deficit/Hyperactivity disorder Personality disorder Schizophrenia -IQ test is given from a psychologist (school psych)

Risk Factors and Characteristics

Studies have shown that among identical twins, if one child has ASD, then the other will be affected about 36-95% of the time. In non-identical twins, if one child has ASD, then the other is affected about 0-31% of the time. Parents who have a child with ASD have a 2%-18% chance of having a second child who is also affected.[5,6] ASD tends to occur more often in people who have certain genetic or chromosomal conditions. About 10% of children with autism are also identified as having Down syndrome fragile X syndrome(http://www.cdc.gov/ncbddd/fxs/facts.html), tuberous sclerosis, or other genetic and chromosomal disorders. Almost half (about 44%) of children identified with ASD has average to above average intellectual ability. Children born to older parents are at a higher risk for having ASD. [Read summary] A small percentage of children who are born prematurely or with low birth weight are at greater risk for having ASD. [Read summary] ASD commonly co-occurs with other developmental, psychiatric, neurologic, chromosomal, and genetic diagnoses. The co-occurrence of one or more non-ASD developmental diagnoses is 83%. The co-occurrence of one or more psychiatric diagnoses is 10%. -impacts development, socialization, behavior, cognitive

Attention Skills can be sub-divided into:

Sustained Attention: It is the ability of a child to remain focused on the task at hand for a substantial amount of time. Selective Attention: It is the ability of a child to remain focused on a task which interests him despite of all the distractions which exists around the child. Divided Attention: It is the ability of a child to maintain his attention on 2 two things at the same time, basically it is the ability of the child to multi-task.

Guidelines for Diagnosis

Two levels of assessment (multidisciplinary approach) Routine developmental surveillance and screening for all children (identify if at risk) Diagnosis and evaluation of autism to differentiate autism form other developmental disorders -need extra expertise to see if there is anything else then autism or if its even autism -pediatrician will diagnosis usually by 2 and a half

Executive Functions

Used to organize and act on information Including: Impulse Control Emotional Control Flexible Thinking - adjust to the unexpected Self-Monitoring Planning and Prioritizing Task Initiation -how we perform with all these cognitive foundations -have implies control ability to wait when its not our turn- pragmatic skills socialization and maintain attention when its not my turn -need to be flexible have to be able to use them flexibly, we are able to adapt and autistic kids are not able to adapt -able to understand everyone experience is not going to be the same, create judgements and observe others that have other ways of doing things -facts they are telling us the truth but if you ask open ended questions are hard to tell if its the truth or not -experience allows us to build self-awareness -task ignition- don't know how to initiate the skill unless they are taught

Sensory Processing Disorder

Was excluded in the DSM-5 Also called sensory integration deficit, it is the way the nervous system receives messages from the senses and turns them into appropriate motor and behavioral responses Sensory signals don't get organized into appropriate responses -truly considered outside of our practice -vestibulo-balance proprioception - a sense of where your limbs are in space relate to your body

book to read:

a childs path to spoken language john locke

what is discourse

any language above the level of a sentence

difference between competency and performance in autism

competency-underlying knowledge, rules, structures, isolate skills performance- is how you use your competence, able to use skills while doing other things, use rules and be flexible with them, pragmatics, interaction and cognition ex.) autism have trouble with not having rules like structure have trouble with performance -balance need for structure without making it too fixed

constitutional factors of autism

is the way the child is born

give screening what distinguishes a child with autism and a child without autism

joint attention!!! and social interactions main things to look for and consider -social interaction: eye-contact, imitating communication (joint-attention), shared enjoyment, responding to attention, both sides of the expressive and receive attention, pointing -basically the underlying factor of why children have autism -the authors are saying this is the main reason why they are autistic -highlighting things that are underlying that are not just a delay -autistic babies don't pick up on emotions or any people they look at objects -if its can't imitate huge sign usually imitate faces!! from automatic controls and responses -auditory responses- not present can't perceive it or have awareness -by 2 have a lot of sensory play

what is generative linguistics?

look this up

delay

normal progression just falling behind and will catch up, some people might have a scattered skill

what has changed in the DSM-IV criteria?

started with 3 then 4 now its listed under one category called autism 1. A total of six (or more) items from heading (A), (B), and (C) with at least two from (A) and one each form (B) and (C) SEE NEXT SLIDE Delays or abnormal functioning in at least one of the following areas with onset prior to age 3 year: Social interaction, language is used in social communication, symbolic or imaginative play The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder. -have to be qualitative!

whats a basil

starting point on a test so you don't have to do the whole test, if they get multiple questions right in order then you get a bail and skip ahead

cognitive linguistic deficits?

staying off topic, sounding winded, socially awkward -need these for pragmatics, skills that we need to be able to social and have good pragmatics

Severity Ratings

two primary sets of symptoms: 1) social communication and social interaction deficit 2) restrictive and repetitive behavior patterns. Each of these symptom sets (social and behavioral) will include three severity levels to identify the supportive services that are required. These three severity levels are: 1) requiring support 2) requiring substantial support 3) requiring very substantial support. The DSM-5 describes each of these severity levels, with examples, to aid clinicians in making these determinations. ex.) 1 would be less severe then a three