Professional Documents
Culture Documents
Outline
Definition Epidemiology Classification Imaging Studies Pathophysiology Etiology Symptoms and Diagnosis Autism therapies Prognosis Implications for Nursing Jordan Specialized Center for Autism References
Definition
Autism is a brain development disorder that manifests in early childhood and is characterized by qualitative abnormalities in social interactions, marked aberrant communication skills, and restricted repetitive and stereotyped behaviors.
First described by Leo Kanner in 1943
Epidemiology
It is a rare condition, occurring in only 2 to 10 of every 10,000 children. Boys are 3-5 times more likely than girls to have autism.
Classification:
Autism is classified by the American Psychiatric Association as one of the pervasive development disorders (PDD). This group of disorders is sometimes called the autism spectrum disorders (ASDs).
The pervasive developmental disorders include Asperger syndrome, childhood disintegrative disorder, Rett disorder, and pervasive developmental disorder not otherwise specified (PDD NOS).
5
Imaging Studies
Pathophysiology
Enlargements of the amygdala and the hippocampus. Elevations of whole blood serotonin occur in one third of patients. Impairment in the metabolism of phenolic amines. Brain weight, volume, and head circumference tend to be greater in autistic children.
Evidence on HC
They take 48 children with autism aged between 25 years. At first they obtained the head circumference ,body length and body Wt from the child record in the first year and who participate in MRI. They divide the group 15 Childs longitudinal group and they take the measurement at 4 periods during infancy: birth, 1 to 2 months, 3 to 5 months, and 6 to 14 months ,and 33 (partial HC data group) had measurements at birth and 6 to 14 months (n = 7), and at birth only (n = 28).
9
anatomy and aged changes in infant with ASD were evaluated by 2 nationally normative databases: cross-sectional normative data from a national survey and longitudinal data of individual growth. Result: Birth HC of autistic infants was significantly smaller, after birth, HC was related to cerebeller gray matter volume at 2-5 years. Although the excessive increase in HC between birth and 6 to 14 months was related to greater cerebral cortex volume at 2 to 5 years. Within the ASD group, every child with autistic disorder had a greater increase in HC between birth and 6 to 14 months.
10
11
Etiology
The etiology of autism is an unsolved and controversial question. Hypotheses include: Genetics Prenatal environment
Genetics
More than one gene may be implicated Different genes may be involved in different individuals and the genes may interact with each other or with environmental factors. Interaction of a genetic predisposition and an early environmental insult
13
Evidence on Genetics
Wendy L. Stone, Caitlin R. McMahon, Paul J. Yoder, Tedra A. Walden. Arch Pediatr Adolesc Med. 2007;161(4):384-390.
14
Objective: To compare the early socialcommunicative development of younger siblings of children with autism spectrum disorders (ASDs) with that of younger siblings of children with typical development .
17
Prenatal environment
Birth defect agents acting during the first eight weeks from conception Teratogens: thalidomide, valproic acid, misoprostol, or rubella. Pesticides Folic acid: taken during pregnancy through modulating gene expression Stress
18
Perinatal environment
Risk factors found associated obstetric conditions that included: Low birth weight. Gestation duration. Hypoxia during childbirth.
19
Postnatal environment
A wide variety of postnatal contributors to autism have been proposed, including: Gastrointestinal or immune system abnormalities. Allergies. Exposure of children to drugs. Vaccines (MMR). Infection. Certain food (dairy products, chocolates, corn, bananas). Heavy metals. Refrigerator mother.
20
Evidence on MMR
MMR-Vaccine and Regression in Autism Spectrum Disorders: Negative Results Presented from Japan Tokio Uchiyama, Michiko Kurosawa, Yutaka Inaba. J Autism Dev Disord. 2007 Feb;37(2):210-7.
Results:
Within the MMR era, the rate of regression in those who received MMR was not higher than those who did not. the rate of regression did not vary across the preMMR, the MMR, and the post-MMR eras.
22
Recommendation:
23
Most symptoms developed within the first 30 months of age. Failure to develop social relations. Impaired communication in verbal and nonverbal skills Stereotyped repetitive behaviors About 75% of individuals with autism also manifest moderate mental retardation. Specific, limited intellectual problem solving abilities. Abnormal responses to sensory stimuli. Decreased sensitivity to pain
24
Poor use of body language and nonverbal communication, such as eye contact, facial expressions, and gestures Lack of awareness of feelings of others and the expression of emotions, such as pleasure (laughing) or distress (crying), for reasons not apparent to others Lack of or abnormal social play
The absence of protodeclarative pointing is predictive of the later diagnosis of autism (Protodeclarative pointing is the use of the index finger to indicate an item of interest to another person). 25
Delay in, or the total lack of, the development of spoken language or speech Repeating words or phrases back when spoken to (known as echolalia) Difficulty expressing needs and wants, verbally and/or nonverbally
26
27
Criteria for the diagnosis of autism are included in the Diagnostic and Statistical Manual of Mental Disorders. DSM IV-TR Criteria for 299.00 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: A. 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 B. failure to develop peer relationships appropriate to developmental level C. 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) D. lack of social or emotional reciprocity.
28
2. qualitative impairments in communication as manifested by at least one of the following: A. 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) B. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others C. stereotyped and repetitive use of language or play appropriate to idiosyncratic language D. lack of varied, spontaneous make-believe play or social imitative developmental level.
29
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
1. 2. 3.
30
3. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
A.
B.
C.
D.
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 manners (e.g., hand or finger flapping or twisting, or complex whole-body movements). persistent preoccupation with parts of objects
31
Autism therapies
An intervention is any action such as a treatment, a therapy or the provision of a service which is designed to help people with autism. There are already more than 100 different interventions designed to help people with autism.
32
Categories of Interventions
33
Psycho-educational
Interventions which use educational, behavioral and other teaching techniques, to change behaviors.
34
Music therapy
Facilitate positive changes in behavior and emotional well-being, increase sense of self-awareness Client and therapist take an active part in the sessions by playing, singing and listening The music played covers a wide range of styles in order to complement the individual needs of each client.
35
The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study
Jinah Kim , Tony Wigram , Christian Gold J Autism Dev Disord 2008 Oct;38(9):1758-66.
37
Results:
Session analysis showed significantly more and lengthier events of eye contact and turn-taking in improvisational music therapy than play sessions. session analysis indicated that the majority of participants showed marked improvement in joint visual attention skills during and after music therapy than during and after the play condition throughout the trials and across the cases. 3 out of 5 non-verbal participants did begin to develop some initial language skills during and after the music therapy condition.
38
39
Play therapy
Children learn to communicate with others, express feelings, modify behavior, develop problem-solving skills, and learn a variety of ways of relating to others. The play materials may include art and craft materials, dressing up props, sand and water, clay, small figures and animals, musical instruments, puppets and books or even Lego.
40
Child is taught a range of skills by a team of therapists using techniques, build on everyday routines, such as eating or getting dressed. The therapists break down skills into small tasks that are achievable and taught in a very structured manner. Desired behavior is positively reinforced and accompanied by lots of praise. Examples include bites of food, play with a favorite toy, hugs and toys. Negative behavior is ignored.
41
By using these techniques, the child progresses from basic self help and language skills to non-verbal and verbal imitation skills. In the second stage he or she learns expressive and early abstract language, and also leans how to play interactively with peers.
42
Psycho-pharmacological
Interventions which use chemical compounds, including medications, to affect the mind.
43
Anti-psychotics
Anti-psychotics are used to treat mental health problems. it can also be used to treat some of the core symptoms of autism, such as poor social communication or repetitive behaviors. Example: Risperidone
44
Evidence on Risperidone
Risperidone Improves Behavioral Symptoms in Children with Autism in a Randomized, DoubleBlind, Placebo-Controlled Trial Gahan J. Pandina , Cynthia A. Bossie, Eriene Youssef, Young Zhu , Fiona Dunbar J Autism Dev Disord (2007) 37:367373
Method: 8-week, multicenter, randomized, doubleblind, placebo-controlled study conducted in Canada. Participants were randomized to treatment with an oral solution of risperidone (1.0 mg/ml) or placebo every morning.
Results: Significant changes at end point in ABC subscales scores for Irritability, Lethargy/Withdrawal, Stereotypic Behavior, and Hyperactivity favored risperidone versus placebo. Hyperactive, and Overly Sensitive subscale scores showed significantly more improvement with risperidone than placebo. Recommendation: risperidone can be an effective
treatment for behavioral problems such as aggression, tantrums, self-injurious behavior, and hyperactivity in children with autism.
47
Anti-depressants
Anti-depressants increase the level of active neurotransmitters in the brain. They are used to treat people with depression, anxiety or other mental health problems. They may also be used to treat people with autism who have other problems, such as repetitive behaviors or social deficits. Example: clomipramine.
48
Stimulant Medications
Stimulant medications affect the action of certain chemicals in the brain, allowing us to control how we pay attention and organize our behavior. Stimulants can be used with some individuals with autism to reduce problem behaviors, such as hyperactivity, impulsivity and inattention. Example: methylphenidate.
49
Complementary
Wide range of interventions which complement traditional, medical treatments and therapies. Essential Fatty Acids Animal therapies (Assistance dogs, Dolphin) Hyperbaric therapy Vitamins and minerals Gluten-free, casein-free diet
50
Some people believe that individuals with autism do not have enough Essential Fatty Acids, or that they have a poor balance of them, that may cause some symptoms of autism, such as impaired communication and social difficulties. These difficulties can be overcome by following a diet rich in essential fatty acids or by taking supplements. There is a wide range of supplements which contain essential fatty acids from a variety of sources such as borage, cod liver oil, evening primrose etc.
51
Purpose: to confirm the efficacy of omega-3 for some symptoms of autism. Participants: 22 children and adolescents (aged 5 to 17 years), attending a specialized day care center for longterm treatment of autistic children; 81.9% were male. Method: a randomized, double-blind, placebocontrolled 6-week pilot trial investigating the effects of 1.5 g/d of omega-3 fatty acids (.84 g/d eicosapentaenoic acid, .7 g/d docosahexaenoic acid) supplementation in children with autism accompanied by severe tantrums, aggression, or self-injurious behavior.
53
conducted by using the ABC, which includes five subscales: irritability, social withdrawal, stereotypy, hyperactivity, and inappropriate speech. Results: The findings suggest that omega-3 fatty acids may be an effective and well-tolerated treatment, in particular of hyperactive behaviors including disobedience, distractibility, and impulsivity. Conclusions: The results of this study provide preliminary evidence that omega-3 fatty acids may be an effective treatment for children with autism.
54
Recommendation: We recommend more researches with larger sample to support or deny this research's results. We recommend omega-3 supplements for autism because of its safety.
55
Prognosis
Only about 1-2% of the autistic population ultimately achieve independence. The majority require lifelong supervision. Aggravation of psychiatric symptoms occurs in about half of the children during adolescence. Girls have a tendency for continued deterioration. Prognosis is most favorable for children communicative speech development by age six years and an intelligence quotient above 50 at the time of diagnosis.
56
When autistic children are hospitalized, they usually present many management problems. Ways to lessen the disruptiveness of hospitalization: Decreasing stimulation by using a private or semiprivate room. Avoiding extraneous auditory and visual distraction. Encouraging parents to bring in possessions the child is attached to.
57
Physical contact frequently upsets autistic children, minimum holding may be necessary to prevent temper tantrums. A key principle in working with these children is establishing trust. They need to be introduced slowly to new situations, with visits with caregivers kept short whenever possible.
58
JORSCA was established in March 2004. It is a non-profit organization that caters specifically for the autism community of Amman. It prides itself in being Jordan's first independent specialist school to accommodate the latest teaching methods and therapeutic programs for children who exhibit learning difficulties associated with autism spectrum disorder.
59
The team of JORSCA works together to create a safe but challenging environment where individuals with autism are valued, achievement is celebrated and where pupils are enabled to communicate as effectively as possible. Currently there are 25 pupils enrolled between ages 3 and 15. Working closely with 5 teachers, 10 assistants, who are overlooked by a master teacher, a speech and language pathologist, an occupational therapist, and a music therapist.
60
61
References
Maternal & Child Health Nursing. Adele Pillitteri. 5th ed. Childrens Nursing. Whaley and Wongs. 1995. http://www.emedicine.com/ http://www.researchautism.net www.wikipedia.com http://www.jorsca.com http://www.autismspeaks.org
62
63
G. Amminger, G. E. Berger, M.R. Schfer, C. Klier, M.H. Friedrich, M. Feucht. Omega-3 Fatty Acids Supplementation in Children with Autism: A Double-blind Randomized, Placebocontrolled Pilot Study. BIOL PSYCHIATRY 2007;61:551553. E. Courchesne, R. Carper, N. Akshoom. Evidence of Brain Overgrowth in the First Year of Life in Autism. JAMA. 2003;290:337-344. J. Kim , T. Wigram , C. Gold. The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study. J Autism Dev Disord 2008 Oct;38(9):1758-66.
64
G. J. Pandina , C. A. Bossie, E. Youssef, Y. Zhu , F. Dunbar. Risperidone Improves Behavioral Symptoms in Children with Autism in a Randomized, Double-Blind, Placebo-Controlled Trial. J Autism Dev Disord (2007) 37:367373. W.L. Stone, C.R. McMahon, P.J. Yoder, T.A. Walden. Early Social-Communicative and Cognitive Development of Younger Siblings of Children With Autism Spectrum Disorders . Arch Pediatr Adolesc Med. 2007;161(4):384390. T. Uchiyama, M.Kurosawa, Y.Inaba. MMR-Vaccine and Regression in Autism Spectrum Disorders: Negative Results Presented from Japan. J Autism Dev Disord. 2007 Feb;37(2):210-7.
65
66