Dr Latha HackettConsultant in Child and Adolescent Psychiatry

(*Thanks to Professor Jonathan Green for some of the intervention slides)

Describe the triad of impairment of the Autism Spectrum Disorder and the difference between autism and Asperger’s syndrome

Autism Spectrum Disorders 10.8.8.1 10.8.8.2 10.8.8.3 10.8.8.4 10.8.8.5

To cover the key diagnostic features, with reference to ICD10/DSM V criteria and highlight key points in the assessment and intervention pathway

• Risperidone in the Treatment of Disruptive Behavioral Symptoms in Children With Autistic and Other Pervasive Developmental Disorders. Sarah Shea, Atilla Turgay, Alan Carroll, Miklos Schulz, Herbert Orlik, Isabel Smith, Fiona Dunbar, American Academy of Pediatrics 2004;114;e634.

• A Placebo Controlled Crossover Trial of Liquid Fluoxetine on Repetitive Behaviors in Childhood and Adolescent Autism, Eric Hollander, Ann Phillips, William Chaplin, Karen Zagursky, Sherie Novotny, Stacey Wasserman and Rupa Iyengar. Neuropsychopharmacology (2005) 30, 582–589.

Signs and symptoms of Autism spectrum disorder

Or Treatment of sleep disorders in ASD

To discuss assessment including, tools such ADI, ADOS, questionnaires (SRS), formulation, NICE guidelines, intervention, co-morbidities, impact on the family

Definition Triad Clinical features Causes Assessment Intervention

‘Autism is a lifelong developmental disability that affects the way a person communicates and relates to people around them’

National Autistic Society

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PervasiveManifest in first

Three years

Social Interaction

Social Communication

Imagination and Flexible thinking (social imagination)

Impairments in the quality of ….

1. Impairment of social relationships aloofness, indifference poor social skills

2. Impairment of communication no communication egocentric

3. Impairment of imagination

no play or imitation repetitive, unimaginative play

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Childhood Autism Asperger’s Synd

Atypical Autism PDD NOS/UAutism Spectrum disorder (DSM

5)

Intellectual Disability

No ID

Both share two key features: Social Communication difficulties Narrow interests & Repetitive actions They differ in two ways Asperger’s IQ is at at least average, no

language delay Childhood Autism/ASD: IQ can be

anywhere on the scale and has language delay

Diagnosed in Childhood Have the triad of impairment Significant learning difficulty Usually recognised by the age of three and

diagnosed preschool Atypical Autism – age or not all features of

the triad but has significant learning difficulties

Asperger’s syndrome is a form of autism, a condition that affects the way a person communicates and relates to others.

People with Asperger’s syndrome may find difficulty in social relationships and in communicating, and limitations in social imagination and creative play.

There is usually no significant delay in language ( single words by two yrs and communicative phrases by 3 yrs)

No significant learning difficulty May have coordination difficulties 8/9:1 Boy:Girl

No language delay, IQ in the average range or above Pedantic style of speech Precocious vocabulary development Narrow interests e.g flags of the world, weather maps,

history of the railway etc Preference for adult company rather than peers Bossy and controlling Social oddities that might appear as social withdrawal or as

social intrusiveness A desire for things to be done in the same way over and

over again An excellent attention to and memory for detail

Basic social interaction can be difficult for children with autism spectrum disorders. Symptoms may include:

Unusual or inappropriate body language, gestures, and facial expressions (e.g. avoiding eye contact or using facial expressions that don’t match what he or she is saying).

Lack of interest in other people or in sharing interests or achievements (e.g. showing you a drawing, pointing to a bird).

Unlikely to approach others or to pursue social interaction; comes across as aloof and detached; prefers to be alone.

Difficulty understanding other people’s feelings, reactions, and nonverbal cues.

Resistance to being touched. Difficulty or failure to make friends with children the same age.

Problems with speech and language comprehension are a tell tale sign of the autism spectrum disorders. Symptoms may include:Delay in learning how to speak (after the age of 2) or doesn’t talk at all.Selective MutismSpeaking in an abnormal tone of voice, or with an odd rhythm or pitch.Repeating words or phrases over and over without communicative intent.Trouble starting a conversation or keeping it going – to and froDifficulty communicating needs or desires.Doesn’t understand simple statements or questions.Taking what is said too literally, missing humor, irony, and sarcasm.Stereo-typed speech learnt off TV adverts, cartoons etcNeologisms ,American Accent in children brought up in the UK.

No imaginary play Not interested in toys or not knowing what

to do with toys Play scripted from TV programme. Repetitive play Lining up toys Solitary play

Children with autism spectrum disorders are often restricted, rigid, and even obsessive in their behaviours, activities, and interests. Symptoms may include:Repetitive body movements (hand flapping, rocking, spinning); moving constantly.Obsessive attachment to unusual objects (rubber bands, keys, light switches).Preoccupation with a specific topic of interest, often involving numbers or symbols (maps, license plates, sports statistics).A strong need for sameness, order, and routines (e.g. lines up toys, follows a rigid schedule). Gets upset by change in their routine or environment.Clumsiness, abnormal posture, or odd ways of moving.Fascinated by spinning objects, moving pieces, or parts of toys (e.g. spinning the wheels on a race car, instead of playing with the whole car).

Have a love of routines Be extra / super sensitive to - noise, touch,

sight, taste and smell Be less sensitive to - noise, touch, sight,

taste, smell and pain May have associated behaviour problems

e.g. with sleeping, eating and toileting May have co-ordination difficulties.

Fombonne (2005) 13 per 10,000 formally diagnosed autistic. but about 21 children per 10,000 meet the ‘triad of impairments’ criteria

Baird et al 2006 (SNAP study)116.1 /1000 (38.9/1000 for CA & 77.1/1000 for all other ASD’s) – 1% prevalence.

Baron-Cohen et al (2009) Cambridgeshire study concurs with previous studies – prevalence rate of 1% for 5-9 year olds.

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Approximately 1 in 100 people are thought to be on the autistic spectrum

More boys than girls (4:1, 9:1) 40%have childhood Autism and 60% have

ASD’s . In Manchester, recent figures suggest

approximately over 100 children a year are receiving a diagnosis of ASD in each of our three services (Central 130 last year)

Numbers are rising :

Improved recognition & detection Changes in study methodology An increase in availability of diagnostic

services Increased awareness among

professionals and parents Growing acceptance of Autism as

comorbid with other conditions Widening of diagnostic criteria

ICD IX (WHO) ICD IX – Pervasive Developmental disorder

(Childhood Autism, Rett’s Syndrome, Other childhood disintegrative disorder, Asperger’s Syndrome, Atypical Autism, PDD-NOS etc)

DSM 5 299.0 Autism Spectrum Disorder - Criteria A, B, C, D, E

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F84.1 Childhood Autism- a pervasive developmental disorder

defined by the presence of abnormal/and or impaired development that is manifest before the age of 3 years

- Characterised by abnormal functioning in social interaction, communication and restrictive, repetitive behaviour

- Boys: girls 3:1 or 4:1

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F 84.1 Atypical Autism- Differs from autism in terms of age of onset

or failure to fulfil all 3 criteria or insufficient demonstrable abnormalities in 1 or 2 of the 3 areas (social interaction, communication and restrictive, repetitive behaviour)

- Occurs most in children with v low functioning who are unable to demonstrate the typical behaviours associated with autism or in those with specific receptive language disorder

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F84.5 Asperger’s Syndrome- Uncertain nosological validity- Qualitative abnormalities of reciprocal

social interaction and restricted and repetitive activities/interests

- No language or cognitive delay- Clumsiness common- Boys:Girls 8:1

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299.0 - Criteria A, B, C, D, E A – Social Communication and Social interaction across

multiple contexts (Social communication) B. Restricted, repetitive patterns of behaviour, interests or

activities as manifested by at least two of the following currently or by history

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

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. ID and autism frequently co-occur; to make co-morbid diagnoses of ASD and ID, social communication should be below that expected of general developmental level

ASD vs Social (Pragmatic) communication disorder

Social Communication and Social interaction across multiple contexts (Social communication)

1. Deficits in social-emotional reciprocity

2. Deficits in nonverbal communicative behaviours used for social interactions

3. Deficits in developing, maintaining and understanding relationships

Specify current severity - severity is based on social communication impairments and restricted, repetitive pattern of behaviour.

Social Communication and Social interaction across multiple contexts (Social communication)

1. Deficits in social-emotional reciprocity – abnormal social approach, failure in to and forth conversation, reduced sharing of interests, emotions, affect, failure to initiate or respond to social interactions

Social Communication and Social interaction across multiple contexts (Social communication)

2. Deficits in nonverbal communicative behaviours used for social interactions – poorly integrated verbal and non verbal communication, abnormalities in eye contact and body language, deficits in understanding and use of gestures, total lack of facial expressions and non verbal communication

Social Communication and Social interaction across multiple contexts (Social communication)

3. Deficits in developing, maintaining and understanding relationships – difficulties adjusting behaviour to suit various social contexts, to difficulties sharing imaginative play, making friends, to absence of interest in peers

Specify current severity – severity is based on social communication impairments and restricted, repetitive pattern of behaviour.

Restricted, repetitive patterns of behaviour, interests or activities as manifested by at least two of the following currently or by history

1. Stereotyped or restricted movements, use of objects or speech – simple stereotypies, lining up of toys, flipping objects, Echolalia, idiosyncratic phrases

2. Insistence on sameness, inflexible adherence to routines, ritualised patterns of verbal and non verbal behaviour – extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day

3. Highly restricted, fixated interests that are abnormal in intensity or focus, e.g. strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests

4. Hypo/hypersensitivity to sensory input or unusual interest in sensory aspects of the environment eg apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movements.

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

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. ID and autism frequently co-occur; to make co-morbid diagnoses of ASD and ID, social communication should be below that expected of general developmental level

Detailed information from Parents Concerns for parents, details about behaviour, language,

social interaction, social communication, play, imagination, sensory sensitivities, repetitive/restricted and other behaviours

Pregnancy, labour, birth, birth weight, development – smiling, rolling over, crawling, siting up, walking, language development, any illnesses, medication etc

Observation of child in clinic – language, play, social interaction, social communication, repetitive behaviour, other abnormal behaviours such as flapping, spinning etc

Structured assessment – Autism Diagnostic Observation Schedule

Parents completing questionnaires such as Social Responsiveness Scale.

Information to be gathered from class teacher, teaching assistant and SENCO (better done after observing the child)

Do ask them whether this was typical behaviour you had observed, if different what else does the child normally do etc…. Let them know what you have just observed.

Special Educational Needs - Manchester has a Matching Provision to Need Tool that they compare children’s needs to consider for Special Educational .

Is any other professional involved? Do they have reports from any other professional that they can share Eg. SLT, EP, Statement

Are they planning to refer the young person to any professional – who? Why? Etc

Child’s academic functioning – above, level with peers and below peers

What were his SATS scores at key stage 1 or 2 if the child has been with them for some time, ask them to show you

the evidence of their progress over the years this is to give you the child’s trajectory in learning. This will give you information on whether he is making progress at the expected rate, has he stopped making progress or deteriorated? THIS IS CHANGING TOO

School complete the Social Responsiveness Scale Observation profile – observation check list completed by teachers

Language Communication Reciprocity Play Interest Sensory sensitivities

Language - Has the child got language? If he has – is it single words, phrase or clearly speaks in sentences? Does he echo – repeat what other says like a parrot? Does he speak at

people? Speaks only on topics he wants and not interested in others interest

Does he initiate a conversation? Does he maintain it appropriate – to and fro conversation Stereotyped utterances – “oh my god” etc that he has heard others

say Prosody - is the rhythm, stress, and intonation of speech. Prosody may

reflect various features of the speaker or the utterance: the emotional state of the speaker; the form of the utterance (statement, question, or command); the presence of irony or sarcasm; emphasis, contrast, and focus; or other elements of language that may not be encoded by grammar or choice of vocabulary.

Pedantic language - Characterized by a narrow, often ostentatious concern for book learning and formal rules: a pedantic attention to details.

Misinterpretation of language – literal understanding of language

Non verbal communication Gestures – using hands and body to communicate social intentions.

Head nodding (for yes), head shaking (for no), shrugging, clapping, pointing, describing the object with your hand such as the shape and size of an object, person etc

 Pointing - Does he point with his index finger  Eye contact - Does he look at people in a socially meaningful way to

communicate social intention? Does he have fleeting eye contact? Does he stare at people

 Facial Expression directed at others Does he have a range of facial expressions directed at others to

communicate his feeling, social intention, share his experience/emotions?

 Giving - Doe he give anything to anyone, If he does is it only to get help or to share his interest

 Showing Does he show any object to anyone else to show his interest

Does he show interest in other children?

 Switching on and off lights Closing and opening doors/taps Running up and down Lining up toys Spinning etc

Imaginary play Is he interested in other children? What is his play like? Is it scripted play? Does he play with toys in an imaginative

play? Does he play with other children? Does he play alongside other children?

Narrow range of interest, unusual focus on these interests,

Adherence to non functional rituals and routines

Motor difficulties: Abnormal gait, clumsy, gross and fine motor

difficulties – unable to tie shoe laces, do buttons, use knife and fork, messy eaters, unable to dress, undress, etc (OT referral)

Touch Pain Temperature Smell taste

Interview with Parents/CarersAutism Diagnostic Interview (ADI) &Diagnostic Interview Schedule for Social Communication (DISCO)Observation of the child/young person Autism Diagnostic Observation Schedule (ADOS)3diQuestionnaires:Social Responsiveness ScaleSocial Communication Questionnaire

A structured Interview conducted with the parents of individuals who have been referred for the evaluation of possible ASD

The interview, used by researchers and clinicians for decades, can be used for diagnostic purposes for anyone with a mental age of at least 18 months and measures behaviour in the areas of reciprocal social interaction, communication and language, and patterns of behaviour

Need to be trained and takes about 3 hours Both inter-rater reliability and internal consistency

were good across all behavioural areas investigated in the interview. The interview was also found to have adequate reliability across time.

Wing, L. and Leekam, S. R. and Libby, S. and Gould, J. and Larcombe, M. (2002) 'The diagnostic interview for social and communication disorders : background, inter-rater reliability and clinical use.', Journal of child psychology and psychiatry., 43 (3). pp. 307-325.

Structured interview Takes about 2-3 hrs Need training Inter-rater reliability is quoted as high and agreement was

achieved for over 80% of the interview items.

Designed to provide structured opportunities for the child to demonstrate social, communication and play skills.

Activities provide ‘social presses’ to see how the child responds

4 Modules – most appropriate selected on the basis of child’s level of language development

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Module Expressive language levelMin Max

1 No speech Simple phrase 2 Flex 3 word phr Verbally Fluent 3 Verbally fluent -

(child/younger adolescent) 4 Verbally Fluent

(Adolescent/Adult)Toddler module added

SRS-2; Constantino & Gruber, 2012 Maintains continuity with the original instrument as an

efficient quantitative measure of the various dimensions of interpersonal behaviour, communication, and repetitive/stereotypic behaviour characteristic of autism spectrum disorders (ASD).

The SRS-2 extends the age range from 2.5 years through adulthood.

There are now four forms, each consisting of 65 items and for a specific age group:

Preschool Form (ages 2.5 to 4.5 years); School-Age Form (4 to 18 years); Adult Form (ages 19 and up); and Adult Self-Report Form (ages 19 and up).

Standardised in the US

Previously known as the Autism Screening Questionnaire (ASQ),

Initially designed as a companion screening measure for the Autism Diagnostic Interview-Revised (ADI-R; Rutter, Le Couteur & Lord).

The SCQ is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than fours years.

It can be completed by the informant in less than 10 minutes. The SCQ is available in two forms, Lifetime and Current, each

with 40 questions presented in a yes or no format. Scores on the questionnaire provide an index of symptom

severity and indicate the likelihood that a child has an ASD.  Compared to other screening measures, the SCQ has received

significant scrutiny and has consistently demonstrated its effectiveness in predicting ASD versus non-ASD status in multiple studies.

August 11th 2010 J. Neurosciences Study based in London Gray Matter anatomy in adults with ASD 5 morphological parameters were used 20 adults with ASD through clini research programme 20 controls via adverts 20-68 years range ASD diagnosed by Adult ASD team ICD 10 criteria – 85%

by ADI R, 15% by ADOS – memory of parents for ADI the older the participant. Only 2 had ADI+ADOS scores

16 ASD did not have delay in language – AS Weakness: adults, MRI is still in its infancy for such

assessments, very small numbers

The outcome of the assessment is based on information from multiple sources – parents/carers, Nursery/School, observations in the clinic and school (usually not secondary school children) in structured and unstructured setting

Formulation: Use of the ICD 10/DSM 5 criteria, describe the child/young person’s symptoms, strengths and difficulties that need to be addressed/supported by parents/carers and school

From the information gathered from all sources and if features that fit in with ICD/DSM diagnostic Criteria

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Charman et al (2005) looked at the extent to which assessments of children at 2 and 3 years predicted outcomes at 7 years. They found that assessment at 3 years was a much better predictor of severity of symptoms and profiles.

Eaves et al (2004) followed up 49, 2 year olds at 4 and a half. Found 79% stayed in same diagnostic category, but more likely if ASD than PDD-NOS. Higher functioning children tended to improve most.

Billsetdt et al (2005) followed up 120 people diagnosed in childhood. Poor outcomes for 78%.Childhood IQ positively correlated with better outcomes

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Behaviour Problems Intellectual disability Neurodevelopmental disorders such as

ADHD, Tourette’s, Developmental Coordination difficulties

Eating, feeding and sleep problems Psychiatric disorders

Autism is strongly associated with a number of coexisting conditions which are not part of the diagnostic criteria but have an impact on the well being of the child or young person and family.

Mental and Behavioural disorders. Approximately 70% of individuals with autism also meet

diagnostic criteria for at least one other (often unrecognised) mental and behavioural disorder, and 40 % meet diagnostic criteria for at least two disorders, mainly anxiety, ADHD and ODD . Typically, these coexisting mental and behavioural conditions further impair psychosocial functioning.

Challenging behaviours, including aggression (to objects or people), destructiveness and self injury (e.g. head-banging, hand or wrist biting, or skin picking), are more common in autism than in other conditions with similar levels of intellectual impairment.

Intellectual disability (IQ<70) occurs in approximately 50% of young people with autism. Characteristic of autism is the gap between intellectual skills and adaptive skills (communication, socialisation and daily living/self-care skills ) frequently markedly lower than general cognitive abilities in ASD which has a significant impact on every day functioning

Neurodevelopmental disorders Language disorders and specific learning difficulties (literacy, numeracy and other academic skills) are common. 10% of people with autism fail to develop speech . Developmental Coordination Disorder (DCD) also commonly co-occurs with autism (approx 50-73% of children with autism have significant motor delays manifesting as general clumsiness or an unusual gait) Handwriting is a particular frustration for many

Intellectual ability and language skills remain the best predictors of outcome and around 25 to 30% of individuals with good intellectual skills are able to achieve well academically and find employment as adults.

Functional problems are common and have a major impact on the child and family.

40%-86 % of children with autism have reported sleep problems affecting sleep onset, frequent waking for longer periods and reduced sleep duration

Eating difficulties (restricted and rigid food choices) may be the presenting feature of autism in early childhood

Gastrointestinal problems are frequently reported - particularly diarrhoea, abdominal pain and constipation

Depression: 50% of AS Anxiety – social anxiety Obsessive compulsive disorder Anorexia – AS girls Psychosis & Schizophrenia – rare

Data from 13 follow up studies (Howlin 2005) – extending to adult like – modest improvement over time.

Some experience real behaviour and social improvements in 20’s & 30’s.

Autism +LD – require supervised living and working Outcome studies over 30 years – normal to above Normal IQ

increased proportion employed Even IQ >70 – only ¼ show normal social functioning Psychiatric disorders – 16% - new Psychiatric disorders – OCD &/or

Catatonia, affective disorders with Obsess. Features, affective disorders

Isolated psychotic symptoms – hallucinations, delusional thoughts, 1/5 of ASD develop experience one or more epileptic attacks in

adult life and 2/3 developed of these onset in adolescence or early adult life

Annectodal evidence of offending – one study in Broadmoor hospital – 2% had diagnosis of ASD. Another study of ASD population – 2% had a history of violent behaviour- no community based studies.

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*Non Verbal IQ below 50 in preschool years – poor prognosis

*Language – if no language by age 5 – poor prognosis

* Most powerful indicators. Other indicators are: Joint attention, verbal

imitation, appropriate educational provision, improved transitional arrangement to college and supported employment

Only minority with ASD find work, live independently, maintain relationships with others

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Education and Management of behaviours Various therapies tried –No evidence that it

works No single approaches have been found

useful

Non specific intervention : Music Therapy – may help children in turn taking. No

specific evidence, many schools offer this Art therapy – has been tried, no specific evidence Speech and language therapy – helping in communication.

Picture exchange communication (PECS) – a picture is exchanged to request an object or activity that he wants

Early Intervention behavioural intervention – focussing on shaping skills using rewards – Applied Behavioural Analysis (ABA) – original included punishment as well as rewards. Now no punishment but it is 40 hours “around the clock” intervention, requiring a team of ABA therapists. No evidence if the intervention is less than 40 hrs a week

TEACCH – Treatment and Education of Autistic and Communication Handicapped Children. Developed 1966 University of North Carolina, Eric Schopler

Individual teaching programme – social skills training, structured teaching, teaching generalisation and Cognitive behaviour therapy .

Considerable evidence that structured approaches to teaching children with Autism is helpful, information provided clearly and no ambiguity

Son-Rise programme (options). Barry and Samahria Kauffman, parent of a child with Autism, New York, early 80’s . Home based 1:1 teacher-child relationship in which the teacher follows the child’s lead. There is no formal evaluation of this method

Social skills teaching and mind reading : Carol Gray’s social stories, comic strip conversations, training using the DVD on mindreading. There is some evidence for DVD training that people with ASD learn about emotion recognising and in children generalisation to emotions they had not learnt

• The NICE guidelines recommend offering psychosocial and pharmacological interventions for the management of coexisting mental health or medical problems in people with autism informed by existing NICE guidance for the specific disorder.

• For those who have the verbal and cognitive ability to engage in a cognitive behavioural therapy (CBT) intervention e.g. for anxiety, adaptations to the method of delivery of cognitive and behavioural interventions should include:

• Psycho social interventions based on behavioural principles are recommended for all young people and adults who need help with daily living and participation in leisure activities,

• If the individual has a sleep problem a stepped approach is recommended

No drug that is specific to Autism Specific behaviours can be helped Risperidone – decrease irritability, temper tantrums, hyperactivity,

aggression and SIB, (anti-anxiety). Best studied medication. Fluoxetine – reducing compulsive and repetitive behaviours,

stereotypies and rituals. Some research evidence Methylphenidate – ADHD is helpful Lithium & Sodium Valproic acid – affective instability, impulsivity

and aggression Anticonvulsants – Epilepsy Buspirone – may help in improving anxiety, Temper tantrums,

aggression Propranolol – aggression, SIB, impulsivity in developmental

disorders – needs close monitoring with ECG – bradycardia and hypotension

Unproven and ineffective – B6, Magnesium, gluten and casein free diet, essential fatty acid treatments, cranial osteopathy etc

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Having a child with Autism in the family has significant impact on parents/carers/siblingsGrief for the loss of “normal child/Grandchild”Stress on marital relationshipReduction in family income due to one parent having to full time carerBehavioural problems and impact on the family – unable to invite friends home, not able to do normal activities which other families are able to doAffect on mental health of carers

Autism is not curable but is treatable.The following children with Autism do

manage better: Children who achieve language by the age

of 5 Children who are cognitively able Children diagnosed early Right educational intervention Parents/Carers who understand their

child’s needs

It is not a mental illness It is not a middle class disorder It is not due to parental rejection

‘refrigerator mother’ Autism is not about being a genius It is not curable

Withdrawing from immediate surroundings? Associated with Epilepsy? Passed from one generation to another? Having challenging behaviours?

......... May be

A developmental disorder More likely in boys than girls Finding it difficult to see things from other’s

point of view Associated with unusual responses to

sensory stimuli........all true

Describes how the ASD assessment and intervention services should be established.

Clear Pathway to referral Trained professional What the assessment should consists of Intervention provided etc

Preschool – Health Visitor/GP refer to Speech and Language therapy, Community Paediatrics – Social Communication Assessment and Intervention Team (SCAIT) which is in CAMHS

School aged children – GP/Community Paediatrics or School nurse refer to the CAMHS – SCAIT

Assessment as per NICE guidelines and as described earlier

Psycho-education for parents and school (APDG) Communication workshops for parents/school –

visual time tables, picture exchange communication etc

Behavioural intervention/Cognitive behavioural therapy

Riding the rapids – parent training Social understanding group/Skills groups Transition groups Medication in a few- associated difficulties such as

sleep and Attention Deficit hyperactivity disorder etc

1 Guidance 1.1 Local pathway for recognition, referral and diagnostic assessm

ent of possible autism 1.2 Recognising children and young people with possible autism 1.3 Referring children and young people to the autism team 1.4 After referral to the autism team 1.5 Autism diagnostic assessment for children and young people 1.6 After the autism diagnostic assessment 1.7 Medical investigations 1.8 Communicating the results from the autism diagnostic

assessment 1.9 Information and support for families and carers

• People with possible autism who are referred to an autism team for a diagnostic assessment have the diagnostic assessment started within 3 months of their referral.

• People having a diagnostic assessment for autism are also assessed for coexisting physical health conditions and mental health problems.

• People with autism have a personalised plan that is developed and implemented in a partnership between them and their family and carers (if appropriate) and the autism team.

• People with autism are offered a named key worker to coordinate the care and support detailed in their personalised plan.

• People with autism have a documented discussion with a member of the autism team about opportunities to take part in age-appropriate psychosocial interventions to help address the core features of autism.

• People with autism are not prescribed medication to address the core features of autism.

• People with autism who develop behaviour that challenges are assessed for possible triggers, including physical health conditions, mental health problems and environmental factors.

• People with autism and behaviour that challenges are not offered antipsychotic medication for the behaviour unless it is being considered because psychosocial or other interventions are insufficient or cannot be delivered because of the severity of the behaviour.

Full guideline - http://www.nice.org.uk/guidance/cg170Summary - Kendall et al BMJ 2013;347:f4865Quality Standard - http://www.nice.org.uk/Guidance/QS51

Committee – terms of reference/definitions and scope/structure of investigationNICE staff – review of literature. Quality test for papers. Entered into Meta-analysis using GRADE criteria for strength of evidence•Quality of papers risk of bias•Consistency and heterogeneity of combined analyisisCommittee – integration of evidence. Committee consensus where insufficient evidenceDraft for consultationFinal writing and recommendationsQuality and audit standards

Intervention for core features‘Consider’ - Social communication intervention;

preschool/school age (low-mod RCT parent/teacher mediated; v low RCT peer mediated)

‘Do not’ - Medication incl neuroleptics/SSRI/anticonvulsants; exclusion diets

(v low-mod RCT + committee)

Behaviour that challenges‘Offer’ - Psychosocial behavioural intervention after thorough

assessment (committee)

‘Consider’ - Antipsychotic medication when psychosocial or other interventions insufficient or could not be delivered because

of severity (low-mod RCT)

Sleep problems‘Offer’ - Sleep hygiene

(committee)

Any context Refer to other NICE guidance for other co-morbid conditions

Service organisationKeyworker approach/Autism team/transition

• The guidelines recommend offering psychosocial and pharmacological interventions for the management of coexisting mental health or medical problems in people with autism informed by existing NICE guidance for the specific disorder.

• For those who have the verbal and cognitive ability to engage in a cognitive behavioural therapy (CBT) intervention e.g. for anxiety, adaptations to the method of delivery of cognitive and behavioural interventions should include:

• Psycho social interventions based on behavioural principles are recommended for all young people and adults who need help with daily living and participation in leisure activities,

• If the individual has a sleep problem a stepped approach is recommended

The emphasis in the guidelines is:In routine assessment and care planning, assess factors that may

increase the risk of behaviour that challengesIf a child or young person’s behaviour becomes challenging, reassess

factors identified in the care plan and assess for any new factors that could trigger or maintain the behaviour including:.

- Impairments in communication that may result in difficulty understanding situations or expressing needs and wishes

- Coexisting physical disorders (such as pain or gastrointestinal disorders), mental health problems (such as anxiety or depression), and other neurodevelopmental conditions (such as ADHD)

- The physical/sensory environment, such as lighting and noise levels- The social environment, including home, school, employment and

leisure activities- Changes to routines or personal circumstances- Developmental change, including puberty- Exploitation or abuse by others- The absence of predictability and structure.

• If no coexisting mental health or behavioural problem, physical disorder, or environmental problem has been identified as triggering or maintaining the behaviour that challenges, offer a psychosocial intervention (informed by a functional assessment of behaviour) as a first line treatment.

• Based on low to moderate quality randomised controlled trials for efficacy antipsychotic medication should be considered for managing behaviour that challenges when psychosocial or other interventions are insufficient or could not be delivered because of the severity of the behaviour.

• Antipsychotic medication should be initially prescribed and monitored by a paediatrician or psychiatrist, who should

- Identify the target behaviour - Decide on an appropriate measure to monitor effectiveness,

including frequency and severity of the behaviour and a measure of global impact

- Review the effectiveness and any side effects of the medication after three to four weeks

- Stop treatment if there is no indication of a clinically important response at six weeks.

• Personalised assessment and care plan• Plan developed and agreed by family and

individual as appropriate• Recognising strengths of individual as well as

impairments and needs• Awareness of mental capacity Act/Equality

legislation and consent issues• Access to information and support/respite & short

breaks etc

• Local autism teams should ensure that every child or young person diagnosed with autism has a case manager or key worker to manage and coordinate treatment, care, support and transition to adult care and involves the young person and their parent carers in the process

• For young people aged 16 or older whose needs are complex or severe, use the care programme approach in England (care and treatment plans in Wales) to coordinate their needs and as an aid to transfer between services

• YP at 18 entitled to social needs assessment (Autism Act)

• Limitations of the episodic intervention model in chronic illness

• Application of chronic illness models to autism (and other childhood disorder) very limited (non-existent?)

• NICE includes (non-evidence-based) recommendation for key worker approach

• The ideal of sequential pulses of developmentally appropriate intervention based on need throughout development using keyworker approach to link them

• How to test this? Use of sequential randomisation designs, factorial designs or accelerated cohorts?

• Kasari et al – current SMART design in early interventions for minimally verbal children

The M:F ratio of Childhood Autism is ◦ 1:1 ◦ 2:1 ◦ 3:1 ◦ 4:1

Answer C

The prevalence of Autism Spectrum Conditions in a school based study in UK was ◦ 99 per 10,000 ◦ 70 per 10,000 ◦ 9 per 10,000 ◦ 1 per 10,000

Answer A: Prevalance of autism is increasing as the recognition of Autism is increasing. The above study was Prevalence of autism-spectrum conditions: UK school-based population study by Simon Baron-Cohen,Fiona J. Scott,Carrie Allison,Joanna Williams, Patrick Bolton,Fiona E. Matthews and Carol Brayn.

The clinical features of Childhood Autism as described by Kanner include all the following except: ◦ autistic aloneness ◦ delayed or abnormal speech ◦ an obsessive desire for sameness ◦ onset in the first one year of life

Answer D: It should be-onset in the first 2 years of life. These are not the features currently used to diagnose Autism, but the question is particular about what Leo Kanner said.

The following are true about the etiology of Autism except:◦ higher concordance among MZ twins. ◦ increased rate of perinatal complications.◦ decreased brain serotonin levels ◦ condition is 50 times more frequent in the siblings

of affected persons

Answer C: Studies on brains of children with Autism have shown high brain serotonin levels rather than low levels of Serotonin

Which of the following is false for Rett’s syndrome: ◦ occurs only in boys ◦ onset between the ages of 7 and 24 months ◦ often develop autistic features and stereotypies ◦ X linked dominant disorder

Answer A: It occurs only in girls. All the other statements are true for Rett’s syndrome

 The following is false for Seizures in Autism:◦ Can affect quarter of autistic individuals with

generalised learning disability ◦ Affects 5% of autistic individuals with normal IQ ◦ In autistic individuals with normal IQ the seizure

onset is usually in early childhood.◦ In autistic individuals with generalised learning

disability the seizure onset is usually in early childhood

Answer C: This statement is false. In autistic individuals with normal IQ the seizure onset is usually in adolescence

.

The following is true about the epidemiology of Autism:◦ Prevalance is decreasing in recent years. ◦ Associated with high socio-economic status. ◦ More common in boys. ◦ No hereditary risk.

 

Answer C

All the following are first line support for a child with Childhhod autism except: ◦ Communication skills workshop ◦ Behavioural support ◦ counselling and advice to parents ◦ anti-psychotic medication.

Answer D

  The following can be used in the

diagnosis of a child with Autism except:◦ Autism diagnostic Inventory (ADI) ◦ Autism Diagnostic Observation Schedule (ADOS) ◦ Social Responsiveness Scale (SRS) ◦ Check list for Autism in Toddlers (CHAT).

 

Answer D: CHAT is a screening tool. History and observation are the mainstay of diagnosis

Which of the following drugs can be used in short term treatment of severe aggression in Autism under specialist supervision:

Risperidone Diazepam Lorazepam Promethazine

Answer A

The M:F ratio of Childhood Autism is A. 1:1 B. 2:1 C. 3:1 D. 4:1

Answer D

The prevalence of Autism Spectrum Conditions in a school based study in UK was A. 99 per 10,000 B. 70 per 10,000 C. 9 per 10,000 D. 1 per 10,000

Answer A: Prevalence of autism is increasing as the recognition of Autism is increasing. The above study was Prevalence of autism-spectrum conditions: UK school-based population study by Simon Baron-Cohen,Fiona J. Scott,Carrie Allison,Joanna Williams, Patrick Bolton,Fiona E. Matthews and Carol Brayn.

The clinical features of Childhood Autism as described by Kanner include all the following except: A. autistic aloneness B. delayed or abnormal speech C. an obsessive desire for sameness D. onset in the first one year of life

Answer D: It should be-onset in the first 2 years of life. These are not the features currently used to diagnose Autism, but the question is particular about what Leo Kanner said.

The following are true about the etiology of Autism except:A. higher concordance among MZ twins. B. increased rate of perinatal complications.C. decreased brain serotonin levels D. condition is 50 times more frequent in the

siblings of affected persons

Answer C: Studies on brains of children with Autism have shown high brain serotonin levels rather than low levels of Serotonin

Which of the following is false for Rett’s syndrome: A. occurs only in boys B. onset between the ages of 7 and 24 months C. often develop autistic features and stereotypies D. X linked dominant disorder

Answer A: It occurs only in girls. All the other statements are true for Rett’s syndrome

 The following is false for Seizures in Autism:A. Can affect quarter of autistic individuals with

generalised learning disability B. Affects 5% of autistic individuals with normal IQ

C. In autistic individuals with normal IQ the seizure

onset is usually in early childhood.D. In autistic individuals with generalised learning

disability the seizure onset is usually in early childhood

Answer C: This statement is false. In autistic individuals with normal IQ the seizure onset is usually in adolescence

.

The following is true about the epidemiology of Autism:A. Prevalence is decreasing in recent years. B. Associated with high socio-economic status. C. More common in boys. D. No hereditary risk.

Answer C

All the following are first line support for a child with Childhood autism except: A. Communication skills workshop B. Behavioural support C. counselling and advice to parents D. anti-psychotic medication.

Answer D

The following can be used in the diagnosis of a child with Autism except:

A. Autism diagnostic Inventory (ADI) B. Autism Diagnostic Observation Schedule

(ADOS) C. Social Responsiveness Scale (SRS) D. Check list for Autism in Toddlers (CHAT).

Answer D: CHAT is a screening tool. History and observation are the mainstay of diagnosis

Which of the following drugs can be used in short term treatment of severe aggression in Autism under specialist supervision:

A.Risperidone B.Diazepam C.Lorazepam D.Promethazine

Answer A

Books : Rutter's Child and Adolescent Psychiatry, Fifth Edition. Sir Michael

Rutter , Dorothy Bishop, Daniel Pine, Steven Scott , Jim S. Stevenson, Eric A. Taylor, Anita Thapar 

Child and Adolescent Psychiatry. Robert Goodman  and Stephen Scott. Third Edition, Wiley-Blackwell

Autism and Asperger Syndrome. Simon Baron-Cohen. The Facts. Oxford university press

 E-Learning Autism, ethnicity and maternal immigration Autism has been the subject of intense public and professional attention in

recent years. One of the biggest questions is what causes it. Like the discoveries made about schizophrenia in the late 20th century, we are learning that autism too has genetic and environmental determinants. Here Dr Daphne Keen discusses her paper (Keen et al, 2010) which attempts to answer the question of whether maternal immigration and ethnicity, together or in tandem, are implicated as being risk factors in young children who develop autism.

http://www.psychiatrycpd.org/default.aspx?page=10591  Guidelines - Autism in children and young people (CG128) http://www.nice.org.uk/guidance/index.jsp?action=byTopic&o=7281

no babbling by 12 months no gesturing (pointing, waving, showing, reaching, etc) by

12 months no single words by 16 months no two-word spontaneous (not echolalic) phrases by 24

months any loss of any language or social skills at any age Other important signs to look out for include: Diminished eye contact Diminished social engagement Limited interest in social games and turn taking exchanges Preference for being alone Visual attention more frequently to objects than people

Limited range of facial expression Less sharing of affect (smiling and looking at others) Unusual hand and finger mannerisms Walking on tiptoes Difficulty adapting to new situations and coping with

changes in routine Not orientating to name being called Not imitating facial expression or gesture Lack of seeking and enjoying cuddles Less likely to look at a parent to seek reassurance and

approval Prone to intense distress Sensory over responsivity such as being afraid of every day

sounds Unusual mannerisms to express emotions Extremes of temperament