Early Detection: Autism and Learning Disorders

Mission Uday

ASD

Abnormal social interaction Persistent & restrictive behaviors

3-yr-old boy• Hyperactivity & aggressive behavior • He does not sit still in his nursery class. • Parents say he says some words and that he responds

depending on his “mood”. • They do not think anything is wrong; but the nursery teacher

insisted they see a doctor.

• Birth History is normal• Examination:

• interested in his surroundings • does not allow you to establish a rapport• frequently putting in and taking out phone

charger from plug-point.• Minimal response to parental requests

• There is no dysmorphology, skin is normal and there are no focal neurological deficits.

Autism Spectrum Disorder

*CDC, Autism and Developmental Disabilities

Monitoring Network. Identified Prevalence of Autism Spectrum

Disorders. 2012.

• Common Neurodevelopmental disorder • Prevalence (India): approx. 1-1.4/100 children• Incidence of ASD*: Males 1:54; Females 1:252• DSM-5 (Diagnostic & Statistical Manual of

Mental Disorders) • Past: autistic disorder/pervasive developmental

disorder

Diagnostic Criteria

A. Persistent deficits in social communication and social interaction

B. Restricted, repetitive patterns of behavior, interests, or activities

C. Present since the early developmental periodD. Significant impairment in current functioningE. Not better explained by ID/GDD

Hearing deficit, ADHD,

Intellectual disability

• Hearing problem: • Follows & uses gestures (good non-verbal

comm.)• Social interaction is as per age

• ADHD• Good interaction and use of speech• Co-morbid ASD may be +nt

• ID vs ID with ASD• Restricted interest or repetitive behaviour • Impairment in social interaction as per

developmental age

Specific Expressive

Verbal Delay

• The child has only Expressive Speech Delay • Follows all oral requests (Receptive Verbal

Communication)• Non Verbal is perfectly age appropriate• Social Behaviour is normal• R/o mild hearing loss by doing objective hearing

tests • Speech therapy

Hearing Impairment

• Neither does the child speak nor does he consistently follow commands given to him orally;

• Responds to oral commands if accompanied by gestures.

• Follow & use gestures (Non verbal communication). • Social Behaviour is as per age.• R/o hearing loss by doing objective tests (BERA)• Counsel: Hearing Aids/speech training/cochlear

implant

Autism Spectrum Disorder:

• Poor Verbal & Non verbal Communication • Poor social behaviour and interaction: poor peer

play• Repetitive actions like spinning/flicking his fingers • Focussed more on a part of object, rather than

whole.• Investigations: Rule out hearing loss,

neurocutaneous lesions, obvious syndromes like Trisomy 21, Fragile X.

• Refer to a Developmental Pediatrician/Team.• Counsel: Increase direct interaction with caregivers.

Some MisconceptionsAbsent no eye contact.• Look at or through you, but eye contact has no social purpose.Are not affectionate.• Are affectionate on their own terms; may even be clingy.Do not talk.• Can use difficult words, usually by imitation w/o meaning.No treatment is available.• May have better outcomes with early and intensive intervention.Children grow out of it.• Autism is a life-time diagnosis

Red Flags

• Decreased interaction with peers/friends• Does not play with toys appropriately• Fixed patterns of interest/activities• Lines things up• Odd movement patterns and/or repetitive behaviors• Demonstrates echolalia (repeats words)• Is hyperactive

M-CHAT

Routine child visit, free of charge

16-30 month of age

20 Questions

<10 min

Score ≥8 Refer

<3 Pass; 3-8 use the detailed follow-up tool

Available in Hindi, Tamil, Bangla, Punjabi etc

Summary of ASD

• Primary physician/teachers usually suspect first• Impairment in social interaction and

communication with restrictive, repetitive pattern of activity, behaviour

• It is a clinical diagnosis - investigations have limited role

• Use MCHAT-R screening• Earlier you intervene better the outcome• Refer early• DSM-5 is current standard for diagnosis

Some symptoms of Autism

• https://www.youtube.com/watch?v=z7NeBs5wNOA

• 0.17: Hand flapping• 1.04: Toe walking• 1.50: Screaming/fussy in public• 3.31: Response to verbal commands• 4.29: Eye contact• 4.47: Speech delay• 5.54: Sensory issues

Specific Learning Disability

Definition

• Group of neuro-developmental disorders manifesting as persistent difficulties in learning to efficiently

• Read (dyslexia) (80%)• Write (dysgraphia) or • Perform mathematical calculations

(dyscalculia) • Normal intelligence, hearing and vision• Conventional schooling • Adequate motivation and socio-cultural

opportunity

• Lagae L. Pediatr Clin North Am. 2008;55:1259-68

SpLD: Common

presentation

• Affects 5-15% schoolchildren• Reading slowly and incorrectly• Skipping lines while reading aloud• Repeatedly making spelling mistakes• Untidy/illegible hand-writing with poor

sequencing• Inability to perform even simple mathematics• Poor school grades despite normal

intelligence

• Karande S, Sholapurwala R, Kulkarni M. Indian Pediatr. 2011.

Anita, a 10-yr-old girl, studying in Grade IV

• C/o avoiding school, poor school performance for past few months & lying to parents about school work.

• She has also become quiet and aloof.• 1-year back: teachers pointed out that

she makes many spelling mistakes and cannot read her grade textbooks.

• Persistent pattern since Grade II – home tuition.

• Parents did not respond as she had done well in Pre Primary and she was otherwise intelligent.

At this stage it is important

to assess how she is in her activities

of daily living!

• O/E: • dull and disinterested, • brightens up when you talk about dancing &

looks anxious again when you ask her about her studies.

• Focused CNS exam is normal.• No hearing or visual deficits on assessment

Activities of Daily Living - Poor

• Rule out Birth Injuries/HIE• Dysmorphic features: R/o Genetic abnormalities• Delayed development: R/o Intellectual Disability• R/o Muscular/neurological disorders • R/o hearing and visual impairment, autism• Malnutrition, Chronic infection• Epilepsy (absence seizures)• Chronic absenteeism from school

Good in her activities of daily living!

• How is her attention span, impulsivity and hyperactivity?

• How is her mood and motivation?• Does she show consistent patterns of

errors in her reading and writing?

Good in her activities of

daily life!

• How is her attention span; what about hyperactivity?

• Children with ADHD are unable to learn due to inattention, inability to finish learning tasks

• With age, this becomes more obvious

• How is her mood?

• Worsening self-esteem & confidence• Isolation & lack of participation • Overtime, withdrawn, sad and depressed

How is her motivation?

• Lack of motivation may be due to familial issues

• May be abuse• Or even in SLD due to constant failures,

criticism, comparison with siblings and peers.

• Accept the child’s weaknesses, de-focus from the weaknesses and focus on the child’s strengths.

Does she have patterns of errors in reading, writing & math inspite of normal IQ, vision & hearing?

• The child shows difficulty in reading, writing and maths for her grade-level, with a consistent pattern of errors.

• She reads hesitatingly, with errors, guesses (sight reads) words, skips words and entire lines, is very nervous while reading, and makes every excuse to avoid reading.

Errors of spelling phonetically(as it sounds)

Not being able to write within the linesError of

Punctuation

Uneven Pressure on pencil while writing

Uneven Shapes and Sizes of alphabets

Omission

Addition

Mirror image

Omission

Omission

Uneven Pressure on pencil while writing

Uneven Shapes and Sizes of alphabets

Test 1: Can you point out the patterns of errors?

Test 2: Can you point out the patterns

of errors?

Patterns of errors in reading, writing & maths

• She makes errors of addition, omission, repetition, reversals/mirror image, spelling phonetically while writing.

• Writes above or below the lines, makes punctuation errors, variation in the size & shape of alphabets, writes with too much/too little pressure on the pencil.

• She makes errors in simple addition, subtraction, multiplication, division, carry-overs, word sums, copying numbers from one page to the other.

What is not SpLD?

ûBorderline ID (IQ 71 to 84) – Get an IQ test! ûMental retardation (IQ ≤ 70)ûVisual handicap (>60% disability) – Get an eye

exam!ûHearing handicap (> 60% disability) – Get a

hearing test!ûPhysical handicap (e.g. cerebral palsy)ûLanguage barrier – should be obviousûEmotional problems ûChronic medical problems

Take home messages

■ Poor verbal/non-verbal communication• Restrictive & repetitive behavioral patterns

• Persistent difficulties in learning• With Normal intelligence, hearing and

vision• Consistent errors in reading/writing and

maths

Thank you!