AUTISM: Explaining The Enigma

Dr. Mamun HussainMBBS M.Phil PhD FCPS

DEPT. OF PSYCHIATRY, RMCH

HHSTTI, RAJSHAHIPrincipal & Subject based Training Courses

AUTISM“The Child is Father of The Man”

(WORDS WORTH: My heart leaps up)“The Childhood Shows the Man as Morning Shows the Day”

(John Milton: Paradise Regained IV)

AUTISM: A pervasive developmental disorder

Child Development: Normal & Abnormal/Deviant

Mile STONE OF MOTOR DEVELOPMENT

1.5 – 4 month: Raise head to 452.5 – 5 month: Roll over4.5 – 8 month: Sit without support05 – 10 month: Starts holding on07 – 12 month: Crawl & creep7.5 – 13 month: Walk holding on to furniture9.5 – 14 month: Stand alone11.5 – 14.5 month: Walk without assistance

In first 02 years: Rapid physical & motor developmentBy age 2: Brain 75% of adult size develops

COGNITIVE DEVELOPMENT (Jean Piaget)• SENSORIMOTOR (Birth – 02 yrs): Physical Exploration of Object

(Push, Poke, Mouth, Bang), Imitate, Speak & Understand simple words

• PREOPERATIONAL (02 – 07 yrs): Reason intuitively, Concept of “Conservation” Not developed, e.g. 01 Sandwich -> 04 pieces or more, Taller glass -> more water.

• CONCRETE OPERATION (07 – 11 yrs): Logical reasoning, Conservation of number/length/weight.

• FORMAL OPERATIONAL PERIOD (11 – Adulthood): Ability to think abstractly, To reason hypothetically e.g. “KI solution” in a dish – BRIGHT YELLOW; To make yellow solution -> 04 beakers with colorless fluid.

Conservation Tasks

Length Weight

Volume Number

Stage of moral development: (Kohlberg)

e.g. Stealing Drug1. Premoral – Age 07 yrsStage 1: Obedience to rule to avoid punishment• For -> wife die, if you don’t spend money• Against -> you’d be in JailStage 2: Obedience for reward / favors• For -> if caught, give money ( decrease Jail sentence)• Against -> wife dies before you get out from Jail2. Morality of conventional role conformity – Age 13 yrsStage 3: Approval of others – ‘Good boy morality’• For -> you’re inhuman, if you don’t steal• Against -> a dishonor to family

Cont..

Stage 4: Conforming to norms to avoid censure by authority figure• For -> guilty at wife’s death ( duty was not done)• Against -> guilty for dishonesty & law breaking (while in Jail)3. Morality of self accepted moral principleStage 5: Obedience to law & contracts• For -> you’d lose self respect

(respect of others if you don’t steal)• Against -> you’d lose respect in community.Stage 6: Morality of individual conscience• For -> you’d condemn yourself always.• Against -> you’d condemn, for not living up to your own

standards of honesty.

ERIKSON’S STAGE OF LIFESocial & personality development

Relationship/crisis or conflict/outcome –• Birth to 1 year: With mother, Trust vs. Mistrust.

• 02 year: With parents, Autonomy vs. Shame and Doubt,Self control/Self doubt/Fearfulness.

• 3-5 year: With family, Initiative vs. Guilt,Purpose or direction/loss of self-esteem.

• 6-11 year: With neighbor hood & school, Industry vs. Inferiority, Competence/failure to thrive.

Cont..

• Adolescence: With peer groups, Identity vs. Role Confusion, ‘Who one is’/uncertainly about one’s role

• Early adulthood: With partners (friendship, sex, competition, co-operation), Intimacy vs. Isolation, Deep relationship/failure to love others.

• Middle age: Divided labor & shared household, Generativity vs. Stagnation, Expansion of interest/caring/with own problem only.

• Old age: ‘Mankind’ ‘My kind’, Integrity vs. Despair, Satisfaction/disappointment/sense of un fulfillment/fear of death.

LANGUAGE

(Criteria of a language)1. Meaning – words & sentences

2. Generativity – Rules to produce infinite statements, e.g. – The boy hit the ball (the ball were hit by the boy/ the boy didn’t hit the boy/what the boy hit?)

3. Displacement – Referring past & future events.

Spoken Language

1. Phonology: a. Sound combined for words/sentence.b. Phoneme: smallest unit of sound (t/k)c. Morpheme: Smallest meaningful elements,e.g. – Pictures: Picture/s; suffix (ing); prefix(anti)

2. Syntax: Rule of combining morpheme, e.g. The boy eat (Boy the eat)

3. Semantics: (How meaning is expressed)• Concrete objects – Ball / Horse• Abstract qualities – Love / Beauty• Connotative – (Emotional meaning) e.g.- Home• Denotative – (Literal meaning) e.g.- House

Development of language

• Babblings: Mixture of adult – phonemes by 5-6 month• Single words: By 1st Birthday, pronounection is erratic e.g.

‘shoe’ – soo, Talk about objects which has “dynamic” quality.

• Word combination: By 1-2 yrs• Sentence & complex constructions: By 2-3 yrs, Embedded

sentence, ‘I see what you made’ (mother was baking cake),Tag question, ‘Dad is here, isn’t he?’

• Acquired through imitation (Leonard, Chapma 1983)• Language is innate (CHOMSKY, 1975) Have LAD

(Language Acquisition Device), biologically prepared, Further development PPT (Principle & Parameter Theory or Government & Binding Theory.

• Language is dependent upon cognition – Language is a tool through which children express their basic understanding of the world.

THEORIES

IS AUTISM A NEW DISORDER?Autism throughout historiesThe “Blessed fools” – (Uta Frith 1989)Folk Tales – Stories of native/simple individuals

• Sheikh Chilli: Love with girlAsked mother: “What’s to be done?” Answer: Throw pebble, while she comes for drawing water. Sheikh threw big stone, broke her head.

(Folktale of India, Kang & kang 1988)• Gahan’s mother went to church, “pull the door behind

you, if you come church. Gahan started dragging/pulling (Australia’s children oh the world, Smith 1979)

History1747: Earliest Document-Brother petitioned in court to

annul Blair’s marriage/ Inheritance.

1798: The Wild Boy of Averyun-A feral child caught-“Signs of autism”.

1867 Henry Maudsley: A category of “psychoses”. 1910: Bleuler-To define symptoms of Schizophrenia.1938: Hans Asperger-“Lecture on autistis psychopath.

Cont..

1943 Leo Kanner: “Infantile Autism”-“He wandered about smiling, making stereotyped movement with his fingers crossing them about in the air. He shook his head from side to side. Whispering or humming the same three-note tune. He spun with great pleasure anything he could seize upon to spin… when taken into a room, he completely disregarded the people and instantly went for objects, preferably those that could be spun… He angrily shoved away the hand that was in this way, or the foot that stepped on one of his blocks…” (Description of DONALD (5 yr) by Kanner, 1938)

Until 1960: Maternal deprivation-“Refrigerator mothers”.Late 1960: Separated “MR” from schizophrenia.After 1980: Autism.

Autism spectrum disorder

1. Autism2. Asperger’s syndrome: language development normal up

to 3 yrs, impairment later3. Rett’s syndrome: in girl - head circumference decrease,

loss of previously learned hand skill between 5-30 month4. Childhood disintegrative disorder - normal development

up to 1-2 yrs, loss of previous skill before 10 yrs e.g. language, social skill, adaptive behavior, play, motor skill, Bowel – Bladder control.

5. Pervasive development disorder, NOS (Atypical Autism)

Epidemiology

• Prevalence: 1-2/1000 (world wide)• Sex: 4-5 times in boys

Etiology & PathogenesisA. Genetic factors• 50-200 times increase in Siblings• Siblings are at risk – Communication disorder, Social skill

disorder• Linkage analysis – Ch-7, 2, 4, 15, 19• Concordance rate: MZ twin –> 36-96%, DZ twin –> 0-27%.• 1% has fragile X syndrome• 2% has Tub. Sclerosis

Autistic individuals tend to use different areas of the brain (yellow) for a movement task compared to a control group (blue).

Autism affects the amygdala, cerebellum, and many other parts of the brain

Cont…B. Biological factors • Supports biological basis – Increase Seizure rate & MR• 70% has MR: 1/3 mild to moderate & near ½ profound• 4 – 32% grand mol Seizure• CT scan: increase ventricle• EEG abnormalities: 10 – 83%• MRI: Polymicrogyria, Hypoplasia of Cerebellar Lobules

(suggests cell migration in 1st 06 month of gestation)• Also associated with Congenital Rubella, PKU, TSC. Immunological Factors: • Lymphocytes of fetus react with maternal antibodies• Damages – Embryonic neural/Extra-embryonic tissues.

Cont..D. Perinatal Factors: • Increase perinatal complication (Bleeding after 1st trimester,

meconium in amniotic fluid• Increase respiratory distress syndrome in neonatal period• Increase neonatal anemiaE. Neuroanatomical Factors:• At 2yr – Increase gray & white matter, Cerebral vol.( but not

Cerebellar volume.)• Decrease Cerebellar Purkinje’s cell – causes abnormalities of

attention/arousal/Sensory processes.F. Biological Factors: 1/3rd patient has increase plasma serotonin.G. Environmental Factors (Not confirmed): Heavy metals,

pesticides, alcohol, phenols, vaccines, smoking, diesel exhaust, certain foods.

CLINICAL FEATURES1) PHSICAL CHARACTERISTICS – No physical signs at first glance, some has

Ear abnormalities/abnormal fingerprints.2) BEHAVIORAL CHARACTERISTICS A. Qualitative impairments in social interaction: Lack social smile No reciprocal social skill Poor eye contact Cant acknowledge persons (parents/teachers/siblings) High anxiety, when usual routine is disrupted Can’t play with peers Can’t make friends Increase skill: visual – spatial tasks Decrease skill: verbal reasoning Cant infer others feeling Can’t develop empathy

• Lack “Theory of mind”

Repetitively stacking or lining up objects is a behavior sometimes associated with individuals with autism.

A young boy with autism who has arranged his toys in row

Cont..B. Disturbances of communication & language: Difficulty in language development & using language Language delay In 1st yr: decrease babbling Emit noises in stereotyped fashion “Word” used once( Not used for wks/months/yrs) Echolalia Pronoun reversals: “you want toy.” (I/you) Decrease Articulation (some use peculiar voice) 50% never useful speech Particular fascination with letters/numbers

Some – HYPERLEXIA (But no comprehension)

Cont..C. Stereotyped Behavior:

“Children’s playing are not sports and should be deemed as their most serious action.” (Montaigne: Essays I)

No imitative play Often spin, bang and line up object Attachment to inanimate object Mannerism/grimacing Reversal of routine: Evoke panic/fear/temper tantrum (e.g. New

house, furniture change, breakfast before bath) Palm towards face while saying ‘good-bye’ Holding ‘object’ close to eyes Holding photo/picture/books ‘inversely’ while showing other While going to market/school: found bird/newspaper – (Say: ‘Bird

came/ paper given’)

Cont..D. Instability of mood & affect• Laughing/crying• Sudden mood change

E. Response to sensory stimuli• Over respond – sound of wristwatch• Under respond – sound/pain/normal Speaking voice• Some enjoy music(hum/commercial jingle)• Pain threshold varies also.F. Associated behavioral symptoms• Hyper kinesis, aggression, temper tantrum• Self injurious behav. – head banging/biting/hair pulling• Short attention span• Insomnia• Feeding & eating problem• Enuresis

Cont..

G. Associated physical illness – RTI, GI symptoms, Febrile seizure3) Intellectual functioning 70-75% MR – 30% mild to moderate & 45-50% severe to

profound. 1/5th : normal nonverbal intelligent. Unusual/precocious cognitive abilities (Splinter functions/Islets

of precocity) : Prodigious rote memories, calculating abilities, hyperlexia, musical abilities.

D/D & ScreeningDIFERENTIAL DIAGNOSIS

• Other pervasive development disorder – Asperger’, Rett’s disorder

• MR• Language disorder• Congenital deafness• Psychological deprivation

SCREENING (When you should suspect?)

• No babbling by 12 month• No gesturing (pointing, waving etc) by 12 month• No single words by 16 month• No 2- word phrases by 24 month• Any loss of any language or social skills at any age.

DSM – IV CRITERIA(I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C)(A) Qualitative impairment in social interaction –1. Lack of nonverbal behavior2. Lack of peer relationship3. Lack of sharing enjoyment4. Lack of social or emotional reciprocity

(B) Qualitative impairments in communication – 1. Delay in, or total lack of, the development of spoken language2. Impairment in the ability to initiate or sustain a conversationWith others.3. Stereotyped and repetitive use of language or idiosyncraticlanguage4. Lack of play or social imitative play.

Cont..(C) Restricted repetitive and stereotyped patterns of behavior, interests and activities:

1. Increase stereotyped and restricted patterns of interest2. Inflexible adherence to specific, nonfunctional routines or rituals3. Mannerisms (e.g. hand or finger flapping or twisting, or complex

whole-body movements)(II) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

(A) Social interaction (B) language as used in social communication(C) symbolic or imaginative play

(III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

COURSE & PROGNOSIS

• A lifelong disorder• Best prognosis: If IQ >70%; communication language

by 5 - 7 yrs.• 2/3 rd Autis. adult: Handicapped (severely).• 01 - 02% normal, independent status.• 05 - 20% borderline normal status.• 04 - 32% grandmal Seizure.

GOALS OF TREATMENT• To target behaviors that will improve their abilities to integrate

into schools• To develop meaningful peer relationship• To increase likelihood of maintaining independent living as adults• To increase socially acceptable behavior• To decrease odd behavior symptoms• To develop verbal & nonverbal communication• To reduce disruptive behavior• To encourage self – care skills• To support & counsel the parents• Structured classroom training.

MANAGEMENT1. Management of abnormal behavior

2. Education & social services- Special care Residential schooling Vocational training

3. Help for family- To cope with distress Genetic counseling (3% risk of further autistic child)

4. Others- Behavior problem Self injury Anxiety/Depression Hyperactivity Epilepsy

CAN WE CHANGE ?How to Accommodate the Pains & Sufferings?“If there is anything we wish to change in the child, we should first examine it & see whether it is not something that could better be changed in ourselves.” (Carl Gustov Jung 1875-1961)

A. Information for parents“I here & I forget. I See & I remember. I do & I

understand.”[CONFUCIUS]1. Parental attitude-• Don’t Say:” My son is autistic.”• Say: “He has autism.”• Not handicapped, but ‘disable.”

LIVING WITH AUTISM

Cont..2. Deficiency of sensory perception• Sensory perception not harmonized in all children.• Vestibular sense – Feet should touch the floor (Otherwise

nausea, fear, ear buzzing): e.g. Being on the chair while taking meal/cutting hair.

• Proprioceptive sense - Walking, jumping, Holding pen, pencil, scissors, spoons, Washing hand, fixing button.

• Clipping nails: ? When• Hair cutting - Not to say “Cutting”.

Cont..3. Inability Vs Reluctanay• ‘Cannot do’ - means he is not disobedient• Use card: ‘Help / Wait’ / Picture of hand• Ask baby to show “Card”• 4. Literal meaning Vs pragmatic meaning- • To avoid Rhetorics/proverbs• Example - Not to say-“So clumsy, get it Removed”, • Say – ‘Keep your clothes away; Keep the books in right order’.• Not to say- ‘this is dog’.• Say- ‘A picture of dog’.

Cont..5. Limitation of usage of ward-• Learned from TV: ”I won’t listen”; Then he had water• Baby, when “thirsty” says - “I won’t listen.”• Say: ‘We are hungry, so we would have meal’.

6. Picture Vs Word• “Keeping your toys aside clean hand, have meal and go for

reading.”• Not understood• Say -Keep toys in the box, Wash your hand, Have meal, Start

reading• More comprehensible if “picture” used.

Cont..7. Ability Vs Limitation-• FOCUS, What he can• IGNORE, What he can’t.

8. Helping in making social relation• Ask other babies to call him in the game• Spend some time with them• Read out a story book• Say:”He likes this story”/”He has a red ball”.

9. Helping to make social interaction• Tell everybody:”How are you? What you had today”.• WHAT/WHO/WHY/HOW?

Cont.

10. Knowing the cause of irritability/Aggressions.• Increase Stress• Physical cause - Food intolerance/allergy, Sleep problem, GI -

symptom, Under nutrition, Illness/Trauma, Biochemical deficiencies

• Psychological cause – Depression, Victim of child abuse• Unreasoning word from adults.• If sleeping problem - Sound of watch, Allergen from

clothes/quilts/bed sheets, Odor from toiletries/powder/insecticides, Breathing difficulties/acidity, ‘As if going down’ (Keep pillow to raise the border/use mosquitoes).

Cont..

11. Development of gross & fine motor movements• To stand on one feet• Hop-step & jump• “Roll” on floor/carpet/grass• Give cylindrical pencil to hold by three fingers.• Make “PLAY-DOUGH”: Can make object.

12. Need to have tolerance13. Give unconditioned love.

B. Make Visible Schedule with pictures• Putting clothes• Uses of toilets• Self care• Rules of desirable behavior

(silence/questions/hallo/seeking help).• Rules of undesirable behavior• Different positions (House, school, perk, shop).• Everybody activities

Cont..

B. Make Visible Schedule

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C. Structured play (For teachers & parents)• Give information about color/shapes• Counting• Household activities: Uses & name• Same/Different• Here one practices

-Listening/Watching/Thinking/Doing/Sharing/Turn - taking

Cont.

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Cont..D. Safe home environment• Removes of sharp weapons/Electrical appliances.• Keeping medicines away

E. Ensuring desirable behaviors• Encourage him• Make eye contact• Touch him (you may have to bend, to touch)

F. Things done in unwanted situation• Good/bad: Two columns in board• Put: Tick/cross• When saying ‘NO’: Make 02 alternative, e.g. Two sets of shirts/shoes.• Withdraw ‘attention’• Say: “I do not like your shouting; it’s not good.”• Don’t say: You’re bad/hopeless

WHERE YOU CAN SEEK HELP ?

• “SHISHU BIKASH KENDRA” – In medical colleges• Society for the welfare of Autistic children (H – 74, Block – E,

Mirpur – 12.• Autism welfare foundation (H – 428, Road no. – 2, Shymali,

Dhaka.• Bangladesh ABA Centre for Autism (H – 377, block – F,

Bashundhara, Dhaka.

THE EPILOGUEA PARENT’S COMMADMENTS (Joshua Liebman)

• Give your child unconditional love, a love that is not dependent on report cards, clean hand or popularity.

• Give your child a sense of your whole - hearted acceptance, acceptance of his human frailties as well as his abilities and virtues.

• Give him a sense of truth; make him aware of himself as a citizen of universe in which there are many obstacles as well as fulfillments.

• Give your child permission to grow up and make their own life independent of you.

There are the laws of honoring your child.