Autism through the pictures

8/10/2019 Autism through the pictures

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Table of ContentsPage 1 Table of Contents

Page 2 Acknowledgements

Page 3 CHAT Poster

Page 45 CHAT Screening tool

Page 6-23 VISUAL GUIDE TO BEHAVIORAL SYMPTOMS

Page 78 Social IssuesPage 9 Communications Issues

Page 10-13 Bizarre/Repetitive BehaviorPage 1415 Motor IssuesPage 16 Sensory OverloadPage 1719 Sensory IssuesPage 20 Self-InjuriousPage 2123 Safety Issues

Page 24 Gastro-Intestinal Disturbances

Page 25 Sleep Disturbances / Altered PainResponses / Seizures

Page 26 Impact on Family

Page 27 The Role of Early Intervention (Educational)

Page 28 List of Potential Referrals

Page 2933 OPTIMIZING OFFICE VISITS FOR CHILDRENWITH AUTISM

Page 34 Helpful Websites


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This Autism Physician Handbookwas designed to support Primary Care

providers in their care of children with autism.

In the absence of a biological marker,autism can only be diagnosed by

observation of the childs behavior, and careful history-takingfrom

the parent.

This handbook has been put together based on input from many

professional experts in both the educational and medical fields.

2006 All rights reserved.

H.A.N.S. is dedicated to helping families

with autism, by supporting physicians and

other professionals in the recognition,

diagnosis and treatment of autism.

Acknowledgements

HANS wishes to thank the following individuals for their generous contributions and

involvement in the creation of this physician handbook.

Dr Simon Baron-Cohen, developer of the CHat screening tool: Professor of

Developmental Psychopathology, Director Autism Research Center,

Cambridge University, England.

Julie Bingham PhD:Pediatric Clinical Psychologist, Salem, Oregon

Richard Bingham MD: Child Psychiatrist, Salem Oregon

Sarojini Budden MD:Pediatric Developmental Specialist, Director of Child

Development and Rehabilitation, Legacy Emmanuel, Portland, Oregon.

Sara Cuthill MD:Pediatric Developmental Specialist. Kaiser Permanente, Portland,

Oregon.

Mike Marlowe MD: Pediatrician, Kaiser Permanente Salem, Oregon

Mary Lynn O Brien MD:Pediatric Developmental Specialist. Kaiser Permanente,

Portland, Oregon.

David Willis MD: Behavioral and Developmental Pediatrician. Northwest Early

Childhood Institute, Portland, Oregon

Registered 501c3 non-profit

www.helpautismnow.com


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At 18 months of ageDoes your child ...

3

2. Lookwhenyoupoint tosomething?

3. Use imaginationtopretendplay?

If the answer is NO,your child may be at risk

for AUTISM. Pleasealert your physician today.

Based on CHAT (CHecklist for Autism in Toddlers)

1. Look at you andpointwhen he/shewants to show yousomething?


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CHAT (CHecklist for Autism in Toddlers)Page 1 of 2 (To be completed at 18-month visit)

Section A: To be completed by parent

1. Does your child enjoy being swung, bounced on your knee, etc? Yes No

2. Does your child take an interest in other children? Yes No

3. Does your child like climbing on things, such as up stairs? Yes No

4. Does your child enjoy playing peek-a-boo/hide-and-seek? Yes No

5. Does your child ever PRETEND, for example, to make a cup

of tea using a toy cup and teapot, or pretend other things? Yes No

6. Does your child ever use his/her index finger to point,

to ASK for something? Yes No

7. Does your child ever use his/her index finger to point, to

indicate INTEREST in something? Yes No

8. Can your child play properly with small toys (e.g. cars orbricks) without just mouthing, fiddling or dropping them? Yes No

9. Does your child ever bring objects over to you (parent) to

SHOW you something? Yes No

Section B: Physician or healthcare provider

1. During the appointment, has the child made eye contact

with you? Yes No

2. Get childs attention, then point across the room at an interesting

object and say Oh look! Theres a (name of toy)! Watch childsface. Does the child look across to see what you are pointing at? Yes No

3. Get the childs attention, then give child a miniature toy cup and

teapot and say Can you make me a cup of tea? Does the child

pretend to pour out tea, drink it, etc.? Yes No

4. Say to the child Wheres the light?, or Show me the light.

Does the child POINT with his/her index finger at the light? Yes No

5. Can the child build a tower of bricks?

(If so, how many_________) Yes No

B2: To record Yes on this item, ensure the child has not simply looked at

your hand, but has actually looked at the object you are pointing at.

B3: If you can elicit an example of pretending in some other game, score

a Yes on this item.

B4: Repeat this with Wheres the teddy? or some other unreachable object,

if child does not understand the word light. To record Yes on this item,

the child must have looked up at your face around the time of pointing.

(See next page for scoring recommendations)


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CHAT (CHecklist for Autism in Toddlers)Page 2 of 2

CHAT key items Section A

A5: Pretend play

A7: Protodeclarative pointing

Section B B2: Following a point

B3: Pretending

B4: Producing a point

CHAT non-key items Section A

A1: Rough and tumble play

A2: Social interest

A3: Motor development

A4: Social play

A6: Protoimperative pointing

A8: Functional play

A9: Showing

Section B

B1: Eye contact

B5: Tower of bricks

Risk AssignmentHigh riskfor autism group Fail (NO answer) A5, A7, B2, B3, B4

Medium riskfor autism group Fail A7, B4 (but not in high risk group)

Low riskfor autism group Not in other two risk groups

Management recommendations:

High risk group: Refer to developmental clinic as well as ESD(Educational Services Department).

Medium risk group: High suspicion refer as above

Low suspicion Re-test in one month

Low risk group: If there are any NO answers, re-test in one month.


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Social

Communication

Bizarre / Repetitive Behaviors

Motor

Sensory Overload

Sensory

Self Injurious

Safety

Behavioral Symptomsof Autism


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SOCIAL ISSUES

May notnotice whenparent leavesor returnsfrom work

May be viciouswith siblings

May sit alone incrib screaming

instead of callingout for mother

May show no interest in other children playing

Behavioral Symptoms of Autism


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SOCIAL ISSUES

May strongly

resist being held,hugged or kissed

by parents

May not raise armsto be picked upfrom crib whensomeone reachesout to pick him up

May show no

interest inPeek-a-Boo orother interactivegames



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COMMUNICATION ISSUES

Children with autism are often unaware of their environmentand may have difficulty with eye-contact. As a result they may

seem uninterested in communication of any kind.

When they do need something they often resort to Hand-Leading. The child places the parents hand on the object hedesires, so using the parent or adult as a TOOL to get what theywant. Typical children communicate their needs by verbalizing,or non-verbal methods such as pointing.

Hand-Leading

Unawareof environment

Avoids eye-contact



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BIZARRE / REPETITIVE BEHAVIORS

Staring at ceiling f

Flapping

Spinning

Lining up toy cars



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May show no interest intoys but get attached to

objects like a space-heater

Picking lintin the sunlight

May not play appropriatelywith toys and insteadfocuses only on one aspect,like spinning the wheels of a toy car



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Eats unusualobjects like clothes,mattress or drapes

Flicksfingers

in frontof eyes

Rocking

Obsessivelyswitching light

on and off



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Finds ways to getheavy impactsto body

Finds waysto getdeep-pressureapplied to body

Smearing feces



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MOTOR ISSUES

Fine Motor DeficitsPoor coordination

Children with autism can exhibit motor abnormalities. Somemay have exceptional motor skills in one area yet could be

impaired in others.

Toe-walking

Depth Perception Deficit



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MOTOR ISSUES

Exceptional Balance

Clumsy

Unableto ridetricycles,or trucks

Even children who exhibit typical motor skills, may havedifficulty with activities like tricycles, ride-on trucks, etc.

Drooling

OR



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SENSORY OVERLOAD

A child with autism may have extreme difficulty toleratingmusic, noise, textures and new experiences or environments.The greater number of sensory exposures, the more likely abehavioral melt-down will occur.



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SENSORY ISSUES

Extreme difficultywith haircuts

May not like new

experiences such asbirthday candles orballoons

May be almostimpossible to bathe

Unable totolerate

seat belts



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SENSORY ISSUES

Gags at commonhousehold smells

Spinningobjectsclose toface

May appear deaf, notstartle at loud noisesbut at other timeshearing seems normal

May havedifficultytoleratingmusic



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SENSORY ISSUES

May have difficultywearing outdoor clothing in winter

May rip at own clothlabels and seams

Resistshaving

clothing

changed

During summermay insist onwearing winterclothing



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SELF INJURIOUS BEHAVIORS

Head-banging

Self-bitingwith noapparentpain

Ripping andscratching

at skin

Pulling outhandfuls of hair



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SAFETY ISSUES

No sense of danger



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SAFETY ISSUES

Doesnt recognize situationswhere he may get hurt



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SAFETY ISSUES

No fear of heights



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Gastro-Intestinal Disturbances

Diarrhea

Undigestedfood in stool

Severe self-limiting dietand/or food sensitivity

Constipation

Dr. Tim Buie,a Gastroenterologist at Harvard University and Mass GeneraHospital, Boston, has performed endoscopies in over 1000 children withautism. In the initial 400 children, he discovered that GI problems weremuch more prevalent in children with autism than in normal controls.

20% Esophagitis 12% Gastritis 10% Duodenitis 12% Colitis 55% Lactase Deficiency

Consider referral to GI where appropriate.


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Sleep-Disturbances / Pain Responses / Seizures

Altered Pain ResponsesDiminished / Absent Pain Responses

orHeightened Pain Responses

Seizures

Co-morbidity with seizureincreasing with age.Unknown etiology

Sleep DisturbancesChildren may go days without any apparent need to sleep. May notseem to notice difference between day and night. May have difficultygoing to sleep and staying asleep. May only sleep brief periods of anhour or two maximum.

Consider the parents sleep-deprived state as a consequence.


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Impact of Autism on the Family

With a child with autism, routine everydayactivities may be impossible.

Stress on marriage and siblings can be tremendous. Referralto family/siblings counselingand local support groupsmay beappropriate.


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The Role of Early Educational Interventions

Studies have shown that early intensive educational interventionsresult in improved outcomes for the child and family. Initialstrategies may include teaching the child to notice what is goingon in their environment, to be able to pay attention, to imitatebehavior, and later progressing to communication skills, etc.

Refer the family to Early Intervention (EI)for evaluationif any developmental delay is suspected.

Depending on the childs needs, EImay include Speech,Occupational and/or Physical Therapy.


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Summary of Potential Referrals

1. Developmental Specialist

2. Evaluation by Early Intervention

3. Hearing Evaluation

4. Speech Therapy

5. Physical Therapy

6. Occupational Therapy

7. Pediatric GI Specialist (if child has severe diarrhea / constipation /

bloody stools / undigested food / frequent vomiting)

8. Neurologist (if seizures present)

9. Child Psychiatrist / Psychologist

10. Social Worker / Family Counseling

11. Local Parent Support Groups


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As Physicianswe are primarilytrained to look forsickness.

Children withautismrarely looksick; they maylook perfectly

normal and haveattained alltheir pediatricmilestones.

Instead theymay behave asthough they are

just lacking firmparental controls.

They are oftenvery resistantto change:newsituations, new

experiences andnew people.

Optimizing Office Visitsfor Children with Autism


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Advantagesinclude theability to:

1. Obtain a clear historyfrom the parent withoutthe distraction of the childpresent.

2. Ask the parent for theirsuggestions as to how thevisit could be made easier.

3. Ask the parent to bringa motivator (bribe) for thechild to assist with exam.

4. If you anticipate the need for blood draw, considerprescribing anesthetic cream so that the parent can apply itin advance of the visit.

5. Suggest the parent prepare the child by reading themedical social stories, Going to see the Dr and/or Going

to have blood drawn by HANS helpautismnow.com

Parents are experts atreading their child.

Where possible treat anyphysical symptoms as youwould a normal child,(without letting autismcloud your judgment).

Optimizing Office Visits for Children with Autism

CONSIDER ADVANCE TELEPHONE-CONFERENCE

WITH THE PARENT

LISTEN TO THE PARENT


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Nurse/ Medical Assistant

can check in advance withthe parent regarding roomaccommodations. These mayinclude :

Quiet room

Room without a window

No Bright lights

No music

If necessary remove allobjects that could potentiallybe used as missiles or weapons.

Consider:

Scheduling the child as thefirst appointment of theday, (ten minutes earlier willprevent the child from see-ing other people when hearrives).

Potential Advantages:

Minimizes risk of:

1. Child melt-down2. Disruption for other

families in the Waiting Room

3. Embarrassment for the parent

4. Damage to the actual Waiting Room

If possible register the child in advance by telephone.


MINIMIZE WAITING TIME IF POSSIBLE

PREPARE THE EXAM ROOM


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Despite the fact that these

children may look neglectedand/ or abused, consider thefollowing;

Severe self-injuriousbehaviors: biting, head-banging, scratching, etc

Limited or no pain-sensation

No sense of danger or whatwill hurt them

Severe sensory issues makingit virtually impossible to changetheir clothing or bathe them

Be alert for your own safety

Some children with autism may not understand thatyou are there to help them, instead they may see you asa threat. They can be calm at one moment and eruptthe next and may:

Head-butt

Bite

Kick

SpitPunch

Pull hair

BOLT

Etc, Etc, Etc

Respect the childs personalspace, (it may be muchlarger than usual)


EXPECT THE UNEXPECTED!

THINGS MAY NOT BE AS THEY SEEM


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Refer when appropriate, e.g.

Sibling Workshops

Family Support groups, etc

Respite services


CONSIDER THE IMPA CT OF AUT ISM

ON THE ENTIRE FAM ILY

LIMITED UNDERSTANDING AND SPEECH

Some children may be ableto recite entire Disneyvideos, yet may be unableto tell you their name or ifthey hurt.

They may have difficultyprocessing auditoryinformation.


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HELPFUL WEBSITES

American Academy of Pediatrics: Pediatricians role in the Diagnosis and

Management of Autistic Spectrum Disorder in Children

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/5/1221

American Academy of Neurology Practice Parameter

http://www.aan.com/professionals/practice/pdfs/g10063.pdf

CDC Autism Information Center

http://www.cdc.gov/ncbddd/dd/aic/cdc/default.htm

NIH Autism Website

http://www.nichd.nih.gov/autism/

Help Autism Now Society http://www.helpautismnow.com

NOTES

Autism through the pictures

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