Hanipsych, autistic disorder

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Transcript of Hanipsych, autistic disorder

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Management of Pervasive Developmental Disorder

Prof. Hani Hamed Dessoki, Prof. Hani Hamed Dessoki, M.D.PsychiatryM.D.Psychiatry

Prof. PsychiatryProf. Psychiatry

Chairman of Psychiatry DepartmentChairman of Psychiatry Department

Beni Suef UniversityBeni Suef University

APA memberAPA member

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DisclosureDisclosure

NO relevant financial relationships with a NO relevant financial relationships with a commercial interest.commercial interest.

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AUTISMAUTISM

Autism is a brain disorder that impairsAutism is a brain disorder that impairs a person’s ability to communicate, form a person’s ability to communicate, form

relationships, socially interact, and relationships, socially interact, and respond appropriately within a given respond appropriately within a given

environmentenvironment..

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From kanner to the From kanner to the MillenniumMillennium

In 1943, Leo Kanner published his paper on autismIn 1943, Leo Kanner published his paper on autism He clearly described 11 children He clearly described 11 children

socially isolatedsocially isolated autistic disturbances of affective contactautistic disturbances of affective contact impaired communicationimpaired communication behavioral inflexibility behavioral inflexibility

It is congenital disease, runs in familiesIt is congenital disease, runs in families It is rare diseaseIt is rare disease More in males, higher social classes More in males, higher social classes

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CHARACTERISTICSCHARACTERISTICS May May avoidavoid eye contact eye contact May appear or respond as if May appear or respond as if deafdeaf May May lack awarenesslack awareness of the existence feelings of of the existence feelings of

othersothers Can be physically Can be physically aggressiveaggressive or have outbursts or have outbursts

when familiar environment or routine is changedwhen familiar environment or routine is changed Can remain Can remain fixated on single activityfixated on single activity or object or object May engage in strange actions such as May engage in strange actions such as hand hand

flapping, or rocking.flapping, or rocking.

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IncidenceIncidence

10 years ago Autism and PDD occurred in approximately 5 10 years ago Autism and PDD occurred in approximately 5 to 15 per 10,000 births. to 15 per 10,000 births.

These disorders were four times more common in boys These disorders were four times more common in boys than girls.than girls.

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Why rising rate of autismWhy rising rate of autism??

Partly due to better awareness/diagnosis.

So, primary reason is most likely increased exposure to environmental factors (mercury, antibiotics, MMR, pesticides, iodine deficiency)

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Autism is a spectrum disorderAutism is a spectrum disorder

Symptoms less classic Symptoms less classic Range of potential manifestation : severely Range of potential manifestation : severely

handicapped to subtle symptoms with minimal handicapped to subtle symptoms with minimal disabilitydisability

High functioning & Asperger syndromeHigh functioning & Asperger syndrome Autistic featuresAutistic features

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TypesTypes

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Parental Concerns (Wiggins, Baio, Rice, 2006(

Recent study indicated most children with an ASD diagnosis had signs of

a developmental problem before the age of 3, but average age of

diagnosis was 5 years.

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Clinical pictureClinical picture Deficits in social behaviorDeficits in social behavior Problems in communicationProblems in communication Unusual pattern of behaviorUnusual pattern of behavior

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Deficits in social behaviorDeficits in social behavior

Central symptom (core symptom)Central symptom (core symptom) No eye contactNo eye contact No interest of human voiceNo interest of human voice No anticipatory postureNo anticipatory posture Decrease facial responsivenessDecrease facial responsiveness No bondingNo bonding No social reference, Showing, shared attention No social reference, Showing, shared attention

& affect& affect No separation anxietyNo separation anxiety

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Problems in communicationProblems in communication

Non verbal communicationNon verbal communication Understanding of speechUnderstanding of speech Speech developmentSpeech development

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Non verbal communicationNon verbal communication

Infant: crying & screamingInfant: crying & screaming Pulling adult (no appropriate facial expression)Pulling adult (no appropriate facial expression) No nodding & shakingNo nodding & shaking No imitative gamesNo imitative games No copy of adult behaviorNo copy of adult behavior Imitative play skill: stereotyped, repetitive, based on Imitative play skill: stereotyped, repetitive, based on

their own experiencetheir own experience Extreme of emotions or expressionless most of the Extreme of emotions or expressionless most of the

timetime

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Speech developmentSpeech development Babble (impaired amount )Babble (impaired amount ) MuteMute EcholaliaEcholalia Pronouns reversalPronouns reversal Monotonous, robot, no change of emphasis or Monotonous, robot, no change of emphasis or

emotional expression emotional expression Impaired function of speech: stereotyped Impaired function of speech: stereotyped

phrases (cartoon), lack imagination & phrases (cartoon), lack imagination & abstractionabstraction

Lack of to-and-fro Lack of to-and-fro

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Unusual pattern of behaviorUnusual pattern of behavior

Resistance to changeResistance to change Ritualistic or compulsive behaviorRitualistic or compulsive behavior Abnormal attachment to odd objectsAbnormal attachment to odd objects Unusual response to sensory experiencesUnusual response to sensory experiences Objects are manipulated without regard of their Objects are manipulated without regard of their

usual functionsusual functions Preoccupations of certain featuresPreoccupations of certain features

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Associated featuresAssociated featuresDisturbance of motilityDisturbance of motility

Delay motor developmental milestonesDelay motor developmental milestones Impaired motor coordinationImpaired motor coordination Stereotyped movementsStereotyped movements

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Intelligence & cognitive deficitsIntelligence & cognitive deficits 40-60% IQ less than 5040-60% IQ less than 50 20-30 % IQ above 7020-30 % IQ above 70 Areas of normal or near normal skillsAreas of normal or near normal skills Verbal IQ lower than performance IQVerbal IQ lower than performance IQ

AspergerAsperger’’s disorders disorder Better verbal than performance IQBetter verbal than performance IQ

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EpilepsyEpilepsy

4-40%4-40% AdolescenceAdolescence FemaleFemale

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Why it is difficult to diagnoseWhy it is difficult to diagnose ??? ??? Cognitive limitationsCognitive limitations Diminished ability to think abstractlyDiminished ability to think abstractly Lack of communication skillsLack of communication skills Symptoms not classicSymptoms not classic Unawareness & inability to describe internal Unawareness & inability to describe internal

state state (interview & questionnaire ineffective)(interview & questionnaire ineffective)

Lack of social relatedness & motivation to Lack of social relatedness & motivation to report symptoms report symptoms

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EtiologyEtiologyAutism is a neurodevelopmental disorder with a biological Autism is a neurodevelopmental disorder with a biological

basis , no definite causebasis , no definite cause Cortical dysfunctionCortical dysfunction Neurotransmitters dysfunctionsNeurotransmitters dysfunctions Vaccination factorVaccination factor Food allergyFood allergy Antibiotic overuseAntibiotic overuse Toxic exposure theoryToxic exposure theory Immune diseaseImmune disease

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Mædica - a Journal of Clinical Medicine

ORIGINAL PAPERS

Maedica A Journal of Clinical Medicine, Volume 7 No.1 2012

Toxic Metals and Essential Elements in Hair and Severity of Symptoms among Children

with AutismEleonor BLAUCOK-BUSCHa; Omnia R. AMINb; Hani H. DESSOKIc; Thanaa

RABAHda Lecturer, researcher and advisor, International Board of Clinical Metal

Toxicology & German Medical Association of Clinical Metal Toxicology, Hersbruck, Germany

b Associate Prof. of Psychiatry, Cairo University, Egyptc Associate Prof. of Psychiatry- Beni-Suef University, Egyptd Researcher of Public Health and Biostatistics, National Research Center,

Egypt

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Vaccines and Autism

No reliable study has shown a link between the MMR vaccine and autism

Avoiding vaccines can place your child at risk for catching serious diseases

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Clinical course & Clinical course & prognosisprognosis

The diagnosis of autism is stableThe diagnosis of autism is stable The outcome in school, work, or social The outcome in school, work, or social

functioning variedfunctioning varied Symptoms persist but changeSymptoms persist but change Adolescence Adolescence

hyperactivity---- underactivityhyperactivity---- underactivity Increase anxiety & attentionIncrease anxiety & attention Increase sexual curiosity (masturbation in public Increase sexual curiosity (masturbation in public

places)places)

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Minority can have independent lifeMinority can have independent life AspergerAsperger’’s disorders disorder Better outcome as regard education, occupation, Better outcome as regard education, occupation,

marriage, need for institution, autonomymarriage, need for institution, autonomy More aggression & sexual offensesMore aggression & sexual offenses

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Comorbid psychiatric disordersComorbid psychiatric disorders

Other psychiatric symptoms are commonOther psychiatric symptoms are common Subsyndromal or comorbid diagnosisSubsyndromal or comorbid diagnosis Important for management planImportant for management plan

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Common Comorbid psychiatric Common Comorbid psychiatric disordersdisorders Inattention & hyperactivity Inattention & hyperactivity (difficulty shifting, lack of (difficulty shifting, lack of

arousal) arousal) Obsession & compulsionsObsession & compulsions Anxiety & fearsAnxiety & fears Mood disorder Mood disorder (average ability, puberty)(average ability, puberty) Oppositional & antisocial behavior Oppositional & antisocial behavior (rigidity ,lack of (rigidity ,lack of

understanding of social norms)understanding of social norms) TicsTics Psychosis Psychosis (more deterioration & positive symptoms) (more deterioration & positive symptoms)

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Differential diagnosisDifferential diagnosis General mental retardationGeneral mental retardation Developmental language disorderDevelopmental language disorder OCDOCD Sensory impairmentSensory impairment Selective mutismSelective mutism Psychosocial deprivationPsychosocial deprivation

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Assessment, WhatAssessment, What?? Autistic symptomsAutistic symptoms Level of intellectual abilityLevel of intellectual ability Language development (expressive & receptive)Language development (expressive & receptive) Learning styleLearning style Neuropsychological strength & weaknessNeuropsychological strength & weakness Adaptive functioningAdaptive functioning Family system Family system Financial resourcesFinancial resources Behavioral problemsBehavioral problems Other psychiatric symptomsOther psychiatric symptoms Other medical condition (epilepsy)Other medical condition (epilepsy)

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TreatmentTreatment No cure for autism No cure for autism –– no cause is known no cause is known ComprehensiveComprehensive MultidisciplinaryMultidisciplinary Individualized (heterogeneous group+ different Individualized (heterogeneous group+ different

goals)goals) Updated according to needsUpdated according to needs

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ASD Management Outcomes are variable

Behavioral characteristics change over time Most remain on spectrum as adults

Ongoing problems with independent living, employment, social relationships and mental health

Predictors of better outcome Earlier age of diagnosis and treatment No cognitive impairment Early language and nonverbal skills Social skills Not – presence, degree of “autistic” symptoms

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Treatment Goals

Minimize core features and associated deficits Maximize functional independence and QOL Alleviate family stress

Educational intervention Developmental Therapies

Communication Sensory, fine motor, gross motor

Behaviorally Based treatments Core and associated symptoms Social skills

Medical or biologic treatments Support family in home and community

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Speech/Language Therapy

Behaviorally based/ intensive structured teaching E.g., Verbal Behavior

Augmentative strategies Sign language Aided augmentative/ alternative systems

Decrease non-communicative language

Developmental-pragmatic approaches appropriate use of language in social situations Social skills training

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Developmental: Motor

Fine motor coordination Adaptive skills Sensory Integration

Addresses sensory abnormalities

“Systematic desensitization”

No evidence of corresponding neurological changes

Coordination difficulties

Natural environment Adaptive physical

education or in the community

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Psychopharmacology Adjunct to educational,

developmental & behavioral treatments

So far no evidence of impact on core symptoms

Evidence supporting is variable

Treat target symptoms Stereotypies Withdrawal Obsessions Irritability Hyperactivity attention span self-injurious behavior Aggression sleep

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MedicationsMedications

AntipsychoticAntipsychotic Antidepressants (classic/SSRI)Antidepressants (classic/SSRI) Psychostimulants & alpha-adrenergic agonistPsychostimulants & alpha-adrenergic agonist Mood stabilizers & anticonvulsantsMood stabilizers & anticonvulsants HormonesHormones SupplementsSupplements

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Other medication & supplementsOther medication & supplements

Vitamin B6 & magnesiumVitamin B6 & magnesium Diet therapyDiet therapy Hormone Hormone Chelating agentChelating agent

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Symptoms/ Disorders Freq Treatments

Attentional, impulsivity, hyperactivity

59% Behavioral interventionPsychopharmacotherapy – stimulants, atomoxetine, alpha agonists, anti-anxiety

Anxiety 43-84% Behavioral treatment – relaxation, cognitive Psychopharmacotherapy – SSRI, alpha agonist

Depression 2-30% PsychotherapyMedication – anti-depressants

Obsessive compulsive symptoms

37% Behavioral treatment, supportive counseling;Medication – SSRI, others

Disruptive, irritable or aggressive behavior

8-32% Behavioral interventionMedication – atypical neuroleptics (risperidone, arapiprazole, others)

Self-injurious behavior 34% Behavioral interventionMedication (e.g., naltrexone, risperidone, others)

Tics 8-10% Medications; Alpha agonist (clonidine, guanfacine), others

Sleep disruption 52-73% Sleep diary; sleep hygiene; behavioral supports; investigate possible medical comorbidity/ies as cause(s)

Psychopharmacology

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Biologically Based ttt Supplements

B6/Magnesium, B12 DMG/ TMG Vitamin A, Vitamin C Folate Omega 3 Fatty Acids

Elimination Diets Casein/ gluten free

Off-label medications Secretin

Immune Antifungal therapy Immunotherapy, steroids Antibiotics/Antivirals Stem cell transplantation

Immunization-related With-hold immunization Chelation

Hyperbaric oxygen therapy (HBOT)

Always others coming along…

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Strategies to Improve Executive Strategies to Improve Executive FunctionFunction

Simplify tasks into discrete, concrete steps.Simplify tasks into discrete, concrete steps. Usual visual aids (pictures, schedules, check-off lists.)Usual visual aids (pictures, schedules, check-off lists.) Use hand’s on learning (see one, do one, repeat as necessary.)Use hand’s on learning (see one, do one, repeat as necessary.) Prepare for transitions and new experiences. Prepare for transitions and new experiences. Decrease distractions.Decrease distractions. Decrease stressors.Decrease stressors. Coordinate assignments.Coordinate assignments.

Make sure challenges are a good match for abilities.Make sure challenges are a good match for abilities.

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Non pharmacologicalNon pharmacological

Educational interventionEducational intervention Language & speech therapyLanguage & speech therapy Behavioral therapyBehavioral therapy Social skills trainingSocial skills training Working with the parentsWorking with the parents Sensiomotor therapySensiomotor therapy Sensory integration therapySensory integration therapy Auditory integration therapyAuditory integration therapy Music therapyMusic therapy

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Language & speech therapyLanguage & speech therapy

Stimulate the natural ability for learning languageStimulate the natural ability for learning language One to one One to one 2-3 hours/week every day2-3 hours/week every day Involvement of parents : generalizationInvolvement of parents : generalization

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Social skills trainingSocial skills training

Identify skill , broke it into several components Identify skill , broke it into several components Recognize social cuesRecognize social cues Response to social cuesResponse to social cues encourage generalization encourage generalization

Role modelingRole modeling Role playRole play VideoVideo Social storiesSocial stories Group (well structured) or individualGroup (well structured) or individual Adult mediated or peer mediatedAdult mediated or peer mediated

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Behavior therapyBehavior therapy

Change of unwanted behaviorChange of unwanted behavior Select the target behavior Select the target behavior Frequency, intensityFrequency, intensity definable, measurable, observabledefinable, measurable, observable (hit self with hand, get frustrated when asked to (hit self with hand, get frustrated when asked to

complete work)complete work) Antecedent event & consequence Antecedent event & consequence (attention, self stimulation)(attention, self stimulation)

Understand the communicative functions of difficult behavior Understand the communicative functions of difficult behavior What to do instead?What to do instead? Positive reinforcementPositive reinforcement Prevent the behavior by changing the antecedent event Prevent the behavior by changing the antecedent event

(scheduling activities) (scheduling activities)

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Take Home MessageTake Home Message

It is very important establish a set of evidence-based standards for pharmacological, educational and behavioral interventions for children with autism spectrum disorders.

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