11/3/2010

ASD Autism Spectrum • 1/110 (CDC, 2009) Disorders • 4:1 boys to girls ratio (1 in 70 to 1 in 94 boys) • Typically appears in first 3 yrs of life • Areas effected: – Socialization (cognitive function, social anxiety) – Communication (use & form of language) Terry Broda – Behaviour RN[EC], BScN, NP-PHC, CDDN

Areas of concern Epidemic?

• Communication & socialization • Milder cases dx’ed • Restricted interests • Changes from DSM III to DSM IV • Repetitive behaviours (stereotypies) • Younger kids dx’ed • “Stickiness” • More awareness by clinicians & parents BUT… Increase in prevalence still not explained by all of that!

Genetics Epigenetics

• 10%: FXS (15-33% w/ ASD), TSC, PKU, Rett • New field of study (5-10 yrs) • 5 %: rare single gene • Genes activated or turned off (methylation) • 7% : rare c hromosoma l anoma lies • EVERYONE has some epigenetic errors • ? %: one or more common gene copy • Environmental triggers: number variation (multiple copies of a gene) – drugs, • ?% : multiple gene involvement – toxins, • Eventually…microarray tests for all! – assistive reproductive technology (ASD 3-4X!)

S. Scherer R. Weksberg

T. Broda, RN[EC], BScN, NP-PHC, CDDN 1 11/3/2010

Neuroinflammation Cause?

• Activation of neuroglial cells • Many causes • Causes: pesticides, diesel fuel, heavy • Multi-factorial metals, air pollution, autoimmune • Complex interaction between response to something? genes & environment • Oxidative stress from free radicals

M. Herbert Vargas, 2005

Genes Epigenetics Autism Spectrum Disorders Environment aka Pervasive Developmental Disorders

Pervasively Molecular Anatomy & & dysregulated sensory physiology biological signaling Sleep Sensori-motor symptoms Epilepsy Somatic

– Communication

– Social interaction Model of ASD by – Behavior Martha Herbert

Autism Spectrum Disorders Autistic Disorder or Autism

Impairments in reciprocal social interaction skills, • Impaired development of social interaction communication skills & stereotyped behaviour, interests or activities. & communication& a markedly restricted •Autism repertoire of activity & interests. • PDD-NOS *Wide variation of presentations: • Asperger’s When you’ve seen one person • Rett’s with autism, • Childhood Disintegrative Disorder (CDD) you’ve seen one person

DSM-IV-TR, 2000 with autism!

T. Broda, RN[EC], BScN, NP-PHC, CDDN 2 11/3/2010

Social interaction Communication

• Non-verbal behaviours: eye-to-eye gaze, • Delay or lack of development of spoken facial expression, body postures, language (& no attempt to use gestures) gestures • Stereotyped or repetitive language or • Joint attention, pointing, bringing sharing idiosyncratic language objects of interest • Lack of make-believe play or social imitative play (according to developmental level)

Behaviours Asperger’s Disorder Impairment in social interaction skills: • Restricted, repetitive stereotyped patterns • Non-verbal behaviours: eye-to-eye gaze, facial of behaviour, interests & activities expression, body postures, gestures • Inflexibility (routines, rituals) • Failure to develop peer relationships (appropriate • Stereotypical motor mannerisms: hand- to developmental to age) flapping, finger twisting • Joint attention: pointing, bringing sharing objects • Persistent preoccupation with parts of of interest objects • Lack of social or emotional reciprocity

DSM-IV-TR, 2000

Behaviours Associated features

• Restricted, repetitive stereotyped patterns - No developmental delay usually of behaviour, interests & activities - Strengths in verbal abilities over non-verbal • Inflexibility (routines, rituals) areas • Stereotypical motor mannerisms: hand- - No delay in language acquisition but can flapping, finger twisting include poor social pragmatic language skills (poor comprehension of jokes, irony, metaphors, • Persistent preoccupation with parts of typical give & take in a conversation) => difficulties objects with social interactions - May have comorbid ADHD

T. Broda, RN[EC], BScN, NP-PHC, CDDN 3 11/3/2010

P.D.D-NOS (Not Otherwise Specified) Rett’s Disorder, DSM-IV-TR • “atypical autism” do not meet criteria due to • Rare genetic progressive degenerative disorder, late age of onset or mild or atypical primarily in females (MECP2 gene) presentation of symptoms • Characterized by normal prenatal & perinatal development , normal psychomotor development • severe and pervasive impairment across all through 5 months of age then decline in growth 3 areas but there are not enough symptoms and loss of skills to meet criteria of P.D.D., schizophrenia, • Normal head circumference at birth but then schizotypal PD or avoidant PD deceleration of head growth btwn 5-48 months

DSM-IV-TR, 2000

Rett’s Disorder, DSM-IV-TR Childhood Disintegrative Disorder • Loss of previously acquired hand skills btwn 5-30 • Normal development for at least the first 2 years months & subsequent development of hand • Significant loss of previously acquired skills in at least stereotypies (washing, wringing) two of the following areas (before age 10): • Loss of social engagement, but may develop – Expressive or receptive language skills social interaction later (with eyes) – Social or adaptive behaviour • Poorly coordinated gait or trunk movements – Bowel or bladder control • Severely impaired expressive and receptive – Play skills language development, dysphagia – Motor skills • Severely impaired psychomotor skills DSM-IV-TR, 2000

Childhood Disintegrative Disorder Screening • Abnormalities of functioning in at least 2 of • Parental reports the following: – Social interaction – Communication • Routine Developmental Monitoring: – Restrictive repetitive & stereotypied patterns of should be done at: behavior, interests & activities including motor – 15 months mannerisms – 18 months • Not accounted for by another PDD or – 24 months schizophrenia DSM-IV-TR, 2000

T. Broda, RN[EC], BScN, NP-PHC, CDDN 4 11/3/2010

Failure to meet Screening developmental milestones • To obtain instructions and permission • No big smiles or other • No gesturing (e.g., pointing, warm, joyful expressions information for free use of the M-CHAT: waving bye-bye,) by 12 months by 6 months; • No single words by 16 months www2.gsu.edu/~wwwpsy/faculty/robins.htm • No back-and-forth sharing of sounds, smiles • No two-word spontaneous (not or facial expressions by 9 just echolalic) phrases by 24 months; months • No babbling by 12 • Loss of any language or social months skill at any age

Referrals ASAP: Team approach:

• Audiology assessment concurrently w/ • Audiologists • Nurse Practitioners referral to interdisciplinary ASD team. • Behavioural • Occupational • Speech-language pathologist for Specialists / Early Therapists Interventionists assessment and intervention concurrently w/ • Pediatricians • Dieticians referral to an interdisciplinary ASD team. • Psychiatrists • Educational • Early intervention or developmental services • Psychologists Specialists • Social Workers upon suspicion that they may have an ASD • Neurologists • Speech Pathologists or other developmental delay.

Examples to view: SL-P Role

Video Glossary at Autism Speaks: • Assessment of communication skills ,speech production, dysphagia, AAC, and pragmatic www.autismspeaks.org/video/glossary.php language skills( => social interaction skills).

• Communication: 1.Expressive language skills: verbal & nonverbal, PECS, use of language (what to say when), writing skills 2. Receptive language skills: comprehension of verbal information and nonverbal cues, reading, interpretation of facial cues and language in specific contexts (V. Prengel)

T. Broda, RN[EC], BScN, NP-PHC, CDDN 5 11/3/2010

Speech Production Barriers to Communication Absence of speech or delay (limited sounds, omissions, • Impairments in receptive & expressive abilities substitutions...) • Cognitive impairments Motor speech disorders are common within ASD (dysphagia!) • Pragmatics of language, motivation and interest in -dysarthria: impairments due to neurological systems communication with others is affected by social (weakness of the musculature used to make sounds) impairments -apraxia of speech(AOS): sensori-motor disorder which • Communication needs & styles of individuals with ASD are impairs the sequence (movement patterns) and position of frequently not understood and/or misinterpreted. the muscles and structures involved in voluntary speech • Distraction or decreased attention due to sensory stimuli production (respiration, jaw, tongue, lips, teeth, palate). (environmental or neurological) NOTE: individuals with AOS can repeat verbal information • Idiosyncratic behaviour patterns, atypical behaviours yet they may be incapable of producing the same utterance » Geneva Centre for Autism spontaneously (echolalia). (V.Prengel)

Atypical Behaviours Additional Barriers

• Strong resistance to change in routine •Anxiety • Self-stimulatory behaviour • Impaired sensory processing (ex. not • HhHyper or hyposens itiittdllitivity to sounds, smells, hearing ‘D’ in dog or ‘B’ in boy very well) taste, sight, etc... • Inconsistent arousal and attending skills • Insensitivity to pain, cold or heat • Self-injurious behaviour • Impaired speech production • Limited interests and activity repertoire • Use of augmentative and alternative communication affected by poor fine

motor skills Geneva Center for Autism

Non verbal Communication Echolalia or • Use of gestures, heads nods and shakes Attempts at Communication? • Facial expressions Singing or repeating commercials? • Eye gaze • may be a request for a certain item! • Body language: posture, proximity & (breakfast cereal, etc) orientation to communication partner • Use of behaviours: requesting Temple Grandin items(banging on a cupboard)

T. Broda, RN[EC], BScN, NP-PHC, CDDN 6 11/3/2010

Communication & Socialization More Resources • AAC: augmentative & alternative communication • PECS: http://www.pecsproducts.com/catalog/ – Lo-tech: use of BoardMaker imaggges for creating a choice board (pointing), visual schedules, & • Do-Watch-Listen-Say by Kathleen Ann Quill PECS (expressive: get the card/image, degree of ($71.95) iconicity: object, representation(mini), photo of object, cartoon image (color, B & W), stick figures (BLISS board) – Hi-tech: computer devices: Dynavox, Oralys, iPad V. Prengel

Communication & Socialization More resources:

• Social stories by Carol Gray •“Social Behavior Mapping - Connecting http://www.thegraycenter.org/social- Behavior, Emotions and Consequences stitories /ht/what-are-socilial-stitories Across the Day”by” by Michelle Garcia Winner • • The New Social Stories Book, Carol Gray • www.socialthinking.com/books-products/featured- products?page=shop.product_details&category_id=9&flypag (10th Anniversary edition) ($39.95) e=flypage.tpl&product_id=118 • Comic Strip conversations, Carol Gray ($12.00)

Educational & Treatment Senses

Approaches • Visual (spatial, color, shape, light, depth)(70% energy to process it!) Many strategies including: • Auditory (underR: hums, craves loud music; overR : covers ears) • TEACCH: Treatment & Education of Autistic • Olfactory & Gustatory (food seeking/avoidance, textures) & related Communication- handicapped • Tactile (touching objects, clothing or touch from others) Children • Proprioception (knowing where body parts are, info from joints, stairs in dark) • ABA (Applied Behavioral Analysis) • Vestibular (human ‘level’, body in space; linear & rotary movement) – Lovaas • Interoception (internal state, messages from inside the body: • Stanley Greenspan hunger, PAIN, bladder fullness, emotions) – Floor time A. Eustace, OT, Nfld

T. Broda, RN[EC], BScN, NP-PHC, CDDN 7 11/3/2010

Sensory Issues Perception is Reality! • Tactile hyposensitivity & proprioception – Deep pressure, squeeze machine, weighted vest “There are no bizarre behaviors – • Tactile hypersensitivity more accurately , there are human – Touch (clothes, tags, soft touch, etc) responses that are not fully understood or appreciated.” • Altered sensory perceptions (synaesthesia ex: colored hearing) Carol Gray, 2007

Sensory Interventions Resources

• Sensory integration / sensory diet • Building Bridges through Sensory – Brushing Integration by Ellen Yack, et al. ($36.95) – Compressions (trampoline) • Ocean Drum – Swing use • Tangle – Snoezelen room • Cool Bananas CD ($24.95) • Music therapy

A. Eustace, OT & A. Eustace, OT & R. White, MT, Nfld R. White, MT, Nfld

Screening Medical concerns • Genetic testing (FraX, TSC, DS, etc) & • Seizures (30-50%) metabolic testing (PKU) PRN (10%) • GI issues in kids (50%): reflux, diarrhea, • Lead screening (DD & pica). constipation, allergies/intolerances, “picky • Seizure disorders. eaters”, dysphagia?

• Hearing and vision • Sleep problems (latency, staying asleep & duration) • SLP for communication abilities • Comorbidities: CP, Tourette’s ADHD, OCD

• Psychiatrist or psychologist • Individual variations: pressure sores (swings), • OT assessment of sensori-motor function RSI, eyestrain, H/A (computer use)

T. Broda, RN[EC], BScN, NP-PHC, CDDN 8 11/3/2010

GI issues Pain assessment • Picky eaters’ risks: FTT, IDA & other deficiencies (Zn, B12, Ca, protein) • Vocalizations • Sensory assessment & food diary: spicy, crunchy, • Changes in appetite or sleep sweet, salty • Changes in activity or behavior: SIB, • Diarrhea: r/o constipation & food diary needed change in movement, even more talkative! (juice ++?) • Changes in appearance • GERD: behavioral s/s (CdLS study: bite fist, pinch chin/neck, punch chest) • Pain reporting? Scales?

• Allergic GI issues, may even be seasonal! F. Volkmar, 2004 • Casein intolerance (Mg & Vit D for casein free diets)

Sleep Dental Care

• Sleep hygiene: routine, bath, meals, • Desensitization: start at age 3, visit w/ exercise, calming activities parents/siblings • Environmental: noise, lighting, blinds, • Dental mirror warmth, comfort, sheets, socks, PJ’s • Multiple visits (smells, etc) • White noise, metronome, loud clock! • Bring toys, soothing items • Waking d/t medical issue? (GERD? Sz?) • Storybook (Surrey Place) • BB monitor? • Favorite toothbrush or paste from home • Rx melatonin?

Psychiatric concerns Resources:

•Anxiety • Social scripts, social stories by Carol Gray • Depression • The Incredible 5-point Scale by Kari Dunn • Risk of suicide? Buron & Mitzi Curtis ($24.95) •SIB • The 5-point Scale & Anxiety Curve Poster • OCD? by Kari Dunn Buron ($29.95) • Aggression & behavioural outbursts or • Relaxation & breathing exercises meltdowns • (Geneva Center)

T. Broda, RN[EC], BScN, NP-PHC, CDDN 9 11/3/2010

Bookstores Organizations

Parentbooks: located in Toronto! DDNA • http://www.parentbooks.ca/ • www.ddna.org Brookes Publishing AADMD • http://www.brookespublishing.com/ • www.aadmd.org/ Cherry Hill Books NADD • http://www.cherryhillbooks.com/ • www.thenadd.org/

Resources: Resources: • The Autism Treatment Network at Autism • Canadian Autism Intervention Network: Speaks: http://www.cairn-site.com www.autismspeaks.org/science/programs/atn/index.php • Health Canada’ s Autism website: • Autism Central: www.autismcentral.ca/research/ • www.hc-sc.gc.ca/dc-ma/autism/index_e.html • Autism Connects: • Surrey Place • www.autismconnects.com • www.surreyplace.on.ca/ • Autism Society of Canada: • CNSC www.autismsocietycanada.ca/ www.community-networks.ca/

T. Broda, RN[EC], BScN, NP-PHC, CDDN 10