AUTISM

Prepared by: Sana

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Outline

Definition Epidemiology Classification Imaging Studies Pathophysiology Etiology Symptoms and Diagnosis Autism therapies Prognosis Implications for Nursing Jordan Specialized Center for Autism References

Definition

Autism is a brain development disorder that manifests in early childhood and is characterized by qualitative abnormalities in social interactions, marked aberrant communication skills, and restricted repetitive and stereotyped behaviors.
First described by Leo Kanner in 1943

Epidemiology

It is a rare condition, occurring in only 2 to 10 of every 10,000 children. Boys are 3-5 times more likely than girls to have autism.

Classification:

Autism is classified by the American Psychiatric Association as one of the pervasive development disorders (PDD). This group of disorders is sometimes called the autism spectrum disorders (ASDs).
The pervasive developmental disorders include Asperger syndrome, childhood disintegrative disorder, Rett disorder, and pervasive developmental disorder not otherwise specified (PDD NOS).
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Imaging Studies

MRI CT scanning Positron emission tomography Electroencephalography

Pathophysiology

Enlargements of the amygdala and the hippocampus. Elevations of whole blood serotonin occur in one third of patients. Impairment in the metabolism of phenolic amines. Brain weight, volume, and head circumference tend to be greater in autistic children.

Evidence on HC

Evidence of Brain Overgrowth in the First Year of Life in Autism

Eric Courchesne, Ruth Carper, Natacha Akshoom JAMA. 2003;290:337-344.

Objective: To determine whether pathological brain

overgrowth precedes the first clinical signs of autism spectrum disorder (ASD) and whether the rate of overgrowth during the first year is related to neuroanatomical.
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Setting, design and participant:

They take 48 children with autism aged between 25 years. At first they obtained the head circumference ,body length and body Wt from the child record in the first year and who participate in MRI. They divide the group 15 Childs longitudinal group and they take the measurement at 4 periods during infancy: birth, 1 to 2 months, 3 to 5 months, and 6 to 14 months ,and 33 (partial HC data group) had measurements at birth and 6 to 14 months (n = 7), and at birth only (n = 28).
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Main outcomes measure: The relationship of brain

anatomy and aged changes in infant with ASD were evaluated by 2 nationally normative databases: cross-sectional normative data from a national survey and longitudinal data of individual growth. Result: Birth HC of autistic infants was significantly smaller, after birth, HC was related to cerebeller gray matter volume at 2-5 years. Although the excessive increase in HC between birth and 6 to 14 months was related to greater cerebral cortex volume at 2 to 5 years. Within the ASD group, every child with autistic disorder had a greater increase in HC between birth and 6 to 14 months.
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Conclusion: 2 phases of brain growth abnormality precedes

autism: a reduced HC at birth and a sudden and excessive increase in HC between 1 to 2 months and 6 to 14 months. Abnormally accelerated rate of growth may serve as an early warning signal of risk for autism.

Recommendation: We recommend early detection of

autism by measure HC of your child

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Etiology

The etiology of autism is an unsolved and controversial question. Hypotheses include: Genetics Prenatal environment

Perinatal environment Postnatal environment

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Genetics

More than one gene may be implicated Different genes may be involved in different individuals and the genes may interact with each other or with environmental factors. Interaction of a genetic predisposition and an early environmental insult

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Evidence on Genetics

Early Social-Communicative and Cognitive

Development of Younger Siblings of Children With Autism Spectrum Disorders .

Wendy L. Stone, Caitlin R. McMahon, Paul J. Yoder, Tedra A. Walden. Arch Pediatr Adolesc Med. 2007;161(4):384-390.

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Objective: To compare the early socialcommunicative development of younger siblings of children with autism spectrum disorders (ASDs) with that of younger siblings of children with typical development .

Participants: Younger siblings of children with ASD

(n = 64) and younger siblings of children with typical development (n = 42) between the ages of 12 and 23 months (mean, 16 months).
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Outcome Measures: Child-based measures included

a cognitive assessment; an interactive screening tool assessing play, imitation, and communication; and a rating of autism symptoms. Parental report measures were an interview of social-communicative interactions and a questionnaire assessing language and communication skills.

Results: Younger siblings of children with ASD

demonstrated weaker performance in nonverbal problem solving (mean difference [MD], 5.91).
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Conclusion: The weaker performance found for children

in the ASD sibling group may represent early-emerging features of the broader autism phenotype, thus highlighting the importance of developmental surveillance for younger siblings.

Recommendation: Autistic children siblings need more

attention

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Prenatal environment
Birth defect agents acting during the first eight weeks from conception Teratogens: thalidomide, valproic acid, misoprostol, or rubella. Pesticides Folic acid: taken during pregnancy through modulating gene expression Stress

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Perinatal environment

Risk factors found associated obstetric conditions that included: Low birth weight. Gestation duration. Hypoxia during childbirth.

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Postnatal environment

A wide variety of postnatal contributors to autism have been proposed, including: Gastrointestinal or immune system abnormalities. Allergies. Exposure of children to drugs. Vaccines (MMR). Infection. Certain food (dairy products, chocolates, corn, bananas). Heavy metals. Refrigerator mother.
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Evidence on MMR

MMR-Vaccine and Regression in Autism Spectrum Disorders: Negative Results Presented from Japan Tokio Uchiyama, Michiko Kurosawa, Yutaka Inaba. J Autism Dev Disord. 2007 Feb;37(2):210-7.

Purpose: investigate whether the MMR vaccination is

associated with regressive autism.

Settings: Yokohama Psycho-Developmental Clinic,

Japan.

Participants: 904 patients with autism.

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Method: cross-generational analyses that could only

have been conducted in Japan, because the MMR vaccination program was conducted only for children born between1985 and 1991. Thus, the rate of regression in autism could be examined before, during, and after the period of the MMR vaccinations.

Results:

Within the MMR era, the rate of regression in those who received MMR was not higher than those who did not. the rate of regression did not vary across the preMMR, the MMR, and the post-MMR eras.
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Recommendation:

No relationship between autism and MMR vaccination. MMR vaccines is recommended.

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What are the symptoms of autism?

Most symptoms developed within the first 30 months of age. Failure to develop social relations. Impaired communication in verbal and nonverbal skills Stereotyped repetitive behaviors About 75% of individuals with autism also manifest moderate mental retardation. Specific, limited intellectual problem solving abilities. Abnormal responses to sensory stimuli. Decreased sensitivity to pain

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Symptoms and Diagnosis

Failure to develop social relations:

Poor use of body language and nonverbal communication, such as eye contact, facial expressions, and gestures Lack of awareness of feelings of others and the expression of emotions, such as pleasure (laughing) or distress (crying), for reasons not apparent to others Lack of or abnormal social play

The absence of protodeclarative pointing is predictive of the later diagnosis of autism (Protodeclarative pointing is the use of the index finger to indicate an item of interest to another person). 25

Symptoms and Diagnosis

Impaired communication in verbal and nonverbal skills:

Delay in, or the total lack of, the development of spoken language or speech Repeating words or phrases back when spoken to (known as echolalia) Difficulty expressing needs and wants, verbally and/or nonverbally

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Symptoms and Diagnosis

Stereotyped behaviors:
Insisting on following routines and sameness, resisting change Repetitive body movements (hand flapping, rocking) and/or abnormal posture (toe walking) Preoccupation with parts of objects or a fascination with repetitive movement (spinning wheels, turning on and off lights) Extreme resistance to change in routine.

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Criteria for the diagnosis of autism are included in the Diagnostic and Statistical Manual of Mental Disorders. DSM IV-TR Criteria for 299.00 Autistic Disorder: A) total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): 1. qualitative impairment in social interaction, as manifested by at least two of the following: A. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction B. failure to develop peer relationships appropriate to developmental level C. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) D. lack of social or emotional reciprocity.

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2. qualitative impairments in communication as manifested by at least one of the following: A. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) B. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others C. stereotyped and repetitive use of language or play appropriate to idiosyncratic language D. lack of varied, spontaneous make-believe play or social imitative developmental level.

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B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
1. 2. 3.

social interaction. language as used in social communication. symbolic or imaginative play.

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3. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
A.

B.

C.

D.

encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus apparently inflexible adherence to specific, nonfunctional routines or rituals stereotyped and repetitive motor manners (e.g., hand or finger flapping or twisting, or complex whole-body movements). persistent preoccupation with parts of objects

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Autism therapies

An intervention is any action such as a treatment, a therapy or the provision of a service which is designed to help people with autism. There are already more than 100 different interventions designed to help people with autism.

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Categories of Interventions

Psycho-educational Psycho-pharmacological Complementary

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Psycho-educational

Interventions which use educational, behavioral and other teaching techniques, to change behaviors.

Music therapy Play therapy Early Intensive Behavioral Intervention

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Music therapy

Facilitate positive changes in behavior and emotional well-being, increase sense of self-awareness Client and therapist take an active part in the sessions by playing, singing and listening The music played covers a wide range of styles in order to complement the individual needs of each client.

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Evidence on Music Therapy

The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study
Jinah Kim , Tony Wigram , Christian Gold J Autism Dev Disord 2008 Oct;38(9):1758-66.

Purpose: to investigate the effects of improvisational

music therapy on joint attention behaviors in pre-school children with autism. And compare it with play therapy.
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Participants: 13 boys and 2 girls aged 3- 5 years old

with autism, who had no previous experiences in music therapy or play therapy..

Method: Each participant had 12 weekly 30 min

improvisational music therapy sessions, which were compared with a control condition of 12 weekly 30 min play sessions with toys.

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Results:

Session analysis showed significantly more and lengthier events of eye contact and turn-taking in improvisational music therapy than play sessions. session analysis indicated that the majority of participants showed marked improvement in joint visual attention skills during and after music therapy than during and after the play condition throughout the trials and across the cases. 3 out of 5 non-verbal participants did begin to develop some initial language skills during and after the music therapy condition.
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Conclusion: The findings of this study highlighted the

social engagement that occurs through improvisational music making, and the therapeutic potential of childcentered approaches like improvisational music therapy.

Recommendation: We recommended the use of

music therapy for autism.

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Play therapy

Children learn to communicate with others, express feelings, modify behavior, develop problem-solving skills, and learn a variety of ways of relating to others. The play materials may include art and craft materials, dressing up props, sand and water, clay, small figures and animals, musical instruments, puppets and books or even Lego.

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Early Intensive Behavioral Intervention

Child is taught a range of skills by a team of therapists using techniques, build on everyday routines, such as eating or getting dressed. The therapists break down skills into small tasks that are achievable and taught in a very structured manner. Desired behavior is positively reinforced and accompanied by lots of praise. Examples include bites of food, play with a favorite toy, hugs and toys. Negative behavior is ignored.

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By using these techniques, the child progresses from basic self help and language skills to non-verbal and verbal imitation skills. In the second stage he or she learns expressive and early abstract language, and also leans how to play interactively with peers.

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Psycho-pharmacological
Interventions which use chemical compounds, including medications, to affect the mind.

Anti-psychotics. Anti-depressants Stimulant Medications

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Anti-psychotics

Anti-psychotics are used to treat mental health problems. it can also be used to treat some of the core symptoms of autism, such as poor social communication or repetitive behaviors. Example: Risperidone

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Evidence on Risperidone

Risperidone Improves Behavioral Symptoms in Children with Autism in a Randomized, DoubleBlind, Placebo-Controlled Trial Gahan J. Pandina , Cynthia A. Bossie, Eriene Youssef, Young Zhu , Fiona Dunbar J Autism Dev Disord (2007) 37:367373

Purpose: to evaluate the efficacy and safety of

risperidone in the treatment of children with autism.

Participants: 55 Physically healthy children (aged 5

12 years) diagnosed with autism.
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Method: 8-week, multicenter, randomized, doubleblind, placebo-controlled study conducted in Canada. Participants were randomized to treatment with an oral solution of risperidone (1.0 mg/ml) or placebo every morning.

Outcome measures: The primary efficacy measure

was the Irritability subscale of the ABC, which includes questions about aggressive and self-injurious behaviors, tantrums, agitation, or unstable mood.
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Results: Significant changes at end point in ABC subscales scores for Irritability, Lethargy/Withdrawal, Stereotypic Behavior, and Hyperactivity favored risperidone versus placebo. Hyperactive, and Overly Sensitive subscale scores showed significantly more improvement with risperidone than placebo. Recommendation: risperidone can be an effective
treatment for behavioral problems such as aggression, tantrums, self-injurious behavior, and hyperactivity in children with autism.
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Anti-depressants

Anti-depressants increase the level of active neurotransmitters in the brain. They are used to treat people with depression, anxiety or other mental health problems. They may also be used to treat people with autism who have other problems, such as repetitive behaviors or social deficits. Example: clomipramine.

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Stimulant Medications

Stimulant medications affect the action of certain chemicals in the brain, allowing us to control how we pay attention and organize our behavior. Stimulants can be used with some individuals with autism to reduce problem behaviors, such as hyperactivity, impulsivity and inattention. Example: methylphenidate.

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Complementary

Wide range of interventions which complement traditional, medical treatments and therapies. Essential Fatty Acids Animal therapies (Assistance dogs, Dolphin) Hyperbaric therapy Vitamins and minerals Gluten-free, casein-free diet

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Essential Fatty Acids

Some people believe that individuals with autism do not have enough Essential Fatty Acids, or that they have a poor balance of them, that may cause some symptoms of autism, such as impaired communication and social difficulties. These difficulties can be overcome by following a diet rich in essential fatty acids or by taking supplements. There is a wide range of supplements which contain essential fatty acids from a variety of sources such as borage, cod liver oil, evening primrose etc.
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Evidence on Essential Fatty Acids

Omega-3 Fatty Acids Supplementation in Children

with Autism: A Double-blind Randomized, Placebocontrolled Pilot Study

G. Paul Amminger, Gregor E. Berger, Miriam R.

Schfer, Claudia Klier, Max H. Friedrich, and Martha Feucht

BIOL PSYCHIATRY 2007;61:551553

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Purpose: to confirm the efficacy of omega-3 for some symptoms of autism. Participants: 22 children and adolescents (aged 5 to 17 years), attending a specialized day care center for longterm treatment of autistic children; 81.9% were male. Method: a randomized, double-blind, placebocontrolled 6-week pilot trial investigating the effects of 1.5 g/d of omega-3 fatty acids (.84 g/d eicosapentaenoic acid, .7 g/d docosahexaenoic acid) supplementation in children with autism accompanied by severe tantrums, aggression, or self-injurious behavior.
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Outcome Measures: Symptom assessments were

conducted by using the ABC, which includes five subscales: irritability, social withdrawal, stereotypy, hyperactivity, and inappropriate speech. Results: The findings suggest that omega-3 fatty acids may be an effective and well-tolerated treatment, in particular of hyperactive behaviors including disobedience, distractibility, and impulsivity. Conclusions: The results of this study provide preliminary evidence that omega-3 fatty acids may be an effective treatment for children with autism.
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Recommendation: We recommend more researches with larger sample to support or deny this research's results. We recommend omega-3 supplements for autism because of its safety.

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Prognosis

Only about 1-2% of the autistic population ultimately achieve independence. The majority require lifelong supervision. Aggravation of psychiatric symptoms occurs in about half of the children during adolescence. Girls have a tendency for continued deterioration. Prognosis is most favorable for children communicative speech development by age six years and an intelligence quotient above 50 at the time of diagnosis.

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Implications for Nursing

When autistic children are hospitalized, they usually present many management problems. Ways to lessen the disruptiveness of hospitalization: Decreasing stimulation by using a private or semiprivate room. Avoiding extraneous auditory and visual distraction. Encouraging parents to bring in possessions the child is attached to.

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Physical contact frequently upsets autistic children, minimum holding may be necessary to prevent temper tantrums. A key principle in working with these children is establishing trust. They need to be introduced slowly to new situations, with visits with caregivers kept short whenever possible.

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Jordan Specialized Center for Autism

JORSCA was established in March 2004. It is a non-profit organization that caters specifically for the autism community of Amman. It prides itself in being Jordan's first independent specialist school to accommodate the latest teaching methods and therapeutic programs for children who exhibit learning difficulties associated with autism spectrum disorder.

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The team of JORSCA works together to create a safe but challenging environment where individuals with autism are valued, achievement is celebrated and where pupils are enabled to communicate as effectively as possible. Currently there are 25 pupils enrolled between ages 3 and 15. Working closely with 5 teachers, 10 assistants, who are overlooked by a master teacher, a speech and language pathologist, an occupational therapist, and a music therapist.
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References

Maternal & Child Health Nursing. Adele Pillitteri. 5th ed. Childrens Nursing. Whaley and Wongs. 1995. http://www.emedicine.com/ http://www.researchautism.net www.wikipedia.com http://www.jorsca.com http://www.autismspeaks.org

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http://www.nichd.nih.gov/publications/pubs/autism/ove rview/index.cfm http://www.ninds.nih.gov/disorders/autism/autism.htm http://autism.com/index.asp http://www.webmd.com/parenting/guide/mental-healthautism http://www.emedicinehealth.com/script/main/art.asp?ar ticlekey=59039&page=1#Autism%20Overview

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G. Amminger, G. E. Berger, M.R. Schfer, C. Klier, M.H. Friedrich, M. Feucht. Omega-3 Fatty Acids Supplementation in Children with Autism: A Double-blind Randomized, Placebocontrolled Pilot Study. BIOL PSYCHIATRY 2007;61:551553. E. Courchesne, R. Carper, N. Akshoom. Evidence of Brain Overgrowth in the First Year of Life in Autism. JAMA. 2003;290:337-344. J. Kim , T. Wigram , C. Gold. The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study. J Autism Dev Disord 2008 Oct;38(9):1758-66.

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G. J. Pandina , C. A. Bossie, E. Youssef, Y. Zhu , F. Dunbar. Risperidone Improves Behavioral Symptoms in Children with Autism in a Randomized, Double-Blind, Placebo-Controlled Trial. J Autism Dev Disord (2007) 37:367373. W.L. Stone, C.R. McMahon, P.J. Yoder, T.A. Walden. Early Social-Communicative and Cognitive Development of Younger Siblings of Children With Autism Spectrum Disorders . Arch Pediatr Adolesc Med. 2007;161(4):384390. T. Uchiyama, M.Kurosawa, Y.Inaba. MMR-Vaccine and Regression in Autism Spectrum Disorders: Negative Results Presented from Japan. J Autism Dev Disord. 2007 Feb;37(2):210-7.
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