Professional Documents
Culture Documents
AUTISM
AND ADHD
Dr. Eusebio
OUTLINE
I. Autistic Spectrum Disorder
II. Autism
Prevalence
Etiology
Diagnosis
Early Signs
Comprehensive evaluation
DSM IV Criteria
Laboratory
Accompanying problems
Management
III. ADHD
Introduction
Prevalence
Causes
Developmental Trend
Co-morbidities
Diagnosis
DSM IV
Treatment
o
Standard treatment
o
Medications
o
Non traditional treatment
Burden of ADHD
AUTISM
A complex developmental disability that typically appears
during the first three years of life
The result of neurological disorder that affects the functioning
of the brain
TRIADS OF IMPAIRMENTS
o Impaired social relatedness
o Impaired communication and play
o Presence of stereotypic and/or ritualistic activities
A lifetime disability
Results from a brain dysfunction but the exact etiology is
unknown
PDD NOS
Fragile X Syndrome
Retts syndrome
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PREVALENCE
The US Center for Disease Control has declared autism as the
fastest growing serious developmental disability
Autism rate doubles every 2 years:
o 1990: 1 out of 10,000
2007: 1 out of 150
A new CDC report:
o One in every 110 American children
o One in every 70 boys
4:1 ratio of boys to girls
Represent a 57% increase from 2002 to 2006
An astonishing 600% rise in the past 20 years
Researches on Vaccinations:
o The final report from IOM, Immunization Safety Review:
Vaccines and Autism, released in May 2004, stated that
the committee did not find a link.
Until 1999, DPT, Hib, and Hep B contained thimerosal as a
preservative
Today, with the exception of some flu vaccines, none of the
vaccines to protect preschool aged children against 12
infectious diseases contain thimerosal as a preservative.
The MMR vaccine does not and never did contain thimerosal.
Varicella, (IPV) and PCV have also never contained thimerosal.
the
Change in diagnostic
criteria
Improved detection
Rise in awareness
Better record keeping
More media attention
The work epidemic must be used with caution. We must avoid unnecessary
panic and be mindful that labels can be misleading.
ETIOLOGY
Exact cause still is unknown
ASDs are biologically based neurodevelopmental disorders that
are highly heritable
GENETICS
Involve multiple genes; demonstrate great phenotypic variation
A rare mutation involving the deletion or duplication of 25
genes on chromosome 16 over 1% of autism cases in the US
(Autism Update, Harvard Magazine, May-June 2011)
Estimates of recurrence risks: 5-6% (range: 2-8%) when there is
an older sibling with an ASD and even higher when there are
already 2 children with ASDs in the family. (Dr. Eusebio said
that the risk is 6-10%)
AUTISM AND VACCINES
BIOLOGIC BASIS
Major brain structures implicated in autism: cerebellum,
cerebral cortex, limbic system, corpus callosum, basal ganglia,
and brainstem
Neurotransmitters: serotonin, dopamine, and epinephrine
Strong belief of Neurobiological alterations but cannot be
exactly pinpoint.
An interesting study was done wherein a Neuroscientist took
the head circumferences of infants diagnosed and suspected of
having Autism. He find out that there is an increase in the head
circumference of these children. His theory: this is because of
abnormal brain development or growth disregulation.
(Nelsons)
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DIAGNOSIS
Two-stage process:
o Developmental screening during well child check ups
o Comprehensive evaluation by a multidisciplinary team
Diagnosis is mainly clinical; must explain to parents that autism is
not diagnosed with newborn screening
AUTISM SCREENING
The AAP (American Academy of Pediatric) announced an
ambitious program to promote routine screening of all infants
for (ASDs) as part of 18-month and 24-month well-baby
examinations
DEGREE OF AUTISM
Mild High functioning autistic can go to regular school,
pursue a career, and some can marry
Moderate to Severely retarded
RED FLAGS
Odd/idiosyncratic behavior (i.e. hand flapping, finger flicking,
constant spinning)
Regression in overall behavior play, social skills,
communication
Emotional ability, out of control tantrums
Odd/idiosyncratic behavior (i.e. hand flapping, finger flicking,
constant spinning)
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skills,
deficits in empathy
ritualistic rigidity
ritualistic behavior
o
often need to maintain a consistent, predictable environment
COMPREHENSIVE EVALUATION
Diagnosed by the clinical examination (Nelson)
DSM-IV criteria
Cognitive testing
o
A.
DSM IV CRITERIA
When an individual displays 6 or more of 12 symptoms listed
across three (3) major areas:
o Social
o Communication
o Behavior
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3.
B.
C.
SPECIALIST/MULTIDISCIPLINARY TEAM
Developmental pediatrician
Pediatric neurologist
Child psychiatrist
Child psychologist
Speech pathologist
Occupational therapist
SPED teacher
Geneticist
Parent support groups
LABORATORY/DIAGNOSTICS
BAER hearing test
EEG some have seizures
Neurological imaging
Metabolism screening (thyroid, lead)
Chromosomal studies to rule out Fragile X syndrome
Critical Elements of the Evaluation (Nelson)
Mental Retardation
Many children with ASD have some degree of mental
impairment
Seizures
Prevalence: 11-39%
HigHer prevalence if 42% with co-morbid mental retardation
and motor deficits
Onset of epilepsy in ASDs has two peaks: before 5 years of age
and adolescent
PATHOLOGY (Nelson)
Head circumference in AD normal or slightly small than normal at
birth until 2 months of age
Afterwards, show an abnormally rapid increase in head circumference
from 6-14 month of age
Increased brain volume in 2-4 years olds
o
Increased volume of cerebellum, cerebrum and amygdale
o
Marked abnormal growth in the frontal, temporal, cerebellar and
limbic regions of the brain
Followed by abnormally slow or arrested growth
o
Areas of underdeveloped and abnormally circuitry in parts of
brains
o
Most affected areas for higher-order cognitive, language,
emotional and social functions
MANAGEMENT
TREATMENT APPROACHES
Applied Behavioral Analysis (ABA)
DIR Method (Floortime)
Miller method
Relationship Development Intervention
Son-Rise
TEACCH Program
CLINICAL THERAPIES
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Biomedical Treatment
Tomatis Method
Hyperbaric Oxygen
Neurofeedback
Floor time (DIR)
Social skills
Therapy is still the best known management and not these niological
treatment methods.
Family Support
Respite
Psychological services
List Services
Autism Society of the Philippines it is hard for parents to accept, as
if they have a child who is terminally ill. It is normal that parents
undergo the normal process of acceptance. If a parent cannot
accept, just lay your cards and explain the developmental problems
in intellect and language of the child that need to be corrected.
If it improved, good then. If not, that is Autism. Because some grow
normal but still have signs of autism like eye fleeting.
PROGNOSIS
Most persons with PDD remain within the spectrum as adults
o
Continue to experience problems with independent living,
employment, social relationships, and mental health
Better prognosis is associated with higher intelligence, functional
speech and less-bizarre symptoms and behavior.
Pharmacotherapy
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HERITABILITY OF ADHD
Mean heritability of ADHD is 0.75
There is a strong genetic component to ADHD
o
2 candidate genes: dopamine transporter gene (DAT1) and
dopamine 4 receptor gene (DRD4)
NEUROBIOLOGY OF ADHD
PET scan shows decreased cerebral metabolism in brain area
controlling attention
PREVALENCE
Accounts for 30-40% of referrals
More common in boys than girls (5:1)
Estimated prevalence of children with ADHD is about 2-12%
(5.2%)
Can persist in adulthood:
o 8.10% of children have ADHD
o 9.6% of adolescents have ADHD
o 4.4 % of adults have ADHD
o Up to 65% of children with ADHD continue to experience
the DO into adulthood
Often underdiagnosed in children and adolescent
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o Hyperactivity
Other symptoms:
o Non compliance
o Impulse aggression
o Social interaction
o Academic efficiency
o Academic accuracy
o Irritable
o Problems with sleep
EARLY INDICATORS
Diagnosis not made until 4years of age but early signs can be
seen
Before I was born, mom said I love to do cartwheels in her
belly
In infancy, may be characterized by unpredictable behavior,
shrill crying, irritability and overactivity
May show only brief periods of quiet sleep
SYMPTOMS OF IMPULSIVITY
Blurts out answers
Cannot wait for his turn
Intrudes, interrupts others
SYMPTOMS OF INATTENTION
Carelessness
Difficulty sustaining attention in activity
Does not listen
Does not follow through with tasks
Is disorganized
Avoids/dislikes tasks requiring sustained mental effort
Loses important items
Easily distracted
Forgetful in daily activities
SYMPTOMS OF HYPERACTIVITY
o
o
ADHD: CO-MORBIDITY
Its presence is more the rule rather than the exception
Only ~30% will have pure ADHD
In those with co-morbidities:
o >80% have one co-morbidity
o 60% have at least 2 co-morbidities
Co-morbidities persist and more obvious when the patient
grows into an adult.
Most common co-morbidity is ODD (Oppositional Defiant
Disorder)
3 subtypes: (Nelson)
o
ADHD, predominantly inattentive type
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1.
2.
3.
4.
5.
DIAGNOSIS OF ADHD
History
o
o
o
o
o
Impaired fine motor movement and poor coordination and other soft
signs are common
o
finger tapping
o
alternating movements
o
finger-to-nose
o
skipping
o
tracing a maze
o
cutting paper
DSM-IV CRITERIA
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o Stress-conflict resolution
ADHD children does not have to be placed in special schools because
actually these children are very smart with normal IQ unless in cases
with concomitant intellectual disbilities
MEDICATION
o
o
o
Atomoxetine (Strattera)
Social stigma
Diversion and abuse potential (DEA Schedule II drugs)
Prescribing Inconvenience
Amphetamine preparation
o Addreall
o Dexedrine
Methylphenidate preparation (best)
o Ritalin
o MPH Oros (Concerta)
o Transdermal delivery system (patch)
Antidepressants
o Bupropion
o Imipramine
o Nortriptyline
Alpha-2 Adrenergic Agents/Antihypertensives
o Clonidine (used prior to Methylphenidate but will only cure
the impulsivity and not the hyperactivity)
o Guanfacine
Arousal Agents
o Modafinil
Non-Traditional Therapies for ADHD
Dietary management
Bio/Neurofeedback Therapy
Tomatis Method
All are controversial and alternative treatments!!!
BURDEN OF ADHD
Tolerability issues
o Insomnia, irritability, headache, appetite suppression
o Parent/patient perception of mood and personality
change on medication
o Adverse effect on height and weight
o In other countries used as diet pills that is why it is
regulated
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