Autism:DiagnosisandInterventionStrategiesDr Saima Hussain Ijaz MD, MA – ABABehaviour Consultant – Intensive

SolutionsBritish Columbia - Canadawww.autismsolutions.info

Autism …Too Complexto Understand?Word Autism was hardly mentioned in the Medical Text in the 80’s and 90’s

Stunning Statistics with an annual rise of 16% Diagnosis keeps Evolving Under Diagnosed to Over Diagnosed Movies like Rain Man and Extraordinary Geniuse slike Einstein & Bill Gates IQ ranging from extreme retardation to over 150 People have made instant millions, by selling a “cure” for autism Unfortunately there is No Cure–Life Long Condition Some individuals with autism have very HI GHIQ –PhDs No SINGLE MAGIC BULLET for sudden improvement–Multiple Therapies No two cases are the same and neither is the advice of any two professionals No clinical test to confirm the Diagnosis Fewer Resources and Professionals and increasing number of cases

Tussle amongst Psychiatrists and Paediatricians as the primary specialist

My Personalanda ProfessionalAttempt:To Empowerthe ParentsBySimplifyingAutismDisorderandtheTherapies

As doctors and therapists, we owe it to our profession and the community we serve to keep ourselves up to date, whether it falls in our jurisdiction or not .

You can encounter an ASD as your patient, so knowing how to communicate and what to expect could be helpful.

Autism is not all that tough to understand if you really get the basics.

On a personal level, with this high an incidence, it can affect someone near and dear to each one of us

Early Diagnosis and Intervention can make a Huge Difference on the child’s prognosis.

You be helping not just a child, but a whole family.

Staggering rise over the last50 Years

UsualPresentingComplaints No attention span with or without Hyperactivity Impulsive or dangerous behaviour Screams and cries without apparent reasons Aggression or Self Injury Tendencies Inability to relate to adults or kids Lack of speech Inappropriate toy play Difficulty dealing with changes No sense of danger Strange attachment to objects Lack of eye contact

Very Important to checktheSocio–CommunicativeAspect

Responded to name by 12 months of agePoints to show something or waves back Avoids eye-contact Prefers to play aloneOnly interacts to achieve a desired Has MOSTLY flat facial expressions

Was babbling or saying a few words and then lost it

AvoidsorresistsphysicalcontactIsnotcomfortedbyothersduringdistress

Unusualreactionstothewaythingssound,look,orfeel

Se

tanAPPOINTMENTof40minutestoanHourSo

meBasicToyslikeBubbles or Abacus

Askabout:

• Onset,suddenversusgradual• HistoryofMultipleEarInfections,EarDrainage• Recentenvironmental,socialoremotionalchanges.

• Who is the Primary Caregiver andhow much timeshe’sspendingwiththe child• Child’sappetite,sleep and activitylevel

Evaluateforthedevelopmentaldelays.

• Observethe way childexploreshis environmentvisuallyandphysically• Hows/he responds to yourwordsandgestures.

• Hows/hereachesoutforanobjectofinterest.

DSM–VCurrently

,orbyhistory,mustmeetcriteriaA,B,C,andD

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 

1. Deficits in social-emotional reciprocity 

2. Deficits in nonverbal communicative behaviors used for social interaction

3. Deficits in developing and maintaining relationships

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following

1. Stereotyped or repetitive speech, motor movements, or use of objects

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change 

3. Highly restricted, fixated interests that are abnormal in intensity or focus

4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; 

DSM–VCurrently,orbyhistory,mustmeetcriteriaA,B,C,andD

C.Symptomsmustbepresentinearlychildhood.

D.Symptomstogetherlimitandimpaireverydayfunctioning.

SingleSpectrumbutSignificantIndividualVariability

Severity ofASD Symptoms:

AutismNonverbalwithodd/severebehavioursPDD-NOSNonverbalwithmildoddbehaviourAspergerVerbalwithodd/severbehaviours

ThreeTypes

WhattoTelltheParentandHowIfnot sure,than don’t label-Your words willbechangingthe lifeofthis family

• Do you need More timetoObserveand Evaluate?

AnotherAppointment/Referral isbetterthanahasty Diagnosis.

Referralto:• Pediatrician– 2ndopinion• ENTorAudiologist• Speech LanguagePathologist• Psychologist• OccupationalTherapist

NoRoleofMedicinesinLittleKidsUnlessanEpileptic

ParentalAdviceregardingcommunicationwiththechild

PickoneLanguageforCommunication.English!UseLesswords,pleasant-neutraltone.LotsofSmilesGesturesandVisualCuesFirmpressureontheshouldersIntroducingVisualCommunicationSystemPraiseorgestureforcooperation

Handfistbump/thumbsup

GeneralRecommendations:LifeStyle

Nutrition

4-5small meal Fingerfoods Bakedandgrilled vsfried Cutup vegesassnacks Stretchingwithchoices Drycerealandraisinsassnack Whitemeat,fish Milk and juicevspop Nuts

Supplements

Levelof Activity

Regularstructuredactivities,likerunning,walking.

Climbing and jumping Teachingtoridetricycle Bikewithtrainingwheels Stepsand balancebeams Walking paths Pool

AdviseforPromotingSocialand

EmotionalGrowt

hPreventingandAddressingChallengingBeh

aviours

• TurnTakingSiblingPlayRoutines• CauseandAffectToys• Building onnonverbal/visualcommunication• UseofLabelledPictures• RelaxationTechniquesfor BOTH• IntroducingComputerorI-Padtime• Relaxingbubblebathbeforebedtime

• PsychologicalandSLPAssessmentandaProgramPlan• OccupationalTherapistforSensoryIntegration

• Mention:

20hr/weekoneononeinterventioncanhavegreatlearningoutcomesandbetterprognosis.

Pictureof anAutistic Child

Tantrum vs Meltdown

Reasons ofMeltdowns

SensoryOverload:Analyze theDeterrents

Ifsuddenonset,thenruleoutsicknessandpain

InabilitytoCommunicateNeeds

Overwhelming Expectations

HowtocalmdownthisKid

WhyThese Sensory Issues

Motivators andDeterrents

# Motivators Effectivesince

# Deterrents Howsevere

MRI and PET Scan Studies

indicate thatthebrainsofchildrenwith autismaredifferent

Unusualbraingrowthfrom6-14months:morebutsmallercells

Frontallobe(visualmemory&planning) Temporallobe(soundandnoise) Amygdala(emotions) Hippocampus(learning&memory)

FunctionalMRI ScanStudies Indicate

Underconnectivityof theAutistic Brain

CommonCo-occurringMedicalConditions

• Oesophagitis• Gastritis• Reflux• Asthma• Eczema• Allergies• Earinfections• Respiratoryinfections• Migraineheadaches• FoodintolerancescausingGIsymptoms

Noncommunicatingkidspainsigns

Suddenchangeinbehaviour Lossofappetite,gagging,throwingup Difficultyfallingasleep Aggression Coveringears Selfinjuriousbehaviour Irritability orextrememoodiness Differentbodyposturing Moaning,whimpering,crying. Meltdowns

PsychiatricDiagnosis inSchoolAge Children withASD

PsychiatricDiagnosis SchoolAge ChildrenwithASD

Anxiety 25%

Depression 6%

OCD 10 %

Psychosis 1%

Other 14%

PresentationofPsychiatricSymptoms

–Thepresentationofpsychiatricsymptomsisinfluencedbytheunderlyingdevelopmentaldisorderanditisoftenquitedifferentfromtheoneofthegeneralpopulation.

Considerinabilitytocommunicationangerorsadness. Considerhighlevelofstrangeranxiety. Considerdifficultythepersonisexperiencinginanunfamiliarplace. ConsiderflatexpressionsandoddbehaviourspresentinASDpopulation. Considerunderlyingmedicalproblem. Considerrecent changesin child’scaregiverstatus orhis environment.

Historyo

frecentchangeinsleep,appetiteandinterestsalongwithmoodchanges.H/O

PsychologicalorSLPAssessmentandCommunicationBuilding PlanH/O OccupationalTherapistInputRegardingSensoryDiet

PsychiatricMeds

SRRI/SNRI- MidTeens

Prozac Effexor

Avoid Atypical

Seroquel Risperdal

Variable RelaxationTechniques

SoothingSounds&

Colours

Rocking and Swinging

MajorityisSoundSensitive

• Noisecanbemagnifiedandsoundsbecomedistortedandmuddled.• Maybeabletohearconversationsandothersoundsinthedistance.• Inabilitytocutoutsounds–

notablybackgroundnoise,leadingtodifficultiesconcentrating.• Maynotacknowledgetalking• May onlyhearsoundsin oneear,theotherear

havingonlypartialhearingornoneatall.

• May notacknowledgeany sounds.

• Anaudiologistcanhelpruleoutdeafness.

Youcouldhelpby:

• Shuttingdoorsandwindowstoreduceexternalsounds• ListeningtopleasantsoundsandstepsforSoundIntegration.• Providingearplugsandmusictolistentowhenfeelingoverwhelmed• Creatingascreenedworkstationinth

eclassroom,positioningthepersonawayfromdoorsandwindows.• Usingshortsentencesorphrasesandlow

toneswhileaddressingthechild• Usingavisualwayofcommunication,likegesturesandPECs

AvoidanceofeyecontactisONLYoneofthecommonvisual behaviours

flickinghandstowatchthem

Positioningfingersinfrontof eyes͞tocropthevisualfield͟.

lookingatsomething,thenlookingawaybeforepickingitup

peeringoutofthesidesoftheeyes

usingperipheralratherthancentralvisionformanyactivities

child'sspinningandrunningaroundincirclestovisualizeobjectsfromallangles

Basicinterventionstoimprovecentralandambientvision

Lightsandmotion,likeusinglavalampforrelaxation.

Usingflashlighttolabeleverydaythinginadarkroomcanhelpfocusalongwithbuildingearlyvocabulary.

Activitieswhilelookingintoamirror,likepointingandnamingself.Teachingchild topointandlabelbodypartsandemotions.

Blowingbubblesforcatchingandpopping.

Over-Sensitive toLightTouch

• Touchcanbepainfulanduncomfortable-peoplemaynotliketobetouched.

• Dislikes havinganythingonhandsorfeet.• Difficultiesbrushingandwashinghairbecauseheadissensitive.• Mayfindmanyfoodtexturesuncomfortable.• Onlytoleratescertaintypesofclothingortextures.

Youcouldhelpby:

• Warningthepersonifyouareabouttotouchthem-alwaysapproachthemfromthefront

• Changingthetextureoffood• Slowlyintroducin

gdifferenttexturesaroundtheperson'smouth,suchasaflannel,atoothbrush.

• Graduallyintroducingdifferenttexturestotouch,eghaveaboxofmaterialsavailable

• Turningclothesinsideoutsothereisnoseam,removinganytagsorlabels• Allowingthepersontowearclothesthey'recomfortablein.• Prewashingnewclothestotakeoutthecrispinesshelps• Handmedownsareappreciated

OtherRelaxing/StimulatingandTeachingSenses

Deeppressure

Vestibular-movement,balanceandemotionalregulation.

Proprioceptive-bodypositioninrelativetobodyparts

Kinesthetic-bodyandmusclepositioningduringmotion

KinestheticLearning

HelpfulStrategies:

Double,tightvestunderneathalltheclothingprovidesdeeppressureandasmoothprotectivelayeringforotherclothes.

Usingweightedblanketsorsleepingbags

Usingrocking,swingingorspinningtogetsomesensoryinput.

Positioningfurniturearoundtheedgeofaroomtomakenavigationeasier

Puttingcolouredtapeorsteppingmatsonthefloortoindicatepathsandboundaries

Usingthe'arm's-lengthrule'tojudgepersonalspace-thismeansstandinganarm'slengthawayfromotherpeople.

Help this Child Play and Relax

Turntakingplaywithenjoyabletoys

Learning,exercise, stimulationandentertainment

Bubbles Rice,waterorsandinalargecontainer Spinningtoys Flashlight Shapesorters Pegpuzzles Squirting,SqueezingToysandplaydough Cushions Blankets Trampoline Tricycle Playdoughandcookiecutters Mirror

Some MotivatorsorSensory Toys

A“SensoryDiet”

Coinedbyan OT Patricia Wilbarger

Personalizedactivityplanthatprovidesthesensoryinputapersonneedstostayfocusedandorganizedthroughouttheday.

• toleratesensationsandsituationsthatarechallenging• regulateemotions,alertnessandincreaseattentionspan• reduceunwantedsensoryseekingandsensoryavoidingbehaviors• handletransitionswithlessstresshttps://

www.sensorysmarts.com/sensory -

c hecklist.pdf

ASampleSensoryDietof anineyearsoldASDKid

IntheMorning

•Massagefeet andbacktohelpwakeup•ListentorecommendedtherapeuticlisteningCD•Usevibratingtoothbrushand/orvibratinghairbrush•Eatcrunchycerealwithfruitandsomeprotein•SpinonDizzyDiscJr.asdirected•Jumponmini-trampolineasdirected

Afterschool

•Gotoplaygroundforatleast30minutes•Spinningondiscorswing•Mini-trampolinejumps•Gym ballexercises•Listentotherapeuticlisteningorfavouritemusicorsongs.

ASampleSensoryDietof anineyearsoldASDKid

Atdinnertime

• Helpset table,using twohandstocarryandbalance• Providecrunchyandchewyfoods

Atnight

• Warmbathwithbubblesandcalmingessentialoil• Listeningtomusic• Massageduringreadingtime

4.5Yearsold,Hope

•6:30 am–Wakeup•6:30–6:40–Playswithbeany bagtoys.•6:40 –7:00 –Getting Hopedressed andprovideherwith

• Lotion rub, massagewithvibrating massager orcircular motion on herarmsand legs.

• Whileeatingbreakfast,Hopewillbeencouragedtoputhernewweightedlappadonherlaporacrosshershoulders.

•7:00-7:30–Freeplaytimebeforeleavingforpreschool.Hopetendstogetintotrouble thistime ofdayasshegetsintoplaces she’snotsupposedto.•Tryheavyworktaskstohelpwithorganization.

• Pushweightedlaundrybasketaroundupstairsbedroomswhileparentsfinishgettingready

• Roll8lb ballaroundbedroom• Helpwaterindoorplantswithgallonjug

•7:30-8:00– transition to Preschool•8:00–8:15–Greetingtimeatpreschool.Hopestruggleskeepinghandstoselfandstayinghercarpetsquareduringfirstpartofherdayatpreschool.

• GiveHopeaheavyworkjobtocompleteimmediatelyeachmorning.

• Helpputbooks(heavytextbooks,notchildren'sbooks)awayontoshelvesaspartofhelpinggettheroomreadyfortheday

• Carryingabucketoftoysfromoneclasstoanother• Eras

echalkboard,encouraginghertousestrong,forcefulbackandforthmovements.

•8:15–9:00–RecessorGym.EncourageopportunitiesforHopetodothefollowing:• Swing onswingset• Hangonmonkeybars• Jumpingontrampoline

•9:00–9:15–Morningsnack• Expose Hopeto foodswithmultipletextures– thingstheother childrenareeating.• ProvideHop

ewithverychewy,crunchyfoodstohelpgivehergoodproprioceptiveinputintoherjaw.

• Granola• Chewybagel• Bighardpretzel

•9:15-10:00–Crafttime• HaveHopecompleteaheavywork/calmingtaskbeforesittingdown

• Chairpushup• Completingthe“job”theyshehasinthemorning• Rolling ontopof therapyball

• Weightedproduct• LetHopewearherlappadfromhome• Consideruseofweightedvestorcompressionvest

•10:00–10:30–Freeplay.Hopeusuallydoeswell atthistime.•10:30–10:45–Bathroombreak.Again,Hopetransitionswell

•10:45–11:15–Music,Art,orComputertime.Hopestrugglesstillatthesetimes