Autism Spectrum Disorders

References:

1. Psychiatric-Mental Health Nursing, 8th Edition, 978-1-975116-37-8, by Sheila L. Videbeck ([ebook] pp. 949-955)
2. Course Module

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ASD (prev. autism, autistic disorder) is composed of various pervasive developmental disorders (PDD; Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Syndrome) characterized by pervasive and often severe impairment of reciprocal social interaction skills, communication deviance (hard-to-follow forms of communication), and restricted stereotypical (repetitive) behavioral patterns.

• ASD is five times more prevalent in boys than girls. It is often identified by 18 months of age, no later than 3 years.
• 80% of children with autism experience early onset (<1 year), with the remaining 20% normally displaying routine development followed by regression during the 2nd to 3rd year of life.
• Autism has a genetic link, with many children having relatives with ASD or other autistic traits.
• There is no relationship between ASD and vaccines.

Children with ASD have persistent deficits in communication and social interaction accompanied by restricted and stereotyped patterns of behavior and interests/activities.

• These children minimally utilize communication techniques such as eye contact, facial expressions, and gestures. Intelligible speech may also be reduced.
• They may experience reduced spontaneous enjoyment and affect. They may not engage in play or in make-believe with toys.
• They may display stereotyped motor behaviors such as hand-flapping, body twisting, or head-banging.
• Deficits in communication due to ASD may improve, sometimes substantially, as the use of language and communication techniques develop. Behavior may deteriorate during adolescence due to hormonal changes. Complex social demands arise, leaving individuals dependent on others possibly until adulthood.

Behaviors Common in ASD

• Not responding to own name by 1 year (e.g., appears not to hear).
• Doesn’t show interest by pointing to objects or people by 18 months of age.
• Avoids eye contact.
• Prefers to be alone.
• Delayed speech and language skills.
• Obsessive interests (e.g., gets stuck on an idea).
• Upset by minor changes in routine.
• Repeats words or phases over and over.
• Flaps hands, or rocks or spins in a circle; answers are unrelated to questions.
• Unusual reactions to sounds, smells, or other sensory experiences.

Throughout the Lifespan

• Autism tends to improve, in some cases substantially, as children start to acquire and use language to communicate with others. However,
• If behavior deteriorates in adolescence, it may reflect the effects of hormonal changes or the difficulty meeting increasingly complex social demands.
• Autistic traits persist into adulthood, and most people with autism remain dependent on some degree on others. Many continue to liver with parents or adult relatives.

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Management

The goal of treatment of children with autism are to reduce behavioral symptoms (e.g., stereotyped motor behaviors) and to promote learning and development, particularly the acquisition of language skills. Comprehensive and individualized treatment, including special education and language therapy, as well as cognitive behavioral therapy for anxiety and agitation, is associated with more favorable outcomes.

Pharmacologic Management

• Haloperidol (Haldol), Risperidone (Risperdal), Aripiprazole (Abilify), or combinations of antipsychotic medications, may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors.
• There are no medications approved for the treatment of ASD itself.

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Related Disorders

1. Tic Disorders: a tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. Tics can be suppressed but not indefinitely. Stress exacerbates tics, which diminish during sleep and when the person is engaged in an absorbing activity. Abnormal transmission of the neurotransmitter dopamine is though to play a part in tic disorders. Tic disorders are usually treated with risperidone (Risperdal) or olanzapine (Zyprexa), which are atypical antipsychotics. It is important for clients with tic disorders to get plenty of rest and to manage stress because fatigue and stress increase symptoms.
   • Common simple motor tics include blinking, jerking the neck, shrugging the shoulders, grimacing, and coughing.
   • Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, and barking.
   • Complex motor tics include facial gestures, jumping, or touching or smelling an object. Tic disorders tend to run in families.
   • Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene), palilalia (repeating one’s own sounds or words), and echolalia (repeating the last-heard sound, word, or phrase).
   • Tourette disorder involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. The complexity and severity of the tics change over time, and the person experiences almost all the possible tics described previously during his or her lifetime. The person has significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious. This rare disorder (4 or 5 in 10,000) is more common in boys and is usually identified by 7 years of age. Some people have life-long problems while others have no symptoms after early adulthood.
2. Chronic Motor or Tic Disorder: Chronic motor or vocal tic differs from Tourette disorder in that either the motor or the vocal tic is seen, but not both. Transient tic disorder may involve single or multiple vocal or motor tics, but the occurrence last no longer than 12 months.
3. Learning Disorders: A specific learning disorder is diagnosed when a child’s achievement in reading, mathematics, or written expression is below expected for their age, formal education, and intelligence. Learning problems interfere with academic achievement and life activities requiring reading, math, or writing. Low self-esteem and poor social skills are common in children with learning disorders. As adults, some have problems with employment or social adjustment; others have minimal difficulties. Early identification of the learning disorder, effective intervention, and no coexisting problems is associated with better outcomes. Children with learning disorders are assisted with academic achievement through special education classes in public schools.
4. Motor Skills Disorder:
   • Developmental coordination disorder: an essential symptom is impaired coordination severe enough to interfere with academic achievement or activities of daily living. This diagnosis is not made if the problem is a part of a general medical condition, such as cerebral palsy or muscular dystrophy. This usually becomes evident when the child attempts to crawl or walk or as an older child attempts to dress independently or manipulate toys. This often coexists with a communication disorder. Its course varies; some persist into adulthood. Adaptive physical education and sensory integration programs emphasize inclusion of movement games such as kicking a football or soccer ball and target improvement in areas where the child has difficulties.
   • Stereotypic movement disorder is characterized by rhythmic, repetitive behaviors, such as hand waving, rocking, head banging, and biting, that appears to have no purpose. Self-inflicted injuries are common, and the pain is not a deterrent to the behavior. Onset is prior to age 3 years and usually persists into adolescence. It is more common in individuals with intellectual disability. Comorbid disorders, such as anxiety, ADHD, OCD, and tics/Tourette syndrome, are common and often cause more functional impairment than the stereotypic behavior.
5. Communication Disorders: Deficits in language, speech, and communication; diagnosed when deficits are sufficient to hinder development, academic achievement, or activities of daily living, including socialization. This may be severe and persist into adulthood. Speech and language therapists work with children who have communication disorders to improve their communication skills and to teach parents to continue speech therapy activities at home.
   • Language disorder involves deficit(s) in language production or comprehension, causing limited vocabulary and an inability to form sentences or have a conversation.
   • Speech sound disorder is difficulty or inability to produce intelligible speech, which precludes effective verbal communication.
   • Stuttering is a disturbance of fluency and patterning of speech with sound and syllable repetitions.
   • Social communication disorder involves the ability to observe social “rules” of conversation, deficits in applying context to conversation, inability to tell a story in an understandable manner, and inability to take turns talking and listening with another.
6. Elimination Disorders: Both encopresis and enuresis are more common in boys than girls. Impairment associated with elimination disorders depends on how these limit the child’s social activities and self-esteem, degree of social ostracism, and rejection by parents or caregivers. Neither persist into adulthood.
   • Encopresis: repeated passage of feces into inappropriate places by a child who is at least 4 years of age either chronologically or developmentally. Often, this occurs in intermittent exacerbations, and is rarely present chronically.
   • Enuresis: repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally.

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Specific Autism Disorders

1. Autism, also known as mindblindedness. A developmental disorder of variable severity characterized by difficulty in social interaction and communication and by restricted stereotyped thought and behavior.
   • Onset, Incidence, and Etiology: often identified within the one year of age, and not later than 3 years. More common in boys than girls (5:1). Etiology is mostly unknown except for a genetic link and mechanical trauma during the birth process.
   • Characteristic: impairment of reciprocal interaction skills
   • Manifestations:
     • Difficulty in Social Interactions: unaffectionate, asocial, inappropriately attached to objects, lack of interest in the environment, inappropriate laughter or giggling, and avoidance of eye contact
     • Difficulty with Communication: underdevelopment of language; the use of gestures rather than language, and other difficulties in expression.
     • Stereotypical Behavior (SPAN)
       • Sustained repetitive motor movements e.g. spinning objects or the self, rocking, hand or finger flapping, body twisting, etc.
       • Preference of same-ness or having a routine: preoccupation with lights, moving objects, or parts of objects.
       • Apparent insensitivity to pain
       • No real fear of dangers
   • Diagnosis: assessment of any developmental delays in the first two years of life
     • 12 months: no babbling, pointing, or gesturing
     • 18 months: no single word spoken
     • 24 months: no two-word spontaneous expressions
   • Management:
     • Reduction of behavioral symptoms:
       • Temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors: Haloperidol (Haldol), Risperidone (Risperdal)
       • Diminish self-injury and hyperactive and obsessive behaviors: Catapres (Clonidine), Anafranil (Clomipramine), and ReVia (Naltrexone).
     • Promote learning and development: special education focused on development of social skills, language, self-care, and academic performance.
     • Family Therapy: parental education
2. Rett’s Disorder: a regressive pattern of development after a period of normal functioning from birth to 5 months of age.
   • Onset, Incidence, and Etiology: more common in girls (4:1). Etiology is unknown.
   • Characteristic: devolution of development from birth to five months of age.
   • Manifestations: stereotyped behavioral patterns (headbanging, tantrums, body twisting), loss of expressive (explaining) and receptive (understanding) language, and loss of interest in the social environment.
   • Differentials from Autism:
     • More common in girls rather than boys
     • Loss of previously acquired language rather than maldevelopment
     • Loss of hand function vs. preserved hand function
     • Presence of ataxia and seizures are common
     • Abnormal chewing ability
     • Delayed physical growth
3. Asperger’s Disorder: milder symptoms of autism; social challenges and unusual (stereotyped) behaviors or interests are still present, but problems with language or intellectual disability is absent. Individuals may have normal IQ or even potentially exhibit exceptional skill or talents in specific areas.
   • Onset, Incidence, and Etiology: later onset, more common among boys, with an unknown but potentially genetic etiology.
   • Characteristic: severe impairment of social interactions with stereotyped behaviors. IQ may be preserved with exceptional talent in specific areas.
   • Manifestations: severe impairment in social interaction, and marked problems with empathizing and modulating social relationships.
   • Management: social skills training
4. Childhood Disintegrative Disorder, also known as Heller’s Syndrome and Dementia Infantialis. This involves marked regression in multiple areas of functioning after at least two years of normal growth and development. Regression may be gradual or rapid (within 6 to 9 months).
   • Onset, Incidence, and Etiology: onset between 3 and 4 years of age, being more common in boys.
   • Manifestations:
     • Stereotyped behavioral patterns e.g. headbanging, tantrums, body twisting
     • Loss of previously acquired spoken language
     • Loss of previous acquired social skills
     • Loss of motor functions e.g. continence