Autism: Practical Tips for Family Physicians

Transcription

1 Autism: Practical Tips for Family Physicians Keyvan Hadad, MD, MHSc, FRCPC Alberta College of Family Physicians 61st Annual Scientific Assembly March 5, 2016

2 No conflict of interest

3 Diagnosis and Misdiagnosis

4 3 year old, speech delay Receptive/expressive delay No back and forth communication Limited eye contact Extreme focus on small objects Severe sensory overstimulation

5 12 year old, socially isolated Highly inflexible, stuck on routines Reduced sharing of emotion Socially misunderstood Strong attachment to specific subjects Reasonable speech

6 Social Communication / Interaction Deficits in social emotional reciprocity Deficits in verbal and nonverbal communication Deficits in developing, maintaining, and understanding relationships

7 Restricted patterns of behaviour Stereotyped or repetitive interests or activities Inflexibility, insistence on sameness Highly fixed interests Hyper or hypo reactivity to sensory input

8 3 year old receptive/expressive delay Preschooler with mild receptive and severe expressive language delay Socially immature, but playful and connected Prone to temper tantrums

9 3 year old boy sensory dysregulation Overwhelmed at preschool by noise. Extreme responses to being touched and tastes. Has associated anxiety around sleep and preschool drop-off. Many self-soothing behaviours. Language and social skills at home are normal.

10 Sensory Dysregulation Physical difficulties involved sleep, eating, and elimination (especially the introduction of toilet training). Sensory challenges may include oversensitivity to touch, sound, visual stimuli, smells, tastes, or swallowing abilities. Primary or secondary behavioural challenges are common including anxiety, hyperactivity, defiance, or obsessive traits. Symptoms common present independently or in association with other psychological diagnoses

11 2 year old, anxiety Significant social and separation anxiety, including fears of sleep Selectively mute in all social settings Speaks well, socially aware at home

12 3 year old Ben, sent in by the preschool teacher Otherwise healthy child Normal speech development Socially appropriate Walks into preschool every morning and flaps his arms

13 MEDICAL AND PSYCHOLOGICAL COMORBIDITIES OF AUTISM

14 WHAT HAPPENS AFTER THE DIAGNOSIS? 3 year old boy, diagnosed at 18 months. Very narrow range of dietary intake, rye bread and tapioca pudding. Falls asleep at midnight, wakes up 2 times in the middle of the night. Chronically constipated, nowhere near toilet training. Anxious and struggles with transitions. Multiple unusual events,? pseudoseizures

15 AUTISM AND COMORBIDITIES Heterogeneous clinical presentation, concurrent disorders, and developmental outcomes. High prevalence of multiple medical and psychiatric comorbidities. Recognition of concurrent disorders provide insight into the therapeutic strategy and may improve the child and family's functioning.

16 AUTISM AND COMORBIDITIES Behaviours such as head banging or selfinjurious acts are often physical in origin and treatable or manageable through appropriate medical care. In a recent survey, 81% of parents of ASD children and 76% of persons with ASD stated that their health concerns had not been adequately investigated.

17 NON-SPECIFIC SYMPTOMS OF COMORBIDITIES Sudden change in behaviour. Irritability, agitation and low mood. Worsening tantrums and self injurious activity. Moaning, groaning, whining. Heightened anxiety or avoidance.

18 SPECIFIC SYMPTOMS OF COMORBIDITIES Sleep disturbance. Change to appetite. Sudden screaming, blinking, fixed look. Covering ears, grinding teeth. Stooling changes.

19 GI COMORBIDITIES Significant GI symptoms in at least 70%. GI conditions common in individuals without ASDs are also encountered in individuals with ASDs. In ASD, GI conditions can present typically or atypically as non-gi manifestations, including behavioural change, sleep disturbance and/or problem behaviours. Presence of GI symptoms appears to increase risk for problem behaviours compared to absence of GI symptoms.

20 GI COMORBIDITIES Chronic constipation, encopresis. Abdominal pain with or without diarrhea. GERD. Irritable bowel disease. Failure to thrive / obesity.

21 NUTRITIONAL COMORBIDITIES 50-90% of ASD children have feeding issues. Includes texture aversion, over or under sensitivity to taste and smell, food avoidance, and narrow food preferences. Nutritional deficiencies are common because of narrow food preferences or inadequate therapeutic diets. Calcium, vitamin D and iron deficiency are common. Available research data do not support the use of a casein-free, gluten-free diet, or combined gluten-free, casein-free (GFCF) diet as a primary treatment.

22 SLEEP DISTURBANCES 50% to 80% of ASD children have sleep problems. Sleep-onset and maintenance insomnia are the primary sleep problems. ASD and sleep disturbance results in worsening irritability, mood swings, hyperactivity and self-injurious behaviour. Sleep disturbance is greatest source of dysfunction for caregivers.

23 SLEEP DISTURBANCES All ASD children should be screened for insomnia Potential physical and psychological contributing should be ruled out. Therapeutic interventions should begin with parent education in the use of behavioural approaches as a first-line approach. Pharmacological therapy may be indicated in many situations.

24 CNS SEIZURES Epilepsy ranges from 5% to 20%, with the highest rates among those most severely affected by ASD. 75% of the children with autism showed abnormal patterns of electrical activity on EEG. Significant relationships exist between the two conditions. Epileptic syndromes are associated with cognitive, language and behavioural dysfunction, all of which are traits of autism. The combination of epilepsy and ASD is often associated with overall poor health and premature death.

25 ENT/ ATOPY 1.8 times more likely than non-asd children to have ever had an asthma diagnosis. 1.6 times more likely to have had eczema or a skin allergy during the previous year. 1.8 times more likely to have had a food allergy during the past year. 2.1 times more likely to have had three or more ear infections during the past year.

26 PSYCHOLOGICAL COMORBIDITIES Anxiety disorders ADHD Learning disability / MR Sensory dysregulation Developmental coordination disorder Depression