Autistic Disorder 26 September 2014 Dr. Ronnie Gundelfinger Zentrum für Kinder- und Jugendpsychiatrie Universität Zürich
Definition of the Autistic Disorder by Leo Kanner 1943 Autistic Disturbances of Affective Contact Inabilty to make social connections Inability to use language for the purpose of communication Compulsive desire to keep sameness Fascination for objects Onset of symptoms before the age of 2 ½ J (normal cognitive abilities)
Hans Asperger The nature of these children is revealed most clearly in their behaviour towards other people. Indeed, their behaviour in the social group is the clearest sign of their disorder and the source of conflicts from earliest childhood.
The autistic spectrum autistic atypical Asperger disorder autism Syndrome severe mild Severity of the autistic symptoms
Definition of autism spectrum disorders Qualitative impairment in reciprocal social interaction Qualitative impairment in verbal and nonverbal communikation Restricted interest and repetitive patterns of behaviour Onset before age 3 years (unusual sensory interests)
Epidemiology Meta-Analysis 2012 autismus spectrum disorders ASD 0, 7 % or 1 : 140 Autistic disorder AD ca. 1/4 Atypical autism PDD-NOS ca. 1/2 Asperger Syndrome AS ca. 1/4 55 % of the cildren with ASD have a normal IQ 30 % of the children with AD have a normal IQ
Is there a biological reason for autistic disorders? Sex ratio Mental retardation Epilepsy Multi-case families ASD with neurological disorders like Tuberous sclerosis, Fra-X syndrome, extreme prematurity Age of parents Medication during pregnancy Infection during pregnancy, eg rubella Effect of folic acid
Diagnosis Categorial diagnosis <-> Dimensional diagnosis
Psychiatric diagnosis No measurable changes (lab tests, EEG, MRI ) no biomarkers only behavioural symptoms
Suspicious symptoms during the 1st year of life Difficulties in the Parent- Child Interaction Acoustic: Little reaction to parents voice No reaction to name calling Very few preverbal sounds Visual: Missing or unusual eye contact Tactile Unusual reaction to touch or body contact
The 1st year a closer look Studies with siblings of children with ASD Until the age of 6 months clinicians can t see a difference between the children who later develop ASD and the children who don t. The worries of the parents of the children who later develop ASD and the healthy children don t differ.
The 1st year a closer look Healthy children will show a steady increase in directed social and interactive behavior between 6 and 12 months of age, whereas children with ASD show very little or no increase and in some instances even a loss of these behaviors.
The 1st year a closer look 13 siblings who will later develop ASD At 6 months 1 child with concerns At 12 months 5 children with concerns At 18 months 3 children with diagnosis, all others with concerns At 24 months 8 children with diagnosis At 36 months all children with diagnosis
The 1st year an even closer look The search for a biological marker Eye tracking differentiates between children with ASD and controls after 2 months Children with ASD look less at the eyes and more at the mouth or at objects The less children look at eyes and the more they look at the mouth, the more autistic signs they will show at 24 months
The 1st year an even closer look After birth and during the first weeks there is no difference in eye tracking!! Children with ASD have the same inborn reflex to look at the eyes This behavior stabilizes and increases in normal children, but it decreases in children with ASD Hypothesis: There is a lack in reinforcement
Suspicious symptoms during the 2nd year of life Delay in speech development No sharing of the world with others (joint attention) No pointing towards interesting objects No bringing of objects in order to show them No looking at parents face for social clues No joint looking at pictures Lack of imitative play Very little or unusual nonverbal Communication Loss of verbal or social competencies
Suspicious symptoms after the 2nd year of life Little interest in other children Missing or unusual language Repetitive and restrictive play behaviour Little interest in picture books or stories Fascination for rotating or glittering objects Unusual hand or body movements Hyper- or hyposensitivity to sounds, smells or touch
Diagnostic tools Screening CHAT, Checklist for Autism in Toddlers M-CHAT, Modified CHAT VSK, Questionnaire on Behaviour and Social Communication ASSQ, Autism Spectrum Screening Questionnaire Interview ADI-R, Autism Diagnostic Interview Revised ASDI, Asperger Syndrome Diagnostic Interview Play observation ADOS, Autism Diagnostic Observation Scale CARS, Childhood Autism Rating Scale
Diagnostic problems autism or mental retardation (intellectual disability) autism or developmental language disorder autism or severe deprivation (Roumanian orphans)
Incidence of ASD in children and adolescents with mental retardation N= 825 56 % mild MR, 44 % severe MR ADI-R: mild MR 11.3 % AD severe MR 21.5 % AD ADOS-G: mild MR 5.8 % AD 4.4.% AA severe MR 25.6 % AD 6.6 % AA DSM-IV: mild MR 3.0 % AD 6.3 % AA severe MR 16.1 % AD 9.9 % AA
Autism from 2 to 9 Years of Age 192 children (2-3 years) were evaluated for possible autism 49 % were diagnosed with autism 28 % were diagnosed with atypical autism 25 % were not diagnosed with a autism-spectrum disorder At age 9 58 % were diagnosed with autism 20 % were diagnosed with atypical autism 22% were not diagnosed with a autism-spectrum disorder Only 1 of 84 children diagnosed with autism and 10 % of the children diagnosed with atypical autism at age 2 did not receive an autism-spectrum diagnosis at age 9!
The Modified Checklist for Autism in Toddlers (M-CHAT) Robins et al. 2001 23 questions, 6 or more positive answers are indicative of a high risk for autistic disorder 6 critical items, 2 or more positive answers are indicative of a high risk for autistic disorder Does your child ever use his/her index finger to point, to indicate interest in something? Does your child respond to his/her name when you call? Does your child take an interest in other children? Does your child ever bring objects over to you to show you something? If you point at a toy across the room, does your child look at it? Does your child imitate you (e.g. When you make a face)?
Early intensive intervention Behavioural models: Applied Behavioral Analysis (ABA) UCLA Modell (Lovaas) Verbal Behavior (Carbone) Early Start Denver Model (Rogers und Dawson) Others: Mifne (Alonim) FIAS (KJPD Basel) Floor Time (Greenspan und Wieder) PLAY (Solomon) Option (Kaufmann) RDI (Gutstein)
Early intensive behavioural intervention the Zurich model 1:1 home treatment 25-35 hours per week 2-3 years Based on Ivar Lovaas work Individual program for every child and family
The Transporters
medication Pharmakotherapy has been disappointing There are no autism specific drugs Situation concerning neurotransmitters is complex no good animal model
medication For comorbid symptoms or disorders hyperactivity and attention problems stimulants, eg Ritalin, Concerta Strattera aggressive, self injurious or extremely hyperactive behaviour antipsychotics, eg. Risperdal, Abilify, Dipiperon depression, anxiety or compulsive symptomes SSRI, eg. Fluctine, Zoloft Sleep disorders Melatonin
films Temple Grandin Mozart and the whale Snow cake Adam Rain Man Extremely loud and incredibly close
Internet www.autismus.ch www.tonyattwood.com Youtube Beiträge zu Temple Grandin Peter Schmidt Nicole Schuster Daniel Tammet TED