AUTISM

Autism is a chronic developmental disorders which was identified and described by Leo Kanner in 1943. It affects many parts of brain with severe, complex and permanent behavioral and cognitive disabilities.

     Autism is defined as pervasive developmental disorder characterized by

             i. Qualitative dysfunctions of social interaction,

             ii. Qualitative impairment in communication abilities,

             iii.Unusual restricted and repetitive ranges of play and interest.

EPIDEMIOLOGY

                 The rate of prevalence of autism is 10 to 20 per 10,000 live births. There is no predilection for any particular social strata. The overall ratio of males to females is about 4:1 and the females with autism are tending to have a higher rate of mental retardation and associated neurological disorders.

                Onset of autism can occur at either of two times: at birth (early onset) and at any time up to the age of 30 months (late onset).

CAUSES:

Genetic factors:

                Heritability explains more than 90% of the risk autism. The empiric recurrence risk for autism in a family with one autistic child ranges from 2% to 8.6%. A subgroup autistic spectrum disorder is closely linked to positive family histories for major affective disorders, particularly by polar disease. There is higher concordant rate for autism in monozygotic twins than dizygotic twins.

Biological factors:

              Adverse obstetric and peri - natal factors such as maternal age and parity, obstetric instrumentation, birth weight, gestational age, and previous fatal loss are associated with development of autistic disorders.

Bio Chemical factors:

              A type of malabsorption syndrome called celiac disease characterized by dietary intolerance to fat and gluten contributes to development of autism.

Environmental factors:

               Environmental factors such as certain foods, infectious diseases, heavy metals, solvents, diesel exhaust, phthalates, pesticides, brominated flame retardants, alcohol, smoking,  illicit drugs, vaccines, and prenatal stress contributes to the occurrence of autism.

CHARACTERISTICS OF AUTISM:

             It is distinguished as a characteristic triad of symptoms such as

·        Impairments in social interaction.

·        Impairments in communication

·        Restricted interest and repetitive behavior.

Social interaction

·        Poor eye contact

·        Less attention to social stimuli

·        Difficulty with reciprocal social interaction.

·        Limitations in emotional empathy

·        Less likely to exhibit social understanding and approach others spontaneously.

Communication

·        Poor eye contact

·        Poor or no response to name call

·        Diminished or absent verbal expression or gestures

·        Poor comprehension of others speech and body language

·        Impaired “pragmatics” of initiating/sustaining conversation

·        Stereotyped, “robotic” or idiosyncratic speech

·        Echolalia and rote repetition of words or dialogue

·        Unusual prosody of speech (sing-song, monotone)

·        Pronoun reversals

·        Neologisms

Restricted interests and repetitive behavior

·        Stereotypical movements such as hand flapping, head rolling, body rocking, finger gazing, etc.

·        Compulsive behavior such as seriation

·        Sameness

·        Ritualistic behavior

·        Restricted behavior such has limited focus, decrease interest or preoccupation with single object or thought

·        Self injurious behavior

DIAGNOSIS:

DSM IV Diagnostic criteria for diagnosis of autism:

A. A total of six (or more) items from (1), (2) and (3) with at least two from (1) one each from (2) and (3):

 1. Qualitative impairment in social interaction, as manifested by at least two of the following;

a.     Marked impairment in the use of multiple non verbal behaviors such as eye-to-eye gaze, facial expressions, body postures and gestures to regulate social interaction

b.     Failure to develop peer relationships appropriate to developmental level

c.      A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing out or pointing to objects of interests)

d.     Lack of social or emotional reciprocity

 2. Qualitative impairments in communication as manifested by at least one of the following;

a.     A delay in or a total lack of the development of spoken language (not accompanied by attempt to compensate through alternate modes of communication such as gesture or mime)

b.     In individuals with inadequate speech, marked impairment in ability to initiate or sustain conversation with others

c.      Stereotyped and repetitive use of language or idiosyncratic language

d.     Lack of varied, spontaneous make-believe or social imitative play appropriate to developmental level

 3. Restricted repetitive or stereotyped patterns of behavior, interests and activities as manifested by one of the following;

a.     Encompassing stereotyped behavior with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

b.     Apparently inflexible adherence to specific, nonfunctional routines or rituals

c.      Stereotyped or repetitive motor manners (e.g., hand or finger flapping or twisting, or complex whole-body movements)

d.     Persistent preoccupation with part of objects

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

TREATMENT OF AUTISM:

              Main goals are to lessen associated deficits of family distress and to increase quality of life and functional independence.

Occupational therapy

              Main treatment aim of occupational therapy is to maintain, improve or introduce skills that allow an individual to participate as independently as possible in meaningful life activities. It is based on the models of sensory integration, occupational role and functioning, Neurodevelopmental therapy, sensory diet approach, social communication approach, behavior modification therapy, auditory integration therapy and play therapy.

 Occupation therapy addresses the areas of self care, productivity, leisure, sensory motor, cognitive, psychosocial and environment.

             The sensory integration aims at the development of the nervous system’s ability to process sensory input in a more typical way. It usesneruosensory and neruomotor exercises to improve brain’s ability. This usessensory diet which provides a variety of activities and adaptations based on the person’s sensory needs that assist the individuals in maintaining an appropriate level of arousal and performance.

             Applied behavioral approach is a science of applying experimentally derived principals of behavior to improve socially significant behavior. It is a natural science of behavior originally described by BF Skinner in 1930’s.

             In treatment of autism ABA involves teaching linguistic, cognitive, social and self help skills across all settings and breaking down these skills into small tasks which are taught in highly structured and hierarchical manner. There is focus on rewarding or reinforcing desire behaviors and ignoring, redirecting or otherwise discouraging inappropriate behaviors.

              All skills are taught using discrete trial teaching which involves breaking down the items to be taught into small tasks. These are taught in a structured way, accompanied by lots of praise and reinforcement. The items which are taught are heavily prompted at first, with prompt gradually being faded out over time.

             ABA also aims to tackle any behavioral issues that the child is experiencing by analyzing the function of behavior which is causing concern.

            Auditory integration training is a form of sensory integration therapy that is based on the rationale that distortions of hearing can contribute to inappropriate or antisocial behavior. By systematically listening to appropriately frequency filtered music, the individual’s brain auditory centers or said to normalize the hearing and there by the resulting behaviors.

Special education

             One of the commonly used behavior curricula in special education programs for children with autism is TEACCH (Training and Education of Autistic and Related Communication Handicapped Children). It is a comprehensive educational approach that includes classroom teaching, parent training and other support services. It focuses on the design of physical, social and communicating environment. The approach is eclectic and involves the use of behavioral strategies to reinforce communication and social interaction. It also emphasizes the parent’s role as co-therapists.

Speech and language therapy

                The goal of speech and language therapy in treatment of autism is always to improve useful communication.  It emphasizes on the pragmatics of language. Interactions and meaningful conversations are modeled and practiced. Both verbal and non verbal communication is addressed.

Relationship developmental intervention

               RDI is a trademarked proprietary treatment program for autistic children based on the belief that the development of dynamic intelligence is the key to improve the quality of life for individuals with autism. The philosophy is that the individuals with autism can participate in authentic emotional relationships if they are exposed to them in gradual systemic way.

             The goal of the treatment is to systematically build up motivation and tools for successfully interacting in social relationship, to correct deficits in this area that are thought to be common to all people with autism. It focuses on cultivating the building blocks of social connection such as referencing, emotion sharing, co regulation and experiences sharing that normally develop in infancy and early in child hood.

The SCERTS:

                   The SCERTS is a comprehensive, team-based, multi disciplinary model for enhancing abilities in social communication and emotional regulation and implementing transactional supports for children and older individuals with ASD and their families. The focus on social communication involves developing spontaneous, functional communication and secures trusting relationships with children and adults. Emotional regulation involves enhancing the ability to maintain a well-regulated emotional state to be most available for learning and interacting. Transactional support includes supporting children, their families and professionals to maximize learning, positive relationships and successful social experiences across home, school and community settings. The SCERTSmodel emphasizes the importance of child initiated communication in natural as well as semi structured activities for a broad range of purposes such as requesting, greeting, experiencing emotions and protesting or refusing. Objectives for the child are developmentally appropriate and targets both verbal and non verbal forms of communication.

Gluten free, Casein free diet (GFCF)

                It is popular dietary treatment for symptoms of autism. It is based on the hypothesis that these proteins are absorbed differently in children with autism spectrum disorders and act alike false opiate-like chemicals in the brain. Dietary elimination of gluten casein helps to regulate bowels habits, sleep, activity, habitual behaviors and enhance over all progress of the autistic child.

Floor time approach:

                 It is a treatment method for interacting with autistic children based on the premise that the child can increase and can build a larger circle of interaction with an adult who meets the child at his current developmental level and who builds on the child’s particulars strengths. The goal is to move the child through six basic developmental milestones such as

1.     Self regulation and interest in the world.

2.     Intimacy or a special love for the world of human relations.

3.     Two way communication

4.     Complex communication.

5.     Emotional ideas and

6.     Emotional thinking.