Session Six (Autism) Flashcards
(44 cards)
1
Q
What is the triad of autistic impairments?
A
- Problems with social reciprocity (affecting the development and maintenance of relationships)
- Problems with language and communication (including difficulties with non-verbal aspects of communication)
- Poor behavioural flexibility
2
Q
What are some classic presentations of autism?
A
- Child not speaking or communicating well
- Child not establishing relationships with peers
- Odd, repetitive behaviour and inability too break from a set routine (e.g. can only drink out of a specific cup)
3
Q
Describe the behaviours linked to Repetition of behaviour displayed by autistic individuals
A
- Stereotyped or repetitive speech, motor movements or use of certain objects.
- Adherence to routines, ritualised behaviour
- Excessive resistance to change
- Restricted, fixated interests that are abnormal in intensity or focus
- Hyper or Hypo reactivity to sensory input or unusual sensory interest
4
Q
Outside of the classic triad (repeated behaviours, social difficulties and language deficits), what are some other common features of ASD?
A
- Movement issues; Poor motor co-ordination including clumsiness, odd gait and posture.
- Sensory issues; Odd responses to sensory stimuli (can be tactile, auditory or visual). Senses either hyper-intense, hypo-intense. Patient may display sensation seeking behaviour. Very classically patients shun people for other forms of visual stimuli.
- Special skills; Some children with ASD have a special skill at a much higher level than the rest of their abilities (for example, art, music, calculations, jigsaw puzzles)
5
Q
Briefly outline the DSM-5 criteria for an autism diagnosis?
A
Must meet all 4 criteria:
- Persistent deficits in social communication and social interactions across contexts (must affect reciprocity, maintenance of relationships, nonverbal communications)
- Restricted, repetitive patterns of behaviour/interests/activities (includes repeated speech and movements, adherence to routine, fixated interests, altered reactivity to sensory input)
- Symptoms must be present in early childhood
- Symptoms must limit and impair everyday function
6
Q
What changes were made to the description of autism in DSM-5?
A
- Name; renamed as Autism Spectrum Disorders
- Asperger’s now dropped as indistinguishable from autism
- Three domains of disease have become two (communication and social interaction are considered so interlinked they may as well be treated as one)
- Symptoms before age 3 are no longer specified
7
Q
What behaviour can be seen in small children that may be absent in those with autism?
A
- Looking at each other
- Mirroring behaviours
- Turn taking
- Emotional range
- Babbling with intonation
Essentially it is important to understand that speaking is not the start of communication development, more of an early milestone following from years of small steps, which may be missed in those with ASDs.
8
Q
Why might autistic symptoms only present quite late in childhood, since we know communication development begins so young?
A
Symptoms may not manifest until social demand exceeds capacity.
9
Q
What are the Specifiers included in the DSM 5 description of autism
A
Things to include in a diagnosis of autism, allow for the significant variation seen in patients. Include:
- Whether or not it is associated with a known medical or genetic condition
- Whether or not it was associated with an environmental factor
- Pattern of onset (e.g. regression)
- Verbal and general cognitive abilities
- Severity of symptoms in the two main domains
- Other mental, behavioural or neurodevelopment disorders
10
Q
How do we think of autism in 2019?
A
- Relatively common condition
- Can be reliably diagnosed by age 2 in some cases
- Outcome is very variable and may depend on treatment
- Spectrum of conditions
- Heritable genetic underpinnings, perhaps with environmental factors influencing
11
Q
What is meant by the Fractionation of the Triad?
A
Happe et all 2006:
- Genetics research
- Surprisingly low degree of correlation between social/communication wing of the diagnosis and the repeated behaviours wing.
- Both genetically linked, but little overlap between the genetic influences
12
Q
What are the two Criteria of ASDs?
A
A way of describing people with the condition based on the two categories of symptoms, but not a total descriptor.
A = Issues with; Social-Emotional reciprocity, Non-verbal social communication, Reciprocal relationships
B = Issues more with; Repetitive speech and movements or Use of objects, Adherence to routines and rules, Restricted interests, Unusual sensory reactions
(N.B. this leaves out many many symptoms linked to ASDs, including intellectual disability, language level…)
13
Q
What features are associated with autism?
A
- Language disability
- Mood disorders
- Hyper-reactivity
- Sleep deficits
- Attention disorders
- Irritability issues such as tantrums, self-injury, aggression..
- Physical symptoms such as GI disorders and immune dysfunction
14
Q
What is the prevalence of autism in the UK?
A
About 1% of people in the UK have some sort of ASD
15
Q
What can explain the apparent rise in autism diagnosis?
A
- Increased awareness among professionals and parents
- Broadening of the definition, from autism to ASDs.
- Increase in availability of diagnostic services
- Inclusion of children with average IQs
- Use of the diagnosis in previously excluded groups.
16
Q
Outline some of the evidence linking genetics and autism?
A
Multiple complex genetic and environmental, as well as gene-environment factors may account for changes in brain development:
- Well established genetic components to ASDs (some inherited, some de novo mutations)
- Most genetic risk lies in common variations
- MZ twin concordance at least 50-60% but some studies suggest its as high as 90%
- 10% chance of developing the condition if you have a sibling with it
- 10-15% of conditions are associated with a known genetic issue (such as Fragile X syndrome, Tuberous sclerosis)
17
Q
Outline some of the evidence linking environmental causes to autism?
A
- This body of evidence suggests someone CAN be born with a genetic vulnerability to autism, but the condition will actually only develop if that person is exposed to a specific trigger.
- Suggested environmental triggers include; mother having a viral or bacterial infection in pregnancy (notable rubella), air pollution and pesticides
- Women exposed to rubella have a 7% risk of giving birth to a child with an ASD
- New fathers who are older than 40 are 6 times more likely to father a child with autism
- Severe deprivation may cause autism; Romanian orphanage study.
18
Q
What are the sex differences seen in autism and how could these possibly be explained genetically?
A
Sex ratio is 4:1 male to female.
Various theories have been suggested:
- Sex-limited X-chromosome contribution
- Gene-environment interaction driven by differences in hormonal milieu
- Risks influenced by brain development differences between the sexes.
19
Q
Apart from a genetic risk factor, what is the other possible explanation for the sex difference seen in autism rates?
A
Difference lies not in PREVALENCE but in PRESENTATION:
- ASD is under diagnosed in girls
- Because it presents so differently in girls
- Girls are generally more socially approaching, may be capable of greater compensatory behaviour
- May be a referral bias in clinic samples
- Most diagnostic instruments have been developed around boys not girls.
20
Q
What are the issues faced by autistic individuals entering adulthood?
A
- Many difficult transitions
- Loss of educational support
- Lack of employment
- Different profile of MH conditions begin to co-occur (e.g. depression)
- Parental concerns (e.g. future care)
- Increased morbidity and mortality
- Autism in old age
Autism Act of 2009 exists to try and protect these people
21
Q
What is meant by Neurodiversity?
A
Neurodiversity is the idea that conditions such as Autism and ADHD aren’t disorders but natural variances within the human population.
Parents of non-verbal children advocate against the ND movement.
22
Q
Why is diagnosing someone as autistic important?
A
- Better outcomes if early diagnosis
- Access to support and services
- Predisposition to other needs and difficulties
- Informs adaptations (e.g. in education, workplace, physical health, mental health)
23
Q
How do we gather the information used to diagnose someone as autistic?
A
- From carers and other informants, via interview or questionnaire (focus is on difficulties at home and at school, structured developmental history)
- Direct observation and interviews of the patient (assess social, communication abilities as well as their cognitive style)
- Cognitive assessments
- Language assessment
24
Q
Why is cognition so important to the understanding of autism?
A
Can act as a signpost:
- tells us about the processes and mechanisms underlying behaviour
- links back to brain function and genetics
And may be suitable as treatment targets:
- by training or bootstrapping cognitive deficits
- by providing alternative routes to problem-solving
- by using cognitive strengths to bolster any difficulties
25
What cognitive processes are thought to underpin social communication deficits in autism?
- Social orienting deficits
- Face processing deficits
- Emotion understanding deficits
- Theory of mind deficits
- Impaired person recognition
- Poor empathic response
26
What cognitive processes are thought to underlie the repetitive, restricted and stereotyped behaviours in autism?
- Basic information processing factors (e.g. attention and features processing)
- Neuro-chemical system imbalance
- Problems in executive function
Alternatively could be secondary to social and communication impairments
27
What are the leading cognitive theories of autism?
Unitary deficit theories focus on one thing wrong:
- ToM deficit
- Executive functioning deficit
- Weak central coherence
Backed up by experimental and neuro-functional evidence, BUT none have completely explained the symptoms of autism.
Newer accounts are more multi-faceted:
- Enhanced perceptual function
- Altered neural connectivity
- Disruptions to multiple systems in different individuals
28
What are the two main developmental accounts how autism develops?
Social hypotheses:
- Reduced social orienteering
- Reduced social motivation
- Atypical face processing
Non-social hypothesis:
- Abnormal, sticky attention and cognitive control
- Sensory/perceptual abnormalities
29
What interventions do children with autism require?
- Managing behaviour (to reduce their maladaptive behaviour and help them manage their anxiety)
- Promoting social and communication abilities (improving social skills, promoting inclusion, providing a means of communicating)
- Support for the family (education)
30
What common interventions are used in autism?
- ABA and TEACCH are general nursery programmes.
- Social skills training e.g. Social Stories aim to use cartoons and peer group interactions to teach social skills
- Sensory integration therapy e.g. weighted vests and physical manipulation
- Picture Exchange Communication System (PECS)
All have mixed or weak evidence to their advantage
31
What do developmental intervention approaches target?
- Non-verbal communication skills through things like joint attention, imitation, pretend play
- Enhancing social reciprocity and social interactions by building language and communication skills through interactions with therapist.
- Building routines and repertoires that are more adaptive.
- Most will target atypical features specific to the child as well.
32
What do developmental therapeutic interventions actually consist of?
- Structured and instructed interaction sessions between the child and the adult
- Specific behavioural techniques, variation in degree they involve these
- All involve an adult following a child's lead
- All involve the parent in the process
33
What is Joint Attention?
Critical precursor behaviours to language
- Responding to an adult (by following their gaze and their point)
- Initiating a communicative exchange (looking to an object and then back at the adult, pointing to an object)
These are all key aspects of non-verbal communications that we are unknowingly experts in, children with autism find these difficult.
34
What is JASPER (Joint Attention, Symbolic Play, Engagement and Regulation) therapy?
A style of therapy devised by Kasari et al, focuses on JA and symbolic play skills.
Found children given this form of therapy displayed improved language outcomes and social interaction outcomes (Kasari et al, 2006).
A further study from 2010 supported these findings.
35
What is the Early Start Denver Model (ESDM)?
A model of therapy that combines developmental, behavioural and pivotal approaches.
Puts emphasis on:
- Interpersonal exchanges and positive affect
- Shared engagement with real life materials
- Adult responsiveness and sensitivity to the child's cues
- Both verbal and non-verbal communication
36
What evidence is there to support the ESDM approach?
Dawson, Rogers et al (2010)
- Children given 15 hours a week of therapy for 2 years
- Showed increased language and communication skills
37
What are PACT trials?
Pre-school Autism Communication Trials.
A parent focused treatment for children with autism, with a focus on adapting parental communication.
38
What is the impact of a child with autism on parenting styles?
- Fail to establish a communicative meshing or fit (infant signals are too scattered or weak, causes asynchrony)
- Parents are forced to recourse to didactic styles (non-reciprocal adult initiations)
39
What is involved in PACT therapy?
- Eliciting shared attention, communication and enjoyment
- Enhancing parental synchronous response (comment and acknowledge child's focus)
- Adapted communication strategies for parents
- Developing and elaborating on child communication
40
Describe Green et al's cycle of autism, which PACT aims to break?
- Child initiates little and signals poorly, SO
- Parent has few leads to follow SO
- They compensate but controlling the interaction SO
- Child is promoted to make responses rather than initiations SO
- Child is less likely to initiate signals.
41
What did Green 2010 tell us about PACT interventions?
PACT can lead to:
- Increased parent-child synchrony
- Increased child initiations
Parents also reported greater communication with their child, although this part was unblinded so may be subject to bias. Also may be just that parent was more attuned to their child. Showed a change in the dyadic interaction between parent and child.
However, it would appear this study has issues of generalisation. While it improved parent interaction with child, this did not necessarily lead to improved child interaction with assessors or teachers.
42
What are the long term effects of PACT therapy?
- The observed increase in parental synchrony disappears after 6 years (so not permanent but still long lasting)
- The increase in social communication skills appears to be permanent
- And these kids say a reduction in their autism symptoms over time
Shows mixed yet overall positive effects of the therapy long term.
43
Different studies have shown ESDM, PACT and JASPER therapies to all be effective in improving autism function in kids. What does all this research agree on?
Good interventions should:
- Target early social communication skills...
- ...within the context of the dyadic relational interaction
The Core curriculum should include:
- Promoting joint attention and joint engagement.
- Imitation
- Pretend play
- Reciprocity and emotional attunement
However there can be variations in intervention structure, delivery and intensity (e.g. degree of directiveness, behavioural techniques, parent or therapist mediated...)
44
Why is it important to enable and empower the parents of children with autism?
Evidence suggests that teaching parents promotes generalisation and maintenance of gains.
Parents like to feel involved and that they are doing something for their child.
