Management of Pervasive Developmental Disorder
Prof. Hani Hamed Dessoki, Prof. Hani Hamed Dessoki, M.D.PsychiatryM.D.Psychiatry
Prof. PsychiatryProf. Psychiatry
Chairman of Psychiatry DepartmentChairman of Psychiatry Department
Beni Suef UniversityBeni Suef University
APA memberAPA member
DisclosureDisclosure
NO relevant financial relationships with a NO relevant financial relationships with a commercial interest.commercial interest.
AUTISMAUTISM
Autism is a brain disorder that impairsAutism is a brain disorder that impairs a person’s ability to communicate, form a person’s ability to communicate, form
relationships, socially interact, and relationships, socially interact, and respond appropriately within a given respond appropriately within a given
environmentenvironment..
From kanner to the From kanner to the MillenniumMillennium
In 1943, Leo Kanner published his paper on autismIn 1943, Leo Kanner published his paper on autism He clearly described 11 children He clearly described 11 children
socially isolatedsocially isolated autistic disturbances of affective contactautistic disturbances of affective contact impaired communicationimpaired communication behavioral inflexibility behavioral inflexibility
It is congenital disease, runs in familiesIt is congenital disease, runs in families It is rare diseaseIt is rare disease More in males, higher social classes More in males, higher social classes
CHARACTERISTICSCHARACTERISTICS May May avoidavoid eye contact eye contact May appear or respond as if May appear or respond as if deafdeaf May May lack awarenesslack awareness of the existence feelings of of the existence feelings of
othersothers Can be physically Can be physically aggressiveaggressive or have outbursts or have outbursts
when familiar environment or routine is changedwhen familiar environment or routine is changed Can remain Can remain fixated on single activityfixated on single activity or object or object May engage in strange actions such as May engage in strange actions such as hand hand
flapping, or rocking.flapping, or rocking.
IncidenceIncidence
10 years ago Autism and PDD occurred in approximately 5 10 years ago Autism and PDD occurred in approximately 5 to 15 per 10,000 births. to 15 per 10,000 births.
These disorders were four times more common in boys These disorders were four times more common in boys than girls.than girls.
Why rising rate of autismWhy rising rate of autism??
Partly due to better awareness/diagnosis.
So, primary reason is most likely increased exposure to environmental factors (mercury, antibiotics, MMR, pesticides, iodine deficiency)
Autism is a spectrum disorderAutism is a spectrum disorder
Symptoms less classic Symptoms less classic Range of potential manifestation : severely Range of potential manifestation : severely
handicapped to subtle symptoms with minimal handicapped to subtle symptoms with minimal disabilitydisability
High functioning & Asperger syndromeHigh functioning & Asperger syndrome Autistic featuresAutistic features
TypesTypes
Parental Concerns (Wiggins, Baio, Rice, 2006(
Recent study indicated most children with an ASD diagnosis had signs of
a developmental problem before the age of 3, but average age of
diagnosis was 5 years.
Clinical pictureClinical picture Deficits in social behaviorDeficits in social behavior Problems in communicationProblems in communication Unusual pattern of behaviorUnusual pattern of behavior
Deficits in social behaviorDeficits in social behavior
Central symptom (core symptom)Central symptom (core symptom) No eye contactNo eye contact No interest of human voiceNo interest of human voice No anticipatory postureNo anticipatory posture Decrease facial responsivenessDecrease facial responsiveness No bondingNo bonding No social reference, Showing, shared attention No social reference, Showing, shared attention
& affect& affect No separation anxietyNo separation anxiety
Problems in communicationProblems in communication
Non verbal communicationNon verbal communication Understanding of speechUnderstanding of speech Speech developmentSpeech development
Non verbal communicationNon verbal communication
Infant: crying & screamingInfant: crying & screaming Pulling adult (no appropriate facial expression)Pulling adult (no appropriate facial expression) No nodding & shakingNo nodding & shaking No imitative gamesNo imitative games No copy of adult behaviorNo copy of adult behavior Imitative play skill: stereotyped, repetitive, based on Imitative play skill: stereotyped, repetitive, based on
their own experiencetheir own experience Extreme of emotions or expressionless most of the Extreme of emotions or expressionless most of the
timetime
Speech developmentSpeech development Babble (impaired amount )Babble (impaired amount ) MuteMute EcholaliaEcholalia Pronouns reversalPronouns reversal Monotonous, robot, no change of emphasis or Monotonous, robot, no change of emphasis or
emotional expression emotional expression Impaired function of speech: stereotyped Impaired function of speech: stereotyped
phrases (cartoon), lack imagination & phrases (cartoon), lack imagination & abstractionabstraction
Lack of to-and-fro Lack of to-and-fro
Unusual pattern of behaviorUnusual pattern of behavior
Resistance to changeResistance to change Ritualistic or compulsive behaviorRitualistic or compulsive behavior Abnormal attachment to odd objectsAbnormal attachment to odd objects Unusual response to sensory experiencesUnusual response to sensory experiences Objects are manipulated without regard of their Objects are manipulated without regard of their
usual functionsusual functions Preoccupations of certain featuresPreoccupations of certain features
Associated featuresAssociated featuresDisturbance of motilityDisturbance of motility
Delay motor developmental milestonesDelay motor developmental milestones Impaired motor coordinationImpaired motor coordination Stereotyped movementsStereotyped movements
Intelligence & cognitive deficitsIntelligence & cognitive deficits 40-60% IQ less than 5040-60% IQ less than 50 20-30 % IQ above 7020-30 % IQ above 70 Areas of normal or near normal skillsAreas of normal or near normal skills Verbal IQ lower than performance IQVerbal IQ lower than performance IQ
AspergerAsperger’’s disorders disorder Better verbal than performance IQBetter verbal than performance IQ
EpilepsyEpilepsy
4-40%4-40% AdolescenceAdolescence FemaleFemale
Why it is difficult to diagnoseWhy it is difficult to diagnose ??? ??? Cognitive limitationsCognitive limitations Diminished ability to think abstractlyDiminished ability to think abstractly Lack of communication skillsLack of communication skills Symptoms not classicSymptoms not classic Unawareness & inability to describe internal Unawareness & inability to describe internal
state state (interview & questionnaire ineffective)(interview & questionnaire ineffective)
Lack of social relatedness & motivation to Lack of social relatedness & motivation to report symptoms report symptoms
EtiologyEtiologyAutism is a neurodevelopmental disorder with a biological Autism is a neurodevelopmental disorder with a biological
basis , no definite causebasis , no definite cause Cortical dysfunctionCortical dysfunction Neurotransmitters dysfunctionsNeurotransmitters dysfunctions Vaccination factorVaccination factor Food allergyFood allergy Antibiotic overuseAntibiotic overuse Toxic exposure theoryToxic exposure theory Immune diseaseImmune disease
Mædica - a Journal of Clinical Medicine
ORIGINAL PAPERS
Maedica A Journal of Clinical Medicine, Volume 7 No.1 2012
Toxic Metals and Essential Elements in Hair and Severity of Symptoms among Children
with AutismEleonor BLAUCOK-BUSCHa; Omnia R. AMINb; Hani H. DESSOKIc; Thanaa
RABAHda Lecturer, researcher and advisor, International Board of Clinical Metal
Toxicology & German Medical Association of Clinical Metal Toxicology, Hersbruck, Germany
b Associate Prof. of Psychiatry, Cairo University, Egyptc Associate Prof. of Psychiatry- Beni-Suef University, Egyptd Researcher of Public Health and Biostatistics, National Research Center,
Egypt
Vaccines and Autism
No reliable study has shown a link between the MMR vaccine and autism
Avoiding vaccines can place your child at risk for catching serious diseases
Clinical course & Clinical course & prognosisprognosis
The diagnosis of autism is stableThe diagnosis of autism is stable The outcome in school, work, or social The outcome in school, work, or social
functioning variedfunctioning varied Symptoms persist but changeSymptoms persist but change Adolescence Adolescence
hyperactivity---- underactivityhyperactivity---- underactivity Increase anxiety & attentionIncrease anxiety & attention Increase sexual curiosity (masturbation in public Increase sexual curiosity (masturbation in public
places)places)
Minority can have independent lifeMinority can have independent life AspergerAsperger’’s disorders disorder Better outcome as regard education, occupation, Better outcome as regard education, occupation,
marriage, need for institution, autonomymarriage, need for institution, autonomy More aggression & sexual offensesMore aggression & sexual offenses
Comorbid psychiatric disordersComorbid psychiatric disorders
Other psychiatric symptoms are commonOther psychiatric symptoms are common Subsyndromal or comorbid diagnosisSubsyndromal or comorbid diagnosis Important for management planImportant for management plan
Common Comorbid psychiatric Common Comorbid psychiatric disordersdisorders Inattention & hyperactivity Inattention & hyperactivity (difficulty shifting, lack of (difficulty shifting, lack of
arousal) arousal) Obsession & compulsionsObsession & compulsions Anxiety & fearsAnxiety & fears Mood disorder Mood disorder (average ability, puberty)(average ability, puberty) Oppositional & antisocial behavior Oppositional & antisocial behavior (rigidity ,lack of (rigidity ,lack of
understanding of social norms)understanding of social norms) TicsTics Psychosis Psychosis (more deterioration & positive symptoms) (more deterioration & positive symptoms)
Differential diagnosisDifferential diagnosis General mental retardationGeneral mental retardation Developmental language disorderDevelopmental language disorder OCDOCD Sensory impairmentSensory impairment Selective mutismSelective mutism Psychosocial deprivationPsychosocial deprivation
Assessment, WhatAssessment, What?? Autistic symptomsAutistic symptoms Level of intellectual abilityLevel of intellectual ability Language development (expressive & receptive)Language development (expressive & receptive) Learning styleLearning style Neuropsychological strength & weaknessNeuropsychological strength & weakness Adaptive functioningAdaptive functioning Family system Family system Financial resourcesFinancial resources Behavioral problemsBehavioral problems Other psychiatric symptomsOther psychiatric symptoms Other medical condition (epilepsy)Other medical condition (epilepsy)
TreatmentTreatment No cure for autism No cure for autism –– no cause is known no cause is known ComprehensiveComprehensive MultidisciplinaryMultidisciplinary Individualized (heterogeneous group+ different Individualized (heterogeneous group+ different
goals)goals) Updated according to needsUpdated according to needs
ASD Management Outcomes are variable
Behavioral characteristics change over time Most remain on spectrum as adults
Ongoing problems with independent living, employment, social relationships and mental health
Predictors of better outcome Earlier age of diagnosis and treatment No cognitive impairment Early language and nonverbal skills Social skills Not – presence, degree of “autistic” symptoms
Treatment Goals
Minimize core features and associated deficits Maximize functional independence and QOL Alleviate family stress
Educational intervention Developmental Therapies
Communication Sensory, fine motor, gross motor
Behaviorally Based treatments Core and associated symptoms Social skills
Medical or biologic treatments Support family in home and community
Speech/Language Therapy
Behaviorally based/ intensive structured teaching E.g., Verbal Behavior
Augmentative strategies Sign language Aided augmentative/ alternative systems
Decrease non-communicative language
Developmental-pragmatic approaches appropriate use of language in social situations Social skills training
Developmental: Motor
Fine motor coordination Adaptive skills Sensory Integration
Addresses sensory abnormalities
“Systematic desensitization”
No evidence of corresponding neurological changes
Coordination difficulties
Natural environment Adaptive physical
education or in the community
Psychopharmacology Adjunct to educational,
developmental & behavioral treatments
So far no evidence of impact on core symptoms
Evidence supporting is variable
Treat target symptoms Stereotypies Withdrawal Obsessions Irritability Hyperactivity attention span self-injurious behavior Aggression sleep
MedicationsMedications
AntipsychoticAntipsychotic Antidepressants (classic/SSRI)Antidepressants (classic/SSRI) Psychostimulants & alpha-adrenergic agonistPsychostimulants & alpha-adrenergic agonist Mood stabilizers & anticonvulsantsMood stabilizers & anticonvulsants HormonesHormones SupplementsSupplements
Other medication & supplementsOther medication & supplements
Vitamin B6 & magnesiumVitamin B6 & magnesium Diet therapyDiet therapy Hormone Hormone Chelating agentChelating agent
Symptoms/ Disorders Freq Treatments
Attentional, impulsivity, hyperactivity
59% Behavioral interventionPsychopharmacotherapy – stimulants, atomoxetine, alpha agonists, anti-anxiety
Anxiety 43-84% Behavioral treatment – relaxation, cognitive Psychopharmacotherapy – SSRI, alpha agonist
Depression 2-30% PsychotherapyMedication – anti-depressants
Obsessive compulsive symptoms
37% Behavioral treatment, supportive counseling;Medication – SSRI, others
Disruptive, irritable or aggressive behavior
8-32% Behavioral interventionMedication – atypical neuroleptics (risperidone, arapiprazole, others)
Self-injurious behavior 34% Behavioral interventionMedication (e.g., naltrexone, risperidone, others)
Tics 8-10% Medications; Alpha agonist (clonidine, guanfacine), others
Sleep disruption 52-73% Sleep diary; sleep hygiene; behavioral supports; investigate possible medical comorbidity/ies as cause(s)
Psychopharmacology
Biologically Based ttt Supplements
B6/Magnesium, B12 DMG/ TMG Vitamin A, Vitamin C Folate Omega 3 Fatty Acids
Elimination Diets Casein/ gluten free
Off-label medications Secretin
Immune Antifungal therapy Immunotherapy, steroids Antibiotics/Antivirals Stem cell transplantation
Immunization-related With-hold immunization Chelation
Hyperbaric oxygen therapy (HBOT)
Always others coming along…
Strategies to Improve Executive Strategies to Improve Executive FunctionFunction
Simplify tasks into discrete, concrete steps.Simplify tasks into discrete, concrete steps. Usual visual aids (pictures, schedules, check-off lists.)Usual visual aids (pictures, schedules, check-off lists.) Use hand’s on learning (see one, do one, repeat as necessary.)Use hand’s on learning (see one, do one, repeat as necessary.) Prepare for transitions and new experiences. Prepare for transitions and new experiences. Decrease distractions.Decrease distractions. Decrease stressors.Decrease stressors. Coordinate assignments.Coordinate assignments.
Make sure challenges are a good match for abilities.Make sure challenges are a good match for abilities.
Non pharmacologicalNon pharmacological
Educational interventionEducational intervention Language & speech therapyLanguage & speech therapy Behavioral therapyBehavioral therapy Social skills trainingSocial skills training Working with the parentsWorking with the parents Sensiomotor therapySensiomotor therapy Sensory integration therapySensory integration therapy Auditory integration therapyAuditory integration therapy Music therapyMusic therapy
Language & speech therapyLanguage & speech therapy
Stimulate the natural ability for learning languageStimulate the natural ability for learning language One to one One to one 2-3 hours/week every day2-3 hours/week every day Involvement of parents : generalizationInvolvement of parents : generalization
Social skills trainingSocial skills training
Identify skill , broke it into several components Identify skill , broke it into several components Recognize social cuesRecognize social cues Response to social cuesResponse to social cues encourage generalization encourage generalization
Role modelingRole modeling Role playRole play VideoVideo Social storiesSocial stories Group (well structured) or individualGroup (well structured) or individual Adult mediated or peer mediatedAdult mediated or peer mediated
Behavior therapyBehavior therapy
Change of unwanted behaviorChange of unwanted behavior Select the target behavior Select the target behavior Frequency, intensityFrequency, intensity definable, measurable, observabledefinable, measurable, observable (hit self with hand, get frustrated when asked to (hit self with hand, get frustrated when asked to
complete work)complete work) Antecedent event & consequence Antecedent event & consequence (attention, self stimulation)(attention, self stimulation)
Understand the communicative functions of difficult behavior Understand the communicative functions of difficult behavior What to do instead?What to do instead? Positive reinforcementPositive reinforcement Prevent the behavior by changing the antecedent event Prevent the behavior by changing the antecedent event
(scheduling activities) (scheduling activities)
Take Home MessageTake Home Message
It is very important establish a set of evidence-based standards for pharmacological, educational and behavioral interventions for children with autism spectrum disorders.
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