AUTISM SPECTRUM DISORDER (ASD): A GENERAL OVERVIEW

1. AUTISM SPECTRUM DISORDER (ASD): A GENERAL OVERVIEW A PAPER PRESENTED BY: OKEY-MARTINS NWOKOLO Mphil/Ph.D student, Developmental Psychology Department UNILAG. Programme Supervisor, Acceleration Therapy, Lagos. E-mail:izuogu44@yahoo.co.uk Cell: 08039112839

3. WHAT TO EXPECT • INTRODUCTION • WHAT IS AUTISM SPECTRUM DISORDER (ASD) ? • DIAGNOSTIC CRITERIA FOR PERVASIVE DEVELOPMENTAL DISORDERS (APA, 2000) • THE TRIAD OF IMPAIRMENT/SYMPTONS OF ASD • ADDITIONAL FEATURES COMMON WITH ASD • WHAT CAUSES ASD? • SOME FACTS ABOUT ASD • DETECTING ASD AT AN EARLY AGE • EARLY SIGNS TO LOOK FOR • OBSERVATIONS TO MAKE • MAKING A COMPREHENSIVE ASSESSMENT • INTERVENTION STRATEGIES • REFERENCES

4. INTRODUCTIONThe term autism is scary. It is replete with stigma, fear, frustration and controversy. Stigma against persons and families with autism. Fear for parents who are worried over the future of their child diagnosed with autism and frustration for parents and teachers who struggle daily with the challenging behaviours and demands of supporting children with the condition. The controversial image of autism is even more serious and concerns professionals’(including medical doctors) differences in opinion regarding definition, causes presences, intervention and cure. This situations leaves parents even more confused. Yet , they are interested in knowing more about their child’s development and pediatric practitioners in Nigeria need to better prepared for this. The best thing you can do for these children and their families is to keep abreast on current developments in the filed and make informed decision about treatment.

5. WHAT IS AUTISM SPECTRUM DISORDER ? • Autism was first described by Leo Kanner of Johns Hopkins in 1943. He identified it as a disorder with impairment in: 1.Reciprocal Social Interaction 2.     Language and Communication development 3.Behaviour development. Autism is actually a subtype of a class of disorders known as Pervasive Developmental Disorder (PDD.) and there are 5 of these disorders. 1. Autism (Autistic disorder) 2.Asperger Syndrome 3.Rett’s disorder – also called Rett’s syndrome4.Childhood Disintegrative (CDD) – Sometimes referred to as Heller’s syndrome or disintegrative “psychosis” 5.Pervasive Development Disorder Not Otherwise Specified (PDD.Nos) – sometimes called a typical autism.Although the term Autistic Spectrum Disorders (ASD) has gained acceptance and is now used to mean the same thing as PDD, it is not yet an “official” diagnostic label. This means that you can’t find the term ASD in either the Diagnostic and Statistical Manual of mental disorder (DSM. IV) or the world health organization’s International Classification of Disorder (ICD).

6. DIAGNOSTIC CRITERIASEE LEAFLET

7. THE TRIAD OF IMPAIRMENT….SYMPTOMS OF ASD LANGUAGE AND COMMUNICATION·Child may not babble, may be mute ·The development of speech and language may be abnormal delayed or absent ·May act as though deaf / or not respond when called by name or even by gesture.·May echo or repeat words, phrases, sentences / or questions over and over again – echolalic speech. ·Facial expressions and gestures may be unusual or absent ·Incorrect understanding of speech . Words may be used incorrectly ·Production of speech may be unusual. A flat monotonous tone or inappropriate variation is tone are of noted ·Difficulties in initiating and or sustaining conversations. SOCIAL INTERATION·Prefers to play alone ·Little awareness of others or of their feelings ·Difficulty in forming relationships.·Theory of mind issues ·Indifference to or dislike being held, cuddled or hugged ·The most severe form in aloofness and indifference to others, although most show an attachment in a simple level of family members or careers.

8. BEHAVIOR AND IMAGINATION Symbolic or imaginative play may be limited or absent e.g. cannot play with a match box as if it is a car.May be routine bound. Insist on sameness and resist change. Do not tolerate change in routine or environment as this may cause distress. E.g. changing his toy, school bag or position of furniture.Inappropriate use of toys in play.Morbid attachment to objects – may hold onto a teddy for the whole day.Throw tantrums, screams often for no apparent reason.A tendency to focus on minor or trivial aspects of things in the environment, instead of being aware of the meaning of the complete situation. Hyperactivity or under-activity.May have a limited interest and range of activities. E.g. only interested in building legos.Some may have exceptional abilities e.g. outstanding memory of calendars, dates, painting, computing arithmetic, music, etc.

9. ADDITIONAL FEATURES • Odd response to sensory input – e.g. covering ears. • Engaging in self injurious behaviors e.g. head banging, hand biting, face/head slapping. • Stereotypical behaviors e.g. hand flapping, incessant rocking, jumping up and down, aimless wandering. • Repetitive/compulsive patterns of behavior – opening and closing door. • Repetitive lining of objects such as legos, finger twisting or curling. • Language and or social regression e.g. sudden loss of previous ability to point, kiss, eye contact, etc. • Walking on toes • Sleep disturbances • Bizarre eating patterns – food fads • Poor muscle tone e.g. clumsy with picking up small objects • No real fear of dangers – may run into a moving car or put finger on a burning gas.

10. WHAT CAUSES AUTISTIC SPECTRUM DISORDER?No one has been able to answer this question precisely and conclusively. The complex and pervasive nature of the disorder makes it even more complicated to pin-point the exact cause or causes. It would appear that ASD occurs as the result of varied and different biochemical causes and presents as malfunctioning of the brain (ASA, 2003). • ASD is definitely NOT the result of bad parenting and children with ASD do not just choose to misbehave. This had been the impression during 1950’s. • Volkmar and Wielsner (2004) gave the following as evidence that autism was a brain-based disorder: • The prevalence of seizures: As children with autism were followed over time, it was clear that many of them went on to develop seizures. • The prevalence of neurological problems: Many children with autism exhibit unusual features on neurological examination such as persistent “primitive reflexes”(which are present at birth but typically disappear in children after a few months). • The high rate of prematurity or other birth problems: Some studies have reported that children with autism are more likely to have had complications during the pregnancy or after birth. • The association of autism with a number of medical conditions that are known to affect brain development e.g. phenylketonuria, congenital rubella, tuberous sclerosis, and fragile x syndrome. These associations are strongest with fragile x syndrome and tuberous sclerosis but research is ongoing.

11. GENETICS AND ENVIRONMENTAL FACTORS • There is evidence that genetic factors are very much involved in autism.Research on genetics of autism suggest that the predisposition to develop autism can be inherited, and that a range of other problems – in language, learning, and social interaction might also be inherited. • There is currently much controversy and interest in the question of whether the environment can cause autism.Some reports suggest a link between immunizations or exposure to mercury in vaccines and autism. My opinion in this matter would be that Nigerian professionals should find out why many states in USA outlaw thimerosal. Also ,it may be needful to reevaluate the quality of vaccines that our children are getting in terms of ensuring that they are of the safest standards..and not rejected commodities from the west and USA. Furthermore, we might need to check or review the safety levels our current immunization schedules. • The Center for Autism and Related Disabilities (CARD) listed many biochemical factors that may be implicated in the etiology of autism,e.g. allergens,leaky gut,vaccines, etc. More information can be obtained from their website(see reference)

12. SOME FACTS ABOUT AUTISM • Autism is the third most common developmental disorder, following mental retardation and cerebral palsy. • Autism as yet, has no known medical test or cure but is TREATABLE. • It occurs more in males than in females at a ratio of 4:1 • It appears to have 2 forms: (a) Infantile/static : In which case symptoms are present from birth. (b) Regressive : In this case, there is an actual loss of previously learned skill. May present from fifteen months to two and half years. Autism has no boundaries . It can affect anybody regardless of social status, religion, country or creed.

13. NEED FOR EARLY DETECTION OF ASDEarly diagnosis and appropriate intervention leads to great positive outcomes.Research has shown that the earlier the intervention the better the prognosis. • Children do not simply outgrow ASD • It appears to be a deteriorating condition…some describe it as progressively degenerative. • The human brain is very plastic. Prior to age 5, major neural networks are possible (Volkmar and Wiesner,2004). If a child does not develop or use certain tracts in the brain during these critical time limit, he may never fully do so. Obviously, children between 6 and 10 or more do improve, but it is a slower process, often requiring more “effort” to “learn” the basics ,and grow up developmentally. From personal experience, I can’t say that I have the same top hope for a patient who is 9 or 10 that I may have for a 2-4 year old.

14. EARLY SIGNS TO LOOK FORAlthough there are individual differences,some characteristics appear to be universal among children with a high risk of developing ASD. • Child does not babble or point …at 12 months. • Child does not use single words …at 16 months. • Child does not try to imitate words, scribbling • Child shows regression or loss of previously learned skill. This may be language regression (e.g. stopped using words) or social regression (e.g. stopped pointing, kissing, etc.) • Acts as deaf or does not respond to name when called • Avoids eye contact • Does not take interest in other children • Does not like to be swung, cuddled, or bounced on knees • Does not play appropriately with toys (e.g. cars) but only mouths, fiddles or drops them.

15. OBSERVATIONS TO MAKEDuring your observation of the child notice the following: • Does the child recognize your presence? • Does he respond to”Hello” or a handshake? • Does he make eye contact • Does he point or follow your pointing See the Checklist for Autism in Toddles (CHAT) at: www.featnt.org/info/chattest.asp

16. COMPREHENSIVE ASSESSMENTSIf your suspicion of autism is still strong, you may consider more specialized assessments by members of other disciplines. Service providers such as Acceleration Therapy, Lagos, may be helpful as well.A comprehensive assessment will normally involve the following: • History • Medical Assessments • Psychological Assessments • Speech-Language – Communication Assessment • Occupational and Therapy physical Assessments

17. Considering that the audience is made up of mostly medical personnel, it might be necessary to outline some of the recommended medical tests for Autism. There is no specific medical test for ASD. However, once you have a suspicion of autism, you may want to run some recommended tests to rule out other possible causes. Doctors may check for: • ·Lead levels • ·        Hearing • ·        MRI scan • ·        EEG- for possible seizures • ·        Fragile x syndrome: 5-10% of children with ASD present with fragile x. • ·    Metabolic Screening: Some treatable metabolic disorders may result in the manifestation of ASD. • ·      Chromosomal Testing: • ·      Immunological dysfunction: Allergens such as gluten and casein may be affecting the child’s behaviour

18. INTERVENTION STRATEGES • To date, (medically speaking) there is no cure for ASD. Behaviour and Educational intervention approaches have proved beneficial to most children on the spectrum. Research has shown that approaches such as ABA, which offer structured intensive programming can be extremely helpful . • There are however, numerous other approaches which have been beneficial for some people with ASD. Some of the techniques overlap but there are basically two approaches: those that attempt to change the child and those that attempt to change the environment for the benefit of the child. The latter has gained more research acceptance. • Intervention techniques which have been found to be beneficial to people with ASD, include: • ·     Lovaas (ABA) • ·     Specialized Education • ·     Behaviour modification • ·    Occupational therapy • ·     Speech – Language and communication therapy • ·    Auditory integration • ·    Relationship Development Intervention (RDI) • ·    Picture Exchange communication system (PECS) • · TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children)

19. Sensory Integration Vitamin therapy Dietary modification etc Option Institute (Son Rise Programme) Drug treatments.Autism is here with us. More and more children are being reported to be on the spectrum. My biggest wish today is that everyone here will become an advocate for these vulnerable children and families. We need to get parents out of shame and denial. We need to campaign for availability of appropriate services. We need to educate the government and the public about ASD, we need to get schools to open their gates for our children.

20. REFERENCESAmerican Psychiatric Association (APA). 1994. The Diagnostic and Statistical Manual of mental disorders. 4th ed. (DSM-IV) Washington D.C. APA Autism South Africa (2003) My Child May be affected by Autism Spectrum Disorder (information for parents).CARD (2004) Biochemical Flowchart: http://www.centerforautism.com /biological / biochemical/Jordan, R. (1997). Education of Children and Young People with Autism BirminghamVolkmar, F.R, and Wiesner, L.G. (2004). Healthcare for Children on the Autism Spectrum. Bethesda, Woodbine House. Wing. L. (2003): The Autism Spectrum. A, guide for parents and professionals.Wing. L. (1993). Autistic Spectrum Disorders: An Aid to Diagnosis.Wing, L., and Atwood. T. (1987). Syndromes of autism and atypical development. In D. Cohen and A. Donnell an, editors. Handbook of autism and pervasive development disorders. New York: John Wiley & Sons, 3-19.

21. THANKS FOR LISTENINGYours in pursuit of hope and help for children in Nigeria with ASD.