XVII Annual Conference of IAP Maharashtra State (Mahapedicon 2006, Solapur, 3-5th November 2006)

Dr. Suchit Tamboli
Chiranjiv Clinic, Ahmednagar

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1. Autism is lifelong disability primarily affecting person’s communication and social abilities.
   
2. Autistics have been described as being in “their own world”
   
3. History : First described by Leo kanner as ‘infantile autism’. Asperger in 1944 used term ‘psychopathy’.
   
4. Incidence: 3.3 to 16 per 10,000 (2nd to blindness in disabilities) but under diagnosed till today in India.
   
5. Definition: (WHO 1994, American psychiatric association (1994) autism is classified as a ‘pervasive developmental disorder’ PDD for children with onset of distortions of multiple psychological functions involving social behavior and language. As deficits are not fully pervasive many clinicians refer term ‘Autistic spectrum disorder’.
   
6. Causes of Autism: No specific cause has been found exactly till today:
   
   
   • Genetic – Sibling risk for autism 2% - Risk to relatives 0.1%.
     
   • Pregnancy/Birth complications – Autistic children may have increased history of birth complications
     
   • Blood serotonin is elevated in 30% of autistic persons. But increased serotonin are not specific to autism.
     
   • Brainstem hypothesis – etiology is related to compromise brain stem and diencephalic structures.
     
   • Infective (congenital rubella) Metabolic (PKU) genetic/developmental (tuberous sclerosis, Rett syndrome) Toxic (Fetal alcohol syndrome) or infantile spasms.
     
     
7. Diagnostic criteria: Conditions included in autistic spectrum disorder as per DSM IV are
   
   
   • Autistic disorder
     
   • Asperger disorder
     
   • Childhood disintegrative disorder
     
   • Rett’s syndrome
     
   • Pervasive developmental disorder not otherwise specified.

Diagnostic criterion of autism (DSM IV Criterion) (diagnostic and statistical manual of mental disorder 4^th ed. American Psychiatric Association 1994).

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

1. Qualitative impairment in social interaction we manifested by at least two of the following:
   
   
   1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye
      gaze, facial expression, body postures and gestures to regulate social interaction.
      
   2. Failure to develop peer relationships appropriate to developmental level.
      
   3. A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest).
      
   4. Lack of social or emotional reciprocity.
      
      
2. Qualitative impairment in communication as manifested by at least one of the following:
   Delay in, or total lack of the development of spoken language (not accompanied by an attempt to compensate) through alternative modes of communication such as gesture or mime)
   
   In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others Stereotyped and repetitive use of language or idiosyncratic language.
   
   Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
   
   
3. Restricted repetitive and stereotyped patterns of behavior, interests and activities as manifested by at least one of the following:
   
   
   1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
   2. Apparently inflexible adherence to specific, nonfiction routines or rituals
   3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole body movements).
   4. Persistent preoccupation with parts of objects.

B. Delay or abnormal functioning in at least one of the following areas with onset prior to age 3 years.
C. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.

Diagnosis of autism done by following ways:
DSMIV, HISTORY, ASSESSMENT BY

a) Screening CHAT (checklist for autism in toddlers)

1. During the appointment has the child made eye contact with you?
2. Get the child’s attention, then point across the room at on interesting object and say “Oh look there is (name of toy) watch the child face does the child look across to see what you are pointing at
3. Get the child’s attention, then give child a miniature toy cup and teapot and say “can you make a cup of tea” (substitute toy picture and glass and say, Can you pour a glass of juice) Does the child pretend to pour out tea (juice) drink it, etc? ]

Sat to the child “Where is the light” or “show me the light” Does the child point with his/her index finger at the light can the child build a tower of bricks) blacks) (if so how many?) no. of bricks

• Autism behavior checklist (ABC) Screening test-cut off 70-75.
• Childhood autism rating scale (ARS)
• Autism diagnostic interview (ADI) 3 hrs. gold standard.
• Autism diagnostic observation scale (ADOS) 3 hrs.

Differential diagnosis

• Mental Retardation: Deficits are global in autism while patchy in MR.
  
• Schizophrenia
  
• Language disorders
  
• ADHD
  
• Seizure disorder with behavioral problems Co morbidity
  
• Medical disorders: Seizure disorder, tuberous sclerosis, herpes encephalitis, measles encephalitis, fragile syndrome
  
• Psychiatric disorders: Depression, anxiety disorders, disruptive behaviors disorders such as ADHD, Tics etc.

• 65% of subjects with ASD have co-morbidity (ADHD) depression, OCD, GAD, TS)
• Stereotyped mannerism 70% \, Morbid/unusual preoccupation – 65%
• Stereotyped utterances – 65%, Compulsions or rituals – 50%
• Poor attention and concentration 65%, Anxiety or fears – 50%
• Hyperactivity – 40%, Tics – 8%
• Obsessive phenomena – 37%, Self-injury – 30%
• Depression/irritability/agitation – 27%.

Types of Pharmacological Approaches

Symptom-based Approach

• Symptoms that are likely to respond to medication – hyperactivity, inattention, obsessions, tics, psychosis, impulsivity, labile mood
  
• Symptoms that need behavioral modification as well – aggression, rituals, self-injury, depression
  
• Symptoms that require specific remediation – deficits in academic, social or sports domain.
  

Symptom	Nor adrenaline	Dopamine	Serotonin
Obsession	-	-	++++
Depression	++	-	+++
Depression	++	-	+++
Hyperactivity	++	+	+
Inattention	++	+++	-
Impulsivity	+	-	++
Aggression	-	-	+
Stereotypes	-	-	+

1. Most widely studied drug in ASD
   
2. Shown to reduce anger, hyperactivity, speech problems
   
3. Main drawback is tardive dyskinesia – 40/118 children developed drug-related dyskinesia – more in those with pre/peri natal complications, large cumulative dose, girls.
   

Last Updated on 01-04-2007