1/11/2011

Understanding Autism for Radiography

History • Autism first identified in 1940’s – Greek word “autos” means self, - isolated self

• Affects information processing in the brain – alters how nerve cells and their synapses connect and organize

• Leo Kanner (US) and Hans Asperger (Germany) used it to describe the withdrawn behavior of several children • Centers for Disease Control and Prevention report that autism disorders now affect almost 1% of children

History

Autism – What is it?

• Autism and schizophrenia were linked until the 1960s • 1960s -1970s, research into treatments for autism focused on medications such as LSD, electric shock, and behavior change techniques (pain and punishment) • 1980s and 1990s, behavior therapy and the use of highly controlled learning environments emerged as the primary treatments for many forms of autism

• Autism spectrum disorder (ASD) • Range of complex neurodevelopment disorders • characterized by: – social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behaviorurodevelopment disorders

• Males are four times more likely to have ASD than females. • Spectrum – range of conditions

http://www.ninds.nih.gov/disorders/autism/detail_autism.htm

Types of Autism

Types of Autism

• Autistic disorder

• Pervasive development disorder -- not otherwise specified (PDD-NOS)

– Cannot use verbal or non-verbal communication to interact effectively with others – Usually have severe delays in learning language. – May have obsessive interest in certain objects or information – May perform certain behaviors repeatedly. – To be diagnosed symptoms must have been noted before age 3

– Symptoms that do not exactly fit those of autistic disorder or any other ASD – Children diagnosed with "atypical autism" are included in this group – Symptoms may have developed after age 3 – Symptoms may not be severe enough to be considered autistic disorder

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Types of Autism

Types of Autism

• Asperger's syndrome

• Rett syndrome

– May display many of the same symptoms as children with autistic disorder – Usually have average or above average intelligence – Often want to be social with others but don’t know how to go about it – May not be able to understand others' emotions, for instance they may not read facial expressions or body language well – Symptoms may not become apparent until school when behavior and communication with peers become more important

– Severe, rare condition begins with normal development from birth through about 5 months of age – From about 5 to 48 months of age, head circumference development slows – Children lose motor skills and social interaction and language development become impaired

Types of Autism

Common Signs of Autism

• Childhood disintegrative disorder

• Impaired social interaction • A baby with ASD may be unresponsive to people or focus intently on one item to the exclusion of others for long periods of time • May appear to develop normally then start to display signs • Often fail to respond to their names and often avoid eye contact with other people • They lack empathy

– Children begin developing normally like Rett Syndrome – From about age 2 to age 10, children are increasingly less able to interact and communicate with others – They develop repetitive movements and obsessive behaviors and interests – Lose motor skills, usually leads to them becoming disabled – Rarest and most severe autism spectrum disorder.

Signs

Signs

• Can’t understand social cues, such as tone of voice or facial expressions, and don’t watch other people’s faces for clues about appropriate behavior • Because of this they have difficulty interpreting what others are thinking or feeling • Often they engage in repetitive movements such as rocking and twirling, or in self-abusive behavior such as biting or head-banging. • Tend to speak later than others their age

• Don’t know how to play with other children • Some speak in a sing-song voice about a narrow range of favorite topics • Higher than normal risk for certain co-occurring conditions: – – – – – –

fragile X syndrome (which causes mental retardation) tuberous sclerosis (in which tumors grow on the brain) epileptic seizures Tourette syndrome learning disabilities attention deficit disorder.

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Autism diagnosis

Diagnosis

• Severity and symptoms and may go unrecognized. • Very early indicators that require evaluation by an expert include:

• Later indicators include:

– no babbling or pointing by age 1 – no single words by 16 months or two-word phrases by age 2 – no response to name – loss of language or social skills – poor eye contact – excessive lining up of toys or objects – no smiling or social responsiveness.

– impaired ability to make friends with peers – impaired ability to initiate or sustain a conversation with others – absence or impairment of imaginative and social play – stereotyped, repetitive, or unusual use of language – restricted patterns of interest that are abnormal in intensity or focus – preoccupation with certain objects or subjects – inflexible adherence to specific routines or rituals.

What causes Autism?

Genetic

• Scientists aren’t sure • Think that genetics and environment play a role • Researchers have identified a number of genes associated with the disorder • Also irregularities in several regions of the brain • Some studies have found abnormal levels of serotonin or other neurotransmitters in the brain • They have also found some genetic predisposition

• Cause may be due to mutations • Have only identified a few • Some of the genes may be inherited, but not all

– Families and twin studies show a link – If one child a 5% chance of second (1 in 20)

Deletion (1), duplication (2) and inversion (3) are all chromosome abnormalities that have been implicated in autism

Causes

Do symptoms change over time?

• Recent literature is looking more and more at environmental exposure to chemicals • Chemicals can affect the developing brain, producing neurodevelopmental disorders • Some of the exposure is in the womb

• May improve with age • Many can work and live independently or with some support • Children whose language skills regress early in life—before the age of 3—appear to have a higher than normal risk of developing epilepsy or seizure-like brain activity • Adolescence is a time where there may be depression or behavior problems and they may need help to transition to adulthood

– Thalidomide – Misoprostol 9ulcer medication) – Valproic acid (anticonvulsant)

• Now looking at phthalates, found in frangance, shampoo, cosmetics, nail polish • Plastics with 3, 6 or 7 on bottom

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Treatment

Imaging

• There is no cure • Therapies and behavioral interventions are designed to remedy specific symptoms • The earlier the treatment the better • Need to tailor treatment to individual • Educational/behavioral interventions-training to help with social and language skills • There are some medications for OCD, seizures, anxiety, depression and ADD among some areas.

• Imaging is being used to explore theories about autism • MR has been used to discover changes in the ASD brain compared to typical brain • ASD children have larger head circumference, MR shows larger brain volume • MR has shown gray and white matter enlargements in frontal, temporal and parietal lobes

•

• Diagram of major brain structures implicated in autism. Reprinted from the National Institutes of Health, National Institute of Mental Health Web site www.nimh.nih.gov/health/publications/autism/research.shtml

From Mason RA, Williams DL, Kana RK, Minshew N, Just MA. Theory of mind disruption and recruitment of the right hemisphere during narrative comprehension in autism. Neuropsychologia. 2008;46(1):274.

Functional activity in control and autism groups for (A) the MENTAL vs MATH contrast (P < 0.001, uncorrected) and (B) the REST vs MATH contrast (P < 0.01, uncorrected); and (C) the regions of overlap between these two contrasts (minimum cluster volume = 1152 mm3).

Brain Studies

Significant functional activity in the familiar faces versus stranger faces comparison. Note that the only brain region significantly active in the autism group was in the posterior cingulate and precuneus region.

Images resulting from fMR imaging studies of theory of mind processing in test subjects with and without autism. Responses to 3 categories of text passages are included. Note that autistic individuals "over-activated" significantly larger brain regions in comparison with neurotypical participants.

Autistic individuals tend to use different areas of the brain (yellow) for a movement task compared to a control group (blue) Kennedy D P , Courchesne E Soc Cogn Affect Neurosci 2008;3:177-190 © The Author (2008). Published by Oxford University Press. For Permissions, please email: [email protected]

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Daily Life

Children with ASD

• Not one “typical” person, individual pattern of behaviors and symptoms • 4 major areas

• May fail to respond to name • Independent for age • May appear not to hear you, does not point at things or wave good bye • Moves constantly, performs repetitive movements • Have routines and rituals, change disturbs • Not interested in other children • May walk on toes • May be sensitive to light, touch and sound • Hard to express feelings or thoughts with words

– Sensory processing challenges – Communication – speech/language delays and impairments – Repetitive or unusual behaviors – Social interactions

Working with ASD Patients

Why is it an "autistic" meltdown? Because this meltdown is not because he can't have a lollipop, or a toy, or another TV show...nope...this meltdown is because it's 9 am and we aren't getting in the car to go to school. Has nothing to really do with wanting to go to school...it's just the routine has been changed. It's 9am on a Thursday and we are suppose to be going to school.

A young boy with autism, and the precise line of toys he made

• ASD patients think differently • May not respond, but may understand, we can’t tell • Understanding common signs and behaviors of ASD patients will assist us in providing care • If possible try to plan for exam ahead of time when you know ASD patient is scheduled • May help avoid difficulties

Working with ASD Patients • Children need routine, parents have a typical routine with children, find out about it, especially for separation • Child may have object that is special, allow them to keep it • Stickers

• Autism does not define person, one aspect • Sensory perceptions disordered – Sights, sounds, smells, tastes and touch may not bother us, but can be painful for ASD – Think about the medical environment – May appear withdrawn or belligerent, but just trying to cope – Vocabulary is a challenge, take literal meaning – Visual orientation, try to show them procedure, repetition helps

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http://www.autismweb.com/materials.htm

More from the web site

Picture Cards

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Words

Words Don’t use

• Tell what to do instead of what not to do • State clearly and simply what you expect child to do • Young children have trouble with contractions • Use developmentally appropriate language • Use positive words • Talk to parents • Explain exam, may do it as a story

• • • • •

Don’t run! Stop climbing Don’t touch! No Yelling! Don’t hit!

• Don’t throw the truck • Don’t get out of bed

• Story gives information about exam, helps child process • May want to let child look at collimator, show light

Do use

• • • • •

Walk or hold my hand Keep feet on floor Look with your eyes Use inside voice Hands down or use words (suggest) • Roll the truck on the floor • Stay in bed

• Pretend to x-ray a toy • Proceed by telling child “first” and “then”, use simple sentences

Buzz Lightyear

• Allow child to hold toy during exam if possible, often children need to hold something • ASD children don’t like unknown • As with any child when using choice, only two choices at a time • Besides using pictures to tell child what to expect they may also use the cards to tell you something

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