Autism Spectrum Disorder Dr Neelakandan Murugesan Consultant Learning Disability Psychiatrist [email protected]

Janet Telford Professional Head of Speech and Language Therapy [email protected] 24 November 2016

What is Autism? • Includes Autistic Spectrum Disorder (ASD) or Autistic Spectrum Condition (ASC), includes Asperger’s syndrome. • Aetiology-unclear • ‘spectrum’ -people with autism share symptoms in 3 main areas.

• Triad of Impairment (Wing and Gould 1979) 1. Social Interaction 2. Communication 3. Having fixed and repetitive behaviours

Present Context • National Autism Strategy -2008 • Autism Act-2010 • Autism Strategy for adults with autism – Fulfilling and rewarding lives (3rd March 2010 by DH): includes guidance on making public services accessible and autism awareness training • Low awareness of autism among mental health professionals can lead to misdiagnosis and inappropriate treatment. • Need to ensure autism is included in undergraduate and postgraduate clinical training. • Non medical staff in the health and social care system also require awareness training of autism

• The National Audit Office (2009) surveyed General Practitioners to understand their views regarding patient numbers, referral of ASD patients, the support they offer ASD patients and their level of confidence in the fact that patients are receiving appropriate and adequate care – response was “not very confident” • Four out of five GPs (80%) indicate that they require additional guidance and training to identify and manage patients with ASD more effectively.

How common is autism? (www.autism.org.uk ) • More than 1 in 100 of the population have autism. • Between 42-55% of people with autism may have a learning disability. • Male > Female 5:1 and in LD can be 2:1 • Genetic reasons, female need more severe mutations, present assessments not always sensitive to presentation in female • Increasing prevalence

Autism A person with autism can have difficulty in the following: 1. Social Interaction 2. Communication 3. Having fixed and repetitive behaviours Asperger’s Syndrome is a type of Autism in which people have normal or even high intelligence. They do not have language difficulties.

Difficulties in social interactions may include: • Prefer to spend time alone • Limited reciprocity, initiation/sustenance of conversations • Sharing-emotions, affect, interests • Behaving in a strange manner in social situations

• Being unable to make or keep friendships or relationships • Difficulty in understanding other people’s

feelings and thoughts

Psychological theories of AutismTheory of mind

Theory of mind • Social imagination difficulties • Abstract thinking

Difficulties in Communication may include • Little use of language • Poor eye contact • Facial expressions • Tone of voice • Gestures • Difficulty in understanding jokes • Mixing up of the words ‘you’ and ‘I’ • Repeating what other people have said

Repetitive and restricted activities or interests: Repetitive speech, motor movements or use of an object.

Being obsessed with a particular topic or object.

Having fixed routine, sameness.

Sensory issues in Autism May include • Noise • Touch • Texture • Light • Proximity • Colour

Executive Dysfunction

Definitions and criteria • NICE guidelines on the best practice for the assessment process. • Diagnosis criteria in DSM-5

Why should we diagnose autism? • Has the potential to help the individual and family • Learn, network and seek support • Understanding reasons for behaviour will help devise strategies to assist and support (proactive vs reactive)

How can we diagnose autism? • • • • •

18 months plus Developmental history (e.g. ADI-R) Observatory assessments Clinical observation (e.g. ADOS, DISCO) Speech and Language Therapy assessment (pragmatics, social skills, abstract language) • Occupational Therapy assessment- skills and sensory

Can autism be a strength? • • • • •

Focus on details Concentrate for long periods of time in an activity of interest Process visual information better than that given in spoken form Greater productivity at given task Achievement in academic tasks that does not require social understanding and the language used is technical e.g. science, engineering, IT etc

Do individuals grow out of autism?

Barriers to accessing services • Inflexibility of thought may lead to the inability to reflect on past experiences, you might not recognise when you have a re-occurring illness and ask for help or know that you need to make an appointment with your GP, dentist or optician. Without the ability to think flexibly it is difficult to make plans and decisions about how to access services or treatment. • People who lack flexibility of thought often struggle to structure their time and plan their day which might include attending appointments or remembering to take medication. If changes are required to treatment it might take the person longer to process the information in order to make a decision.

• People may struggle to generalise. We can imagine that each time we go to the dentist, even if its a different place and a different person, it will be a similar experience – not being able to use past experience and knowledge means that these types of events are new and they may be perceived as unpredictable and frightening which may lead me to become disengaged/need explanations repeatedly/challenging.

• Our society has lots of unwritten social codes that we expect members of the public to abide by –including our health care services! Such as queuing systems, waiting quietly in the GP surgery, being expected to wait to be called to the GP room (even if this is later than the stated appointment time), know that we need to explain to the professional what the problem is. Someone who does not understand the nuances of social codes will struggle with these.

Unmet health needs • Unrecognised - additional health problems in adults with an ASC can go unrecognised/diagnostic overshadowing • Poor access to health care without reasonable adjustments • Premature deaths (CIPOLD) • Missed opportunities to take part in screening • 35% have epilepsy • 70% have additional mental health problems • Carers health needs not recognized

REASONABLE ADJUSTMENTS – make sure their diagnosis is coded as a significant active problem on the records – make sure their carers are on the carers register if appropriate – highlight any reasonable adjustments that are needed to allow the patients or their carers to access services - see the section below – make sure these adjustments are clearly “flagged” on the records – if someone is registering at the practice and they are anxious about visits, arrange some time to visit when no interventions are needed – encourage them to use a patient passport and take it to appointments in case they see a member of staff who does not know them – if they do not understand something – encourage them to say so – if you refer them to hospital or to another secondary service for tests or treatment, write on the referral letter the reasonable adjustments they will need.

• be prepared to make early/late appointments or longer appointments • provide somewhere quiet to wait • allow them to see the same clinician if at all possible (recognising that in an emergency this may not be possible) • nominate a key named contact person who will navigate the system, this may be a receptionist, administrator or nurse or GP • provide alternative ways of booking appointments, such as on-line, that do not involve the telephone • explain at the beginning of the consultation what will happen and how long it should take • recap and write down the key points at the end of the consultation for them to take away • provide accessible information in a format they understand about how and when appointments are available and how to get prescriptions or access services like cancer-screening tests.

Tips for working with adults with Autistic Spectrum Disorders • • • • •

Keep language simple Use short phrases Use written or picture lists for complicated jobs Check the person has understood Make it very clear when it is that person’s turn to talk e.g. say “it’s your turn to talk now” • Say the person’s name so they know you are talking to them • Use concrete language e.g. “That music is a bit loud isn’t it?” needs to be, “Please turn the music down” • Do not use sarcasm or “banter” e.g. “this won’t hurt” should mean just that!

Anxiety about change • Time lines and diaries can help • A picture or work to show “surprise” or something different might help with unplanned change • People may have very rigid thoughts and follow set rules. We may have to try and accommodate these. • Be clear about what is about to happen

Auditory Memory Problems • • •

Short instructions One thing at a time People my be confused with choice so limit choices to one or two at a time.

Time to Process Information • Give instructions – then wait • Some people need a considerable amount of time to process information • Add a picture to written word to back up what you say

Lack of Empathy • Understand that a person genuinely can’t see your point of view and make allowances. Be aware that this person will not “pick up” on your emotions. You have to tell them directly

Problems planning tasks • Break a task down into clear steps.

• Only have the “must do’s” in it.

Stereotypes and individuals

Medications for Autism • Does it work? • What are we treating?

Medications and autism • 40-50% receive medications • Antipsychotics • Antidepressants

• Stimulant drugs • Mood Stabilisers

• Opiate antagonists • Antidementia drugs

Level of evidence for primary target symptom(s) Class

Agent

Primary Target symptom(s)

Level of Evidence

Alpha 2 Agonist

Clonidine Guanfracine Aripiprazole

Hyperactivity Hyperactivity Irritability, hyperactivity, stereotype Behavioural symptoms Irritability, hyperactivity Repetitive behaviour, stereotyp Global functioning Irritability

Insufficient evidence Insufficient evidence Established evidence

Repetitive behaviour

Insufficient evidence (conflicting results) Insufficient evidence

Antipsychotics

Haloperidol Risperidone Risperidone Olanzapine Mood stabilisers

Norepinephrine reuptake inhibitor Serotonin reuptake inhibitor Clomipramine

Divaloproex, sodium/valproic acid Divalproex sodium/valproic acid Lamotrigine Levitiracetam Atomoxetine Hci

Citalopram Fluoxetine

Irritability, social behaviour Irritability Hyperactivity Repetitive behaviour Repetitive behaviour Repetitive behaviour, stereotyp, irritability, hyperactivity

Established evidence Established evidence Preliminary evidence Insufficient evidence

Insufficient evidence Insufficient evidence Preliminary evidence Insufficient evidence Insufficient evidence Insufficient evidence

Level of evidence for primary target symptom(s) Class

Agent

Primary target symptom(s)

Level of evidence

Stimulants Miscellaneous

Methylphenidate Amantadine Naltrexone

Hyperactivity Hyperactivity, irritability Social behaviour, communication, indiscriminant learning, SIB Hyperactivity Irritability, social withdrawal

Promising evidence Insufficient evidence Insufficient evidence

Naltrexone Pentoxifylline

Preliminary evidence Preliminary evidence

Medications and autism • Non-sustained improvement seen in – Core » » » » »

Repetitiveness Mood changes Irritability Social withdrawal Speech

– Non core » Self injury » Attention and concentration » Aggression

Other treatments •

Anticonvulsants

•

Cholinesterase Inhibitors

•

Omega 3 fatty acids

•

Acupuncture

•

Secretin

•

Chelation

•

Oxytocin

•

Testosterone

•

Hyperbaric oxygen therapy

•

Vitamins and mineral supplements

•

Exclusion diet

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