Social and Language Disorders DTW

  1. Pervasive Developmental Disorders
    1. Key Points for Pervasive Developmental Disorders
    2. Clinical Guides (See Clinical Guide Algorithm)
    3. Definitions
    4. Management of Pervasive Developmental Disorders
  2. Asperger's Disorder
    1. Key Points
    2. Definitions
    3. Clinical Guides (See: Clinical guide algorithm)
    4. Differential Diagnosis / Comorbid Conditions, Asperger's
    5. Management
  3. Autism
    1. Key Points
    2. Clinical Guide Algorithm (See: Clinical guide algorithm)
    3. Differential Diagnosis / Comorbid Conditions of Autism
    4. Management of Autism
  4. Tools
  5. Resources for Parents
  6. References

Pervasive Developmental Disorders

Key Points for Pervasive Developmental Disorders

Rett's Disorder

Latest research on Rett's Disorder

Childhood Disintegrative Disorder

Latest research on Childhood Disintegrative Disorder

Pervasive Developmental Disorder, NOS

Latest research on Pervasive Developmental Disorders

Clinical Guides (See Clinical Guide Algorithm)

Definitions

According to the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) (American Psychiatric Association 1994) , the following are the definitions for the Rett's, Childhood Disintegrative, Aspergers, and Pervasive Developmental Disorder NOS.

299.80 Rett's Disorder

  • All of the following:
    • apparently normal prenatal and perinatal development
    • apparently normal psychomotor development through the first 5 months after birth
    • normal head circumference at birth
  • Onset of all of the following after the period of normal development:
    • deceleration of head growth between ages 5 and 48 months
    • loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)
    • loss of social engagement early in the course (although often social interaction develops later)
    • appearance of poorly coordinated gait or trunk movements
    • severely impaired expressive and receptive language development with severe psychomotor retardation

299.10 Childhood Disintegrative Disorder

  • Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.
  • Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:
    • expressive or receptive language
    • social skills or adaptive behavior
    • bowel or bladder control
    • play
    • motor skills
  • Abnormalities of functioning in at least two of the following areas:
    • qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)
    • qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play)
    • restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypes and mannerisms
  • The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.

299.80 Pervasive Developmental Disorder Not Otherwise Specified (Including Atypical Autism)

This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities, are present, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this category includes "atypical autism"- presentations that do not meet the criteria for Autistic Disorder because of late age at onset, atypical symptomatology, or subthreshold symptomatology, or all of these.

Parent text, preschool Parent text, school age

Management of Pervasive Developmental Disorders

General management of Pervasive Developmental Disorders[note]

Treatment

Medication

Psycho-Education

Rett's Disorder

Child Disintegrative Disorder

Pervasive Developmental Disorder-NOS

Asperger's Disorder

Key Points

Latest research on Asperger's Syndrome

Definitions

Clinical Guides (See: Clinical guide algorithm)

Assessment

  • There is no universal agreement on diagnostic criteria.
    • Most restrictive criteria: DSM IV definition
    • Least restrictive criteria: Gillberg and Gillberg (1989) criteria
  • Each case should be approached individually, as there is no universally agreed upon assessment protocol for Asperger's (Klin, A 2000)
  • Complete comprehensive medical evaluation and refer for psychological testing[note]
  • Few assessment scales are designed specifically for AS and autism scales may focus on symptoms that are not necessarily as severe in AS (See Tools). The most widely used are:
    • Australian Scale for Asperger's Syndrome (Garnett & Attwood, 1995)
    • The Childhood Asperger Syndrome Test (CAST; Scott et al., 2002)
    • The Autism Spectrum Screening Questionnaire (ASSQ; Ehlers et al., 1999)
    • The Childhood Autism Rating Scale (CARS ©; Schopler et al., 1988).

Differential Diagnosis / Comorbid Conditions, Asperger's

Management

Autism

Key Points

Prevalence

Etiology

  • Mostly genetic with 60-90% concordence for Monozygotic twins with transmission associated with a wide range of etiologies such as specific genetic syndromes (e. g., Williams, Tuberous Sclerosis, Fragile X, megalencephaly (e.g., Sotos) , chromosomal (e.g., Down), mitochondrial disorders, intrauterine infection (e.g., Rubella), biochemical errors (e. g., PKU), teratogenic (e.g., intrauterine Valproate exposure) or perinatal injuries and over 20 different genes identified for "idiopathic autism" with multigenic and polygenic inheritance considered likely.
  • Autism is NOT caused by emotional trauma or the mercury-based preservative thimerosal contained in the MMR vaccine[note] (NIMH, 2004)
  • Neurophysiologic differences[note]

Prognosis

  • Adaptability is related to IQ level
  • Not being able to speak by age 5 makes it unlikely that child will ever have speech

Latest Research on Autism

Latest Research on Prevalence of Autism

Latest Research on Etiology of Autism

Latest Research on Autism and Genetics

Differential Diagnosis / Comorbid Conditions of Autism

Latest Research on the Autism Diagnosis

Management of Autism

Treatment/Educational Intervention

  • Early and sustained intervention appears to be important regardless of the philosophy of the program, so long as a high degree of structure is provided (Rogers, SJ 1996)
  • Programs typically incorporate .behavior modification procedures and applied behavior analysis[note] which can significantly facilitate acquisition of language, social and other skills (Campbell, M 1996) Campbell et al., 1996 (Koegal 1992 a, b)
  • Psychotherapy may be useful in treating co-morbid depression in high functioning autism and Asperger's (Wing, L 1983) otherwise limited usefulness
  • Medication may be a useful adjunct to treatment/education when used to target specific symptoms of co-morbid conditions such as use of SSRI's for anxiety and Stimulants for associated ADHD symptoms. There is data to support the use of atypical antipsychotic medication for the irritability (RUPP 2002) that is often associated with Autism and Risperidone is the only medication thus far approved (for ages 5 -16) for a specific Autism indication. Because of the serious side effects, it is especially important to determine if the irritability can be better managed by improved and clearer routines or improved communication.

Latest Research on Autism and Medication

Latest Research on Autism Intervention and Treatment

Tools

General Socio-Emotional Development
For a brief office assessment of socio-emotional development consider the Brief Infant-Toddler Socio-Emotional Assessment (BITSEA; Briggs-Gowan, 2004). It is comprised of 42-items requiring a 4th-6th grade reading level and takes about 7 minutes to complete. Areas covered include internalizing behavior, externalizing behavior, dysregulation, competence, social relatedness, maladaptive behaviors and atypical development. Although the clinical validity of the BITSEA in diagnosing Autism Spectrum Disorders has not yet been formally evaluated, it can still be a useful method for screening social-emotional behavior and competence delays in children in the 0-3 age range.

Autism Spectrum in Toddlers
The 23-item Modified Checklist for Autism in Toddlers (M-CHAT ; Robins et al., 2001) is very good brief in-office screener for autism. It has been demonstrated to have excellent sensitivity and specificity. A positive endorsement of any 3 items yielded a sensitivity of .97 and a specificity of .95. It is appropriate for children up to 24-months of age.

Autism Spectrum in School age children (4 years of age and older)
The Social Communication Questionnaire© (SCQ; Berument et al., 1999) is a 40-item screener used to identify autism with DSM-IV and ICD-10 diagnostic criteria (formerly known as the Autism Screening Questionaire). Primarily used in research settings with children older than four years and with parents who are familiar with completing screening measures. Copyrighted and distributed by Western Psychological Services.

Asperger's
The Australian Scale for Asperger's Syndrome (Garnett & Attwood, 1995) is a 24-item questionnaire designed to be completed by a parent or primary caregiver. It is divided into major life areas: Social and emotional skills, Communication skills, Cognitive skills, Specific interests, and Movement skills. A "yes" answer with a score of 2-6 to more questions does not necessarily indicate Asperger's but a referral is appropriate (Attwood, 1998).

The Childhood Asperger Syndrome Test (CAST; Scott et al., 2002) is a 31-item questionnaire designed to identify possible Asperger's. A score of 15 or greater is indicative possible Asperger's.

The Childhood Autism Rating Scale (CARS©; Schopler et al., 1988) is a 15-item scale that rates children based on direct behavior observation. It distinguishes between mild, moderate and severe autism in children older than two. Copyrighted and distributed by Western Psychological Services.

Diagnostic Criteria for Asperger's Syndrome (Gillberg & Gillberg, 1989)

1. Social impairment (extreme egocentricity) (at least 2 of the following):
a) Inability to interact with peers
b) Lack of desire to interact with peers
c) Lack of appreciation of social cues
d) Socially and emotionally inappropriate behavior

2. Narrow interest (at least 1 of the following):
a) Exclusion of other activities
b) Repetitive adherence
c) More rote than meaning

3. Repetitive routines (at least 1 of the following):
a) On self, in aspects of life
b) On others

4. Speech and language particularities (at least 3 of the following):
a) Delayed development
b) Superficially perfect expressive language
c) Formal pedantic language
d) Odd prosody, peculiar voice characteristics
e) Impairment of comprehension including misinterpretations of literal/implied meanings

5. Non-verbal communication problems (at least 1 of the following):
a) Limited use of gestures
b) Clumsy/gauche body language
c) Limited facial expression
d) Inappropriate expression
e) Peculiar stiff gaze

6. Motor Clumsiness
a) Poor performance on neuro-developmental examination

Resources for Parents

Books:

Attwood T (2000). Asperger's Syndrome: A guide for Parents and Professionals Tony Attwood. London and Philadelphia: Jessica Kingsley Publishers.

Exkorn KS (2005). The Autism Sourcebook[note] : Everything You Need to Know About Diagnosis, Treatment, Coping, and Healing. New York, NY: Regan Books/Harper Collins.

Harris SL (1994) Siblings of Children with Autism: A Guide for Families. Rockville, MD: Woodbine House Publishing

Powers MD (1989) Children with Autism: A Parent's Guide. Rockville, MD: Woodbine House Publishing

Siegel B (1996) The World of the Autistic Child: Understanding and Treating Autistic Spectrum Disorders. Oxford, England: Oxford University Press

Willey LH (1999). Pretending to be Normal: Living with Asperger's Syndrome. London ; Philadelphia: Jessica Kingsley.

Wing L (1985) Autistic Children: A Guide for Parents and Professionals. New York: Brunner/Mazel

Online Resources

http://www.asperger.org (Asperger Syndrome Coalition of the United States)

http://www.aspergersyndrome.org (Online Asperger Syndrome Information and Support)

http://www.aspennj.org/index.html

http://www.socialskillbuilder.com (Software to improve social skills)

http://www.nimh.nih.gov/publicat/unravel.cfm (NIMH Website Information about Autism)

www.cureautismnow.org (Cure Autism Now Foundation)

http://www.thegraycenter.org (The Gray Center for Social Learning and Understanding)

Parent Support Groups

Autism Society of America: 301-565-0433

Childhood Disintegrative Disorder Network; c/o Madeline Catalano; 1172 Four Mile Road Allegany, NY 14706

International Rett Syndrome Association: 301-248-7031

National Alliance for Autism Research: 908-359-9957

References

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