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Autism

Dr. Henderson is on the medical advisory board of the U.S. Autism & Asperger Association (www.USAutism.org)

 

Autism Spectrum Disorders

autism top child psychiatristAutism Spectrum Disorders are a group of developmental disabilities that can severely impair an individual’s ability to communicate and socially interact with others. Specific diagnoses within this group include Autism, Asperger’s Disorder, Pervasive Developmental Disorder NOS, Childhood Disintegrative Disorder, and Rett’s Syndrome. In a controversial move, the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-V) will be eliminating Asperger’s and other diagnoses and lumping all of these different disorders under a single entity – Autism Spectrum Disorders. Generally, these diagnoses are made four times more often in males than females.  In the 1980s and 1990’s, autism was diagnosed in approximately 1 in 1,000 children. Currently, autism is believed to affect 1 in every 166 people. Although we do not yet know all the reasons why the rate of people being diagnosed with autism has increased substantially over the past two decades, a part of the answer may be improved diagnostic techniques. However, there also is evidence for an “epidemic” possibly caused, in part, by an as-yet unidentified infectious pathogen.

Classic Autism (also known as Kanner’s Autism or Syndrome), Asperger’s Syndrome and Pervasive Developmental Disorder (PDD) are specific types of neurobehavioral complications, which have long been classified within a group of developmental conditions loosely known as “Autism Spectrum Disorders”. Autism is considered a spectrum disorder because the number and intensity of the symptoms people with autism display may vary widely. However, all individuals afflicted with autism demonstrate challenges to some degree in the following three areas: communication, social relationships and restricted patterns of behavior.  For example:

Sad boy with headphones

Communication.  There can be a significant delay in, or a total lack of, speech development, with no corresponding attempts to communicate by gestures. An autistic individual may have difficulties in sustaining or initiating conversation or (s)he may repeat his or her speech over and over again concerning the same topic. Patients with Asperger’s Syndrome tend to be very verbal, often orating like “Little Professors” on topics that interest them. Yet, nonverbal communication and the emotional qualities of speech can be a mystery to them.

Social Interaction.  A person with an autism spectrum disorder may not use or understand non-verbal communication, or (s)he may not develop peer relationships that are appropriate to his or her developmental level. Often, there is a noticeable lack of emotional reciprocity (you smile at him, but he does not smile back). Adults with autism may appear aloof and indifferent to others; children seem to be wrapped up “in their own world”.

Behavior and Interests.  Restricted, repetitive and stereotyped patterns of behavior, interests and activities are a hallmark of autism. An individual with autism or a related disorder may have an intense preoccupation with one subject area or interest.  The affected individual may have nonfunctional, rigid rituals or routines. In children, there is a lack of make-believe or social imitative play. Repetitive motor mannerisms (for example, hand flapping or spinning of objects) may also be present.

Below are some examples of behaviors that are characteristic of Autism Spectrum Disorders. An individual with autism may exhibit some or all of these behaviors, depending on where (s)he falls on the spectrum:

  • An infant does not imitate other children and/or does not reach out to the parents.
  • Becomes stiff when held, does not liked to be touched, or is ‘floppy’ and has low muscle tone.
  • Delays is speech development
  • A child does not develop age-appropriate peer relationships and has difficulty mixing with others.
  • Little or no eye contact, aloof manner, appears detached, lacks spontaneous sharing of interests with others.
  • Inappropriate attachment to objects
  • Obsessive, odd play (for example, lining up or spinning toys).
  • Resists changes in routine more than typically expected for a child his/her age.
  • Eats only certain foods or insists on a preferred texture of clothing.
  • Repetitive motor movements and/or demonstrates uneven fine and gross motor skills development.
  • Does not develop speech or has speech and then loses it; does not point or gesture.
  • Repeats words or phrases over and over again; talks only about narrowly defined topics.
  • Difficulty in discussing abstract concepts, takes everything literally or has impaired language skills.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) clurrently lists the following specific diagnoses used for autism and related disorders:

Autistic Disorder (Classic Autism). Onset occurs before child is 3 years old. The child shows impairment in the three areas of observable symptoms: difficulty in communication, social interaction and repetitive, stereotyped patterns of behavior.

Childhood Disintegrative Disorder. The child develops normally in all areas for the first two years, then shows a significant loss of previously acquired skills.

Rett’s Disorder (also known as Rett Syndrome). Found almost exclusively in females, the child achieves normal development for the first five months, then loses previously acquired communication skills and the purposeful use of the hands. These losses are soon followed by other areas of deterioration, including apraxia (loss of ability to control complex muscle movements), gait disturbances and sometimes seizures. This disorder is very rare.

Asperger’s Disorder (also known as Asperger’s Syndrome). Children with this disorder demonstrate average to above-average intelligence and no significant delay in language, but show impairment in social interactions and have a restricted range of interests and activities. These children often can be very talkative, although their speech tends to lack normal fluctuation of tone or prosody. They can speak in a pedantic or lecturing tone.

Pervasive Developmental Disorder, Not Otherwise Specified (Atypical Autism). In the case of “PDD-NOS”, there is significant impairment in the three areas described above, but the child does not meet the full criteria for a specific diagnosis.

TESTING FOR AUTISM SPECTRUM DISORDERS

At this time, there is no single diagnostic test that can conclusively prove a child has an autism spectrum disorder. The most important signs to watch for are delays in the development of speech and of reciprocal interactions between the child and his/her caregivers. Parent’s intuition is an important yardstick here, as well. If you feel that there is something going wrong with your child’s development – trust your intuition. This is because you may be picking up on subtle failures in your child’s nonverbal communication with you.

There are several screening tools or checklists which can be useful in deciding whether to pursue further diagnostic workup.  These include:

  • CHAT – Checklist for Autism in Toddlers
  • CARS  Childhood Autism Rating Scale
  • Autism Screening Questionnaire
  • Screening Test for Autism in Two-Year Olds
  • Social Reciprocity Scale

If a child demonstrates elements suggestive of an autism spectrum disorder, then a comprehensive evaluation is indicated. The standard clinical diagnostic tool in the field is the ADOS (Autism Diagnostic Observation Schedule) which is a semi-structured assessment of communication, social interaction, and play or imaginative use of materials.

Other testing also is necessary to rule out other causes of neurological impairment and clarify the diagnosis:

  • Hearing Tests.  The first assumption most parents make when their child has speech problems or does not respond to aural stimuli is that their child may be deaf.  A hearing test can indicate if a child has a hearing impairment. Tests can be performed on children even in infancy; audiologists measure responses such as blinking, staring or turning the head when a sound is presented.
  • Genetic Testing involves using a blood test to screen for any genetic abnormalities that could cause developmental delays.
  • Metabolic Screening consists of blood and urine tests to measure how a person is metabolizing food.  Problems in this area can significantly impact a child’s growth and development resulting in symptoms similar to autism.
  • Electroencephalograms (EEGs) measure brain waves, and can uncover seizure disorders or other abnormalities.
  • Head CTs and MRIs are helpful in detecting structural abnormalities.  However, because most children with autism do not have structural abnormalities, these tests usually do not demonstrate specific structural abnormalities.
  • Brain SPECT Imaging is a method to physiologically map and detail the regions of the brain which are impaired from functioning effectively. Some autism treatment programs are using SPECT scans as part of a battery of tests in initial assessment and to track a child’s improvements.

TREATING AUTISM SPECTRUM DISORDERS

There is no FDA-approved medication for the treatment of Autism Spectrum Disorders. Risperidone (Risperdal) is often cited, but it is FDA-approved for the treatment of aggression in autism. The treatment of autism has to be targeted to the symptoms that are creating difficulties for the patient. Many individuals with Austism Spectrum Disorders struggle with anxiety. Specifically, targeting their anxiety can greatly improve their quality of like and reduce many episodes of emotional and behavioral dysregulation. Cognitive rigidity or difficulty tolerating transitions also is often present. While this can often be attributed to obsessive-compulsive tendencies, it actually results from overactivity in the anterior cingulate gyri (a portion of the brain). Medications can be helpful. Each patient presents with his or her own unique set of symptoms and issues. Care has to be tailored to the individual.

The goals of treatment for children and young adults with Autism Spectrum Disorders are to encourage development of relationships with family and peers, improve their communication skills, increase behaviors which will allow them to be successful in the school or job setting, and lay the groundwork for as much independent living as an adult as is possible. Language skills and assistive devices can help tremendously. Guidance of the parents and the school personnel concerning academic and behavioral interventions is often required.

Dr. Henderson trained under some of the top experts in autism and brings a wealth of knowledge and experience. He gains insights from what the patient expresses as feelings and concerns, as well as parental reports. He will often pull together a number of resources (for example art therapy, equine therapy, sensory integration programs, social skills programs) to help a person with Autism Spectrum Disorders develop new skills and confidence.

Complementary or Alternative Treatments for Autism Spectrum Disorders

In part because of the uncertainty about the causes of Autism Spectrum Disorders, alternative treatments have flourished. A number of treatments can be frankly dangerous and should only be undertaken after careful consideration and rational appraisal of all potential risks and dangers. For example, DMSO – an industrial solvent – has been purported to have benefit for Autism. There is little or no research to justify the use of the dangerous solvent. Similarly, chelation therapy carries significant risk both from the toxicity of the chelating agent and from the loss of critical trace elements. Herbal remedies must be used with caution – just because they are natural, does not mean they are harmless. Valerian root is often used, but daily use can lead to bleeding disorders. Too much fat-soluable vitamins can lead to toxicity. Strategies like balancing the brain or metronomic exercises can be very expensive and yield little in the way of lasting results. On the other hand, there are a number of benign strategies that carry relatively little risk and possibly a slim chance of benefit. Such strategies include elimination diets, moderate Vitamin B6 and/or magnesium supplementation, or omega-3 fatty acid supplementation. These strategies should be undertaken with the guidance of a physician because there is some risk associated with overzealous administration. Patients with Autism Spectrum Disorders will sometimes benefit from treatments for Sensory Integration Disorder, as they often have symptoms. Pharmaceutical interventions based on evidence of biological causes in at least some cases may be of benefit.

However, it must be kept in mind that Autism probably represents a final common pathway of behaviors and impairments resulting from a number of etiological pathways. So, some cases may benefit from antifungal therapy, but only those cases in which fungal overgrowth and poor intestinal integrity exist. One example that underscores the diversity of probable causes of Autism Spectrum Disorders is the variable efficacy of Secretin therapy. In some cases, it works remarkably well. But in clinical trials, the majority of patients showed little or no response. Does this mean Secretin does not work as treatment for autism or does it mean that autism is caused by several different pathways? What we see as Autism Spectrum Disorders is most likely the final common pathway of a number of different processes which damage or interfere with brain function.