autism overview presentation
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These PowerPoint slides were made available from the Autism Research
Institute www.Autism.com
ARI’s Toll-Free Resource
Call Center: 866.366.3361
These slides were adapted with permission from a presentation developed by James B. Adams, Ph.D. Dr. Adams has a teen-age daughter with autism and is a Full Professor in the Department of Chemical and Materials Engineering at Arizona State University. Dr. Adams currently serves as president, Greater Phoenix Chapter of Autism Society of America and a Board member of the Autism Research Institute.
A Word of Thanks
This information is for educational purposes only
and is not intended as medical advice. For medical assistance, please consult a knowledgeable healthcare
professional
Core symptoms
Major impairments:•Social Skills/Relationships•Communication•Stereotypical Behaviors•Desire for Sameness
Autism is a spectrum disorder:
Autism / PDD-NOS/ Asperger Syndrome – key impairment in social skills is common to all
How do they diagnose full-syndrome?DSM-IV Criteria for an Autism Diagnosis
DIAGNOSTIC CRITERIA FOR 299.00 AUTISTIC DISORDER
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)
How do they diagnose full-syndrome?1. DIAGNOSTIC CRITERIA FOR 299.00 AUTISTIC DISORDER –
AT LEAST TWO OF THE FOLLOWING
a) Marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
a) Failure to develop peer relationships appropriate to developmental level
How do they diagnose full-syndrome?
c) 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 to other people)
d) Lack of social or emotional reciprocity (note: in the description, it gives the following as examples: not actively participating in simple social play or games, preferring solitary activities, or involving others in activities only as tools or "mechanical" aids )
How do they diagnose full-syndrome?2. DIAGNOSTIC CRITERIA FOR 299.00 AUTISTIC
DISORDER – AT LEAST ONE OF THE FOLLOWING
a) 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)
b) 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
How do they diagnose full-syndrome?
How do they diagnose full-syndrome?3. DIAGNOSTIC CRITERIA FOR 299.00 AUTISTIC DISORDER
- AT LEAST ONE OF THE FOLLOWING
a) Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
b) Apparently inflexible adherence to specific, nonfunctional routines or rituals
c) Stereotyped and repetitive motor mannerisms (e.g hand or finger flapping or twisting, or complex whole body movements)
d) Persistent preoccupation with parts of objects
How do they diagnose full-syndrome?
e) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
1. social interaction
2. language as used in social communication
3. symbolic or imaginative play
D. The disturbance is not better accounted for by Rett's Disorder
How do they diagnose full-syndrome?
How do they diagnose Asperger Syndrome?
Same Social and Behavioral Issues as Autism
(III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
How do they diagnose Asperger Syndrome? (IV) There is no clinically significant general
delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)
How do they diagnose Asperger Syndrome? (V) There is no clinically significant delay in
cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.
Autism Diagnostic Interview – Revised (ADI-Revised): 2-4 hour interview with parents of child’s history
Autism Diagnostic Observation Schedule (ADOS) – one-hour structured and unstructured interaction with child
Childhood Autism Ratings Scales (CARS) E-2 Diagnostic Checklist – Parents’ checklist
scored for no charge. Download pdf file from www.autism.com
Diagnostic tools
Genetic or environmental cause? Studies of identical twins reveal:
Co-occurrence is 40-80%; if 100%, then only due to genes; so genes are important, but so are unknown environmental factors
5-10% chance siblings of ASD children will have autism
25% chance of major speech delay
… so carefully monitor siblings
No straight lines from genes to behavior
Genetic vulnerability + environmental exposure
Remember:
Genes alone produce proteins – not behaviors
Which Genes?
Many genetic studies of autism, but they generally disagree: too few subjects and too many genes
Probably 10-20 genes involved in complex manner
Translational Genomics (TGen) plans largest study ever (1000 subjects)
In two similar conditions, Fragile X and Rett’s Syndrome, a single gene has been identified for each
Which Environmental Causes? No general agreement
Possible causes with limited scientific data include: High levels of heavy metals (e.g., mercury, lead,
aluminum) due to limited excretion because of low glutathione
Excessive oral antibiotic usage (gut damage = poor health and neurodevelopment due to poor digestion of nutrients)
Vaccine damage (especially MMR) Exposure to pesticides Lack of essential minerals (iodine, lithium) Other unknown factors
Rapid increase in incidence
1970’s: 2-3 per 10,000 2007: 1 per 150 (U.S.); 1 per 58 (U.K.) In the U.S., affects 1 in 80 boys, since 4:1 boy:girl ratio In California (which has best statistics), autism now accounts
for 45% of all new developmental disabilities
YOUR STATE (get the stats from DDD if you can): 1996: 1999: 2003: 2005:
Why rising rate of autism? Partly due to better
awareness/diagnosis, but that is only modest effect (per study by MIND Institute)
Not due to genetics – gene pool changes slowly
So, primary reason is most likely increased exposure to environmental factors (mercury, antibiotics, MMR, pesticides, iodine deficiency, other?)
Prognosis?
Two major lifetime studies:
Autism: 90% of adults unable to work, unable to live independently, < 1 social interaction/month
Asperger (50% with college degrees):Similar prognosis – social skills, limited use of intellectual abilities
Grim prognosis if untreated, but many treatments now available, and there is MUCH more hope
Autism is TREATABLE!
Many children now greatly improve, and some even recover, due to evidence-based behavioral and/or biomedical interventions, primarily: Behavioral Therapies Biomedical Therapies
Behavioral therapies ABA – most widely accepted/implemented –
evidence based – well documented results Pivotal Response Training Carbone method Floortime RDI
“Behavior is determined by its consequences.”
B.F. Skinner
Applied Behavior Analysis (ABA) Pioneered by Dr. Ivar Lovaas at UCLA in the 1960s. Research study (1987) evaluated 19 young autistic
children ranging from 35 to 41 months of age. Children received over two years of intensive, 40-hour/week behavioral intervention by trained graduate and undergraduate students.
Nearly half of the children improved so much they were indistinguishable from typical children, and they went on to lead fairly normal lives.
Of the other half, most had significant improvements, but a few did not improve much.
Several variations today, but general agreement that: Usually beneficial, sometimes very beneficial Most beneficial with young children, but older children can
benefit 20-40 hours/week is ideal Prompting, as necessary, to achieve high level of success, with
gradual fading of prompts Therapists need proper training and supervision Regular team meetings needed to maintain consistency Most importantly: keep the sessions interesting to
maintain child’s attention and motivation
In YOUR STATE, (insert ABA policy)Example: In Arizona every child diagnosed with AUTISM (not
PDD-NOS) can receive ABA services from DDD (Arizona Division of Developmental Disabilities)
ABA Today
Other Evidence-Based Therapies
Speech Therapy Occupational Therapy/Physical Therapy Physical Therapy Sensory Integration Auditory Integration Therapy (AIT) Vision Therapy
Prism lenses Irlen lenses
Improve Diet Food Allergies GFCF Diet (no gluten, no casein/dairy) Vitamin/Mineral Supplements High-Dose Vitamin B6 and Magnesium Essential Fatty Acids Amino Acids Gut Treatments Thyroid Supplements Sulfation Glutathione Detoxification Anti-Viral Treatments Immune System Regulation
Rationale for the Biomedical ApproachEndorsed by ARI/DAN!
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No Change % Better Number of
Reports Removed Sugar 2% 51% 48% 3695 Feingold Diet 2% 45% 53% 758
Consume 3-4 servings of nutritious vegetables and 1-2 servings of fruit each day.
Consume at least 1-2 servings/day of protein Greatly reduce or avoid added sugar (soda, candy, etc.) Avoid “junk food” – cookies, fried chips, etc. (even if GF/CF, etc) Greatly reduce or avoid fried foods or foods containing transfats Avoid artificial colors, artificial flavors, and preservatives Go organic
Improving the Diet
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No Change % Better Number of
Reports Food Allergy Treatment
3% 37% 61% 560
Rotation Diet 2% 50% 48% 792 Removed Chocolate 2% 49% 49% 1721 Removed Eggs 2% 58% 40% 1096
A study by Vojdani et al. found that many children with autism have food allergies. “Immune response to dietary proteins, gliadin and cerebellar peptides in children with autism.” Nutr Neurosci. 2004 Jun;7(3):151-61.
Detecting Food Allergies Look for:
Red cheeks Red ears Dark circles under eyes Changes in behavior
Keep a diet log: Look for patterns between symptoms and foods eaten in the last 1-3 days
Order IgE and IgG blood tests: IgE related to an immediate immune response IgG relates to a delayed immune response.
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No
Change % Better Number of
Reports Gluten- and Casein-Free
Diet 3% 32% 65%
1446
Casein-Free Diet 2% 49% 49% 5574 Wheat-Free Diet 2% 50% 48% 3159
Autism Network for Dietary Intervention: www.autismndi.com
Rationale: T. Buie at Harvard Medical School found that many children with autism have defective and/or few digestive enzymes or few enzymes – means food doesn’t break down. This is different from a food allergy. Large proteins like gluten and casein cause problems in the bloodstream.
Recommendations: Requires 100% avoidance of all gluten products and all dairy products (and
often soy, corn and rice as well) Give digestive enzymes with food Caution: need calcium supplement unless on excellent diet
Allergies or not: Gluten-/Casein-free Diet
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No Change % Better Number of
Reports Vitamin A 2% 58% 41% 618 CalciumE: 2% 62% 36% 1378 Folic Acid 3% 54% 42% 1437
Magnesium 6% 65% 29% 301 P5P (Vit. B6) 13% 37% 51% 213 Vitamin B3 4% 55% 41% 659
Vitamin B6 alone 8% 63% 30% 620 Vitamin B6 with
Magnesium 4% 49% 47% 5780
Vitamin B12 4% 33% 63% 192 Vitamin C 2% 57% 41% 1706
Zinc 2% 51% 47% 1244
Using Vitamin and Mineral SupplementsRationale:
A double-blind, placebo-controlled study (published by Adams et al.) found that a strong, balanced multi-vitamin/mineral supplement resulted in improvements in children with autism in sleep and gut function, and possibly in other areas.
Recommendation:Use an allergen-free multi-vitamin. There are many formulas specifically for ASD.
Methylcobalamin
Rationale:Methyl-B12 is closely allied with the folic acid biochemical pathway and is necessary for detoxification. Unfortunately, many autistic children have a defect in this enzyme.
Recommendations:MB-12 is only by prescription. For approximately 85% of children 64.5 mcg/kg/every 3 days works well.
Giving High Dose Vitamin B6 + MgRationale:
Over 20 studies on efficacy of B6 with Magnesium:
• 45-50% of children and adults with autism benefited from high-dose supplementation of B6 with magnesium.
• Vitamin B6 is required for production of serotonin, dopamine, and others and glutathione.
• Magnesium helps curtail hyperactivity caused by B6 alone.
Recommendations: 8 mg/pound of vitamin B6 (maximum of 1000 mg) 4 mg/pound magnesium
Using Essential Fatty Acids – Fish Oil, etc.Rationale:
Most people in the US do not consume enough omega 3’s. Two studies found that children with autism have lower levels of omega 3 fatty acids than do typical children.
Recommendations: Omega 3: 20-60 mg omega 3/kg-bodyweight, from fish oil Omega 6: ¼ as much omega 6 as omega 3; Evening primrose oil or borage oil
Supplementing Amino Acids
Rationale: Some children with autism have digestive problems and self-limited diets that are low in protein. This can lead to amino acid deficiency, depriving the brain of neurotransmitters, hormones, enzymes, antibodies, immunoglobulins, glutathione, etc.
Recommendations: Test: Fasting plasma amino acids, or 24 hr urine (NOTE:
unusually high levels in urine may indicate wasting) Increase protein intake Use digestive enzymes Give a customized amino acid
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No Change % Better Number of Reports
Digestive Enzymes 3% 42% 56% 737
Using Digestive Enzymes
Rationale: T. Buie at Harvard Medical School found that many children with autism have defective and/or few digestive enzymes or few enzymes – means food doesn’t break down.
Recommendations: A Comprehensive Digestive Stool Analysis can reveal if some types of foods are
not being digested well, suggesting a problem with specific digestive enzymes. Use allergen-free digestive enzymes to aid in breaking down food and facilitation
better nutrient absorption Enzymes come in capsule form (but can be sprinkled on food) Give with every meal.
Yeast in the Gut
Rationale:
Many anecdotal reports of yeast overgrowth in children with autism, and limited research evidence. Suspect some yeast toxins (alcohol) can have major effect on behavior/aggression.
Recommendations: Probiotics: 30-500 billion CFU’s Antifungals: Nystatin, Diflucan Low-sugar diet Stool analysis for gut bacteria/yeast
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No
Change % Better Number of
Reports AntifungalsC: Diflucan 5% 41% 55% 330 AntifungalsC: Nystatin 5% 46% 49% 986
Antibiotics (not recommended) 31% 57% 12% 1799
Thyroid Disorders
Rationale: Perhaps 10% of general population has low thyroid levels, and at least that many children with autism also may have that problem. One study found that children with autism have unusually low iodine levels Low iodine is the major cause of mental retardation worldwide (over 80 million
cases) - becoming more common in US (decreased use of iodinized salt).
Recommendations: Testing:
Measure body temperature before waking; Measure iodine levels Thyroid test (caution re. reference ranges being too broad in some cases)
Treatment: Iodine supplementation if low Thyroid supplements, preferably natural animal extracts; caution re.
overdosing;
Treating Thyroid Problems
Testing: Measure body temperature before waking; Measure iodine levels Thyroid test (caution re. reference ranges
being too broad in some cases)Recommendations: Iodine supplementation if low Thyroid supplements, preferably natural
animal extracts; caution re. overdosing;
Rationale: Many children with autism have excess loss of sulfate in their urine, resulting in a low level of sulfate in their body.
Recommendations: Testing: Urine testing of free and total sulfate is useful to check
for excessive loss of sulfate. Blood testing can be used to check for levels of free and total plasma sulfate.
Treatments: Oral MSM (500-2000 mg depending on size and sulfate level) Epsom Salt (magnesium sulfate) baths – 2 cups of Epsom salts
in warm/hot water, soak for 20 minutes, 2-3x/week.
Treating Sulfation Problems
Glutathione Deficiency
Rationale:
Studies show low glutathione (critical antioxidant) in children with autism due to abnormalities in their methionine pathway.
Recommendations: Testing: Measure level of glutathione (fasting plasma or
RBC). Treatment: Oral glutathione is poorly absorbed (perhaps
15%). Alternatives include IV glutathione, N-acetyl cysteine, 500 mg vitamin C, DMSA therapy.
ARI Survey of Parent Ratings of Treatment Efficacy: % Worse % No
Change % Better Number of
Reports Chelation 2% 22% 76% 324
Heavy Metal Toxicity
Rationale: Low/inactive glutathione results in less excretion of mercury and toxic metals/chemicals, resulting in a higher body burden. Also, many children with autism had increased use of oral antibiotics in infancy, which alter gut flora and thereby almost completely stop the body’s ability to excrete mercury.
Recommendations for Detoxification Testing:
Urinary porphyrins reveal presence of mercury and other toxic metals by evaluating steps in porphyrin pathway. Nataf et al, Porphyrinuria in childhood autistic disorder: implications for environmental toxicity. Toxicol Appl Pharmacol. 2006 Jul 15;214(2):99-108.
Treatment: DMSA (FDA-approved for lead poisoning in infants) or DMPS. See DAN! consensus report at www.autismresearchinstitute.com
Immune System Regulation
Rationale:Several studies found altered immune system in autism, generally with shift to Th-2, and some evidence for auto-immunity
Recommendations: Treatments include: IVIG: Gupta et al., found IVIG benefited 4 of 10
children, with 1 case of marked improvement. ACTOS: Open study of ACTOS in children with autism found
substantial improvements. Antiviral therapies (Valtrex, acyclovir)