Prof. Dr. Vladimir Trajkovski ja prezentirashe temata: "Autism and mental health" na letnata shkola vo Ohrid na 18 avgust 2010 godina. Prezentacijata e na angliski jazik.

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University “St. Kiril and Metodij”University “St. Kiril and Metodij”
Faculty of PhilosophyFaculty of Philosophy
Institute of Special Education and RehabilitationInstitute of Special Education and Rehabilitation
AUTISM AND MENTALAUTISM AND MENTAL
HEALTHHEALTH
Prof. Dr. Vladimir Trajkovski
Ohrid, August 18, 2010

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IntroductionIntroduction
 Verbal and non-verbal communication
 Reciprocal social interaction
 Repetitive and stereotyped patterns of behaviours and interests
Onset before 3 years of age
Population prevalence of autism is ~10-20 per 10,000.
Male to female ratio of ~3-4:1.
75% of autistic people have mental retardation
~30% of cases have epilepsy
Belongs to the spectrum of Pervasive Developmental Disorders
(PDDs) which include Asperger syndrome, Atypical autism, Childhood
disintegrative disorder, PDD NOS. Prevalence of PDDs ~ 60/10,000
Neurodevelopmental disorder characterised
by impairments in 3 domains:

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What is autismWhat is autism
 People with autism
have difficulties
communicating,
understanding people
and the world around
them
 These pin people
illustrate some of the
ways in which autism is
displayed

4. 4
Autism as a
syndrome
2o
to a
medical
disorder
Limited imagination / creativityLimited imagination / creativityRepetitive/stereotyped movementsRepetitive/stereotyped movements
OCDOCDCircumscribed interestsCircumscribed interests
Social responsivenessSocial responsiveness CommunicationCommunication
AutismAutism What is ‘autism’
symptomssymptoms
symptoms
SyndromeSyndrome
Autism as a
1o
disorder
Disorder
genetic
cause

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PrimaryPrimary
Genetic disorder - interaction of 3+ sitesGenetic disorder - interaction of 3+ sites
SecondarySecondary
to any disorder that causes LDto any disorder that causes LD
 tuberous sclerosistuberous sclerosis
 fragile Xfragile X
disorder
syndrome
What is ‘autism’AutismAutism

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Theory of MindTheory of Mind
Social responsiveness
EmpathyEmpathy
CommunicationCommunication
Executive FunctionExecutive Function
VoluntaryVoluntary AutomaticAutomatic
Repetitive/stereotyped movementsRepetitive/stereotyped movements
OCDCircumscribed interestsCircumscribed interests
Motor abnormalityMotor abnormality
ToneTone
Co-ordinationCo-ordinationCentral coherenceCentral coherence
PerceptionPerception
DepressionDepression
EpilepsyEpilepsy
ImmunologyImmunologyBowel dysfunctionBowel dysfunction
SocialSocial responsivenessresponsiveness
AutismAutism Pervasive & complex disorder

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Recognizing Autistic TendenciesRecognizing Autistic Tendencies
Inability to relate to children or adultsInability to relate to children or adults

8. 8Poor speech or lack of speechPoor speech or lack of speech

9. 9Oversensitivity or undersensitivity to noisesOversensitivity or undersensitivity to noises

10. 10Inappropriate toy playInappropriate toy play

11. 11Difficulty dealing with changes in routineDifficulty dealing with changes in routine

12. 12Inappropriate laughter or cryingInappropriate laughter or crying

13. 13Lack of awareness of dangerLack of awareness of danger

14. 14Hyperactivity or passivenessHyperactivity or passiveness

15. 15Oversensitivity or undersensitivity to touchOversensitivity or undersensitivity to touch

16. 16Strange attachment to objectsStrange attachment to objects

17. 17Lack of eye contactLack of eye contact

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 Polygenic disorderPolygenic disorder
 There are many theories as to theThere are many theories as to the cause of Autismcause of Autism suchsuch
as……as……
 abnormal cerebral blood flow to areas of the brain,abnormal cerebral blood flow to areas of the brain,
 high fevers,high fevers,
 birth trauma,birth trauma,
 brain injury,brain injury,
 infections,infections,
 reactions to vaccinesreactions to vaccines
 lack of oxygen before, during or after delivery.lack of oxygen before, during or after delivery.
 chromosomal -fragile X syndrome, tuberous sclerosis
 genetic -increased risk in twins, sibs
 structural -anatomic, cellular.
Causes of AutismCauses of Autism

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How common is autismHow common is autism ??
• Baird G, Simonoff E,Baird G, Simonoff E,
Pickles A, Chandler S,Pickles A, Chandler S,
Loucas T, Meldrum D,Loucas T, Meldrum D,
Charman TCharman T..
• Prevalence of disorders ofPrevalence of disorders of
the autism spectrum in athe autism spectrum in a
population cohort ofpopulation cohort of
children in South Thames:children in South Thames:
TThe Special Needs andhe Special Needs and
Autism Project (SNAP)Autism Project (SNAP)
Lancet 2006;368:210-215Lancet 2006;368:210-215 1 in 86 (UK)
1 in 150 (USA)

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EMERGING EVIDENCE REQUIRES A NEW DISEASE MODELEMERGING EVIDENCE REQUIRES A NEW DISEASE MODEL
AND DEFINES THE AGENDA FOR POLITICAL ACTIONAND DEFINES THE AGENDA FOR POLITICAL ACTION
A rare tragic disorderA rare tragic disorder
– constant prevalenceconstant prevalence
Clear, if complex, genetic causesClear, if complex, genetic causes
Outcomes are inevitably determinedOutcomes are inevitably determined
in uteroin utero
A neuro-genetics problemA neuro-genetics problem
The best (and only) treatment isThe best (and only) treatment is
behavioral therapybehavioral therapy
““Your children are defective”Your children are defective”
FromFrom ToTo
An alarmingly frequent diseaseAn alarmingly frequent disease
– rising incidencerising incidence
An environmental disease, withAn environmental disease, with
possible genetic vulnerability factorspossible genetic vulnerability factors
Outcomes result from preventableOutcomes result from preventable
events in otherwise normal childrenevents in otherwise normal children
A multi-disciplinary problem,A multi-disciplinary problem,
spanning toxicology, epidemiology,spanning toxicology, epidemiology,
neurology, immunology,neurology, immunology,
gastroenterology, etc.gastroenterology, etc.
Many opportunities for prevention,Many opportunities for prevention,
treatment and recoverytreatment and recovery
““ Our children are sick”Our children are sick”

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Autism assessment-instruments (1)
•parent report –
 Modified Checklist for Autism in Toddlers
[M-CHAT] -screening
 Childhood Autism Rating Scale [CARS]
 Gilliam Autism Rating Scale [GARS-2]
 Social Communication Questionnaire [SCQ]
•parent history –
 Autism Diagnostic Interview [ADI-R]

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Autism assessment-instruments (2)
•behavioral data –
 Functional Analysis of Behavior, menu
of reinforcers/ motivators
•observation/ interview –
 Autism Diagnostic Observation
Schedule [ADOS] modules 1-4
Lord et al., 2000

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Autism assessment-
testing
 speech, language, communication
 developmental
 genetics
 hearing
 cognitive, psychoeducational
 neuropsychological
 psychiatric

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Autism intervention
categories
 educational/ vocational approaches
 communication therapies
 behavioral interventions (ABA)
 environmental strategies (antecedent
management)
 social skills training
 psychotherapies -individual, family, group
 biomedical/ integrative/ complementary
-medications, vitamins, diets

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Autism interventions
 Applied Behavior Analysis
 ABA Discrete Trial Training
 Pivotal Response Training; Incidental
Teaching
 Picture Exchange Communication System
(PECS)
 TEACCH Program

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Pharmacological Intervention
 No medications can cure autism
 None affects social pragmatic
understanding
 Helps improve the quality of life
1. target symptoms/behaviors of concern
2. thereby reduce social withdrawal

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PrognosisPrognosis
 The goal is for early intenseThe goal is for early intense
intervention and therapy approaches.intervention and therapy approaches.
 Collaboration of a variety orCollaboration of a variety or
professionals and family is needed inprofessionals and family is needed in
order to have the best outcome fororder to have the best outcome for
children with autism.children with autism.
 With proper education, support, andWith proper education, support, and
treatment, hopefully improvements willtreatment, hopefully improvements will
be made in various areas such asbe made in various areas such as
communication and social interactioncommunication and social interaction
skills.skills.

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Common Psychiatric
Comorbidities seen with ASD
 ADHD
 Aggression
 Self injurious behaviors 24 – 43%,
 Anxiety Disorders
 Depressive Disorders 9 – 44%
 Obsessive Compulsive Behaviors >40%
 Sleep disturbances
 Sexualized behaviors
 Psychosis
 Tics

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Autism and psychosis:Autism and psychosis:
How common is the overlap?How common is the overlap?
 Prevalence of ASD: 0.5-1%Prevalence of ASD: 0.5-1%
 Prevalence of Schizophrenia: 1%Prevalence of Schizophrenia: 1%
 Probability suggests 1 in 10,000 generalProbability suggests 1 in 10,000 general
populationpopulation
 Some have suggested overlap to be rare asSome have suggested overlap to be rare as
autism is diametrically opposite conditionautism is diametrically opposite condition
(Crespi & Badcock, 2009)(Crespi & Badcock, 2009)
 But studies are limited: no population studiesBut studies are limited: no population studies

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Effects of non-imprinted genes
and Environment
Autism Spectrum Psychotic Spectrum
Effects of
paternal genes
Effects of
maternal genes
Higher birth weight
More Cancer
Larger brain in childhood
More white matter
More foetal testosterone
More lateralised brain
Lower birth weight
Less cancer
Smaller adult brains
Less white matter
Less foetal testosterone
Less lateralised brain
MALE FEMALE
Crespi & Badcock, 2008

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Potential areas ofPotential areas of
confusionconfusion
Positive symptomsPositive symptoms
 Internal states expressedInternal states expressed
concretely can sound likeconcretely can sound like
hallucinationshallucinations
 Extreme egocentricity orExtreme egocentricity or
idiosyncratic world viewidiosyncratic world view
can mimic paranoia andcan mimic paranoia and
delusional fixitydelusional fixity
 Overinclusive and ramblingOverinclusive and rambling
accounts about specialaccounts about special
interest sound like thoughtinterest sound like thought
disorderdisorder
 Agitation and aggressionAgitation and aggression
will respond towill respond to
antipsychoticsantipsychotics
Negative symptomsNegative symptoms
 Impassivity and reducedImpassivity and reduced
empathy can look likeempathy can look like
blunted affectblunted affect
 Lack of enthusiasm forLack of enthusiasm for
“irrelevant” tasks like self“irrelevant” tasks like self
care can be taken for abuliacare can be taken for abulia
Early Language DelayEarly Language Delay
 Feature of both conditionsFeature of both conditions

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High arousal
hallucinations
thought disorder
Difficulty in expressing thoughts & feelings
Reality ≈ observed fiction
Pragmatic difficulty – irrelevant detail
Thoughts & Perceptions
Motor Catatonic symptomatology
Impassivity
• negativism
• initiation
• mutism
Performance & Skills Maintained in anxiety states
Developmental trajectory
Why the confusion?Why the confusion?
Comorbid disorderComorbid disorder SchizophreniaSchizophrenia

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Does Autism predispose to schizophrenia?Does Autism predispose to schizophrenia?
Autism does not protect against schizophreniaAutism does not protect against schizophrenia
Similar underlying abnormalities
How do we define schizophrenia
• presenting symptomatology?
• course & prognosis?
Not supported by outcome studies
Comorbid disorderComorbid disorder SchizophreniaSchizophrenia
What is the relationship?What is the relationship?

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ADHD symptoms in ASD
 Inattention
 difficulty in shifting their attention from one task to another
 Focused on object of interest
 Over activity
 Anxiety
 stereotypic behavior
 agitated depression or even mania
 Aggression:
 sometimes incorrectly attributed to hyperactivity

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ADHD symptoms in ASD
 In early childhood
 hyperactivity
 stereotyped behaviors
 irritability and temper tantrums
 Later
 aggressiveness/self injurious behavior
 stereotypic behaviors
 In adolescence and adulthood:
 esp. in higher functioning individuals depression or
OCD may develop and interfere with functioning

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Learning Disabilities
Some children with autism have
diagnosable learning disabilities such
as dyslexia, while others have unusual
abilities such as hyperlexia (the ability
to read at an extremely young age).
Some have a very tough time gaining
basic math skills; others are
mathematical "savants,“ achieving far
beyond their grade level.

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Serious Emotional
Disturbances
 It can also be tough to distinguish
between mood disorders and bipolar
disorder, schizophrenia, and autistic
behaviors.
 It is not unusual for a person with autism
to also have a mental health diagnosis of
bipolar disorder, clinical depression,
obsessive compulsive disorder or
schizophrenia.

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Behavioral Issues
 Common reason for presentation to mental
health services
 20% with severe mental retardation have
some form of severe behavioral disorder
 Problem behaviors: self harm/aggression to
others
 Significantly disabling/ not responding to
other measures

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Sleep problems
 The cause of sleep problems in autistic
children is unknown.
 Social cues may be important in addition to
the light dark cycle.
 A perseveration of thoughts and anxieties at
bedtime or during night awakenings may be
important.
 There is some evidence that melatonin
levels are lower in autistic children.

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Epilepsy
 Most common medical disorder in mental retardation
 20% of autistic children between the ages of 1 and 18
years suffer some kind of epileptic seizures (Munoz-Yuna
et al., 2003)
 Incidence
 8 – 18% of mild cases
 30 – 36% of severe cases
 25% of all children with mental retardation and epilepsy
have autism
 In more severe cases, stereotypies and involuntary
movements may be difficult to distinguish from epilepsy

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Epilepsy
 Combination medication regimens address both
seizures and behavioral emotional difficulties
 Anticonvulsants suppress seizures, aggressive
behavior & impulsivity in children with PDD
 Initiated as monotherapy
 Often not sufficient
 Combination of neuroleptic & anticonvulsant
preparations needed for better symptom control

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ASD in epilepsy
Selected populations
Disability - more severe / multiple
Cause of autism - 10
& 20
Diagnosis - how narrow / broad
Regression (probably) unrelated to epilepsy
Bimodal onset - childhood & adolescence
Epilepsy (seizures) in ASD (5-30%)
Depends on degree & nature of disability
 About 5-10% in childhood Asperger
 Up to 70% in disintegrative disorder
EpilepsyEpilepsyComorbid disorderComorbid disorder

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Social
impairment
Repetitive &
stereotyped
behaviours
Communication
abnormality
Comorbid disorderComorbid disorder
Social
impairment
Repetitive &
stereotyped
behaviours
Communication
abnormality
Epilepsy can amplify the symptoms of autism
EpilepsyEpilepsy

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Comorbid disorderComorbid disorder
Social
impairment
Repetitive &
stereotyped
behaviours
Communication
abnormality
Can epilepsy mimic the symptoms of autism?
EpilepsyEpilepsy

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Anxiety PanicFear
Obsessions
Compulsions
Anger Sexual arousal
Symptoms Emotional arousal

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Maladaptive response
Comorbid symptoms
Autism
symptoms
InteractionInteraction →→ complex presentationcomplex presentation

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Social Policy RecommendationsSocial Policy Recommendations
 Health insurance and public funding policies mustHealth insurance and public funding policies must
support evidence-based practices for ASD and providesupport evidence-based practices for ASD and provide
mechanisms to evaluate the effectiveness of treatmentsmechanisms to evaluate the effectiveness of treatments
in addressing individual and family goals, and toin addressing individual and family goals, and to
coordinate health care with educational and othercoordinate health care with educational and other
services.services.
 Government policies and funding should promote equalGovernment policies and funding should promote equal
access to services across state and across allaccess to services across state and across all
individuals with ASD (i.e., from different ethnic groupsindividuals with ASD (i.e., from different ethnic groups
and family income levels).and family income levels).
 Research that meets standards for evidence-basedResearch that meets standards for evidence-based
practices in model programs and community settings inpractices in model programs and community settings in
diverse populations and including families in differentdiverse populations and including families in different
circumstances should be prioritized.circumstances should be prioritized.

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ConclusionsConclusions
 Autism is a complex neurodevelopment disorder whichAutism is a complex neurodevelopment disorder which
is serious social, medical and mental health problem.is serious social, medical and mental health problem.
 Autism is characterized by: social deficits;Autism is characterized by: social deficits;
communication deficits; repetitive behaviorscommunication deficits; repetitive behaviors
 Evidence for autism as executive disorder at cognitive &Evidence for autism as executive disorder at cognitive &
biological levels.biological levels.
 Genetic basis plus environmental events.Genetic basis plus environmental events.
 Autism has epidemic prevalence.Autism has epidemic prevalence.
 Comorbid disorders are very frequent in ASD.Comorbid disorders are very frequent in ASD.
 Macedonian authorities who create social policy mustMacedonian authorities who create social policy must
establish services and should take better social care forestablish services and should take better social care for
them.them.

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Prof. Vladimir Trajkovski, MD, PhD
Phone: +389-2-3148-834
Fax: +389-2-3118-143
E-mail: vladotra@fzf.ukim.edu.mk
Web blog: http://vladotra.blog.mk
Skype: vladotra
“Autism is Treatable”
www.Autism-RecoveredChildren.org