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Early intensive behavioral interventions can help young children with autism spectrum disorder gain skills and improve long-term outcomes.
Applied behavior analysis (ABA) is currently considered the gold-standard treatment for autism spectrum disorder. ABA is a methodology based on learning theory principles that teaches skills and decreases maladaptive behaviors through repetition and reinforcement. It can be used to improve communication, socialization, adaptive behaviors, and cognition. ABA can be delivered in an outpatient clinical setting, in the home, or in school. Other approaches are also available, such as Floor-time, Play-Therapy and other Behavior Interventions. The goal is to target core autism deficits of social engagement, emotional thinking, and social skills. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: February 2018 Once a child is diagnosed with autism spectrum disorder, adequate time should be made available to answer questions, guide the family toward treatment and service options, and make appropriate referrals. Educational materials need to be provided and discussed. Multiple resources are available, including those available online from various government resources (eg, the CDC and the National Institutes of Health [NIH]) and private foundations and groups (eg, Autism Speaks, Autism Society of America, American Academy of Pediatrics). Families should also be referred and given information about local autism support centers, which are available in most states. The written evaluation report is often used by families to advocate for services, therapies, and educational programs. Therefore, it should provide specific documentation of the diagnostic evaluation findings and evidence-based recommendations for treatment. Recommendations should be detailed and tailored to the child’s individual developmental needs. Behavioral and educational therapies are the mainstay of treatment for autism spectrum disorder. Children younger than 3 years of age should be assessed by the early intervention team, and an individualized family service plan (IFSP) should be developed. They should be referred for both general developmental and autism-intensive services. Children older than age 3 years should be referred to their local public school for a school evaluation to determine special education eligibility (often referred to as a team or core evaluation). Most children with autism spectrum disorder will be deemed eligible for services through an individualized education program (IEP). Some children may receive accommodations under a 504 plan. Home-based services may also be accessed through the IFSP, IEP, or private or public health insurance. Many states now have laws mandating private insurance to pay for autism spectrum disorder–related behavioral therapies. Recently, the Centers for Medicare & Medicaid Services mandated public insurance coverage for autism spectrum disorder services as well. The National Research Council Recommendations for Educating Children With Autism include at least 25 hours of total service time, maximal individualized instruction with a low student to teacher ratio, and parent/family involvement. These recommendations are available for free download from the National Academies Press (click here for to download the PDF file). We will discuss details of General Management for Autism Spectrum Disorder including in future postings. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: February 2018
This domain includes a number of aberrant behaviors in four different areas as follow. The diagnosis for Autism Spectrum Disorder requires these behaviors to be present in two of the four areas. 1) STEREOTYPIC MOVEMENTS, REPETITIVE OBJECT USE, OR VOCALIZATIONS/VERBALIZATIONSThese motor behaviors may include finger movements, body posturing, rocking, spinning, hand/arm flapping, full-body tensing, toe walking, or repetitive jumping. Unusual and repetitive use of objects can be seen in nonfunctional and repetitive play (eg, flipping light switches, opening/closing doors), or unusual use of toys rather than playing with them as intended (eg, lining up toys, spinning the wheels on cars). Repetitive behaviors can also be vocal, with repetitive sounds or verbal echolalia. Echolalia can be the immediate echoing of what was said around the child or delayed echoing, with scripting/reciting lines from books or videos. 2) INFLEXIBILITY, ROUTINES, AND RITUALSThese children may need to always take the same route to a given destination, eating the exact same foods or having food presented in the same way, or always having to finish what is started. Cognitive inflexibility is shown by black-and-white rigid thinking, repetitive questioning, overly strict adherence to rules, and behavioral or verbal rituals. A hallmark of children with autism spectrum disorder is that minor changes to routine, transitions, or unexpected events often elicit excessive tantrums or major changes in affect. 3) OUT OF PROPORTION INTENSE OR UNUSUAL INTERESTSInterests can involve topics that are seemingly abnormal in focus (eg, a 5-year-old knowing everything about elevators, politics, or astrology) or excessive and persistent age-appropriate interest down to an unusual level of detail and to the exclusion of other topics or activities (eg, cars/trains or letters/numbers or animals). Children may show an unusual attachment to objects (eg, needing to carry something with them at all times) or show an atypical or intense interest in small parts of things or how things work. 4) OVERREACTIVITY OR UNDERREACTIVITY TO SENSORY STIMULATION OR UNUSUAL SENSORY BEHAVIORSSensory symptoms may involve any of the senses (eg, auditory, visual, tactile, or olfactory). They can be unusual sensory interests (eg, overfascination with water play), adverse responses to seemingly innocuous sounds (eg, the vacuum cleaner) or things touching the skin (eg, clothing tags), a high pain tolerance, or excessive mouthing or smelling of objects. Individuals may show fascination with lights or spinning objects. Children may demonstrate unusual visual behaviors, such as peering out of the corners of their eyes, viewing objects from unusual angles, or holding objects very close to their eyes. Some children engage in behaviors such as crashing into things, pushing their bodies into small spaces, or being calmed by tight hugs, which may represent proprioceptive sensory seeking behaviors. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: February 2018
Current diagnostic criteria for Autism Spectrum disorder focus on two domains of function: deficits in social communication and the presence of restricted interests and repetitive behaviors. Social communication encompasses a number of skills. A diagnosis of Autism Spectrum Disorder, as per DSM-5, requires that deficits be present in all three of the following areas: Children with good expressive speech often will not use it to functionally communicate in a social manner such as to express ideas, ask questions, engage in back-and-forth conversation, volunteer information, or comment on the environment. 1) Social-Emotional Reciprocity:Abnormalities in social reciprocity involves the quantity and quality of social interest and engagement. It includes social initiation, response and engagement in basic social exchange, reciprocal back-and-forth communication, sharing of emotions, and appropriate response to the environmental. The earliest symptoms can manifest as a lack of a reciprocal social smile, poor eye contact, lack of response to the child’s name being called, decreased engagement in age appropriate activities and games. Children also struggle with social engagement, showing little awareness or interest in others and difficulty sharing interests and enjoyment. Some may demonstrate social interest but lack the social skills to initiate social engagement. They may struggle to join others in play activities, take turns, follow rules, and play cooperatively. They may be socially immature and have difficulty respecting appropriate social boundaries. They may also struggle communicating their emotions or understanding the emotions of others. 2) Nonverbal Communication:Deficits in nonverbal communication encompass problems in expressing and understanding various behaviors such as eye contact, tone of voice, body language, facial expressions and gestures. They have limited or no ability to integrate verbal and nonverbal communication. Children with autism spectrum disorder do not typically compensate for difficulty in verbal communication with nonverbal strategies (as seen in those with developmental language disorder), demonstrating a more significant and specifically social communication deficit. 3) Social Relationships:Children with autism spectrum disorder have deficits in a wide range of behaviors required for building and maintaining successful social relationships, especially with same-age peers. Young children with autism spectrum disorder may show little interest in other children or may be avoidant of any interaction, instead engaging in solitary or parallel play. Many children have difficulty varying or adapting their behavior to different social situations and have difficulty understanding different points of view or taking another’s perspective. Verbal children often only converse about topics of personal interest and are not aware when someone is not interested or even overwhelmed. Language can be overly literal, and children may not understand idioms or sarcasm, making it difficult to discern joking from teasing or real bullying. Many children with autism spectrum disorder do not have understanding or insight into friendships or other social relationships. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: February 2018
ADHD is the most prevalent neuro-developmental disorder in children. The disorder is defined by inattention, hyperactivity, impulsivity, or a combination of these symptoms, which must cause functional impairment.
In the United States, approximately 5.4 million (9.5%) children ages 6 to 17 are diagnosed with ADHD. Although the prevalence of ADHD has seen a dramatic increase of more than 30% in the last two decades, considerable debate continues regarding to over diagnosis and reporting, without confirmation of functional impairment. The diagnosis of ADHD relies on the use of validated parent and teacher rating scales to demonstrate a child’s impairment across a variety of settings (eg, home and school) as well as a clinical history of symptoms obtained by a trained clinician. Stimulants are first-line treatments, but a family history of cardiac disease should be obtained. While no formal guidelines exist regarding cardiac risk, a strong family history of early-onset cardiac disease warrants greater caution when prescribing stimulants or certain nonstimulants (atomoxetine). While being treated with stimulants, blood pressure, heart rate, weight, height, and history about sleep patterns should be obtained and followed every 3 months. I baseline EKG and additional cardiac workup should be decided in a case by case basis. We will discuss additional treatment details in future postings. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: June 2015 Brain tumors are the second most common malignancy in childhood and the most common solid tumor in children.
Headache is the most common presenting symptom and can occur in isolation, but it is often accompanied by vomiting, unsteadiness, or focal symptoms. In children, the ability to describe the headache is limited by their developmental stage. Hence, the primary goal is to identify any red flags. Because initial symptoms are nonspecific, either the persistence of the symptoms or additional localizing symptoms should prompt further evaluation. The most sensitive indicator is an abnormal neurologic examination or the development of neurologic symptoms such as double vision, unsteadiness, altered mental status and seizures. The prevalence of brain tumor in patients with a normal examination and headache history of greater than 6 months is 0.01% to 0.4%. Patients with headaches for less than 6 months and either sleep-related headache, vomiting, confusion, absence of visual aura, absence of family history of migraine, or an abnormal neurologic examination have a brain tumor prevalence of 4%. These numbers might be able to determine the need and urgency to expand an evaluation to include imaging studies such as a Brain MRI, as well as the fact that a delay in diagnosis does not appear to change the long-term morbidity or mortality. We will discuss imaging modalities for headache in children evaluation in future postings. REFERENCE: CONTINUUM: Lifelong Learning in Neurology: August 2012 - Volume 18 - Issue 4, Headache
It is worth noting that the basic definition of Epilepsy includes at least two unprovoked seizures occurring more than 24 hours apart.
Accurately making an early assessment can avoid unnecessary treatment of patients unlikely to have a second unprovoked seizure. In many cases extensive workup might not be needed. Decisions about treatment after a single seizure include considerations of the chance of having a second seizure, the consequences of having a second seizure, efficacy of medications in preventing future seizures, and the potential toxicity of antiepileptic drugs (AEDs). The chance of seizure recurrence is one of the most important determinations that will guide treatment decisions. While one must still deal with probabilities, fortunately, a number of population studies exist that can assist in this determination. As a general rule, after one unprovoked seizures (or more than one within 24 hours), the risk for a recurrent seizure is about 30 - 40%. However, after a second unprovoked seizure (more than 24 hours apart), the risk of subsequent seizures increases dramatically to about 70 - 80%. Most recurrences are within 1 year of the second or third seizure. In assessing a child with a “first” seizure, the neurologist must also determine whether the patient has actually had multiple and previous seizures. It is common for patients to seek medical care after the first generalized tonic-clonic seizure, but they may not have appreciated the significance of twitches and jerks, nocturnal events and staring spells. A careful history will often determine that many patients with newly diagnosed seizures have actually had previous unrecognized events. This is particularly true in children with complex partial and absence seizures. The process of making the diagnosis and proper evaluation will need to be based on a detailed history of the event(s) as well as past medical and family history in conjunction a Neurological examination. We will discuss details of a comprehensive neurological evaluation for Epilepsy in future postings. CONTINUUM: Lifelong Learning in Neurology: February 2016 - Volume 22 The current diagnostic criteria for Autism Spectrum Disorder focus on two domains of function: 1) deficits in social communication and the presence of restricted interests and 2) repetitive behaviors. As behavioral profiles change with developmental age and specific symptoms may come and go over time, the new DSM-5 classification allows for a history of symptoms, even if not currently manifested, to meet criteria for diagnosis. The diagnosis can be made by noting these behaviors by history as long as the current presentation is consistent significant ongoing functional impairment consistent with autism spectrum disorder. Impairment in social and communication skills and behaviors must be out of proportion to what is expected for the individual’s developmental functioning. Symptoms must be present in the early developmental period, and it is important to consider whether the impairing symptoms are best explained by autism spectrum disorder. Beware of other medical conditions, such as global developmental delay or cognitive impairment/intellectual disability that can mimic Autism.  REFERENCE: CONTINUUM: Lifelong Learning in Neurology: February 2018
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Dr. Germano FalcaoDr. Germano Falcao is a Mayo Clinic Trained Pediatric Neurologist who has a passion to care for children with neurological disorders and give support to their families. He is a compassionate and experienced physician, a published author, and a professor who specializes in areas involving Seizures and Epilepsy; Headaches and Migraine syndromes; Neurodevelopment Disorders; ADHD and Autism Evaluation. Archives
October 2018
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