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Pervasive developmental disorder - autism

Last reviewed: April 26, 2010.

Autism is a developmental disorder that appears in the first 3 years of life, and affects the brain's normal development of social and communication skills.

Causes, incidence, and risk factors

Autism is a physical condition linked to abnormal biology and chemistry in the brain. The exact causes of these abnormalities remain unknown, but this is a very active area of research. There are probably a combination of factors that lead to autism. Genetic factors seem to be important. For example, identical twins are much more likely than fraternal twins or siblings to both have autism. Similarly, language abnormalities are more common in relatives of autistic children. Chromosomal abnormalities and other nervous system (neurological) problems are also more common in families with autism. A number of other possible causes have been suspected, but not proven. They involve: y y y y y Diet Digestive tract changes Mercury poisoning The body's inability to properly use vitamins and minerals Vaccine sensitivity

AUTISM AND VACCINES Many parents are worried that some vaccines are not safe and may harm their baby or young child. They may ask their doctor or nurse to wait, or even refuse to have the vaccine. However, it is important to also think about the risks of not having the vaccination. Some people believe that the small amount of mercury (called thimerosal) that is a common preservative in multidose vaccines causes autism or ADHD. However, studies have NOT shown this risk to be true. The American Academy of Pediatrics, and The Institute of Medicine (IOM) agree that no vaccine or component of any vaccine is responsible for the number of children who are currently being diagnosed with autism. They conclude that the benefits of vaccines outweigh the risks. All of the routine childhood vaccines are available in single-dose forms that do not contain added mercury. The Centers for Disease Control and Prevention website provides further information. HOW MANY CHILDREN HAVE AUTISM? The exact number of children with autism is not known. A report released by the U.S. Centers for Disease Control and Prevention (CDC) suggests that autism and related disorders are more common than previously thought. It is unclear whether this is due to an increasing rate of the illness or an increased ability to diagnose the illness. Autism affects boys 3 - 4 times more often than girls. Family income, education, and lifestyle do not seem to affect the risk of autism.

Some doctors believe the increased incidence in autism is due to newer definitions of autism. The term "autism" now includes a wider spectrum of children. For example, a child who is diagnosed with high-functioning autism today may have been thought to simply be odd or strange 30 years ago. Other pervasive developmental disorders include: y y y y Asperger syndrome (like autism, but with normal language development) Rett syndrome (very different from autism, and only occurs in females) Childhood disintegrative disorder (rare condition where a child learns skills, then loses them by age 10) Pervasive developmental disorder - not otherwise specified (PDD-NOS), also called atypical autism

Most parents of autistic children suspect that something is wrong by the time the child is 18 months old and seek help by the time the child is age 2. Children with autism typically have difficulties in: y y y Pretend play Social interactions Verbal and nonverbal communication

Some children with autism appear normal before age 1 or 2 and then suddenly "regress" and lose language or social skills they had previously gained. This is called the regressive type of autism. People with autism may: y Be overly sensitive in sight, hearing, touch, smell, or taste (for example, they may refuse to wear "itchy" clothes and become distressed if they are forced to wear the clothes) Have unusual distress when routines are changed Perform repeated body movements Show unusual attachments to objects

y y y

The symptoms may vary from moderate to severe. Communication problems may include: y y y y y Cannot start or maintain a social conversation Communicates with gestures instead of words Develops language slowly or not at all Does not adjust gaze to look at objects that others are looking at Does not refer to self correctly (for example, says "you want water" when the child means "I want water") Does not point to direct others' attention to objects (occurs in the first 14 months of life) Repeats words or memorized passages, such as commercials Uses nonsense rhyming

y y y

Social interaction:

y y y y y y y

Does not make friends Does not play interactive games Is withdrawn May not respond to eye contact or smiles, or may avoid eye contact May treat others as if they are objects Prefers to spend time alone, rather than with others Shows a lack of empathy

Response to sensory information: y y y y y y Play: y y y Doesn't imitate the actions of others Prefers solitary or ritualistic play Shows little pretend or imaginative play Does not startle at loud noises Has heightened or low senses of sight, hearing, touch, smell, or taste May find normal noises painful and hold hands over ears May withdraw from physical contact because it is overstimulating or overwhelming Rubs surfaces, mouths or licks objects Seems to have a heightened or low response to pain

Behaviors: y y y y y y y y "Acts up" with intense tantrums Gets stuck on a single topic or task (perseveration) Has a short attention span Has very narrow interests Is overactive or very passive Shows aggression to others or self Shows a strong need for sameness Uses repetitive body movements

Signs and tests

All children should have routine developmental exams done by their pediatrician. Further testing may be needed if the doctor or parents are concerned. This is particularly true if a child fails to meet any of the following language milestones:

y y y y y

Babbling by 12 months Gesturing (pointing, waving bye-bye) by 12 months Saying single words by 16 months Saying two-word spontaneous phrases by 24 months (not just echoing) Losing any language or social skills at any age

These children might receive a hearing evaluation, blood lead test, and screening test for autism (such as the Checklist for Autism in Toddlers [CHAT] or the Autism Screening Questionnaire). A health care provider experienced in diagnosing and treating autism is usually needed to make the actual diagnosis. Because there is no biological test for autism, the diagnosis will often be based on very specific criteria from a book called the Diagnostic and Statistical Manual IV. An evaluation of autism will often include a complete physical and nervous system (neurologic) examination. It may also include a specific screening tool, such as: y y y y y Autism Diagnostic Interview - Revised (ADI-R) Autism Diagnostic Observation Schedule (ADOS) Childhood Autism rating Scale (CARS) Gilliam Autism Rating Scale Pervasive Developmental Disorders Screening Test - Stage 3

Children with known or suspected autism will often have genetic testing (looking for chromosome abnormalities) and may have metabolic testing. Autism includes a broad spectrum of symptoms. Therefore, a single, brief evaluation cannot predict a child's true abilities. Ideally, a team of different specialists will evaluate the child. They might evaluate: y y y y y y Communication Language Motor skills Speech Success at school Thinking abilities

Sometimes people are reluctant to have a child diagnosed because of concerns about labeling the child. However, without a diagnosis the child may not get the necessary treatment and services.

An early, intensive, appropriate treatment program will greatly improve the outlook for most young children with autism. Most programs will build on the interests of the child in a highly structured schedule of constructive activities. Visual aids are often helpful. Treatment is most successful when it is geared toward the child's particular needs. An experienced specialist or team should design the program for the individual child. A variety of therapies are available, including:

y y y y y

Applied behavior analysis (ABA) Medications Occupational therapy Physical therapy Speech-language therapy

Sensory integration and vision therapy are also common, but there is little research supporting their effectiveness. The best treatment plan may use a combination of techniques. APPLIED BEHAVIORAL ANALYSIS (ABA) This program is for younger children with an autism spectrum disorder. It can be effective in some cases. ABA uses a one-on-one teaching approach that reinforces the practice of various skills. The goal is to get the child close to normal developmental functioning. ABA programs are usually done in a child's home under the supervision of a behavioral psychologist. These programs can be very expensive and have not been widely adopted by school systems. Parents often must seek funding and staffing from other sources, which can be hard to find in many communities. TEACCH Another program is called the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH). TEACCH was developed as a statewide program in North Carolina. It uses picture schedules and other visual cues that help the child work independently and organize and structure their environments. Though TEACCH tries to improve a child's adaptation and skills, it also accepts the problems associated with autism spectrum disorders. Unlike ABA programs, TEACCH programs do not expect children to achieve typical development with treatment. MEDICINE Medicines are often used to treat behavior or emotional problems that people with autism may have, including: y y y y y y y y y y y Aggression Anxiety Attention problems Extreme compulsions that the child cannot stop Hyperactivity Impulsiveness Irritability Mood swings Outbursts Sleep difficulty Tantrums

Currently, only risperidone is approved to treat children ages 5 - 16 for the irritability and aggression that can occur with autism. Other medicines that may also be used include SSRIs, divalproex sodium and other mood stabilizers, and possibly stimulants such asmethylphenidate. There is no medicine that treats the underlying problem of autism. DIET Some children with autism appear to respond to a gluten-free or casein-free diet. Gluten is found in foods containing wheat, rye, and barley. Casein is found in milk, cheese, and other dairy products. Not all experts agree that dietary changes will make a difference, and not all studies of this method have shown positive results. If you are considering these or other dietary changes, talk to both a doctor who specializes in the digestive system (gastroenterologist) and a registered dietitian. You want to be sure that the child is still receiving enough calories, nutrients, and a balanced diet. OTHER APPROACHES Beware that there are widely publicized treatments for autism that do not have scientific support, and reports of "miracle cures" that do not live up to expectations. If your child has autism, it may be helpful to talk with other parents of children with autism and autism specialists. Follow the progress of research in this area, which is rapidly developing. At one time, there was enormous excitement about using secretin infusions. Now, after many studies have been conducted in many laboratories, it's possible that secretin is not effective after all. However, research continues.

Support Groups
For organizations that can provide additional information and help on autism, see autism resources.

Expectations (prognosis)
Autism remains a challenging condition for children and their families, but the outlook today is much better than it was a generation ago. At that time, most people with autism were placed in institutions. Today, with the right therapy, many of the symptoms of autism can be improved, though most people will have some symptoms throughout their lives. Most people with autism are able to live with their families or in the community. The outlook depends on the severity of the autism and the level of therapy the person receives.

Autism can be associated with other disorders that affect the brain, such as: y y y Fragile X syndrome Mental retardation Tuberous sclerosis

Some people with autism will develop seizures. The stresses of dealing with autism can lead to social and emotional complications for family and caregivers, as well as the person with autism.

Calling your health care provider

Parents usually suspect that there is a developmental problem long before a diagnosis is made. Call your health care provider with any concerns about autism or if you think that your child is not developing normally.

1. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2002 Principal Investigators; Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders-autism and developmental disabilities monitoring network, 14 sites, United States, 2002. MMWR Surveill Summ. 2007 Feb 9;56(1):12-28. [PubMed] Johnson CP, Myers SM; American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120:11831215. [PubMed] Dover CJ, Le Couteur A. How to diagnose autism. Arch Dis Child. 2007;92:540-545. [PubMed] Shah PE, Dalton R, Boris NW. Pervasive developmental disorders and childhood psychosis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 29. Bertoglio K, Hendren RL. New developments in autism. Psychiatr Clin North Am. 2009;32:1-14. [PubMed]


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Attention deficit hyperactivity disorder (ADHD)

ADD; ADHD; Childhood hyperkinesis
Last reviewed: April 11, 2011.

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child's age and development.

Causes, incidence, and risk factors

ADHD is the most commonly diagnosed behavioral disorder of childhood. It affects about 3 - 5% of school aged children. ADHD is diagnosed much more often in boys than in girls. ADHD may run in families, but it is not clear exactly what causes it. Whatever the cause may be, it seems to be set in motion early in life as the brain is developing. Imaging studies suggest that the brains of children with ADHD are different from those of other children. Depression, lack of sleep, learning disabilities, tic disorders, and behavior problems may be confused with, or appear with, ADHD. Every child suspected of having ADHD should be carefully examined by a doctor to rule out possible other conditions or reasons for the behavior. Most children with ADHD also have at least one other developmental or behavioral problem. They may also have a psychiatric problem, such as depression or bipolar disorder.

The symptoms of ADHD fall into three groups: y y y Lack of attention (inattentiveness) Hyperactivity Impulsive behavior (impulsivity)

Some children with ADHD primarily have the inattentive type. Others may have a combination of types. Those with the inattentive type are less disruptive and are more likely to not be diagnosed with ADHD. Inattentive symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9. Fails to give close attention to details or makes careless mistakes in schoolwork Has difficulty keeping attention during tasks or play Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace Has difficulty organizing tasks and activities Avoids or dislikes tasks that require sustained mental effort (such as schoolwork) Often loses toys, assignments, pencils, books, or tools needed for tasks or activities Is easily distracted Is often forgetful in daily activities

Hyperactivity symptoms:

1. 2. 3. 4. 5.

Fidgets with hands or feet or squirms in seat Leaves seat when remaining seated is expected Runs about or climbs in inappropriate situations Has difficulty playing quietly Is often "on the go," acts as if "driven by a motor," talks excessively

Impulsivity symptoms: 1. 2. 3. Blurts out answers before questions have been completed Has difficulty awaiting turn Interrupts or intrudes on others (butts into conversations or games)

Signs and tests

Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue. The diagnosis is based on very specific symptoms, which must be present in more than one setting. y Children should have at least 6 attention symptoms or 6 hyperactivity/impulsivity symptoms, with some symptoms present before age 7. The symptoms must be present for at least 6 months, seen in two or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties in many settings, including home, school, and in relationships with peers.

In older children, ADHD is in partial remission when they still have symptoms but no longer meet the full definition of the disorder. The child should have an evaluation by a doctor if ADHD is suspected. Evaluation may include: y y y Parent and teacher questionnaires (for example, Connors, Burks) Psychological evaluation of the child AND family, including IQ testing and psychological testing Complete developmental, mental, nutritional, physical, and psychosocial examination

Treating ADHD is a partnership between the health care provider, parents or caregivers, and the child. For therapy to succeed, it is important to: y y y Set specific, appropriate target goals to guide therapy. Start medication and behavior therapy. Follow-up regularly with the doctor to check on goals, results, and any side effects of medications. During these check-ups, information should be gathered from parents, teachers, and the child.

If treatment does not appear to work, the health care provider should:

y y y

Make sure the child indeed has ADHD Check for other, possible medical conditions that can cause similiar symptoms Make sure the treatment plan is being followed

MEDICATIONS A combination of medication and behavioral treatment works best. There are several different types of ADHD medications that may be used alone or in combination. Psychostimulants (also known as stimulants) are the most commonly used ADHD drugs. Although these drugs are called stimulants, they actually have a calming effect on people with ADHD. These drugs include: y Amphetamine-dextroamphetamine (Adderall) y Dexmethylphenidate (Focalin) y Dextroamphetamine (Dexedrine, Dextrostat) y Lisdexamfetamine (Vyvanse) y Methylphenidate (Ritalin, Concerta, Metadate, Daytrana) A nonstimulant drug called atomoxetine (Strattera) may work as well as stimulants, and may be less likely to be misused. Some ADHD medicines have been linked to rare sudden death in children with heart problems. Talk to your doctor about which drug is best for your child. BEHAVIOR THERAPY Talk therapy for both the child and family can help everyone understand and gain control of the stressful feelings related to ADHD. Parents should use a system of rewards and consequences to help guide their child's behavior. It is important to learn to handle disruptive behaviors. Support groups can help you connect with others who have similar problems. Other tips to help your child with ADHD include: y y Communicate regularly with the child's teacher. Keep a consistent daily schedule, including regular times for homework, meals, and outdoor activities. Make changes to the schedule in advance and not at the last moment. Limit distractions in the child's environment. Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients. Make sure the child gets enough sleep. Praise and reward good behavior. Provide clear and consistent rules for the child.

y y y y y

Alternative treatments for ADHD have become popular, including herbs, supplements, and chiropractic treatments. However, there is little or no solid evidence that these work.

Expectations (prognosis)
ADHD is a long-term, chronic condition. If it is not treated appropriately, ADHD may lead to:

y y y y

Drug and alcohol abuse Failure in school Problems keeping a job Trouble with the law

About half of children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, adults are often more capable of controlling behavior and masking difficulties.

Calling your health care provider

Call your doctor if you or your child's school personnel suspect ADHD. You should also tell your doctor about any: y y y Difficulties at home, school, and in relationships with peers Medication side effects Signs of depression

Although there is no proven way to prevent ADHD, early identification and treatment can prevent many of the problems associated with ADHD.

1. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921. [PubMed] Prince JB, Spencer TJ, Wilens TE, Biederman J. Pharmacotherapy of attention-deficit/hyperactivity disorder across the life span. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 49.