1. THE AUTISM EPIDEMIC
Ahmad Almai, M.D.
Head of
Child and Adolescent Psychiatry
BSP

2. Increasing Media Attention

3. .
UAE NEWSPAPERS
LIFE & STYLE | HEALTH
The rise of autism in the UAE
With more and more children being diagnosed as autistic in the
UAE, parents have to deal with the financial burden of treatment
and therapy, as well as the emotional fall-out, discovers Suchitra
Bajpai Chaudhary
By Suchitra Bajpai Chaudhary, Friday magazine
Published: 00:00 May 11, 2012
Credit: Dennis B. Mallari/GNM
Many UAE residents are still ‘clueless’ about
autism
This comes in face of the recent statistic that indicates a child
is diagnosed with autism every 20 minutes in the UAE
By Bindu Suresh Rai
Published Sunday, April 08, 2012
The blank stares that reflected in the eyes of many UAE
residents when quizzed over their knowledge of autism backed
the claim that more needs to be done in raising awareness for
this medical condition in the country.
The recently concluded World Autism Day on April 2, which was
also marked in Dubai, saw awareness for this developmental
condition still at its grassroots level with several members of
the public; this was supported further via the results of a spot
poll conducted by Emirates 24|7 that indicated only six per
cent of the 123 people questioned were aware of autism. A child undergoes therapy at the Dubai Autism Centre.
According to local experts, a child is diagnosed with autism
every 20 minutes in the UAE and one out of every 110 children
is autistic.

4. History of Autism
o Term autism originally used by Bleuler (1911)
o To describe withdrawal from social relations into a rich
fantasy life seen in individuals with schizophrenia
o Derived from the Greek autos (self) and ismos (condition)
o Leo Kanner – 1943
o Observed 11 children
o Inattention to outside world: “extreme autistic aloneness”
o Similar patterns of behavior in 3 main areas:
1. Abnormal language development and use
2. Social skills deficits and excesses
3. Insistence on sameness

5. History of Autism
o Psychiatrist Hans Asperger (1944) - describes “little
professor” syndrome
o Eisenberg and Kanner (1956)
o Added autism onset prior to age 2
o Further refined definition of autism
o Creak (1961)
o Developed 9 main characteristics
o Believed they described childhood schizophrenia
o Incorporated into many descriptions of autism and commonly used
autism assessment instruments today

6. History of Autism
o Rutter (1968)
o Said the term autism led to confusion!
o Argued autism was different than schizophrenia
o Higher M:F ratio
o Absence of delusions & hallucinations
o Stable course (not relapse/marked improvement)
o Further defined characteristics (for science, research)
o National Society for Autistic Children
o One of the 1st & most influential parent groups for children with autism in U.S.
o Wrote separate criteria (for public awareness, funding)
o Added disturbances in response to sensory stimuli & atypical development
o Did not include insistence on sameness

7. Diagnostic and Statistical
Manual of Mental Disorders
o Published by the American Psychiatric Association
oClassification of mental disorders used in the US
oInfantile autism included for
first time in DSM-III
oChanged to autism in DSM-III-R
oDSM – IV published in 1994
o Text Revision in 2000

8. Pervasive Developmental
Disorders
o Come under section in DSM-IV-TR entitled…
o Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
o Includes
o Mental retardation
o Learning disorders
o Motor skills disorders
o Communication disorders
o Pervasive developmental disorders
o Attention-deficit and disruptive behavior disorders
o Feeding and eating disorders of infancy or early childhood
o Tic disorders
o Elimination disorders
o Others: separation anxiety disorder, selective mutism, reactive attachment disorder of
infancy or early childhood, stereotypic movement disorder, disorder of infancy,
childhood, or adolescence - NOS

9. DSM Category: PDDs
Pervasive Developmental Disorders
Childhood
Autistic Rett’s
Disintegrative
Disorder Disorder
Disorder
PDD-
Asperger’s
Not Otherwise
Disorder
Specified
• PDDs are characterized by severe and pervasive impairment in 3 main areas
• Social interaction
• Communication
• Repetitive and restricted behaviors

10. Autistic Disorder.
Impairment in social interaction .
Impairment in verbal and non Restricted, repetitive and
verbal communication. stereotyped patterns of behaviour.
Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in
children: epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11-29.

11. Autism
Sensory
Sensory
sensitivity
sensitivity
Seizures
Communication Repetitive
& language & Self-injurious
deficit stereotyped behavior
behaviors
Mental
retardation
Social Sleep
interaction disturbance
deficits
GI problems
Immune
Immune
problems
problems

12. Planned changes in autism diagnostic criteria
• Revisions to the current DSM-IV are being finalized in 2012, with DSM-V
due for publication in May, 2013.
• Reason for proposed changes: attempt to establish more
reproducibility and homogeneity in diagnosis

13. Planned changes in autism diagnostic criteria
Proposed changes:
– Eliminate subcategories including Asperger’s syndrome, PDD-
NOS, Rett syndrome, and childhood disintegrative disorder. All of
these would be subsumed under the umbrella term, autism spectrum
disorder (ASD).
– Instead of 3 domains of autism symptoms (repetitive behaviors
and deficits in social interaction and language), 2 categories would
be used: impairment in social communication and interaction, and
restricted interests/repetitive behaviors. No mention of verbal
language – it will be considered a co-morbidity.
– A new symptom would be included in the second category: hyper-
or hypo-reactivity to sensory input, or unusual interest in sensory
aspects of the environment.
– Each person will also be evaluated in terms of known genetic
causes, level of language and IQ, and presence of seizures and/or
GI problems.
– A new category of Social Communication Disorder will be added
to the DSM (people without repetitive behaviors).

14. Planned changes in autism diagnostic criteria
• Positives: The subtypes that will be eliminated cannot be reliably
distinguished by expert clinicians; more information will be required in
the diagnosis (genetics, IQ, GI issues, seizures, regression history,
nature of language impairment), so subtyping will be more
straightforward.
• Negatives: There is some concern that the criteria will exclude some
people who currently have the diagnosis, particularly the higher
functioning, milder cases, that do not display repetitive behaviors, for
instance. This may result in denying medical treatment and social
services to some people on the autism spectrum.

15. Planned changes in autism diagnostic criteria
• Three published studies suggest that 25-78% of Asperger's or high
functioning autism will be excluded from the autism diagnosis in DSM-V.
Two other, small studies did not support these conclusions, however.
• The Autism Speaks foundation is currently funding studies to determine
how many people might be excluded and what the healthcare
consequences might be.
• A significant change in diagnostic criteria in 2013 would complicate
future longitudinal studies of prevalence.

16. Prevalence Of Autism
• Went from 1 in 2500, to 1 in 1000, to 1 in 166 over
the past decade. Some recent studies 1:88.
• Autism is now more common than childhood
cancer, down’s syndrome, spina bifida or cystic
fibrosis.
• Boys are affected 4 times as often as girls but
unknown as to why.
• 1 out of 68 families will have a child with autism.
• Growing at a rate of 10-17 percent per year (it is
thought).

17. Prevalence Of Autism.
Prevalence of Autism
80
p
.
l
o
Number of cases per 10,000
60 n
j
m
40
i k
h
20
a c d g
e f
0 b
1965 1970 1975 1980 1985 1990 1995 2000 2005

18. What we know…
• ASD Prevalence is increasing (1992: 1 in 1500)
CDC - ASD in 8 year olds: California DDS on Autism:
2002: 1 in 150 12 fold inc from 1987 – 2007
2006: 1 in 110 13% annual growth

19. California DDS Increase in Autism Appears Specific
California DDS, 2009

21. % Visits to Child Psychiatry Clinic, BSP March, 2012

22. Assessment & Diagnosis
• Assessed on a behavioural basis.
• ICD-10 and DSM-IV; tick-list medical approach.
• Missed diagnosis and misdiagnosis.
– Multiple referral routes.
– Pressures on resources.
– Multiple assessment protocols.
• There’s also pressure NOT to diagnose (limited
support resources ).

23. Assessment & Diagnosis
The NICHD lists these five behaviours that
signal further evaluation is warranted:
– Does not babble or coo by 12 months.
– Does not gesture (point, wave, grasp) by 12
months.
– Does not say single words by 16 months.
– Does not say two-word phrases on his or her
own by 24 months.
– Has any loss of any language or social skill at
any age.

24. Assessment & Diagnosis
• It’s easier to ‘spot’ autism at the low functioning
end of the spectrum.
• High functioning children do adapt .
• Early intervention is critical.
– Younger children have a greater degree of brain
plasticity (Edelman, 1992).
• Late screening:
– Very few tools sensitive to adolescent/adult
diagnosis.
– Self-diagnosis common (AQ published on web).

26. “Trendy” Theories of Autism.
• Vaccines, MMR.
• Allergies.
• Gut/Intestine problems .
• Food intolerance.
• Environmental toxins.
• Refrigerator Mothers.
• Poor Parenting.
• Vitamin Deficiency.

27. Etiology: Psychodynamic Theory
• Eveloff (1960) – parents are cold, detached, ritualistic
• Bruno Bettelheim (1967)
– Coined term “refrigerator mothers”
• No empirical support

28. Etiology: Genetic Evidence
• Strong evidence for genetic
component, but nature of the
component is unknown
• Doesn’t look like a single gene
• Monozygotic twin concordance high,
but less than 100%

29. Aetiology And Theories Of Autism.
• Genetic/biological factors.
– 2-4% rates for siblings.
– MZ twins up to 96% concordance.
– DZ twins up to 27% concordance.
– More common after chromosomal, infections,
traumatic insults to CNS.
• One of the hallmarks of Autism is that the
characteristics vary significantly among different
children with autism. No two children with
Autism are the same.

30. Etiology: Neurotransmitters
• Serotonin
– Some studies have found higher levels in
children with ASD
• Opioids
– Display properties similar to morphine
– Administration can result in stereotypy,
insensitivity to pain, reduced socialization
– Some studies have found higher levels in
children with ASD

31. Etiology: Vaccines
• Vaccines
– Thimerosal - Preservative used in MMR vaccine used to contain
mercury
– Wakefield et al. (1998)
• 12 children with PDD and gastrointestinal disease
• Purpose was to look at relationship b/w these
• Participants were selected b/c they had been referred to a
pediatric gastroenterology dept for tx of intestinal problems (e.g.,
diarrhea, pain, bloating)
• Onset appeared to be near time of MMR vaccination
• Theory…MMR led to impaired intestinal functioning
– Permeability of the intestines increased
– Resulted in excess absorption of peptides from food
– The peptides have opioid effects
– Opioid excess led to brain dysfunction, and…
– Concluded that ASD was caused by MMR vaccine

32. Etiology: Vaccines
• Wakefield Study
• Methodological Issues
– Didn’t discuss specific diagnoses of participants (or how obtained)
– The exact onset of intestinal problems wasn’t known
– Evidence for link b/w behavior changes and MMR was based on
report
– Correlational study only
• Ethical Problems
• Financial and scientific conflicts that Dr. Wakefield did not reveal in
his paper.
• For instance, part of the costs of Dr. Wakefield’s research were paid
by lawyers for parents seeking to sue vaccine makers for damages.
• Dr. Wakefield was also found to have patented in 1997 a measles
vaccine that would succeed if the combined vaccine were
withdrawn or discredited.

33. Etiology: Vaccines
• In 2004, 10 of the 13 authors on the Wakefield et al.
study published an article in the same journal (The
Lancet) retracting the conclusions made in the original
article
• In 2010, the Lancet retracted the study altogether
• In May, 2010, Wakefield was banned from
practicing medicine in Great Britain due to
unprofessional conduct

34. Explanations for the rise in autism
• Increase in diagnosis, not actual incidence: better ascertainment;
financial and scholastic support is linked to this diagnosis; changing or
broadening of criteria of diagnosis
• Increase in maternal auto-immune disease (diabetes) and obesity:
These disorders are increasing and are associated with increased risk
for ASD in the offspring
• Hygiene hypothesis: cleaner environment leads to deficiency in
educating the immune system as well as increased asthma, allergies and
autoimmune disorders; over-use of antibiotics and anti-fever medications
may also contribute
• Environmental toxins:
– Lead
– PCBs (polychlorinated bi-phenyls)
– Organophosphate pesticides
– Endocrine disruptors
– Automotive exhaust
– Polycyclic aromatic hydrocarbons
– Brominated flame retardants
– Perfluorinated compounds

35. Time window of vulnerability
in fetal brain development – thalidomide example
First trimester is also the vulnerable time
for the maternal viral infection risk factor
Rodier, 2000

36. Immune involvement in autism
• The rate of autoimmune disease or allergies is higher in
families with autism, particularly in the mother
• Auto-antibodies directed against CNS antigens have been
detected in sera of autistic subjects, as well as in the sera of
mothers of autistic children
• Immune-related genes are dysregulated in autism brains;
microglia and astrocytes are activated; cytokines are
elevated in brain and cerebral spinal fluid

37. Cytokines are elevated in autistic brains
Vargas et al., 2005

38. Is There A Cure For Autism?
• No – a lifelong disorder.
• But people with Autism often make good progress
and develop coping strategies.
• Range of therapies and treatments but no real
consensus on what is most effective.
• Because there is a wide variability in people with
Autism there is a need to develop an individual
treatment and management plan.

39. Approach to treatment of Autism Spectrum
Disorders
Medical
Neurological
Treatment
Speech and
Social Skills
Occupational
Therapy
Therapy
Improved
Function
Vocational
Psychopharm.
Treatment
Skills
Training
Behavior
Education
Therapy

40. Behaviour Modification Treatment.
Many different types of behavioural based
interventions for ASD. but general agreement
that:
• Usually beneficial, sometimes very beneficial.
• Most beneficial with young children, but older
children can benefit.
• Despite the fact that Autism apparently is caused
by neurological abnormalities, the most effective
treatment for the disorder is highly structured
and intensive ‘Applied Behavioural Analysis’
(ABA). (See: Lovaas, 1987; McEachin et al., 1993; Smith et al., 2000.).
41

41. Collaborative Integrated Care
Mental/ Behavioral
Medical Care
Health Care
Education

42. THANK YOU
Questions?