This document provides information on autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). It discusses the prevalence, symptoms, diagnostic criteria, etiology, course, and treatment options for both conditions. For ASD, it describes early markers, regression patterns, intelligence outcomes, communication issues, and restricted behaviors. It also outlines the DSM-5 diagnostic criteria. For ADHD, it discusses genetic and environmental risk factors, clinical features across the lifespan, diagnostic criteria, and prognosis. Both conditions are treated primarily with stimulant medications and behavioral therapies.

1. AUTISM & ADHD
DR. PIYUSH OJHA
DM RESIDENT
DEPARTMENT OF NEUROLOGY
GOVT MEDICAL COLLEGE, KOTA

2. • Current estimated frequency – 1 per 100
children
• Males >>> females ( 4 times)
• Both advanced maternal and paternal age
may play a role (Durkin et al 2008)
• High concordance in monozygotic twins (5-
10%)
AUTISTIC SPECTRUM DISORDERS
(ASD)

3. • Symptoms of ASD often change with age.
• Early markers of the disease include
• Atypical eye contact
• Decreased response to name
• Poor imitation
• Absent social smile
• Passive temperament
• Delayed language
AUTISTIC SPECTRUM DISORDERS
(ASD)

4. • Sibling studies suggest there are both early-onset(clear
by 12 months) and late-onset(clear by 18 months)
forms of autism. (Zwaigenbaum et al 2009)
• Approx 1/3 of autistic children regress between ages of
1-3, with a peak at 2 years. (Lord et al 2004)
• Conversely some toddlers and preschoolers with
typical symptoms of autism may no longer appear
autistic by school age.
• Most children however retain the typical features of
autism, particularly those who are intellectually
impaired.
AUTISTIC SPECTRUM DISORDERS
(ASD)

5. • Outcome studies of children diagnosed with ASD
have shown that although 40% may show overall
improvement during adolescence, as many as 1/3
may deteriorate (Howlin et al 2005).
• Autistic adults who are not intellectually impaired
tend to improve more than those who are
intellectually impaired.
AUTISTIC SPECTRUM DISORDERS
(ASD)

6. • INTELLIGENCE & COGNITION :-
– IQ is not a defining criteria for ASD diagnosis.
– 70-85% children with ASD are intellectually
disabled.
– IQ is a key predictor of long-term outcome in
autism, especially those with <50 – fare poorly.
– So normal IQ is a positive prognostic sign.

7. • COMMUNICATION :-
– Verbal & nonverbal communication disturbance
are cardinal features.
– Lower functioning ASD children have echolalia
with common stereotyped phrases.
– Some children may have verbal auditory agnosia.
– Higher functioning children talk too much with
with semantic and pragmatic defects.
– Long term prognosis correlate with language skill
at 5-6 yr age.
– Pretend play is often impaired.

8. • SOCIAL SKILLS :-
– Social dysfunction is a cardinal feature of ASD.
– “The Aloof Child” most resembles the popular
notion of autism.
– Donot follow their parents around, run to greet
them or seek comfort.
– Donot make social approaches, but accept when
made by others.
– Engage in pretend play but take a passive role.

9. • RESTRICTED RANGE OF BEHAVIORS, INTERESTS AND
ACTIVITIES :-
– Another cardinal feature of autism.
– Consist of repetitive stereotyped behaviors like
rocking, flapping, licking and opening and closing
doors.
– Tic disorders and obsessive-compulsive disorders
may be another manifestation.

10. EVALUATION OF ASD
• Clinical history and observation of child are the basis for
diagnosis of an ASD.
• Several questionnaires for parents are available for
quantifying the diagnostic criteria.
• For young children – the Modified Checklist for Autism in
Toddlers (M-CHAT)
• The Autism Diagnostic Observation Scale(ADOS) and Autism
Diagnostic Interview-Revised (ADI-R) are the gold standard
diagnostic measures but are time consuming and require
special training to administer.

11. • Neurological examination is generally normal.
• Often clumsy.
• Macrocephaly occurs in approx 1/3 of cases.
• Tuberous sclerosis is probably the most common
definable cause of Autism.
• Audiometry testing to rule out hearing disorders.
• EEG to exclude subclinical seizures when there is
impaired language comprehension or
developmental regression.
• Mild to severe epilepsy – 1/3 cases and onset
may play a role in deterioration.

12. ETIOLOGY OF ASD
• Neuropsychological theories :-
– Underdeveloped theory of mind(TOM)
– Weak central coherence
– Executive dysfunction

13. AUTISTIC SPECTRUM DISORDERS
(ASD)
• Diagnosis currently requires early onset of
triad of :
– Impaired sociability
– Impaired verbal and non-verbal communication
and
– Restricted activity and interests. (Rapin and
Tuchman 2006)

14. TENTATIVE DSM-5 CRITERIA FOR AN AUTISTIC
SPECTRUM DISORDER DIAGNOSIS
1. Clinically significant, persistent deficits in social
communication and interaction , as manifested by all of
following :
a. Marked deficits in nonverbal and verbal communication
used for social interaction
b. Lack of social reciprocity
c. Failure to develop and maintain peer relationships
appropriate to developmental level

15. TENTATIVE DSM-5 CRITERIA FOR AN AUTISTIC
SPECTRUM DISORDER DIAGNOSIS
2. Restricted, repetitive patterns of behavior, interests and
activities, as manifested by at least TWO of the following :
a. Stereotyped motor and verbal behaviors or
unusual sensory behaviors
b. Excessive adherence to routines and ritualized patterns
of behavior
c. Restricted, fixated interests
3. Symptoms must be present in early childhood (but may
not manifest until social demands exceed limited
capacities)
DSM = Diagnostic and Stastical Manual of Mental Disorders

16. MEDICATIONS FOR AUTISM
• HYPERACTIVITY AND INATTENTION :-
– Psychostimulants (Methylphenidate, Dextroamphetamine),
clonidine
• OBSESSIVE COMPULSIVE DISORDERS :-
– TCA’s, SSRI ( Fluoxetine, Setraline, Paroxetine,
Fluvoxamine) ; Atypical Neuroleptics (Olanzapine etc)
• AGGRESSIVE & IMPULSIVE BEHAVIORS :-
– Mood stabilizers (Carbamazepine, Divalproex sodium,
Gabapentin, Lithium) ; clonidine ; Beta-blockers
(Propranolol)

17. MEDICATIONS FOR AUTISM
• TICS AND STEREOTYPES :-
– Clonidine, Clonazepam, Haloperidol, Baclofen, Deep brain
stimulation
• SELF MUTILATION :-
– Naloxone, propranolol, fluoxetine, clomipramine, lithium
• PSYCHOSIS:-
– Neuroleptics, Haloperidol, Risperidone, Olanzapine

18. ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)

19. • First described in 1902 by George Still
• Most common childhood behavioral disorder
diagnosed in outpatient settings in the US.
• Worldwide prevalence = 5.2%
ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)

20. • According to the DSM-IV criteria, ADHD is a
behavioral and neurocognitive condition
characterized by developmentally
inappropriate and impairing levels of gross
motor overactivity, inattention, and
impulsivity.
ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)

21. ETIOLOGY OF ADHD
• The exact etiology is yet to be determined.
• Growing consensus-functional and anatomical
dysfunction in the brain's frontal cortex and basal
ganglia segments of the cortico-basal ganglia-
thalamo-cortical circuitry.
• Family studies have suggested that genetic
factors play an important role in ADHD.
• First-degree relatives of children with ADHD have
a 20 to 25 percent risk for ADHD.
• If a parent has ADHD, 50 percent of his or her
offspring are likely to have that condition.

22. • Dopamine appears to be the primary
neurotransmitter involve in ADHD.(Cools 2008)
• The dopamine D4 receptor (DRD4) has been the
most well studied and is prevalent in basal
ganglia-frontal networks implicated in the
pathophysiology of ADHD.
• Most structural and functional imaging studies
have shown abnormalities in frontal and striatal
regions

23. POSSIBLE ENVIRONMENTAL CAUSES/
CONTRIBUTORS TO ADHD
• Chronic illness : asthma, celiac disease, sleep disorder
• Endocrine : thyrotoxicosis, hypothyroidism
• Epilepsy
• Genetic disorder : Turner syndrome, Fragile X syndrome
• Infections : otitis media, HIV
• Metabolic disorders : phenylketonuria
• Prematurity
• Psychosocial adversity
• Toxins (pre & postnatal) : maternal smoking, alcohol, lead,
mercury
• Trauma : head injury

24. CLINICAL FEATURES OF ADHD
• Most children with ADHD are referred for care
because of impairment in academic, family,
and/or peer relationship functioning.
• Symptoms of impulsivity, overactivity, and
inattention drive this impairment across the
lifespan.
• Symptoms of gross motor overactivity decreases
with age
• Impairment from inattention and impulsivity may
continue with age

25. • There are 5 main diagnostic criteria:
(1) an onset before age 7 years
(2) duration greater than 6 months
(3) an 18-item symptom list of which 6 of 9 inattention
or 6 of 9 hyperactive/impulsive symptoms have
persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental
level.
(4) some impairment in two or more settings (eg at
school and at home) ; and
(5) symptoms that do not occur exclusively during the
course of a pervasive developmental disorder,
schizophrenia, or other psychotic disorder and are not
better accounted for by another mental disorder, such
as depression.

26. • There must be clear evidence of clinically
significant impairment in social, academic, or
occupational functioning.

27. CRITERIA FOR DIAGNOSIS OF ADHD
ADHD HYPERACTIVE,
IMPULSIVE SYMPTOMS
ADHD INATTENTION
SYMPTOMS
• Fidgets with hands or feet
• Leaves seat in classroom or
situations where sitting is expected
• Runs about or climbs
excessively inappropriately
• Has difficulty playing quietly
• Often on the go “as if driven by a
motor”
• Talks excessively
• Blurts out answers even before
question is completed
• Difficulty awaiting turn
• often interrupts others
• Has difficulty sustaining
attention &makes careless
mistakes
• Doesnot give close attention to
details
• Doesnot seem to listen
• Doesnot follow through
• Has difficulty organizing tasks
• Avoids engaging in tasks
requiring sustained mental
effort (eg homework)
• Often loses necessary things
(toys, pencil, books etc)
• Easily distracted
• Forgetful in daily activities

28. OTHER FEATURES OF ADHD
• Due to lack of Persistence - become bored with
interactive games with peers - leave such games
early even before they are finished.
• Often show difficulty with time management with
inability to maintain an internal sense of pace in
planning tasks.
• Impaired executive functioning with disturbed
goal-directed behavior.
• Recent data show - academic functioning is more
strongly affected by impulsivity (to get through
tests quickly) rather than poor executive
functioning.

29. • Often associated with dysregulation of affect – leading
to temper outbursts, mood lability, and reactivity.
• Problems accurately interpreting nonverbal social cues
and do react inappropriately – reported by peers as
insensitive to the needs of others.
• Donot cooperate with other children or follow rules in
games.
• ADHD children often have strong reactions -
overreacting to situations - can be predictably
triggered by others, leading to teasing and ridicule - a
strong stimulus for peer rejection - shown to be a
reliable long-term negative predictor of development,
particularly in adolescence.

30. EVALUATION OF A CASE OF ADHD
• Detailed history (prenatal, perinatal, toddler,
and preschool phases of development) –
Primary basis of diagnosis.
• History should be taken from multiple
informants (parents, teachers etc).
• Neurological examination is generally normal.
• Executive frontal lobe functions – ability to
initiate, inhibit, sustain and shift attention,
organizational skills – are often impaired.

31. COURSE & PROGNOSIS
• Approximately 60 % of those who develop
childhood ADHD continue to be impaired well
into adult life.
• Adult ADHD prevalence - 4 %
• Present with instability in job status and
relationships
• Serious psychiatric or antisocial disorders in 40-
50%.
• Substance abuse esp alcohol is very common.

32. TREATMENT OF ADHD
• STIMULANTS – Methylphenidate, dextroamphetamine
• ALPHA-AGONISTS – Clonidine
• ANTIDEPRESSANTS – SSRI’s, TCA, SNRI’s (venlafaxine,
duloxetine)
• ANTIMANIAC – Lithium
• MOOD STABILISERS – Carbamazepine, Divalproex
sodium,Gabapentin, Topiramate
• BETA BLOCKERS – Propranolol
• NON STIMULANTS – Atomoxetine, Modafinil

33. • Medication particularly Psychostimulants are the
mainstay of therapy.
• The National Institute of Health (NIH) sponsored
Multimodal Treatment study of ADHD (MTA) has
shown both behaviorally and by neuropsychological
testing that Stimulants work and they even work
better than behavioral modification.(Biederman et al
2006)

34. • Approximately 75% of children respond to
stimulants initially.
• Longitudinal data from MTA study has shown
that effectiveness of medication may decrease
over time.
• Early initiation of medical therapy into the
course has a better prognosis compared to
late initiation.

35. THANK YOU

36. REFERENCES
• Bradley’s Neurology in clinical practice 6th
edition
• Adams & Victor’s Principles of Neurology 10th
edition
• Kaplan & Sadock's Comprehensive Textbook of
Psychiatry, 9th Edition
• IAP Textbook of Pediatric Neurology