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What are the guidelines for the diagnosis, treatment and rehabilitation of childhood autism?
I. Overview
(A) the concept
Autism in children, also known as autism in children, is a mental development disorder characterized by social communication barriers, communication barriers and limitations, rigid and repetitive behavior, which began before the age of 3. This is the most typical disease in a series of developmental disorders.
Generalized developmental disorders include childhood autism, Asperger's syndrome, Reiter's syndrome, child disintegration, atypical autism and other specific generalized developmental disorders. At present, there is a tendency to collectively refer to childhood autism, Asperger's syndrome and atypical autism as loneliness spectrum disorder, and the principles of diagnosis, treatment and rehabilitation are basically the same.
(2) Epidemiology
Autism in children is an increasingly common mental development disorder. The results of the second national sampling survey of disabled people show that children with mental disabilities (including multiple births) aged 0-6 years in China account for 1. 10‰ of the total number of children aged 0-6 years, which is about1.10000, of which 36 are children with mental disabilities caused by autism. Autism in children is more common in boys, and its prevalence rate has nothing to do with race, region, culture and socio-economic development level.
(III) Etiology
Children's autism is a psychological development disorder with biological basis caused by many factors, and it is a disease that occurs in individuals with genetic susceptibility under the action of specific environmental factors.
Genetic factors are the main cause of autism in children. Environmental factors, especially the critical period of fetal brain development, are also the causes of the disease.
Second, the clinical manifestations
(1) onset age
Autism in children begins before the age of 3, and gradually develops about 2/3 after birth, and develops about 1-2 years after normal development.
(2) Clinical manifestations
The symptoms of autism in children are complicated, but they are mainly manifested in the following three core symptoms.
1. Social barriers
Autistic children have qualitative defects in social communication. They lack interest in communicating with others to varying degrees, and they also lack normal communication methods and skills. The specific manifestations vary with age and severity of illness, especially with children of the same age.
(1) In infancy, children avoid eye contact, lack interest and response to other people's calls and teasing, do not expect to be picked up, or are stiff and unwilling to approach others when being picked up, lack a smile, and do not observe and imitate other people's simple actions.
(2) Early childhood: children still avoid eye contact, often ignore it, often have no attachment to their main caregivers, lack due fear of strangers, lack interest in interacting and playing with children of the same age, and have problems in communication methods and skills. Children will not attract others' attention to what they refer to through their eyes and voices, share happiness with others, seek comfort, express comfort and concern for others' physical discomfort or unhappiness, and often do not play games that require imagination and role-playing.
(3) School age: With the growth of age and the improvement of illness, children may become friendly and affectionate to their parents and compatriots, but they still lack the interest and behavior of actively communicating with others to varying degrees. Although some children are willing to communicate with others, there are still problems in communication methods and skills. They often entertain themselves, go their own way, go their own way, don't understand, and it is difficult to learn and follow general social rules.
(4) Adults: Patients still lack social interest and skills. Although some patients are eager to make friends and may be interested in the opposite sex, it is difficult to establish friendship, love and marriage because of their lack of proper understanding of social occasions, their lack of proper response to other people's interests and emotions, and their difficulty in understanding humor and metaphor.
2. Communication barriers
Autistic children have obstacles in both verbal and nonverbal communication. Among them, speech communication disorder is the most prominent, which is usually the main reason for children to see a doctor.
(1) Speech communication disorder
1 speech delay or lack: children often speak late, and their speech progress is slow after they can speak. Children with late onset may have relatively normal speech development stage, but after onset, speech gradually decreases or even disappears completely. Some children are speechless about life.
② Impaired speech comprehension: Children's speech comprehension is impaired to varying degrees, and most mild patients can't understand humor, idioms and metaphors.
③ Abnormal speech form and content: For children with speech, the speech form and content are often obviously abnormal. Children often imitate words immediately, that is, repeat what others have just said; Postpone imitation speech, that is, repeat what you have heard before or advertisement; Stereotype repetition means repeating some words, saying a thing or asking a question.
Children may use special and fixed speech forms to communicate with others, such as answering irrelevant questions, lack of connection between sentences, grammatical structure errors, unclear personal pronouns and so on.
④ Abnormal intonation, speech speed, rhythm and stress. Children's intonation is often dull, lacking cadence, unable to use intonation and tone changes to assist communication, and often has problems with speech speed and rhythm.
⑤ Impaired speech ability: Children's speech organization and speech ability are obviously impaired. Children have little active speech, and most of them will not express their wishes or describe events with the words they have learned. They don't take the initiative to raise or maintain the topic, or only rely on the rigid discourse they are interested in to communicate, repeating the same thing or entangled in the same topic. Some children will use certain self-created phrases to express fixed meanings.
(2) Non-verbal communication barriers
Autistic children often hold other people's hands and reach for what they want, but there are few other expressions, movements and gestures used for communication. Most of them don't express their ideas by nodding, shaking their heads, gestures and actions, and their expressions often lack change when interacting with people.
3. Narrow interests and rigid and repetitive behaviors.
Autistic children tend to deal with daily life in a rigid and rigid way. The specific performance is as follows:
(1) Narrow range of interests: children are not interested, and the things they are interested in are often different.
Children are usually not interested in toys, cartoons and other things that normal children are interested in, but are obsessed with watching TV advertisements, weather forecasts, rotating objects, arranging objects or listening to a piece of music, a monotonous and repetitive voice, etc. Some children can concentrate on words, numbers, dates, timetable calculation, maps, paintings, musical instruments and so on. , and can show unique ability.
(2) Stereotype and repetition of behavior: Children often insist on doing things in the same way, refusing the laws of daily life or changes in the environment. If the routine or environment of daily life changes, children will be restless. Children will play with toys repeatedly in the same way, draw a picture or write a few words repeatedly, stick to a fixed route, put things in a fixed position, and refuse to change clothes or eat only a few foods.
(3) Special attachment to inanimate objects: Children usually lack interest in people or animals, but may have a strong attachment to some inanimate objects, such as bottles, boxes and ropes. It may make children fondle admiringly and carry it at any time. If it is taken away, it will make you fidgety, cry and be anxious.
(4) The weird behavior of rigid repetition: Children often have rigid repetition and weird actions, such as jumping repeatedly, clapping, slapping, staring at the eyes with their hands, walking on tiptoe, etc.
It is also possible to have special interest and behavior in some non-main and non-functional features (smell, texture) of objects, such as repeatedly smelling objects or touching smooth surfaces.
4. Other performances
In addition to the above-mentioned core symptoms, autistic children often have behaviors such as self-laughing, emotional instability, impulsive attacks and self-injury. Cognitive development is unbalanced, and music, mechanical memory (especially word memory) and computing ability are relatively good or even extraordinary. Most children have sleep disorders before the age of 8, of which about 75% are accompanied by mental retardation, 64% have attention disorder, 36% ~ 48% have hyperactivity, 6.5% ~ 8. 1% have Tourette syndrome, 4% ~ 42% have epilepsy and 2.9%.
The above symptoms and accompanying diseases complicate the child's condition and increase the difficulty of diagnosis, which requires more treatment and intervention measures.
Third, diagnosis and differential diagnosis
(1) diagnosis
Autism in children is mainly diagnosed according to the diagnostic criteria by asking medical history, mental examination, physical examination, psychological evaluation and other auxiliary examinations.
1. Ask for medical history
First of all, we should know the growth and development process of children in detail, including the development of sports, speech and cognitive ability. Then ask the underdeveloped areas and the behaviors that make parents feel abnormal, and pay attention to the age, duration, frequency and influence on daily life of abnormal behaviors. At the same time, we should also collect information such as maternity history, family history, past history and medical history. The main points of consultation are as follows.
(1) What are the main problems of children at present? When does it start?
(2) History of speech development: When did you respond to calling his/her name? When did you start learning languages, such as the pronunciation of "father" and "mother"? When can I understand simple instructions? When can I say phrases? When can I say a word Has speech function regressed? Is there any abnormal pronunciation and intonation?
(3) Verbal communication skills: Can you answer questions raised by others? Do you actively communicate with others? Is it difficult to communicate? Can you talk to yourself and imitate words again and again?
Are there meaningless pronunciations such as chatter?
(4) Non-verbal communication skills: Do you express your needs with gestures and postures?
When do you point your finger at objects and pictures? Is there a tendency to replace verbal communication with nonverbal communication? Are facial expressions as rich as children of the same age?
(5) Social communication ability: When can we distinguish between relatives and strangers? When did you start to be afraid of strangers?
Are you attached to your main dependent? When will you point something with your finger to attract others' attention? Did you answer the call? Do you avoid eye contact? Can we play games like house? Can you play with other children? How? Will you comfort others or take the initiative to ask for help?
(6) Cognitive ability: Has cognitive ability regressed? Do you have superpowers? How about self-care ability? Has the ability of self-care regressed?
(7) Interest behavior: What is game ability? Is it the right age? Do you have any special interests or quirks? Is there too much activity or too little? Do you repeat strange hand movements or body movements? Do you rotate objects repeatedly? Do you have a special attachment to something?
(8) Exercise ability: When can you look up, sit alone, climb and walk? How about sports coordination? Have motor skills deteriorated or suffered from ataxia?
(9) Family history: Are there any parents or other relatives who are eccentric, indifferent, rigid, sensitive, anxious, stubborn, lack of verbal communication, social disorder or speech development disorder?
Any history of mental illness?
(10) Others: What is the family rearing environment? Have you ever had any major psychological trauma or shock? Do you go to school or kindergarten? How are you settling in at school? Have you ever had a serious physical illness? Have you ever been malnourished, hospitalized or separated from your loved ones due to physical illness?
Have you ever had a seizure? Do you use any special drugs? Is it a partial eclipse? How did you sleep?
2. Mental examination
Observation is the main method, and children with verbal ability should combine conversation. Checkpoints are as follows:
(1) How do children react to unfamiliar environment, strangers and parents leaving?
(2) Is the development level of children's speech comprehension and expression commensurate with their age? Is there any stereotyped repetition, immediate or delayed imitation of speech, self-stimulation speech? Can you follow the instructions around a topic?
(3) Does the child avoid eye contact with others? Do you communicate with gestures, nods or other gestures, postures and facial expressions?
(4) Does the child have empathy? If parents or examiners pretend to be hurt and painful, how does the child react? What's the reaction?
(5) Are children interested in toys and objects around them? How are toys used? What are their game abilities?
Does the child have stiff movements, compulsive behaviors, ritual behaviors and self-injury behaviors?
(7) Is the child's intellectual development level commensurate with his age? Do you have any better or special abilities?
Step 3 have a physical examination
Mainly about physical development, such as head circumference, facial features, height, weight, congenital malformation, audio-visual barrier-free, positive signs of nervous system, etc.
4. Psychological evaluation
(1) general screening scale
① Autism Behavior Scale (ABC): * * * 57 items, each item has a four-level score, with a total score of 365,438+0 indicating suspicious autism-like symptoms and a total score of 62 indicating autism-like symptoms, which is suitable for people aged 8 months to 28 years.
② Creutzfeldt-Jakob Autism Behavior Scale (CABS): * * * 14 items, each with two or three grades. The total score of the second grade is not less than 7 or the total score of the third grade is not less than 14, suggesting that there is a suspicious autism problem. The scale is aimed at people aged 2 ~ 15, and is suitable for rapid screening of children in child health clinics, kindergartens and schools.
When the results of the above screening scale are abnormal, they should be referred to professional institutions for further diagnosis.
(2) Common diagnostic scale
Children Autism Rating Scale (CARS) is a commonly used diagnostic tool. The scale has *** 15 items, and each item has four grades. A total score of less than 30 is non-autism, a total score of 30-36 is mild to moderate autism, and a total score of not less than 36 is severe autism.
The scale is suitable for people over two years old.
In addition, the Autism Diagnostic Observation Scale (ADOS-G) and the Autism Diagnostic Interview Scale (ADI- R) are widely used in foreign countries at present, but they have not been formally introduced and revised in China.
When using the screening scale, we should fully consider the possible false positive or false negative results. The evaluation results of the diagnostic scale can only be used as a reference for the diagnosis of autism in children, and can not replace the diagnosis made by clinicians based on comprehensive medical history and mental examination.
(3) develop the scale of assessment and intelligence test.
The scales that can be used for development assessment include Denver Development Screening Test (DDST), Gaither Development Diagnostic Scale (GDDS), Porter Early Development Checklist and Psychological Education Scale (PEP). Commonly used intelligence test scales include Wexler Intelligence Scale for Children (WISC), Wexler Intelligence Scale for Preschool Children (WPPSI), Stanford-Binet Intelligence Scale, Peabody Picture Vocabulary Test, Raven Progressive Model Test (RPM) and so on.
5. Auxiliary inspection
Laboratory examination can be selected according to clinical manifestations, including electrophysiological examination (such as EEG and evoked potentials), imaging examination (such as head CT or magnetic resonance imaging), genetic examination (such as karyotype analysis and fragile X chromosome examination), screening for metabolic diseases, etc.
(2) Diagnostic criteria
Refer to ICD diagnostic criteria for autism in children-10.
Abnormal development or damage before the age of 3, at least in one of the following fields:
(1) Feeling or expression language needed for interpersonal communication.
(2) the development of selective social attachment or social communication ability.
(3) Functional or symbolic games.
Have at least six symptoms under the following (1)(2)(3), at least two symptoms under (1) and at least one symptom under (2)(3):
(1) shows substantial abnormality in social communication ability in the next at least two generations:
① Eye contact, facial expression, posture and gestures cannot be properly applied to adjust social interaction.
(2) Although there are plenty of opportunities, it is impossible to develop a peer relationship suitable for their intellectual age, which can be used to share interests, activities and emotions.
(3) Lack of mutual communication of social emotions, which is manifested in biased or defective responses to other people's emotions, or inability to adjust one's behavior according to social occasions, or weak ability to integrate social, emotional and communicative behaviors.
(4) You can't spontaneously seek to share happiness, interests or achievements with others (such as not showing, expressing or pointing out what you are interested in to others).
(2) Substantial abnormality in communication ability, manifested in at least one of the following aspects:
(1) oral development is slow or lacking, and there is no attempt to compensate for communication by gestures or imitation (there was often no babbling communication before).
(2) When the other party responds to the conversation, it is relatively impossible to take the initiative to talk with others or let the conversation continue (any language skill level may happen).
(3) Use language rigidly and repeatedly, or use some words creatively.
(4) lack of spontaneous The Imitation Game, or (in the early years) unable to carry out social The Imitation Game.
(3) Limited, repetitive and rigid interests, activities and behavior patterns are manifested in at least one of the following aspects:
① Focus on one or more rigid and limited interests, and the interest content is abnormal or children pay attention to it, or although the content or form of children's attention is not abnormal, the intensity and limitation of their attention are still abnormal.
(2) obviously fixed on a special and useless routine or ceremony.
③ Stiff and repetitive weird movements, such as slapping, rubbing hands or fingers, or complex movements involving the whole body.
(4) infatuation with the nonfunctionality (such as smell, texture, noise or vibration) of an object or a part of a toy.
Clinical manifestations cannot be attributed to the following circumstances:
Other types of pervasive developmental disorders; Specific sensory language development disorder and secondary social emotional problems; Reactive attachment disorder or disinhibitory attachment disorder; Mental retardation with emotional/behavioral disorders; Schizophrenia and Rett syndrome in children and adolescents.
(3) Differential diagnosis
Autism in children needs to be differentiated from other subtypes of pervasive developmental disorders and other common mental and neurological diseases in children.
1. Asperger's syndrome
Asperger's syndrome is characterized by social barriers and interests, limited activities, stereotyped repetition, and normal or basically normal speech and intelligence development. Compared with children with autism, children with Asperger's syndrome are characterized by lack of social skills, verbal communication tends to focus on topics of interest and over-writing, and they may have a strong interest in certain subjects or knowledge, clumsy movements and backward motor skills.
2. Atypical autism
Atypical autism is diagnosed when the onset age is over 3 years old, or three core symptoms appear at the same time in clinical manifestations, and only two of them appear. Atypical autism can be seen in children with extremely severe mental retardation, children with normal or near-normal IQ, and autistic children whose school-age symptoms have improved or disappeared and no longer fully meet the diagnosis of childhood autism.
3. Reiter syndrome
Rett syndrome is almost only found in girls, and children develop normally in the early stage. They began to get sick at the age of 6 ~ 24 months, showing obvious deterioration of speech, intelligence and communication skills, as well as the loss of hand motor function and other nervous system symptoms. The following points play an important role in differential diagnosis: ① Children do not actively communicate and respond to other people's calls, but they can maintain a social smile, that is, smile and stare at others; (2) Stiffness of hand movements is a characteristic manifestation of this disorder, which can be manifested as "washing hands" and "rubbing hands"; ③ With the development of the disease, the children's hand grasping function gradually lost; ④ Hyperventilation; ⑤ Dyskinesia of trunk.
4. Childhood disintegration disorder
Also known as Heller syndrome, infantile dementia. The child's development is completely normal before the age of two, and skills are rapidly lost after the onset, and communication barriers and stereotyped repetitive behaviors similar to children's autism appear. It is difficult to distinguish this disorder from childhood autism that develops after a period of normal development. The main difference is that all the existing skills of children with Heller's syndrome are completely degraded and lost after the onset, and it is difficult to recover.
5. Speech and language development barriers
This obstacle is mainly manifested in the fact that the ability of speech understanding or expression is obviously lower than the level it should be. Children have no obvious obstacles in nonverbal communication, good social skills, narrow interests and rigid and repetitive behaviors.
6. mental retardation
The main manifestations of children with mental retardation are mental retardation and poor social adaptability, but they still retain their communication ability equivalent to their intelligence, and there is no social communication and verbal communication damage with autism characteristics. At the same time, their interests are narrow and their behaviors are rigid and repetitive, which is not as good as autism and children are prominent.
7. Schizophrenia in children and adolescents
Schizophrenia in children and adolescents mostly occurs in adolescence, and rarely occurs in preschool age. There are no reports of onset before the age of 3, which is different from childhood autism.
Some clinical manifestations of this disease are similar to those of childhood autism, such as withdrawn personality, laughing at oneself, indifference and so on. There are also psychotic symptoms such as hallucinations, pathological fantasies or delusions. Children with this disease may have reduced speech or even become silent, but their speech function has not been substantially damaged. With the remission of the disease, their speech function can gradually recover. The curative effect of drug treatment for children and adolescents with schizophrenia is obviously better than that of autistic children, and some children can reach the level of complete recovery after drug treatment.
8. Attention deficit hyperactivity disorder
The main clinical features of attention deficit hyperactivity disorder are hyperactivity, attention deficit and impulsive behavior, but its intelligence is normal. Autistic children, especially children with normal intelligence, often have behaviors such as inattention and hyperactivity, which are easily confused with children with attention deficit hyperactivity disorder. The focus of identification is that children with attention deficit hyperactivity disorder have no impairment of social communication ability, rigid behavior and narrow interest.
9. Others
Diseases that must be differentiated from childhood autism include severe learning disabilities, selective mutism and obsessive-compulsive disorder.
Fourth, intervention treatment.
The treatment of autism in children is mainly educational intervention, supplemented by drug treatment. Because there are many developmental disorders and abnormal emotional behaviors in autistic children, comprehensive intervention measures such as educational intervention, behavior correction and drug treatment should be taken according to the specific situation of children.
Educational intervention
The purpose of educational intervention is to improve the core symptoms, promote intellectual development, cultivate the ability of self-care and independent living, reduce the degree of disability, improve the quality of life, and strive to make some children have the ability to study, work and live independently after adulthood.
1. Intervention principle
(1) Early and long-term treatment: Early diagnosis, early intervention and long-term treatment should be carried out, and attention should be paid to daily treatment.
For suspicious children, education intervention should also be carried out in time.
(2) Scientific system: clear and effective methods should be adopted to systematically educate and intervene children, including intervention training aimed at the core symptoms of autism, and training in promoting children's physical development, preventing and treating diseases, reducing nuisance behavior, improving intelligence, promoting self-care ability and social adaptability.
(3) Individual training: According to the symptoms, intelligence, behavior and other problems of autistic children, individual training is planned on the basis of evaluation. For children with severe autism, the teacher-student ratio of early training should be 1: 1. Group training should also be grouped according to children's development level and behavioral characteristics.
(4) Family participation: give all-round support and education to children's families, improve the degree of family participation, help families evaluate the appropriateness and feasibility of educational intervention, and guide families to choose scientific training methods. Family economic status, parents' mentality, environment and social support will all affect children's prognosis. Parents should accept the facts and properly handle the relationship between children's educational intervention and life and work.
2. Intervention methods
(1) behavioral analysis therapy
Principles and purposes: ABA adopts behaviorism principle, mainly adopting positive reinforcement, negative reinforcement, differentiation reinforcement, regression, differentiation training, generalization training and punishment to correct various abnormal behaviors of autistic children and promote their ability development.
The core of classic ABA is behavior round training (DTT), which is specific and practical. The main steps include the instruction given by the trainer, the child's reaction, the trainer's reaction and pause, which are still used at present. Modern ABA combines other technologies on the basis of classic ABA, emphasizes emotional and interpersonal development, and adopts different steps and methods according to different goals.
When it is used to promote the ability development of autistic children and help children learn new skills, it mainly takes the following steps:
① Evaluate children's behaviors and abilities, and analyze the target behaviors. (2) Step by step to strengthen the training of decomposed tasks, and only train a decomposed task within a certain period of time.
③ Every time a child completes a decomposition task, he must be rewarded (positive reinforcement). Rewards are mainly food, toys, verbal and physical actions, and reward behaviors gradually recede with the progress of children. (4) Using tips and fade-out techniques, give different levels of tips or help according to children's abilities, and gradually reduce tips and help with children's proficiency in what they have learned. ⑤ There must be a short rest between two task trainings.
(2) Treatment and education courses for children with autism and related disorders.
Principles and Objectives: Although autistic children have extensive developmental disabilities, they have certain advantages in vision. We should make full use of children's visual advantages to arrange the educational environment and training procedures, improve children's understanding and obedience to the environment, education and training contents, and comprehensively improve children's defects in language, communication, sensory perception and sports.
Steps: ① Arrange the training ground according to different training contents, emphasizing visual cues, that is, the training ground is specially arranged, and toys and other items are specially placed. (2) Establish a training schedule and pay attention to training procedures. ③ Determine the training contents, including children's imitation, thick and thin movements, perception, cognition, hand-eye coordination, language understanding and expression, self-care, socialization and emotion.
④ In teaching methods, it is required to make full use of language, posture, tips, labels, charts and words to improve children's understanding and mastery of training content. At the same time, behavior correction techniques such as behavior reinforcement principle are used to help children overcome abnormal behaviors and increase good behaviors. This course is suitable for hospitals, rehabilitation training institutions and families.
(3) Interpersonal relationship development intervention
RDI is the representative of interpersonal training. Other methods include floor time, picture exchange system, and attention training.
Principle: At present, it is considered that * * * homomorphism defect and theory of mind defect are the core defects of children's autism. * * * Synaptic attention deficiency means that children can't form the ability to pay attention to something with their caregivers at the same time as normal babies from infancy. The defect of theory of mind mainly refers to children's lack of ability to speculate on other people's psychology, which is manifested by lack of eye contact, inability to form the same attention and inability to distinguish other people's facial expressions. Therefore, children have no social reference ability, can't share their feelings and experiences with others, and can't establish feelings and friendship with relatives and friends. RDI can improve children's ability to care about others, deepen their understanding of others' psychology and improve their interpersonal skills through interpersonal training.
Steps: ① Evaluate and determine the development level of children's interpersonal relationship. (2) According to the evaluation results, according to the law and order of normal children's interpersonal relationship development, gradually carry out the ability training such as gaze-social reference-interaction-coordination-sharing emotional experience-enjoying friendship. ③ Carry out gradual and diversified training game activities. Activities are mostly led by parents or trainers, including various interactive games, such as eye contact, facial expression discrimination, hide-and-seek and "two people with three legs".
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