Scientific name of western medicine: autism
English name: autism
Main symptoms: social disorder, communication disorder, narrow interest, rigid and repetitive behavior.
The main reasons: genetic factors, infection and immune factors, physical and chemical factors during pregnancy.
catalogue
Cognitive process of autism
The cause of the disease
clinical picture
Diagnosis and differential diagnosis
Disease treatment
Disease prognosis
disease prevention
launch
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Cognitive process of autism
Autism was first described clinically in the 1940s. 1943, American doctor Kanner reported 1 1 patient and named it "early infantile autism". At that time, he described the characteristics of such patients as follows: a serious lack of emotional contact with others; Weird and repetitive ritual behavior; Silence or obvious language abnormality; High-level visual spatial skills or mechanical memory ability are in contrast with other learning difficulties; Smart, alert and attractive appearance. At first, such patients reported by Kanner were regarded as a subtype of childhood schizophrenia and were not taken seriously. In the 1940s and 1960s, some people described cases similar to those reported by Kanner and gave them various names. At that time, the international and American psychiatric classification and diagnostic standards classified such patients as "children's schizophrenia-like reaction". As for the cause of autism, it is generally believed that parents' improper parenting style led to the occurrence of autism. Canner described the parents of autistic children as a group of highly educated, enterprising but indifferent people, which seemed to have little objection at that time.
In the sixties and seventies of last century, Root's research pointed out that it is more reasonable to think that the behavior of autism is caused by developmental disorders from birth to childhood. Therefore, autism is gradually recognized as a physical development disorder that has nothing to do with parental rearing patterns. During this period, Lotter published a new diagnostic criteria for autism, emphasizing social interaction, verbal communication and repetitive activities as the basic criteria, and abandoning the "special skills and attractive appearance" in Kanner's diagnostic criteria. After that, on the basis of Lotter standard, an extensive epidemiological investigation was carried out. At present, it is generally believed that "the incidence of autism is 4 ~ 5/ 10,000" is the most important research achievement at that time.
In 1980s, the research on autism entered a new stage. People began to abandon the so-called "improper parenting" hypothesis, explore the causes of autism from the biological field, and completely separate autism from schizophrenia in the identification of clinical symptoms and clinical diagnosis. Colvin's research shows that autism has nothing to do with adult mental disorders, especially adult schizophrenia. DSM-III published by 1980 regards childhood autism as a generalized developmental disorder for the first time. Later, with the in-depth study of autism, I gradually realized that autism is caused by some genetic factors and is a diffuse central nervous system development disorder stimulated by various environmental factors. On the basis of this understanding, many studies have been carried out from molecular inheritance to neuroimmunity, functional imaging, neuroanatomy and neurochemistry, and people try to find the cause of autism from these studies. But so far, no hypothesis can fundamentally and perfectly explain the causes of autism.
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The cause of the disease
Although the etiology of autism is not completely clear, current research shows that some risk factors may be related to the onset of autism. The risk factors of autism can be summarized as follows: heredity, infection and immunity, physical and chemical stimulation during pregnancy.
hereditary factor
Twin research shows that the autism prevalence rate of identical twins is as high as 665,438+0% ~ 90%, while fraternal twins have no obvious autism prevalence rate. The recurrence rate between brothers and sisters is estimated at around 4.5%. These phenomena indicate that autism has a genetic tendency.
Studies have shown that some chromosomal abnormalities may lead to autism. At present, the related chromosomes are 7q, 22q 13, 2q37, 18q and XP. Some sex chromosome abnormalities can also show autism. Such as 47, XYY and 45, X/46, XY chimera, etc. There are four common chromosome diseases showing autism symptoms: fragile X chromosome syndrome, tuberous sclerosis, 15q diploid and phenylketonuria.
Every year, there are new reports about candidate genes for autism. In recent years, newly reported candidate genes for autism include clock, PRKCBl, CNTN4, CNTCAP2, immune gene, STK39, MAOA, CSMD3, DRD 1, neurexinl, SLC25A 12, JARDlC and Pax6. Another study reported the genetic polymorphism of NRP2 gene in Han autism patients.
Many candidate genes suggest that autism is a polygenic genetic disease, that is, autism may be a disease induced by environmental pathogenic factors under a certain genetic tendency.
Infection and immune factors
As early as the late 1970s, it was found that pregnant women infected with the virus made their offspring more susceptible to autism. Later, several studies suggested that there may be a certain relationship between pregnancy infection and autism. At present, the related pathogens are rubella virus, cytomegalovirus, varicella-zoster virus, herpes simplex virus, Treponema pallidum and Toxoplasma gondii. At present, it is speculated that the antibodies produced by these pathogens enter the fetus from the placenta and cross-immunoreact with the developing nervous system of the fetus, which interferes with the normal development of the nervous system and leads to autism.
Physical and chemical stimuli during pregnancy
If pregnant women have a history of taking thalidomide and sodium valproate antiepileptic drugs and drinking alcohol in the early pregnancy, the probability of their offspring suffering from autism will increase. According to these studies, the offspring of pregnant 12.5 d rats who were injected with a large dose of sodium valproate intraperitoneally showed autism-like behavior. Another study found that exposure to repeated freezing stimuli during pregnancy will also increase the chances of autism in future generations; Repeated freezing stimulation of pregnant rats also showed the behavioral characteristics of autism in their offspring.
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clinical picture
The disease usually begins within 36 months, which is mainly manifested in three core symptoms, namely: social disorder, communication disorder, narrow interest and stereotyped behavior.
Social barriers
Children with this disease have a qualitative defect in social interaction. In infancy, children avoid eye contact, lack interest and response to people's voices, don't expect to be picked up, or are stiff when they are picked up and don't want to be close to people. In early childhood, children still avoid eye contact, often do not respond to calls, have no attachment to their parents, lack interest in interacting or playing with children of the same age, do not interact with children of the same age in an appropriate way, do not establish partnerships with children of the same age, do not share happiness with others, and do not seek comfort from others when they are unhappy or hurt. After school, with the growth of age and the improvement of illness, children may become friendly and affectionate to their parents and compatriots, but they still obviously lack the interest and behavior of actively interacting with others. Although some children are willing to communicate with others, there are still problems in their communication methods. They lack understanding of social customs, lack of response to other people's emotions, and can't adjust their behavior according to social occasions. Children still lack interest in communication and socialization when they are adults, and they can't establish a love relationship and get married.
Communication disorder
1. Children with this disease often cry or scream to express their discomfort or needs. Older children may hold an adult's hand at what he wants, lack corresponding facial expressions, and their expressions often appear indifferent, and rarely use actions such as nodding, shaking their heads and waving their hands to express their wishes.
2. Speech communication disorder There are obvious obstacles to speech communication in children with this disease, including: ① the language understanding ability is impaired to varying degrees; (2) speech development is slow or underdeveloped, and some children have expressive speech before the age of 2-3, but it gradually decreases or even disappears completely; ③ Abnormal speech form and content: children often imitate speech, repeat speech rigidly, make mistakes in grammatical structure and personal pronouns, and have abnormal intonation, speech speed, rhythm and stress. 4 Impaired speech ability: Although some children can recite children's songs and advertisements, they rarely communicate in words, and they will not bring up topics, maintain topics or speak only with stereotyped and repetitive phrases, and they are entangled in the same topic.
Narrow interests and rigid and repetitive behavior patterns
Children with this disease are not interested in toys and games that ordinary children like, but they are particularly interested in things that are not usually used as toys, such as round and rotatable things such as wheels and bottle caps. Some children are also attached to inanimate objects such as plastic bottles and wooden sticks. Children's behaviors are often very rigid, such as doing things or playing with toys in the same way, requiring items to be placed in a fixed position, going out by the same route, and eating only a few foods for a long time. There are often rigid repetitive actions and strange behaviors, such as repeated jumping, staring at the eyes with hands, flapping or walking on tiptoe.
Other symptoms
About 3/4 children with this disease have mental retardation. About 1/3- 1/4 children have epilepsy. Some children may have "autism ability" while their intelligence is low, such as extraordinary performance in music, calculation, date calculation, mechanical memory and recitation, and are called "idiot scholars".
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Diagnosis and differential diagnosis
diagnose
The diagnosis should be made by combining the medical history, physical and nervous system examination, mental examination and auxiliary examination results.
The main points of diagnosis include: ① onset within 36 months; ② Obstacles in social communication, communication, narrow interests and stereotyped behaviors are the main manifestations; ③ Other diseases such as Rett syndrome, Heller syndrome, Asperger syndrome, speech and language development disorder were excluded. If a child begins to suffer from the disease after 36 months or does not have all the core symptoms, it is diagnosed as atypical autism.
The diagnostic criteria of DSM-IV autism are as follows:
Diagnostic criteria for autism include A, B and C. ..
A, in the following three items (item * * * 12), (2) and (3), at least six items must be met, of which two items in item (1) and at least 65438+ in items (2) and (3).
(1) Social communication is damaged qualitatively, which is manifested as follows: a. The application of nonverbal sexual intercourse is obviously damaged, such as eye contact, facial expression, body posture and gestures. B. you can't associate with your peers. C. can't share happiness, benefits, achievements, etc. Spontaneous with others (for example, you can't bring or show others what you are interested in). D. can't interact with people socially and emotionally.
(2) The communication ability is qualitatively impaired, which is manifested as: a. The speech development is completely developed or delayed, and no attempt is made to compensate by other means (such as gestures or imitation). B. People who have a certain ability to speak also have obvious impairment in the ability to raise topics and maintain dialogue. C. use rigid or repetitive language or special language that you can understand freely. D. lack of spontaneous pretend games or games that imitate daily life corresponding to their age.
(3) The form of behavior, interest or activity is limited, repetitive or rigid: a. There are one or more fixed, repetitive and limited interests, the degree and content of which are abnormal and difficult to change. B. stubbornly follow a special and meaningless routine or ceremony. C. Stereotyped and repetitive postures and behaviors, such as finger flapping or twisting, complicated whole body movements, etc. D. long-term and continuous attention to only the part of things.
B before the age of 3, at least one of the following three aspects is stunted or has abnormal function:
(1) Social interrelationships.
(2) words used for socializing.
(3) symbolic or imaginative games.
C. The above symptoms cannot be explained by Rett disorder or childhood disintegration disorder (infantile dementia).
differential diagnosis
1.Rett syndrome is only found in girls and usually begins at 7-24 months. Before the onset, the development was normal. After the onset, the head development slows down, the acquired speech ability and social communication ability are rapidly lost, and the acquired hand purposeful motor skills are also lost, resulting in stiff hand movements (similar to hand washing or stiff fingers twisting). It is often accompanied by hyperventilation, gait instability, trunk ataxia, scoliosis and seizures. The course of the disease progresses rapidly and the prognosis is poor.
2. Children's disintegrating mental disorder (Heller syndrome) Most of this disorder begins at 2-3 years old, and its development is completely normal before the onset. After the onset, his intelligence declined rapidly, and other acquired abilities (including speech ability, social ability, self-care ability, etc. ) also rapidly declined or even lost.
3. Asperger's syndrome, also known as schizoid psychosis in children, has some characteristics similar to autism in children, which are more common in boys. Generally, the symptoms are not obvious until the school age is about 7 years old, mainly manifested in interpersonal obstacles, limitations, rigid and repetitive interests and behavior patterns. There is no obvious speech or mental retardation.
4. Expressive or receptive language barriers. This kind of children are mainly characterized by impaired language expression or understanding, normal or near-normal intelligence (IQ ≥70), good nonverbal communication skills, lack of social quality, narrow interest and rigid repetition of behavior.
5. Schizophrenia in children mainly begins in pre-puberty and adolescence, and develops normally before onset. After the onset of schizophrenia, symptoms such as hallucination, thinking disorder, apathy or disharmony, insufficient will activity and weird behavior gradually appear, which is helpful for differentiation.
6. The mentally retarded children with this disorder have no qualitative defects in social communication. Although their language level is insufficient, they are consistent with their intelligence level, and there is no obvious narrow interest and rigid repetitive behavior. However, if the child has both typical symptoms of autism and mental retardation, then both diagnoses should be made. [ 1-2]
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Disease treatment
Principles of treatment
Principles of autism treatment: ① Early detection and early treatment. The earlier the treatment age, the more obvious the improvement; ② Promote family participation, so that parents can also become collaborators or participants in the treatment. Children themselves, child care doctors, parents and teachers, psychologists and society should all participate in the treatment process to form a comprehensive treatment team; (3) Insist on a comprehensive treatment training program with non-drug treatment as the mainstay, drug treatment as the supplement, and mutual promotion between them; ④ The treatment plan should be individualized, structured and systematic. According to the patient's condition, the treatment varies from person to person, and the treatment plan is adjusted at any time according to the treatment response; ⑤ Pay attention to children's health and prevent other diseases while treating and training; ⑥ Persist in treatment and persevere.
Some ideas about the treatment of autism;
There is no specific drug treatment for autism. Early diagnosis and early intervention can improve the prognosis of autism, so it is generally believed that the younger the age, the better the effect, but so far there is no age cut-off point, in fact, some patients have improved when they are older.
② Many countries in the world, especially developed countries, have established many special education and training curriculum systems for autism. The above main training methods have their own advantages and disadvantages, and there is no evidence that one therapy is obviously superior to the other. At present, various methods tend to be integrated with each other.
③ Due to the lack of specific therapy for autism, there are still hundreds of alternative therapies, which lack evidence-based medical evidence and should be used with caution. A small number of autistic children without special training and treatment have the possibility of self-improvement, and the efficacy claimed by some therapies may be related to this.
therapeutic method
Before 1980s, autism was generally considered as an incurable disease. Since Lovaas reported in 1987 that 9 autistic children were successfully "cured" by behavioral analysis therapy, many countries in the world (mainly the United States) have successively established and developed many autism education and training therapies or courses. The founders of most therapies or courses claim that their therapies have achieved remarkable results, but the efficacy of some therapies is exaggerated.
Helfin et al. classify various autism therapies into the following four categories. (1) Therapy based on promoting interpersonal relationship: including floor time therapy established by Greenspan and RDI therapy established by Goustein; (2) Skill-based intervention therapy: including Picture Exchange System (PECS) and Discrete Experiment Training (DTT); (3) Physiological-oriented intervention: including sensory integration training, auditory integration training, detoxification treatment and diet treatment; (4) Comprehensive therapy, treatment and education (TEACCH) and applied behavior analysis (ABA) for children with autism and related communication therapy belong to this category. The following is a brief introduction to the common interventional therapy.
1 teacher
TEACCH is a comprehensive education method mainly aimed at autistic children, which was founded by Schopler of the University of North Carolina in the United States. It is a highly praised autism training course in Europe and America. This method mainly aims at the defects of autistic children in language, communication and sensory movement, and the core is to improve their understanding and obedience to the environment, education and training content. This course designs personalized training content according to the ability and behavior characteristics of autistic children. The training content includes children's imitation, accumulated exercise, perceptual ability, cognition, hand-eye coordination, language understanding and expression, self-care, social communication and emotion. Emphasize the special arrangement of training ground or family furniture, toys and related items; Pay attention to the arrangement of training procedures and visual clues; Make full use of language, posture, tips, labels, charts, words and other methods in teaching methods 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. Courses can be conducted in relevant institutions or at home.
2 abscisic acid
1987 Lovaas reported that a group of 19 autistic children received ABA treatment and intervention for 2 years. Results Nine children basically recovered, and other children also improved in different degrees. This report caused a sensation. Since then, many researchers have repeated ABA and achieved varying degrees of success. It is reported early that ABA has a good effect on high-functioning autism. At present, it is considered that this therapy has a good effect on all kinds of children with pervasive developmental disorders. Lovaas' research object is mainly autistic children around 3 years old, which is an important factor to achieve good curative effect. However, ABA is still considered to have high application value even for older autistic children. ABA adopts the principle of behavior shaping to positively strengthen and promote the development of various abilities of autistic children. Traditionally, the core of ABA is task decomposition technology. The typical task decomposition technology has four steps: the trainer gives instructions, the children's reaction, the reaction to the children's reaction, and the pause. Specifically, it includes: (1) task analysis and decomposition; (2) Intensive training of decomposition tasks, that is, only one decomposition task is trained within a certain period of time; (3) Reward the completion of (positive reinforcement) tasks, and each task must be reinforced. Strengthening is mainly food, toys and verbal or posture praise, and it gradually retreats with progress; (4) Prompting and downplaying, giving different levels of prompting or help according to children's development, and gradually reducing the prompting and help with the proficiency of the learned content; (5) intertrial interval, which requires a short break between two decomposition task trainings. Training requires personalization, systematization, strictness, consistency and scientificity. Ensure that the treatment should have a certain intensity, 20-40 hours a week, l-3 times a day, 3 hours each time. Modern ABA technology is gradually integrated with other technologies, emphasizing emotional interpersonal development.
3 RDI and floor time
With the in-depth study of the neuropsychological mechanism of autism, the defect of theory of mind is gradually considered as one of the core defects of autism. The so-called theory of mind defect mainly refers to the lack of ability of autistic children to speculate on other people's psychology. Therefore, children are characterized by lack of eye contact, inability to form common attention, inability to distinguish other people's facial expressions, inability to form social reference ability, inability to share feelings and experiences with others, and inability to form emotional ties and friendship with relatives. In view of this, Gutstein established an RDI to "improve children's psychological understanding of others". Goustein believes that the law and order of normal children's interpersonal relationship development are: gaze-social reference, interaction-coordination-sharing emotional experience-enjoying friendship. Based on this, he designed a training program consisting of hundreds of activities for autistic children, led by parents or trainers, including various interactive games, such as eye contact and facial expression recognition. Gutstein claims that the RDI method has achieved remarkable success.
Compared with RDI, Greenspan's free-time training system also focuses on interpersonal relationships and social interaction, but unlike RDI, in free-time training, teachers or parents decide the training content according to children's activities and interests. In training, parents or teachers cooperate with children's activities, and at the same time constantly create changes, surprises and difficulties in training, and guide children to establish problem-solving ability in free and happy time, and then develop social communication ability. This kind of training has higher requirements for parents or teachers. At present, this method is also highly respected in the United States.
4 sensory integration training
Sensory integration training therapy was founded by Ayers in the United States. At first, it was mainly used to treat ADHD and learning disabilities in children. Autistic children generally have abnormal perception, so this method is also widely used to treat autistic children. This therapy mainly uses skateboards, swings, balance beams and other game facilities to train children. It has been reported that it has a certain effect on reducing hyperactivity and increasing language in autistic children. In addition, therapies similar to sensory integration training include auditory integration training, music therapy, chiropractic therapy, squeezing therapy, hug therapy and touch therapy. The efficacy of sensory integration training therapy is controversial abroad and has not been recognized by mainstream medicine.
5 drug therapy
At present, there is no specific drug to cure autism, but the following drugs may improve some symptoms of autism and be beneficial to education and training. Specifically including:
(1) Haloperidol (0.5mg-4.0mg/ day), Sulindazine (12.5mg-50mg/ day) and Sulpiride (100 mg-400mg/ day) are commonly used antipsychotics. The first two can reduce hyperactivity, impulsiveness, self-talk, self-injury and rigid behavior, and stabilize children's emotions; Sulpiride can improve autism and withdrawal, make children active, increase speech and improve mood. The above drugs should be taken from a small dose, and gradually increase according to the improvement of symptoms and adverse drug reactions. At present, it is reported that risperidone, olanzapine, quetiapine and aripiprazole can also improve some symptoms of the disease, but this aspect needs further study and discussion.
(2) antidepressants. These drugs can improve the stereotyped repetitive behavior of diseases, improve mood and relieve obsessive-compulsive symptoms. Chlorpropionamide (25mg- 150mg/ day), sertraline (25mg- 150mg/ day) and fluvoxamine (50-200 mg/ day) can be selected. This medicine should also be taken from a small dose, and the adverse drug reactions will gradually increase according to the improvement of symptoms.
(3) Central stimulant or clonidine is suitable for children with attention disorder and ADHD. Please refer to the relevant contents in Attention Deficit Hyperactivity Disorder for medication methods.
(4) Drugs that improve and promote the function of brain cells are related to mental retardation.
(5) Vitamin B6 and magnesium have been reported. Large doses of vitamin B6 and magnesium may improve some symptoms of the disease, but further research and determination are needed in this regard.
6 The role of family in autism education and training
The education and training of autism is not entirely a medical problem. Family's socio-economic status, parents' mentality, environmental or social support and resources all have an impact on children's coping. Through comprehensive education and training, supplemented by drugs, the prognosis of autistic children can be significantly improved, and a considerable number of children may acquire the ability to live, study and work independently, especially those with Asperger's syndrome and high-functioning autism. Three principles should be adhered to in the process of education or training: (1) tolerance and understanding of children's behavior; (2) correction of abnormal behavior; (3) The discovery, cultivation and transformation of special abilities. Training should be family-centered, while paying attention to making full use of social resources, setting up day training and educational institutions, and spreading relevant knowledge to parents while training children are the main measures for autism education and treatment at present. Parents need to accept the facts, overcome psychological imbalance, and properly handle the relationship between children's education and parents' life and work. With love, patience and perseverance as the driving force, actively participate in children's education, training and treatment activities, and establish long-term consultation and cooperation with doctors. [3-7]
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Disease prognosis
This disease is a chronic disease with poor prognosis. About two-thirds of children cannot live independently as adults and need lifelong care and maintenance. The main factors affecting the prognosis are IQ, whether there is communicative language at the age of 5, education and training, etc. If we can carry out planned drug treatment and corrective education as early as possible and persist in it for a long time, it will help improve the prognosis.
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disease prevention
Prevention is an important measure to reduce the birth risk of autism. Women should avoid abusing drugs, especially antiepileptic drugs, in the early pregnancy, that is, the formation and development stage of embryonic neural tubes. Avoid virus infection; Avoid the environment where the temperature difference between hot and cold changes greatly; And avoid major mental stimulation and trauma.