HEALTH WATCH TABLE — AUTISM

Considerations Recommendations
1. Head, eyes, ears, nose, throat
  • Children: Hearing:  Recurrent otitis media is common
  • Nasal:  Nasal allergies are common
  • Both of these conditions may be undertreated due to communication difficulties that interfere with the child expressing pain or discomfort.
  • Children and Adults: Greater risk of significant hearing loss
  • Hyperacusis is common
  • Vision: Sensitivity to light is common
  • Strabismus and refractive errors may be more prevalent
  • Visualize tympanic membranes at each visit.
  • Consider referral to otolaryngologist if otitis media persists.
  • Screen hearing and vision regularly
  • Screen for nasal allergies

 

2. Dental
  • Children and Adults: Dental caries are common. Individuals with sensory sensitivities may not be thorough in toothbrushing, and restricted diets may predispose some to dental caries.
  • Bruxism may lead to excessive tooth surface wear/damage and predispose to decay.
  • Refer to a dentist for semi-annual exams, or more frequently if indicated.
  • Consider treatment for bruxism, if present
3. Sleep
  • Children and Adults: Difficulty initiating or maintaining sleep is common (50%-80%).
  • Ascertain a sleep history, including whether habits are in place to promote sleep (e.g., adequate physical exercise , minimizing caffeine and, in the case of adults, alcohol, and limiting use of electronic devices close to bedtime).
  • Evaluate for causes of night wakings, including obstructive sleep apnea, restless legs syndrome/periodic leg movements of sleep (which may be more common in this population due to low iron from restricted diets), nocturnal  seizures, and parasomnias (sleepwalking, sleep terrors, confusional arousals).
  • Implement simple behavioral strategies to improve sleep habits.
  • Refer to a sleep specialist and/or for a sleep study as appropriate.
4. Gastrointestinal
  • Children and Adults: Constipation, diarrhea, gastroesophageal reflux disease (GERD), and food adversions/preferences are common.
  • Some individuals may be on specialized diets, e.g., gluten-free, casein-free diet.
  • Food allergies are also common.
  • Refer to a gastroenterologist, nutritionist, or dietician, as appropriate. Depending on the nature and severity of the gastrointestinal problems, treatments can include dietary interventions, behavioral interventions focused on feeding and diet, nutritional supplements, and medications that address gastrointestinal disorders.
  • Ascertain whether the individual is on a specialized diet and if so, whether nutritional needs are being met since these individuals may be at risk for nutritional deficiencies.
5. Sexual Function
  • Adults: Males and females are fertile.
  • Consider discussion of recurrence risk and reproductive options, with possible referral to gynecologist.
  • Given risk for unwanted pregnancy, it is recommended that women with intellectual disability who are menstruating should be prescribed contraception.
  • Consider evaluation by geneticist if patient and/or family is interested in determining whether a genetic etiology can be identified
6. Musculoskeletal (MSK)
  • Children: Hypotonia is common (~ 50%)
  • Hypotonia gradually improves over time.
  • Consider evaluation by neurologist.
  • Physical therapy can improve gross motor control and overall body strength.  Occupational and speech-language therapy can help with fine motor control, speech, and feeding difficulties
7. Neurology
  • Children and Adults: Seizures are relatively common (6%-30%).
  • Some individuals may experience onset of seizures during puberty. These seizures may be subtle and not readily observable.
  • Motor dysfunction is common (gross and fine motor delays, apraxia, and difficulty with walking and coordination).
  • Motor apraxia improves over time.
  • Tic disorders are more common (Tourette syndrome or chronic motor tic).
  • Ascertain a history of staring spells, loss of consciousness or awareness, and convulsive activity. Refer to a neurologist and/or for an EEG as appropriate.
  • Consider evaluation with neurologist if adolescent begins to exhibit significant behavior problems, e.g., aggression or self-injury, or if academic progress is affected.
  • Ascertain a history of motor difficulties. Refer to a physical therapist or an occupational therapist as needed for evaluation and/or treatment
8. Behavioral/mental health
  • Children and Adults: Individuals may have impaired social relationships. Some may not show an interest in social interactions while others seek interaction but are not skilled in how to proceed.
  • Individuals often have restricted patterns of interests or repetitive behaviors. Young children may rock, stare, or twirl strings.
  • Elopement/wandering is common, particularly in children.
  • Individuals of all ages may express a need for sameness in daily routines.
  • Up to 90% may be undersensitive or oversensitive to sensory input (sound, visual stimuli, taste, smell, or touch).
  • Tantrums, self-injurious or aggressive behaviors are common.
  • Co-morbid psychiatric problems are common. Individuals may have more than one condition, with a high prevalence of psychotropic medication treatment in this population. Conditions include depression, anxiety, obsessive-compulsive disorder, and attention deficit hyperactivity disorder.
  • Regular surveillance for behavioral issues is important. Refer for behavioral therapy and psychiatric intervention as appropriate.
9. Infectious disease/Immune Deficiency
  • Children and Adults: ~ 25% have immune deficiency and dysfunction. This may manifest as frequent infections (e.g., ear, sinus, upper respiratory).
  • Consider referral to infectious disease specialist if infections occur frequently
10. Etiology
  • Autism is a behaviorally defined entity. While most individuals with ASD have a “multifactorial etiology,” some have identifiable etiologies, such as Fragile X or tuberous sclerosis, which may help guide treatment.
  • Consider evaluation by geneticist if patient and/or family is interested in determining whether a genetic etiology can be identified.
11. Other
  • Up to 50% of individuals with ASD may have an intellectual disability.
  • It is important to have an accurate measure of underlying cognitive potential determined by a psychologist or other qualified examiner, including nonverbal measures. Such psychological assessments may need to be repeated periodically through childhood.

Original tool: © 2014 Vanderbilt Kennedy Center
Developed by Malow BA, and Shouse J.

This tool was reviewed by physicians on the Toolkit’s Advisory Committee; for list, view here.

Four published autism spectrum disorder health care guidelines were reviewed and compared.

References:

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  2. Rosenhall U, Nordin V, Sandstrom M, Ahlsen G, Gillberg C., Autism and Hearing Loss. Journal of Autism and Developmental Disorders, 1999; 29( 5).  link.springer.com/article/10.1023%2FA%3A1023022709710#page-1. Accessed February 2014.
  3. Kern JK, Trivedi MH, Garver CR, Grannemann BD, Andrews AA, Savla JS, Johnson DG, Mehta JA, Schroeder JL, The pattern of sensory processing abnormalities in autism. Autism. 2006 Sep;10(5):480-94. www.ncbi.nlm.nih.gov/pubmed/16940314. Accessed February 2014.
  4. Ming X, Brimacombe M, Wagner GC, Prevalence of motor impairment in autism spectrum disorders. Brain Dev. 2007 Oct; 29(9):565-70. Epub 2007 Apr 30. www.ncbi.nlm.nih.gov/pubmed/17467940. Accessed February 2014.
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  6. Simmons DR, Robertson AE, McKay LS, Toal E, McAleer P, Pollick FE. Vision in autism spectrum disorders. Vision Res. 2009 Nov;49(22):2705-39. doi: 10.1016/j.visres.2009.08.005. Epub 2009 Aug 12. www.ncbi.nlm.nih.gov/pubmed/19682485. Accessed February 2014.
  7. Lane AE,  Young RL, Baker AEZ,  Angley MT, Sensory Processing Subtypes in Autism: Association with Adaptive Behavior. Journal of Autism and Developmental Disorders, 2010 Jan; 40 (1) 112-122. link.springer.com/article/10.1007%2Fs10803-009-0840-2. Accessed February 2014.
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