Dans cet article:
- 1 Treatment
- 2 Research into the causes (etiology)
- 3 Theorization of autism
- 4 Screening and diagnosis
- 5 References
Mental retardation is the lack of development of intellectual faculties, which occurs after the early infantile period. There are about 1% of mentally retarded persons in the population.
Symptoms may include eczema, blue eyes, blond hair. The Guthrie test routine at birth allows for early diagnosis. The treatment involves a diet low in phenylalanine.
Symptoms may include hyperexcitability, convulsions, lethargy, hypotonia, plaintive cry. The diagnosis is made on the blood glucose below 0.3 g / l in the newborn. The treatment involves the infusion of glucose and frequent meals and fractionated.
The diagnosis is based on hormonal measurements: plasma thyroxine low TSH (hormone-stimulating thyréo) high, no thyroid or ectopic thyroid in the scan.
The treatment involves phototherapy and exchange transfusion above. Systematic injection of gamma globulin anti-D to Rhesus negative women who gave birth to a baby rhesus positive is the best prevention.
The lead poisoning (lead poisoning), vitamin B6 deficiency, hypercalcemia from other causes are rare, early diagnosis allows initiation of treatment before the installation of neurological damage.
Language difficulties, understanding simple commands, appreciation of the environment and situations, the slow reaction characteristic of mental retardation. Psychometric tests (tests) are used to classify Retarded Persons:
Some feeble light to medium are known as ‘harmonious’. They do not have behavioral problems and are able to adapt and attach to a given job. They are educable. Even if their mental level is low, an appropriate education will enable them to acquire a certain autonomy.
By cons deficient ‘disharmonious’ have intellectual deficit worsened by emotional and behavioral disorders. Reactions of opposition, aggression, instability complicate management.
Neurological disorders (epilepsy, movement disorders, ataxia, abnormal muscle tone, tremors, tics, stuttering, clumsiness of fine manual motor skills, poor appreciation of body image etc. …), mental (delirious, psychotic child etc..) emotional (instability, hyperactivity, irritability etc. …), physical deformities (clubfoot, hydrocephalus, etc..) are sometimes associated.
The goal is not to develop intellectual performance that will remain very low. It is especially important to develop autonomy, building ‘social’ of the child: social and psychomotor automatisms to make it as flexible as possible. Social maturity makes the task less difficult for those who will inevitably one day replace the child’s parents. The acquisition of sphincter control is such a milestone.
Parents may choose this themselves or to entrust the child to an institution. It is a very delicate personal problem that requires mature consideration.
Deficient children means must also be helped up to develop as much as possible their poor development potential.
The retarded child requires constant care and should be considered by his parents according to their mental age rather than his real age. He needs just like any other child love, affection and attention to feel safe and happy. He needs to play, have friends and so on.
Some parents choose to ignore the mental retardation of their child and pretend to believe that their child is normal. They are trying by all means of inculcating knowledge far beyond his abilities. The retarded child will encounter while failure, lose confidence in him, becoming aggressive, or psychotic opponent.
Psychotherapy is an important part of treatment. It allows the child to treat his imbecile family maladjustment, anxiety.
Siblings of retarded children should be helped as well as parents.We must indeed make them accept the intellectual deficit (often denied) of the child, feeling guilty, tell them to have the right attitude and avoiding rejection hyperprotection, as bad as one another.
Centers of early medico-social action (CAMSP) are midway between hospitals and MCH services. They allow the assessment of disability in children of preschool age, to organize the therapeutic management without subtracting from the family environment. They have a role of psychological guidance and technical support in rehabilitation.
The solutions are aimed at teaching children deficient light. Expectation classes allow children to kindergarten entry back into first grade.
The master classes (order of August 12, 1964) are reserved for low enrollment and weak light. Admission is decided by the Commission medico-pedagogical.
Medico-pedagogical solutions are offered by public or private organizations under contract with the list can be obtained from the DASS.
The medical-educational boarding (EMP) is reserved for light and medium deficient. Special educators, psychotherapists, psychomotor, physical therapists, speech therapists and psychiatrists working with these children.
The medical-educational boarding school (IMP) is for morons temperamental poorly tolerated in their families and severely retarded (big encephalopathy).
The Committee for the Study and Care of Deep Arrears in the Paris region (ESCAP) provides medical consultations for children supported by their families.
The child mental health clinics (CMP) and psycho-medical centers (PPC) are reserved for children living at home and suffering from psychological difficulties. Psychologists, psychiatrists, therapists, social workers make up the infrastructure for these centers.
For adolescents, the medical professional institutes (IMPro) and sheltered workshops (or CAT Aid Centres by Labour) are intended to promote employability.
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These criteria were first highlighted by Lorna Wing. They were then taken to the medical classification of the WHO ICD-10. This classification puts autism in the category of pervasive developmental disorders (PDD).
The term is also used more or less independently of the diagnostic criteria for qualifying TEDs in general or to identify a symptom or psychological attitude theorized on the basis of so-called ‘autistic withdrawal’ (eg in the case of the Hospital).
It seems that currently, in the state of research, you can link autism to a ‘neurological disorder of early brain development.’ The investigations which would induce this state have not produced any firm conclusions, although combinations of genetic factors are presented as a possible cause of hereditary character.
In terms of clinical diagnosis, for historical reasons linked to the spread of knowledge on these disorders, autism is the term often used for childhood autism from the definition of Leo Kanner, but others separate diagnostic qualified autism, atypical autism as such, and in general Asperger syndrome.
To overcome this ambiguity of terminology, autism and other pervasive development today tend to be grouped under the generic name of autism spectrum disorder (ASD short), even if there are distinctions within this spectrum. According to a July 2009 publication of the Association Autism-Europe:
The word autism is also associated with many considerations that do not fit the clinical disorder. Since the 1990s, authors autism (who had a diagnosis of infantile autism in their childhood) described their view their singularities. Highlighting aspects that are not deficient in particular has been greatly expanded through the Internet.
On the other hand, the current language or journalism tends to use the term autism based on these etymological bases to describe the conduct of someone falling back on itself, refusing to listen to see the others: ‘Autism government ‘for example. If this is common sense, yet it is absolutely not representative of autism in the clinical sense, because ‘the problem of autism is not lack of desire to interact and communicate, but a lack of opportunity to do so. ‘
There is no cure for autism. Nevertheless, and in a practical, scientific studies have now demonstrated the efficacy of early treatment using educational methods behavioral (ABA), cognitive (TEACCH) or developmental. The scientific literature is unanimous on this point: we need the intervention is early, massive and structured.
Guides to good practices exist: a French guide to 1996 (but the results of an ‘Autism Plan 2008-2010’Are expected), a guide for Spanish Ministry of Health newest, SIGN for Scotland in 2007, or guide the State of New York. All references to converge and what is expressed in France in 2008 (CCNE)
Beyond childhood, monitoring lines are proposed by the report of Autism Europe 2009: ‘The treatment plan’ adult ‘should focus on:
Research into the causes (etiology)
However, it was determined that ‘genetic factors are a major cause of autism. But the interaction of many other factors also play a role. ‘
But we often talk about autism in the plural, and autism spectrum, hence the establishment of causes involving the choice of a framework for definition of autism, whether it is applied to the typical autism described by Kanner, if we include Rett syndrome, autism called the ‘high level’ and Asperger syndrome.
Possible causes are multiple genetic abnormalities to infectious or toxic damage, and may be cumulative. Nevertheless, it appears that all forms of autism are associated with brain development differs from the norm, that is why they are among the neuro-developmental disorders.
The theory of heavy metal poisoning
The recent increase in the number of autism cases in industrialized countries suggests that it may have environmental causes. Such as exposure to certain heavy metals (including mercury, but not only) has increased over the past two centuries, it was thought that a link was possible between these two problèmes.Et body of autism (and especially the brain) seems to contain more heavy metals than the average. In addition, the urine of several hundred children with autism show an abnormal frequency analyzed with a high rate of porphyrins (which can be explained by exposure to heavy metals blocking the synthesis of heme and causing renal accumulation and urinary porphyrins .
One theory is that in autism, the natural ability to detoxify the body deal with heavy metals is reduced due to genetic polymorphism, and there might be a causal relationship (direct or indirect) between exposure to the brain heavy metals and some symptoms of autism. These metals are made (possibly in utero) through food, water, dental fillings, some drugs or vaccines, or inhaled air. Metal toxicity to the brain may explain, at least in part the diminished brain response to the perception of voice observed in autism. Mercury has been particularly implicated, including the study of a large cohort of French children, then by an American study followed 37 children with autism (also studied the genetic point of view) in the latter case with clear correlation observed between the severity of autism and the rate of urinary porphyrin. Mercury (or other metals) may inhibit the functions of glutathione antioxidant and detoxifying;Laboratory mice susceptible to autoimmune disease, exposed to repeated injections of thimerosal and neurological damage have behavioral and oxidative stress increased correspondingly to a fall of intracellular glutathione in vitro. (But this theory is further supported by a minority of doctors). This track could not at present be rigorously demonstrated (abnormal levels of heavy metals could be a secondary consequence misunderstood and not a primary cause). The United States dropped in 2008 a clinical study on the subject under medical risks incurred by participants.
A possible link proposed by empirical experiments of casein or gluten-free diet, is the permeability of the intestine to the opioid peptides which can be increased for various reasons, including exposure to heavy metals.
Brain abnormalities and defects of the placenta
Scientists have discovered that the earliest indicators of autism to date could be the presence of defective cells in the placenta.The discovery could lead to earlier diagnosis of developmental disorder that affects about one in 200 children and can result in learning difficulties, speech problems and difficulty in interpersonal relationships.
There cytoarchitectonic abnormalities in the limbic system and cerebellum. The increased size was observed in some cells and a decrease in intercellular connections. ‘The absence of anomalies in other regions suggests that the lesions occur before 23 weeks gestation.’ Volumetric changes were also found in the amygdala of the brain, the cerebellar vermis (inconstant), temporal lobe and from different parts of the ‘default-mode network’ (see below). These anomalies may reflect a failure of brain maturation probably genetic.
It was revealed the presence of defective cells in the placenta of children with Asperger syndrome, with presence of abnormal microscopic wells, three times more numerous than in normal placentas.These findings could lead to early diagnosis of a disorder.
All this research should be viewed with caution but they are confirmed it could open new horizons for the detection, treatment and possibly the beam causal factors that are involved in autism.
By 1964, in his book Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behavior Bernard Rimland suggested the possibility of genetic factors in the etiology of autism.
There is a strong preponderance of autistic disorder to genetic diseases identified, which together account for 10% of those identified as autism (Fragile X Syndrome, Rett Syndrome, Sotos Syndrome, Joubert syndrome, Neurofibromatosis type I; Sclerosis Tuberous, Prader-Willy, Angelman Syndrome).
The evidence for the genetic origin of autism [Ref. desired]:
In addition, abnormalities mitrochondriales, particularly in its DNA, seem more common in children with autism.
Area of voice perception
A team of French-Canadian researchers, published in the monthly Nature Neuroscience and was highly publicized in 2004, the ‘perception of voice’ active in normal brain specific area on the outer surface of the left superior temporal sulcus, whereas in subjects with autism, the voice does not cause activation of this area. This handicap has therefore a mistake of the recognition of the human voice.
This discovery whose findings remain to be confirmed brings new light to the understanding of major communication disorders suffered by autism. Behavioral studies have already allowed to observe the deficit in voice perception in autism, and in 2000, other teams had already showed abnormalities at what we think we can consider as the area specializes in face recognition.
This work thus supports the hypothesis that autism is linked to a number of deficits in the perception of social stimuli (voice, intonation, facial expressions …), and could allow the development of new educational strategies for taking Early management of very young patients, if future studies confirm that such anomalies can already be found in very young patients 12 to 18 months. This could confirm that these very young children are struggling to identify and respond to basic social cues, such as answering the smile of their mother or to reach out, and it could be established therapies communication designed to activate brain systems disrupted.
More recent experiments have demonstrated that, far from showing any reaction (deficit), the human voice, ‘perception of voice’In subjects with autistic disorder activates an area in the right cerebral hemisphere corresponding to a range of emotional processing (including those induced by listening to music) in normal subjects.
Functional imaging (fMRI) has objectified defects of brain activation (compared with a matched group in age and IQ control) in the superior temporal sulcus (STS) connected to prefrontal cortex ventral-dorsal, inferior parietal and peritonsillar, and involved: 1. in recognition of the intentional aspects, social and emotional voice, gaze and movements, 2. of imitation (neuron system ‘mirrors’), and 3. the attribution of intentional acts and thoughts to others (which leads to a disruption in the development of the ‘mental theory of mind’). Studies in Voxel-Based morphometry-measuring the volume of white matter and gray matter volume also indicated significantly reduced in STS and knew from the first temporal gyrus in autism.The hypothesis of an attack dysconnective this circuit, of genetic origin, which would result in early deterioration of the decoding of emotional cues and social problems in motor and vocal expressions (especially gaze direction) in autism has been issued.
Recently (Kennedy et al., 2006), differences in activation of ‘default-mode network (DMN) involving the ventromedial prefrontal cortex and precuneus, were seen in autism compared to normal subjects. MND is a neural network-specific state of ‘rest’ involved in mental imagery, episodic memory, the agents how self-consciousness … and that is ‘Disabled’ during procedures and intentional attentional. There are, moreover, a significant correlation between the degree of deactivation of DMN during such a procedure, and social disruption in autism. It was also shown a reduced activation of fronto-parietal network that is supposed to regulate interactions between DMN and circuits related to attention (Cherkassy et al., 2006).In this case, the achievement of DMN could instead reflect an under-default activation of fronto-parietal this modulator. In any case, there would be a breach of joint brain networks responsible for perception of inner experience the rest of the representation of mental states of others and empathy.
In France, the day hospitals are not designed for children with autism because success in these institutions does not exceed 8%, it is strongly recommended that parents of children with autism to look for plants using methods known as ‘behavioral’ as the ABA as the success of these behavioral methods exceeds 50%, and we must act as soon as possible to increase his chances.
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Theorization of autism
The psychoanalytic approach
Among psychoanalysts, the question of autism has always been debate as that under the guise of psychoanalysis, the approach of Bruno Bettelheim sociogenetic or ideological Maud Mannoni threw confusion. Lustin for JJ (psychoanalyst) who speaks of autistic states: ‘It always appeared to me necessary to exclude autism from the strict framework of infantile psychoses because their appearance and their extreme gravity does not seem to result from a real process. We can consider them as ‘states’ more or less early in the etiology very mysterious and probably multi-factorial. . The confusion on the theories and practice of psychoanalysis claiming generated excesses which have been heavily criticized, especially causal claims and interference to other modes of care. Major controversies occur, especially in France where many complaints of parents’ associations are successful and other reports to the National Advisory Committee on Ethics:
These controversies also arise largely from the hyper-mediated dissemination of the work and theories of Bruno Bettelheim, especially those concerning children with autism who fall back on himself because he was ‘traumatized’ by his environment, parents in particular and especially the mother. This type of assumption has already been mentioned by Leo Kanner was not a psychoanalyst, but had found that parents of ‘autistic’ were cold or distant. Today this vision is no longer valid, psychoanalysis is more likely referring to the writings of Margaret Mahler, Frances Tustin or Donald Meltzer and others to theorize or autism (s). It speaks also more likely to autistic states, the term nominal leaving room for the word in the phrase.
The fact remains that sometimes irreconcilable differences exist between the psychoanalytic approach to autism and supported who claim it, and cognitive-behavioral approach used today mostly in the world to understand autism and develop best practices of care.In addition many professionals trained at the time of Bettelheim expression of autism was considered a reference to remain attached, causing still difficult situations for some families.
Theory of mind
The theory of mind is set in 1978 by Premack and Woodruff as the ability to infer mental states (beliefs, desires, intentions …) to represent the behavior of others. It would explain and understand the social environment, and the ability to understand and predict the behavior of others and thereby to adapt to his social situation experienced.
Origin, and Sally Anne test
This formalization has been implemented in the context of autism through several sets of experiments. The first is carried out by Baron-Cohen, Leslie and Frith in 1985 with autistic children, children with Down syndrome and control children (taking approximately the principle of the test established by Wimmer and Perner 1983), but in the form of experiment called ‘Sally and Anne ‘
The experimenter played the following situation with dolls: Sally lays a ball into a basket and then leaves the room. Anne leaves the ball in the basket and places it in a box. Sally comes into the room. The experimenter then asked the child: ‘Where will Sally does get the log? ‘
If the answer is ‘basket’, the investigator believes that the child was able to get ‘in the skin of the character of Sally as they are asked to do, and understand that in the history represented the child can not be aware of the maneuver Anne.
Children with Down Syndrome as ordinary children give the expected response to more than 80%. Conversely, in twenty autistic children tested, sixteen have failed that question, so that everyone knew where the ball was.
The authors conclude that the experience of autism is that a specific deficit independent of overall general mental retardation. The idea of a ‘lack of theory of mind ‘is the working hypothesis, based on the fact that only a small minority of children with autism pass the test of’ representation of the second order, ‘they state that their assumption that children generally autism ‘fail to use the theory of mind’ is strengthened.
Challenging and changing concept
In this experiment, and even more in the following (call with a banana, a box of Smarties …) the problem of the role of the experimenter is raised by critics. What is questioned is the link made between the side of a failure of understanding of a situation created by the experimenter and the other at the conclusion of the overall failure mechanism understanding of the other in general.
Simon Baron-Cohen, one of the protagonists of the first experiment, the difficulty in forming metarepresentations and therefore difficult to infer mental states to oneself and others, has an important impact on behavior. A person immersed in an environment populated with people he barely understand and predict the actions, which he does not have any language, will present avoidance behaviors or aggression, motivated by misunderstanding. Therefore the structuring of the environment, making it predictable and understandable, enabling the person with autism to better manage its deficit in theory of mind and improves behavior problems.
According to Christiane Riboni, doctor of linguistics, ‘the analysis of interviews with patients with autism shows that the lack of theory of mind is not clear, however in some cases.’ It describes an intentional but ‘use the language more marked on the side that representational communicative.’It also refers to Tager-Flusberg to offer an explanation of a ‘marked failure to master a causal explanatory framework.’
Temporomandibular disorder treatment spatial sensory information
This theory has been developed over the past fifteen years by Bruno Gepner et al, on the basis of several clinical and psychophysical studies conducted among children and adolescents with autism or Asperger syndrome.
These studies show that sensory information dynamics (movements of the environment, human body or facial movements, speech) are too fast to be perceived in real time by people with autism spectrum disorder. This problem of temporal processing of dynamic information cascade explain their understanding of language disorders and emotions, their imitative disorders, their executive function disorders, including delays in their motor responses, and ultimately their social interaction disorders .If dynamic information poses major problems for people with autism spectrum disorders, however they may show off and increased attention to the static spatial information, spatial details or sound, and develop greater skills in the field visuo-spatial (puzzles, spatial memory, graphics), or the calculation (the brain pathways dedicated to the calculation are partly the same as those that address spatial information). These features of temporal-spatial processing of sensory information is probably correlated with abnormalities in brain functional connectivity and neuronal synchronization, that is to say the alignment of different brain areas and neuronal groups, whether at rest or during cognitive tasks simple or complex.It is clear from studies using fMRI (functional magnetic resonance imaging) or coherence EEG (electroencephalographic) that the brains of autistic people would rather be less connected and less synchronized in tasks involving visual or auditory dynamic, and unlike most connected and more synchronized during focused attention tasks or involving static stimuli, relative to the brains of control subjects. Gepner and colleagues refer to these mechanisms of hypo-or hyper-syncing, or under-or over-connectivity among multiple brain regions: the cerebral disconnectivité-dissynchronisation multi-system (DDCM).
Still in the working hypothesis, this theory offers the opportunity to make connections with other problems often associated with autism spectrum disorders such as epilepsy (considered as a pathological hyper-syncing), and miscellaneous disorders development (dysphasia, dyslexia, dyspraxia, …), and suggests ways to better distinguish the different disorders, including within the autism spectrum. Finally, this theory opens new therapeutic avenues.Indeed, studies of Gepner and colleagues show that the slowdown of visual and auditory signals can improve the recognition of emotional facial expressions and non-emotional, improve the imitation of gestures, and improve understanding of language in autistic children, especially those with the most severe disorders or whose development levels are low. These results could in future lead to reeducation tracks using software slow and audible.
Screening and diagnosis
There is so far no biological test to detect autism. The diagnosis of autism and other pervasive developmental disorders is clinical and based on development and behavior of children between 0 and 3 years (or beyond in some cases such as Asperger syndrome).
Early detection can then be performed at 18 months of fairly reliable test with the M-CHAT, a pediatrician (or parents if applicable).This test has been validated internationally and is currently being tested in France. In suspicious cases after this test it is recommended that in the months after a detailed diagnosis.
In case of doubt it is very important to seek an early diagnosis. Indeed, all studies on the development of people with autism show that early detection allows the implementation of appropriate care at the earliest, thereby significantly increasing the chances of further progression of the child.
The diagnosis must be supervised by a medical specialist (neurologist or psychiatrist) and must include (see the recommendations of the HAS):
The specialist (neurologist or psychiatrist) performs the synthesis of these elements and his own clinical observations to deliver the diagnosis, which must be made according to the nomenclature of ICD-10, as recommended by the HAS.