Transcript Assessing Young Children with Social

Autism Spectrum Disorders: An
Introduction
Rhea Paul, Ph.D., CCC-SLP
Southern Connecticut State University
Yale Child Study Center
Feb. 11-15, 2008
[email protected]
Diagnostic Concepts: Pre 1940
• Insanity of Childhood (Maudsley, 1867)
• Dementia Praecox (Kraeplin, 1893)
• Dementia Praecocissima (DeSanctis, 1906)
• Dementia Infantilis (Heller, 1908)
• Childhood Schizophrenia (Potter, 1930)
A Brief History of Autism: Kanner
(1943)
“There is from the start an extreme autistic aloneness (p. 33)…
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these children have come into the world with innate inability
to form the usual, biologically provided affective contact with
people, just as other children come into the world with innate
physical or intellectual handicaps (p. 42-43).”
described echolalia
pronoun reversals
inappropriate word usages
noted better abilities with objects
than with people
A Brief History of Autism:
Kanner (1943)
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Autism first used by Leo Kanner (1943) to
describe a syndrome of "disturbances in affective contact,"
 observed in eleven boys who
 lacked the dysmorphology often seen in mental retardation,
 lacked social motivation toward communication and
interaction.
 Did well on some parts of IQ tests leading to speculation they
were not MR
Kanner borrowed autism from Bleuler (1950),
 used to describe the withdrawal into fantasy world seen in people
with schizophrenia.
Kanner's report stated that autism was an inborn, constitutional
disorder, but
 choice of terminonology led to some confusion about the source of
the deficits in autism.
Hans Asperger
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At about the same time, a German psychiatrist
reported a similar syndrome (Asperger, 1944)
 Boys reported to be highly intelligent and verbal but socially inept
 Like “little professors”
 Noticed similar profile in their fathers
Asperger’s report was not translated from the German until the 1980s
 it had little impact on the literature on autistic syndromes in the
English speaking world.
 Still a matter of debate:
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Do the intelligent boys with well-developed language, poor social skills,
and obsessive interests have something different from Kanner’s autism?
Or merely a variety of autism in high functioning individuals?
A Brief History of Autism: 1950s
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Work on autism through the 1960s dominated by psychoanalysts
(e.g., Bettelheim, 1967)
focused on the theory that autism was caused by "refrigerator
mothers.”
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Other mental illnesses were also seen this way; e.g., schizophrenia
Kanner's boys came from upper middle class, often intellectual
families, reinforcing suggestion that autism was the result of cold
parenting.
In the 1970s research began to show that autism, properly
diagnosed, can be seen in all social classes in every part of the
world
At the same time, grassroots efforts by parents to dispel
“refrigerator mother” myth
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Parents of children with autism had other, normal children
A Brief History of Autism: 60s-70s
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1970s Rutter, Wing researched cognitive and linguistic
impairments
This led to behavioral/educational Rx
Wing’s patterns of autistic presentation
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Aloof
Passive
Active but odd
Cohen, others, began neurobiological research
A Brief History of Autism: 70s-90s
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1990s focus on interrelated core symptoms: sociocommunicative, social-cognitive dysfunctions
DSM-IV criteria (1994): triad of impairments
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Impairment in social interaction
Impairment in communication
Restricted, repetitive and stereotyped patters of behaviors, interests, and
activities
ICD-10 criteria: PDD defined by
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abnormal and/or impaired development that is manifest before the age of
3 years
abnormal functioning
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social interaction
communication
restricted, repetitive behavior
Etiology of Autism: A brief history
 Early focus on parents
 Psychodynamic views
 BUT evidence against
No abnormalities in child care
No major personality problems
No obvious deficits in parenting
 By 1970's a large body of evidence favoring
neurobiological etiology
1990s-present: Biological Influences
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It is now clear that the disorders seen in autism originate in the child, not
the parents.
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Neurochemical differences are seen in pts. (hyperserotonemia)
Head size and brain differences are subtle, but measureable
Prenatal abnormalities (trophoblasts)
Research on the genetics of autism suggests there are heritable factors
that convey a susceptibility (Rutter, Bailey, Simonoff, & Pickles, 1997).
Social, communicative, and cognitive difficulties seen in varying degrees
in parents, siblings, and other relatives (Broader autism phenotype-BAP)
Although genetic factors contribute to appearance of autism, it can also
be associated with other medical conditions.
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25% of individuals with autism develop seizure disorders (Rapin, 1991).
Tuberous sclerosis (abnormal tissue growth) associated with autism
The co-occurrence of autism and Fragile X syndrome (the most common
heritable form of mental retardation) is higher than would be expected (Dykens
& Volkmar, 1997).
A Brief History of Autism:
90s-present
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DSM-IV Field Trial to
validate diagnostic
criteria
Definition of
syndromes and
subgroups within PDD
spectrum
STS
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New areas of research:
 Neuroimaging
 Genetics
 Event-related potentials
 Theory of Mind;
neuropsychology
 Early identification and
intervention
 Treatment research
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Fig. 1. AV emotional stimuli greater than AV bouncing ball
perception; arrows point to the right STS
Psychopharmacology
Behavioral/Educational
Etiology
Autism as a final common pathway
CNS Pathology
seizures, "soft" sign, reflexes, EEG abnormalities
Other medical conditions
infectious, structural, chromosomal, etc.
Strongest associations: Fragile X (1%) & Tuberous
sclerosis
Genetic Factors
Need for testable neurobiological hypotheses
and mechanisms
Diagnostic Concepts: Post 1940
• Early Infantile Autism (Kanner, 1943)
• Autistic Psychopathy (Asperger, 1944)
• Atypical Personality (Rank, 1949)
• Pervasive Developmental Disorder (APA, 1980)
• Autism Spectrum Disorders (2000s)
Behavioral Features
 Severe social deficits
 Communication deficits (verbal and nonverbal)
 Unusual responses to environment
 Insistence on Sameness
 Stereotyped movements
 Special interests/preoccupations
Social Disturbance
Distinctive & greater than expected given MA
Some social skills emerge with time
Types
Aloof
Passive
Active but Odd
Deficits in
mutual gaze
joint attention
theory of mind
Triad of Symptoms that Define
Autism in DSM-IV
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Severe, qualitative impairment in social
interaction
Qualitative impairment in communication
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Delayed language = autism or PDD-NOS
No language delay = AS
Restrictive, repetitive or stereotyped
behaviors or interests
Empirical Bases for DSM-IV
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Field Trial: Volkmar et al., 1994
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Multiple sites
977 patients with autism, other pervasive developmental
disorders, and other disorders
standard coding system used
125 raters with range of experience
Patterns of agreement among existing diagnostic systems
examined
International Classification of Diseases (ICD), 10th Revision, most
closely approximated the clinicians' diagnoses
Inclusion of other disorders within pervasive developmental
disorders appeared justified
Modifications in the ICD-10 definition were made; DSM-IV
definition made equivalent
Normal Social Development
• From the first days of life infants are profoundly
sociable
• Human face/voice are the most interesting
stimuli in the environment
• Early emergence of
• Selective attention to faces and voices
• Social reciprocity: mutual gaze, smiling
• Attachments to familiar people
• Social-communicative skills
Early Acquired Social Skills
Joint attention, attachment, imitation
Normal Social Interaction: Infants
Normal Social Interaction:
Toddlers
Normal Social Interaction:
Preschoolers
Normal Social Interaction:
Language Delay: Brittany
Normal Social Interaction:
Language Delay
Autism Every Day video
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http://www.milestonevideo.tv/nonprofit.php