Transcript The Triad of Impairments Past, Present and Future

The Triad of Impairments
Past, Present and Future
Dr Judith Gould
Director
The NAS Lorna Wing Centre for Autism
Development of the Concept of the Autism
Spectrum
Lotter (1960) in his Middlesex prevalence study, used Kanner’s criteria
very strictly applied in a total population of children of all levels of
ability.
Wing and Gould (1979), in their Camberwell study, looked for any kind
of strange behaviour in a total population of children identified as
having any kind of special need. This group was selected because
virtually all the children Lotter identified were known to have special
needs.
A group fitting Kanner’s criteria were identified, with the same
prevalence as found by Lotter.
A few children fitting Asperger’s criteria were also identified. This
group was very small because the mainstream children in the area
were not screened.
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Continued
There were many more children who did not fit Kanner’s or Asperger’s
criteria but who had all kinds of mixtures of features of these
“syndromes”.
It was found that impairments of social interaction, communication and
imagination could occur in a very wide range of manifestations. But,
however they were manifested, there was a strong tendency for them
to cluster together and to be associated with a narrow, repetitive
pattern of activities. It was very difficult to draw neat boundaries
between the named “syndromes” and those with the triad of
impairments who did not fit into a “syndrome”.
The concept of a spectrum of autistic disorders fitted the findings better
than the categorical approach. This does not imply a smooth
continuum from the most to the least severe. All kinds of combinations
of features are possible.
WING AND GOULD (1979)
Camberwell study
• Group fitting Kanner’s criteria – 4.9 in 10,000
• Group fitting Asperger’s criteria – 1.7 in 10,000
(mainstream children in the area were not screened)
• Group with mixtures of features – 15.4 in 10,000
(The groups overlapped with each other. Clinical
pictures on the borderlines could be classified
differently by different workers)
WING AND GOULD (1979)
Camberwell study
What held all these groups together was a triad of
impairments of:
social interaction
communication and
imagination.
There was a strong tendency for these impairments
a) to cluster together
b) to be associated with a narrow, repetitive pattern of
activities.
The triad and the repetitive activities
could be shown in a wide range
of different ways
Social Impairment
Different manifestations:
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Aloof, indifferent
Passive
Active but odd, bizarre
Over-formal, stilted
Sociable with 1 person – problems with groups
(* Kanner
# Asperger
Social Communication Impairment
(verbal and non-verbal)
Different manifestations:
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No communication
Communicates own needs
Repetitive, one sided
Formal, long-winded, literal
(* Kanner
# Asperger)
Imagination Impairment
Different manifestations:
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Handles objects for simple sensations
Handles objects for practical uses
Copies pretend play of others
Limited “pretend” play; repetitive, isolated
Invents own imaginary world – but rigid, stereotyped
(* Kanner
# Asperger
Repetitive Activities
Different manifestations
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Bodily movements
Fascination with sensory stimuli
Simple, object directed
Routines involving objects
Routines in space or time
Verbal routines
Routines related to special skills
Intellectual interests
(* Kanner
# Asperger
Other Features Often Present With The
Triad
Untypical patterns of:
• Language comprehension / use
• Responses to sensory stimuli
• Movement and posture
• Attention / level of activity
• Eating / drinking / sleeping
• Mood
• Behaviour
Factors Affecting the Clinical Picture
• The way the triad is manifested
• Associated features
• Associated disabilities: developmental, physical,
psychiatric
• The overall level of ability
• Age
• Gender
• Personality and temperament
• Environment
• Education
Evidence For A Spectrum
• Many people show mixtures of features of different
sub-groups
• One person can show different features in different
environments
• One person can show different features at different
ages
• Members of the same family can show different
features
• Identical twins or triplets can show different features
• The same basic principles underlie methods of
education and care for whole spectrum
Conditions That May Be Associated With
The Spectrum
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Attention deficit/hyperactive
disorder
Tourette’s syndrome
Developmental receptive
language disorder
Dyspraxia
Dyslexia
DAMP syndrome
Generalised learning disability
Epilepsy
Tuberous sclerosis
Fragile X
Phenylketonuria (untreated)
Rett’s syndrome
Williams’ syndrome
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Sotos’ syndrome
Cornelia de Lange syndrome
Turner’s syndrome
Kleinfelter’s syndrome
Neurofibromatosis
Down’s syndrome
Obsessive-compulsive disorder
Catatonia / Parkinsonism
“Psychotic” states in response to
stress
Anxiety
Affective disorders
Schizophrenia – rare
Any other developmental, physical
or psychiatric condition
The Importance of the Social Impairment
Leo Kanner 1943
• Present from birth
• Genetic:“We must assume that the children have come into the
world with innate inability to form the usual, biologically
provided affective contact with people”
Social Withdrawal
Lorna Wing 1964
“Social withdrawal is an important characteristic of autistic children
which perhaps is related to the inability to communicate in speech.
A mother often senses this in her child almost from birth. Later the
mother notices that the child does not attract her attention to
things going on around – indeed her child appears oblivious of
them”
This is now referred to as lack of joint-referencing.
The Social Impairment is the Key to
Diagnosis
In children and adults with severe or profound learning
disabilities the level of development may be too low for
communication and imagination.
But, interest in other humans is present virtually from
the beginning of life.
The Social Impairment is the Key to
Diagnosis
Children and adults with extremely high levels
of cognitive ability may be verbally articulate
with good imagination but have learned social
skills through their intellect rather than by social
intuition.
Revision of the Triad of Impairments
Social Interaction
Social Communication
Social Imagination
The Triad is usually associated with repetitive
patterns of activities
The reason for selecting social impairment as
the only defining feature of autism spectrum
disorders is purely practical and not related to
any causal theory.
Research
• Neuropathology underlying social impairment
• Biology of the social instinct
• Causes:
Genetic, pre-natal environment, post-natal
environment
• Neurological relationships to other conditions
Physical – Phenylketonuria, Tuberose Sclerosis
Developmental – ADHD, Tourette’s, Dyspraxia
Psychiatric – Anxiety, Depression, OCD
• Effective methods of helping and support
Change in Thinking
Attempts to define sub-groups among autism
spectrum disorders by behavioural features and
arbitrary age-based cut-off points – related to
current International Diagnostic Systems.
Apart from the lack of the social instinct untypical
behaviours are found to varying degrees in all
diagnostic sub-groups, in all developmental
disorders and to some extent in typical
development.
Dimensions Versus Categories
In clinical practice, it is extremely difficult to define the
boundaries between different diagnostic categories,
whatever the criteria used.
The clinical pictures found in those with autistic spectrum
disorders fit better with the concept of multiple
dimensions than with the concept of separate, definable
categories.
Individual needs are more accurately assessed from the
profile of levels on different dimensions than from
assigning a categorical diagnosis.
Key Similarities and Methods of Supporting
all People within the Autism Spectrum
What can a person with severe learning disability and typical
autism have in common with someone brilliant in a chosen field
and whose behaviour fits Asperger’s descriptions?
Everyone with an autism spectrum disorder has a number of
specific problems in coping with everyday life
• All have difficulties following subtle, unwritten rules that
govern social life
• All need other people to communicate with them in clear
and easily understandable terms
• All are helped if complex, shifting ideas are explained in
concrete terms eg with visual illustrations
• All have difficulty comprehending the passage of time
Continued
• All have, to varying degrees difficulty working out the
consequences of their own and other peoples’ actions
• All need more time than most other people to process
information
• All need to be informed clearly in advance with careful
explanations if plans are changed
• Difficulties caused by over sensitivity to various kinds of sensory
input are very common