Transcript Slide 1

Pervasive Developmental
Disorders
September 6, 2005
PSYC 4930
Pervasive Developmental Disorders
The current DSM-IV category of
Pervasive Developmental Disorders
includes several more severe forms
of child psychopathology.
 Historically disorders of this type
have been referred to by a variety
of labels such as
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atypical psychosis
child psychosis
symbiotic psychosis
childhood schizophrenia
infantile autism
Pervasive Developmental Disorders
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Pervasive Developmental Disorders
are characterized by
impairments/difficulties in several
areas:
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social interactions,
communication skills, and
stereotyped
behaviors/interests/activities
Pervasive Developmental Disorders
At one time, conditions referred to
as Pervasive Developmental Disorders
were often thought to be reflective
of Child Psychosis
 However, PDD are not related to the
psychotic conditions of adulthood
(e.g. Schizophrenia), and are now
referred to as "developmental"
rather than "psychotic" disorders.
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Pervasive vs. Specific Disorders
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PDD are to be distinguished from "Specific
Developmental Disorders" (e.g., reading,
articulation, arithmetic, and language
disorders).
This is because they are characterized by
severe disturbances in many basic areas of
development.
They may also be reflected in behaviors
having no counterpart in normal
development.
Thus, children with these conditions often
display distorted rather than simply
delayed development.
Pervasive Developmental Disorders
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Several disorders are included under the
DSM-IV heading of Pervasive Developmental
Disorders:
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Rett's Disorder
Childhood Disintegrative Disorder
Asperger's Disorder
Autistic Disorder
With the exception of autism, little is
known regarding most of the other
disorders in this category, although case
studies describing each of these
conditions can be found in the clinical
literature.
Pervasive Developmental Disorders:
Rett’s Disorder
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This disorder, which was first described
in the German medical literature in 1966
is a degenerative disorder manifested in
both physical and behavioral symptoms
The disorder has its initial onset after a
period of apparently normal early
development.
Onset is usually thought to be toward the
end of the first year or the beginning of
the second year.
However, it can occur as early as 5 months
or as late as 48 months.
Pervasive Developmental Disorders:
Rett’s Disorder
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Major symptoms include the
following;
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a deceleration in normal head growth
a loss of previously acquired hand
movements
the appearance of poorly coordinated
gait and/or trunk movements
The loss of previously existing
motor skills is usually accompanied
by the development of stereotyped
hand movements such as hand wringing
or washing type movements
Pervasive Developmental Disorders:
Rett’s Disorder
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Other symptoms include developmental
regression in both expressive and
receptive language
This is usually accompanied by severe
psychomotor retardation
Behavior is often characterized by
autistic-like behaviors which include;
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stereotypic behaviors (e.g., hand movements
noted above)
a lack of sustained interest in persons and
objects and
a marked decrease in interpersonal contact
Rett’s Disorder:
Prevalence and Course
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Prevalence of Rett's disorder has not been
well established, but it is thought to be
much rarer than autism
Occurs only in females
Usually associated with severe mental
retardation.
Marked by rapid deterioration after
initial onset and a course which is
chronic and often progressive
However, sometimes a renewed interest in
social interactions may appear as the
child becomes older
Rett’s Disorder:
Etiology
Little is known regarding
etiological factors
 There are some neurological findings
associated with Rett’s (e.g., motor
symptoms, abnormal EEG, cortical
atrophy on CT scans, cerebrospinal
fluid abnormalities)
 These factors suggested that there
may be reason to view the disorder
as a progressive degenerative brain
disorder
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Rett’s Disorder:
Treatment
Very little information or research
on the treatment of this condition
 Possible treatments include:
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Behavioral approaches designed to deal
with the behavioral deficits and
excesses
special education approaches to deal
with cognitive impairments
physical therapy to assist with the
motor problems that result from this
condition.
Pervasive Developmental Disorders:
Childhood Disintegrative Disorder
Originally labeled as "dementia
infantilis" by Heller (1930),
Childhood Disintegrative Disorder is
another severe and progressive
disorder occurring after a period of
normality
 Usually develops after age two, and
involves a rapid regression in
behavior where there may be a loss
of social, language, motor, and
other skills (e.g., play, bladder
and bowel control)
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Childhood Disintegrative Disorder
Other symptoms include impairments
in social interaction and
communication as well as repetitive
and stereotyped patterns of behavior
or interests
 The regression or disintegration
seen in the disorder usually takes
place over a period of six to nine
months
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Childhood Disintegrative Disorder vs.
Autism
The obsessional and stereotypic
behaviors and the impairment in
social interactions that often
accompany this disorder can resemble
certain aspects of autistic
disorder.
 However,
this disorder can be
distinguished from autism by
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its later age of onset and
the absence of other autistic features
(e.g., language characteristics, desire
for the maintenance of sameness)
Childhood Disintegrative Disorder
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Childhood Disintegrative Disorder is very
rare and more common in males than females
May develop slowly or suddenly (between
ages of 2 and 10) and its course is
variable
Sometimes, after the initial loss of
skills, the condition will remain static,
with some limited improvement in the area
of social behavior
In other cases there is progressive
deteoriation
Usually, however, problems in social
interaction, communication, and behavior
Childhood Disintegrative Disorder:
Etiology
As with Rett's Disorder, little
information is available regarding
the etiology of this disorder
 Central nervous system involvement
plays a role
 While these findings are suggestive,
more definitive investigations into
the etiology of this disorder remain
to be done.
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Childhood Disintegrative Disorder:
Treatment
Multi-component approach similar to
that suggested for the treatment of
Rett's disorder might be useful
 Use of behavioral approaches to
modify problematic behavioral
excesses and deficits, along with
appropriate special educational
approaches
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Pervasive Developmental Disorders:
Asperger’s Disorder
First published account of this
disorder by Austrian psychiatrist
Hans Asperger in 1944 who initially
referred to the condition as
"autistic psychopathy“
 However, more recent authors have
commented on the similarities
between Autism and Asperger’s
 Indeed, there is some debate as to
whether this disorder is actually
distinct from autistic disorder
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Asperger’s Disorder
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Essential features of the disorder:
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severe impairments in social interactions
restricted and repetitive patterns of
interests, activities and/or behaviors
No clinically significant delays in
cognitive development, language
development, or impairments in adaptive
behavior, apart from those related to
impairments in social interaction
While not considered a specific symptom of
Asperger's Disorder, children with this
condition are often delayed in meeting
major motor milestones (e.g., crawling,
walking) and are frequently characterized
as clumsy
Asperger’s Disorder
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Unlike autism, where social impairments
seem to result from an intense desire to
withdraw from or avoid social
interactions, the social impairment in
Asperger’s seems to result from a lack of
social skills.
These children seem to have a marked
inability to understand and use rules
which typically guide social behavior.
The child may show significant problems
with:
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nonverbal behaviors such as maintaining
appropriate physical proximity to others while
interacting
making and sustaining eye contact
appropriately using gestures, facial expression
and other nonverbal behaviors to regulate
social interactions
Asperger’s Disorder
Social behavior often appear quite
egocentric and self-centered
 Children with Asperger’s may
frequently pursue their own highly
personalized interests in social
encounters without apparent
awareness that the other person does
not share similar interests
 Behavior occurring within the
context of two way social
interactions often appears as inept,
naive and peculiar
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Asperger’s Disorder
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Restricted and repetitive patterns
of behaviors, interests, or
activities are often striking and
may be manifest in a variety of
ways:
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Some may be preoccupied with specific
activities (e.g., spinning objects) or
become overly attached to certain
objects or familiar places and become
intensely upset when separated from them
Others show an inflexible adherence to
daily routines
Asperger’s Disorder
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Commonly, children with this disorder show
an extreme all-consuming involvement in
some specific area of interest
The child may spend most of his/her time
learning facts related to the area
They may collect things having to do with
the area, and spend an enormous about of
time talking to others about this area
whether or not they are interested
While, investing a great deal of time
learning about their area of interest, the
child may have little understanding of the
facts that they learn
Asperger’s Disorder
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Unlike other PDD’s, in Asperger's
Disorder, there is no clinically
significant delay in cognitive development
or in the area of language
the child may learn to speak at a normal
age however, they may show marked
peculiarities in language:
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may invent words
use pronouns incorrectly
repeat words or phrases over and over in a
stereotyped manner
speech content is often overly pedantic,
consisting of long one-sided discussions
about the child's favorite topic
CASE EXAMPLE
Asperger’s Disorder:
Prevalence
little data on prevalence, but
children with Asperger's Disorder
are quite rare
 probably more rare than autism
 more common in males than in females
with sex ratios ranging from 4:1 to
9:1 being reported
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Asperger’s Disorder:
Etiology
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Regarding etiology, the disorder was
originally considered to have a genetic
basis (Asperger, 1944).
While no formal studies to assess the
possibility of genetic transmission have
been published, Wing (1981) has provided
relevant case study findings:
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of the 34 cases with this disorder that she
studied, 5 of the 16 fathers and 2 of the 24
mothers had, "to a marked degree" behavior
resembling that observed in their children
Although not definitive, some support for
the role of biological factors in this
disorder comes from the fact that these
Asperger’s Disorder:
Course and Prognosis
given higher level of functioning
(due to a lack of basic cognitive
and language deficits) their
prognosis appears much better than
with other PDD’s
 Indeed, Wing (1981) has presented
case studies of individuals who were
able to engage in gainful employment
and function in a semi-independent
manner.
 Obviously, prognosis is intimately
related to treatment and management
approaches designed to deal with the
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Asperger’s Disorder:
Treatment
no treatment has been shown to
modify the basic underlying
impairment
 treatment should include behavioral
approaches focusing on enhancing the
child's ability to function in
social situations along with an
educational program
 psychotherapy may be useful as the
person becomes aware of the degree
to which social skills difficulties
make it difficult to function
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Pervasive Developmental Disorders:
Autistic Disorder
Infantile autism was first described
by Leo Kanner (l943) in his classic
paper " Autistic Disturbances of
Affective Contact"
 In this article, Kanner highlighted
the defining characteristics of 11
children seen in his child
psychiatry practice at Johns Hopkins
University
 His views regarding this disorder
have heavily influenced present day
views of the disorder, emphasized a
number of features
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Autistic Disorder
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Unlike certain other severe disorders of
childhood, Kanner assumed autism to have
an early onset.
He believed the disorder to be present
from the beginning of life, or at least to
become obvious during the first year
Indeed, he referred to it as an "inborn
disturbance"
He felt that this early onset served to
differentiate the disorder from other
problems, which at that time, were judged
to
be
manifestations
of
childhood
psychosis
Autism:
Social Deficits
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Autistic children have a primary
disturbance in social relationships and an
apparent inability to relate to others.
They seem aloof, often oblivious to the
presence of others, and are often
described as being in a world of their own
– “Like in a shell”, “Happiest when left
alone”, “Acting as though people aren’t
there”, etc.
Early life, infants may fail to show
anticipatory posturing when the parent
attempts to pick them up from the crib,
and the failure of the infant to mold him
or herself to the body of the parent
Autistic Disorder
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Kanner suggested that the outstanding
fundamental disorder is “the children’s [in]ability
to relate themselves in the ordinary way to
people and situations from the beginning of life”
He goes on to note that “this is not as in
schizophrenic children or adults, a departure from
an initially present relationships - it is not a
“withdrawal” from formerly existing
participation.”
There is from the start, an “extreme aloneness
that whenever possible disregards, ignores, shuts
out anything that comes to the child from the
outside”.
Autistic Disorder
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All autistic children show evidence of a
severe language disorder
Many remain mute
Those that develop speech typically show
unusual features such as echolalia (i.e.,
the repetition of what someone else has
said), pronoun reversal (e.g., referring
to oneself as "you" and to others as "I"),
or atypical tone (e.g., monotone,
inappropriate to content)
Even though some children with autism
develop fairly large vocabularies, they
usually cannot use speech to communicate
Autistic Disorder
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Kanner noted that although some of his 11
cases developed language, they were no
better able to communicate than were those
who remained mute
children with autism who speak often have
no difficulty naming objects and may have
an aptitude for for learning previously
constructed verbal materials such as
poems, songs, and lists of things
Such learning, however, seems to be
without any appreciation of the meaning of
these words
There is usually minimal evidence of
Autistic Disorder
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Kanner and others have noted that autistic
children seem to display an desire for the
maintenance of sameness
children with autism often get upset when
things in their environment are
changed - when routines are changed or
when toys the child has left in a
particular position are moved
This may result in a catastrophic reaction
(e.g., tantrum, screaming) lasting until
things are returned to their former state
This desire for sameness may lead some
children to display a wide range of
ritualistic behaviors
Autistic Disorder
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Other behaviors frequently observed in
children with autism:
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stereotyped behaviors (e.g., mouthing objects,
flapping arms and hands, rocking, toe-walking).
over responsive to environmental stimuli (e.g.,
light, sound, foods, clothing)
under responsiveness and insensitivity to pain
and in associated self-injurious behaviors
(e.g,. head banging, scratching, skin picking)
In play, interest in parts of objects and
little symbolic play
Usually associated with mental retardation
CASE EXAMPLE
Autistic Disorder:
Prevalence
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Although autism is a relatively rare
disorder it has been difficult to
determine its exact frequency of
occurrence.
Varying rates of prevalence are due to:
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different diagnostic criteria
frequently confused with other severe disorders
of childhood
not all children with autism come to the
attention of researchers
Prevalence data from early studies
suggested very low rates of occurrence,
typically 4 or 5 cases per 10,000
children, and as low as 2 per 10,000 for
"classic" cases
Autistic Disorder:
Prevalence
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Gillberg (1990) cites studies, employing
differing diagnostic criteria that report
figures ranging from 6.6 to 13.6 per
10,000.
The few studies using DSM criteria have
reported rates on the order of 10 per
10,000.
The higher rates found in more recent
studies has had to do, at least in part,
with better detection of autistics among
those with severe mental retardation
The disorder is more frequent in boys than
in girls, with sex ratios ranging from 2.0
Autistic Disorder:
Prognosis
In reviewing follow-up studies of
children with autism DeMyer, et al.
(1981) note that as many as 60 to 70
percent live a life of complete or
semi-dependence, at home or in an
institution
 Only about 1-2% achieve normal
levels of independence, while others
show a borderline level of
functioning
 A better prognosis seemed to be
associated with higher IQ (> 60)
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Autistic Disorder:
Prognosis
In a paper entitled "How far can
autistic children go in matters of
social adaptation?" Kanner (l973)
reported on a follow-up of 96
children with autism seen prior to
l953
 Although most did not fare as well,
11 of the 96 achieved a “favorable
outcome”
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3
3
1
4
obtained college degrees
went to junior college.
other was doing well in college
did not go beyond high school or
Autistic Disorder:
Prognosis
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Their occupations included accountant,
duplicating machine operator, lab
technician, bank teller, and several
other types of unskilled work
Kanner noted that although these 11
children did show a “favorable outcome”,
none seemed to show any interest in the
opposite sex or marriage, suggesting
continued problems in close relationships
Outcome was unrelated to having received
psychiatric treatment
Best predictor seemed to be having useful
speech by age 5
Etiology of Autism
Views regarding the causes of autism
can generally be classified as
psychogenic or biogenic in nature
 Psychogenic theories characterized
the parents of autistic children as
cold, aloof, obsessional,
refrigerator-like, and in other less
than positive terms (see Kanner,
l943)
 Bettelheim (l967) suggested that
negative maternal attitudes are of
major importance in the development
of this disorder (“refrigerator
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Etiology of Autism
research designed to link family
variables to autism has provided
little support for psychogenic
theories
 DeMyer, et al. (1981) have noted
that, ". . . Parents of autistic
children have been found to display
no more signs of mental or emotional
illness than parents of children
with organic disorders (with or
without psychosis).”
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Etiology of Autism
Growing evidence suggests that
autism is a biologically based
disorder
 This point of view is supported by a
wide range of studies that have in
one way or another implicated the
role of biological factors
 The specific biological factors that
cause this disorder have not been
identified, although several
candidates have been identified
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Etiology of Autism
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Autism has been shown to be related
to biological problems such as:
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the development of seizure disorders
abnormal EEG's
congenital infections (e.g,.rubella)
chromosomal abnormalities
pregnancy and birth complications
neurotransmitter abnormalities
abnormal CT scans
structural abnormalities of the left
hemisphere
genetic factors
Etiology of Autism
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taken together, research findings provide
strong support for a biogenic perspective
Indeed, after reviewing much of the
literature
related
to
neurobiological
factors in autism, Gillberg (1990) has
concluded that "autism is now regarded as
a
behaviorally
defined
syndrome
of
neurological
impairment
with
a
wide
variety of underlying medical etiologies
(p. 106)"
Again, the specific biological factors
most relevant to the etiology of autism
and their specific role remain to be
uncovered
Autistic Disorder:
Treatment
Due to cognitive and social
impairments, most children with
autism are unlikely to benefit from
"talk therapies", although some
authors have suggested that
individual psychotherapy can be of
some value in working with a small
number of higher functioning
children
 While there is presently no "cure"
for autism, behavioral approaches
have achieved the most obvious
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Autistic Disorder:
Treatment
Operant procedures (e.g., rewards,
shaping) combined with modeling,
have been found useful in teaching
language, as well as other socially
adaptive behaviors, and in
decreasing many inappropriate
behaviors
 bringing about such behavioral
changes requires skills which very
few clinicians possess and an
enormous amount of time
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Autistic Disorder:
Treatment
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Lovaas (1987) conducted intensive, longterm, treatment program that focused on
imitation, language development, the
expression of appropriate emotions, and
appropriate play behaviors
Of the 19 children participating in the
program, it was possible to mainstream 8,
and 7 were described as being
indistinguishable from typical children
While the degree to which these children
did in fact approach normality has been
questioned, the results clearly highlight
the potential contribution of behavioral
treatments
Autistic Disorder:
Treatment
Treatment and Education of Autistic and
Related Communication Handicapped
Children (TEACCH)
 N.C. program for individuals with autism
Includes education, communication, and
behavior strategies for working with
children with autism
 Focuses on the building upon the
strengths of children rather than just
improving deficits
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Autistic Disorder:
Treatment
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TEACCH structured teaching:
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Use of schedules
Classroom structure (e.g., setting up clear
areas for work/play, minimizing distractions)
Use of visual cues (e.g., polaroids, color-coded
tasks)
Alternate enjoyable and less enjoyable
activities
Use minimal language or gestures
www.teacch.com
Autistic Disorder:
Treatment
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Some drugs may have beneficial effects for
children with autism:
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Haloperidol has been shown to improve the
learning ability of children with autism and
make them more responsive to special education
and behavior modification
Fenfluramine, which reduces levels of serotonin
in the blood, has shown some promise in
improving social and intellectual functioning
While behavior therapy and drug treatments
have both shown some promise in treating
autism, there is research evidence to
suggest that treatment should not be an
either/or proposition
Living with Autistic Disorder:
Dr. Temple Grandin
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On cognitive processes:
“Thinking in language and words is alien to me. I think totally in pictures.
It is like playing different tapes in a video cassette recorder in my
imagination. I used to think that everybody thought in pictures until I
questioned many different people about their thinking processes.
I have conducted an informal little cognitive test on many people. They
are asked to access their memory of church steeples or cats. An object
that is not in the person's immediate surroundings should be used for this
visualization procedure. When I do this, I see in my imagination a series of
"videos" of different churches or cats I have seen or known. Many
"normal" people will see a visual image of a cat, but it is a sort of
generalized generic cat image. They usually don't see a series of vivid cat
or church "videos" unless they are an artist, parent of an autistic child, or
an engineer. My "cat" concept consists of a series of "videos" of cats I
have known. There is no generalized cat. If I keep thinking about cats or
churches I can manipulate the "video" images. I can put snow on the
church roof and imagine what the church grounds look like during the
different seasons.”
Living with Autistic Disorder:
Dr. Temple Grandin

“For me, there is no language based
information in my memory. To access
spoken information, I replay a "video" of
the person talking. . . . To retrieve facts, I
have to read them off a visualized page of
a book or "replay the video" of some
previous event. This method of thinking is
slower. It takes time to "play" the
videotape in my imagination.”
Living with Autistic Disorder:
Dr. Temple Grandin
On communicating:
“I screamed because it was the only way I could
communicate. . . . I had the words I wanted to
say in my mind, but I just could not get them
out; it was like a big stutter. When my mother
wanted me to do something, I often screamed. If
something bothered me, I screamed. This was
the only way I could express my displeasure. If I
did not want to wear a hat, the only way I could
communicate my desire not to wear the hat was
to throw it on the floor and scream. Being unable
to talk was utter frustration.”
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Living with Autism:
Temple Grandin, Ph.D.
http://www.npr.org/templates/story/story.
php?storyId=4278538
 Emergence: Labeled Autistic
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