Overview Of Autism

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Overview Of Autism

• PS 553 Assessing Autism Interventions

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Overview of Autism
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History of Autism

• Term autism originally used by Bleuler (1911)
• To describe withdrawal from social relations into
  a rich fantasy life seen in individuals with
  schizophrenia
• Derived from the Greek autos (self) and ismos
  (condition)
• Leo Kanner 1943
• Observed 11 children
• Inattention to outside world extreme autistic
  aloneness
• Similar patterns of behavior in 3 main areas
• Abnormal language development and use
• Social skills deficits and excesses
• Insistence on sameness

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History of Autism

• Psychiatrist Hans Asperger (1944) - describes
  little professor syndrome
• Eisenberg and Kanner (1956)
• Added autism onset prior to age 2
• Further refined definition of autism
• Creak (1961)
• Developed 9 main characteristics
• Believed they described childhood schizophrenia
• Incorporated into many descriptions of autism and
  commonly used autism assessment instruments today

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History of Autism

• Rutter (1968)
• Said the term autism led to confusion!
• Argued autism was different than schizophrenia
• Higher MF ratio
• Absence of delusions hallucinations
• Stable course (not relapse/marked improvement)
• Further defined characteristics (for science,
  research)
• National Society for Autistic Children
• One of the 1st most influential parent groups
  for children with autism in U.S.
• Wrote separate criteria (for public awareness,
  funding)
• Added disturbances in response to sensory stimuli
  atypical development
• Did not include insistence on sameness

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Diagnostic and Statistical Manual of Mental
Disorders

• Published by the American Psychiatric
  Association
• Classification of mental disorders used in the US
• Infantile autism included for
• first time in DSM-III
• Changed to autism in DSM-III-R
• DSM IV published in 1994
• Text Revision in 2000

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Pervasive Developmental Disorders

• Come under section in DSM-IV-TR entitled
• Disorders Usually First Diagnosed in Infancy,
  Childhood, or Adolescence
• Includes
• Mental retardation
• Learning disorders
• Motor skills disorders
• Communication disorders
• Pervasive developmental disorders
• Attention-deficit and disruptive behavior
  disorders
• Feeding and eating disorders of infancy or early
  childhood
• Tic disorders
• Elimination disorders
• Others separation anxiety disorder, selective
  mutism, reactive attachment disorder of infancy
  or early childhood, stereotypic movement
  disorder, disorder of infancy, childhood, or
  adolescence - NOS

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DSM Category PDDs
Pervasive Developmental Disorders
Childhood Disintegrative Disorder
Retts Disorder
Autistic Disorder
PDD- Not Otherwise Specified
Aspergers Disorder

• PDDs are characterized by severe and pervasive
  impairment in 3 main areas
• Social interaction
• Communication
• Repetitive and restricted behaviors

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Diagnostic Criteria for Autistic Disorder (299.00)

• To receive a diagnosis of autism, a child must
  have at least 6 of the characteristics in the 3
  areas (note minimums in each area)
• In one of the areas, onset must be before age 3
  

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DSM Criteria for an Autism Diagnosis Social
Interaction

• Must meet 2 of the following
• Marked impairment in multiple nonverbal behaviors
  (e.g., eye contact, facial expressions)
• Failure to develop peer relationships for age
• Lack of spontaneous seeking to share enjoyment,
  interests or achievement with others
• Lack of social or emotional reciprocity

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DSM Criteria for an Autism Diagnosis
Communication

• Must meet 1 of the following
• Delay in, or total lack of, the development of
  spoken language (not accompanied by an attempt to
  compensate through alternative modes of
  communication)
• Marked impairment in ability to initiate or
  sustain conversation with others
• Stereotyped and repetitive use of language
• Lack of varied, spontaneous make-believe play or
  social imitative play appropriate to
  developmental level

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DSM Criteria for an Autism Diagnosis Restricted
Repetitive and Stereotyped Patterns of Behavior,
Interests, and Activities

• Must meet 1 of the following
• Encompassing preoccupation
• with one or more stereotyped
• and restricted patterns of
• interest thats abnormal in intensity or focus
• Inflexible adherence to specific, non-functional
  routines or rituals
• Stereotyped and repetitive motor mannerisms
  (e.g., hand flapping, rocking)
• Persistent preoccupation with parts of objects

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DSM Criteria for PDD-NOS

• Severe and pervasive impairment in the
  development of reciprocal social interaction
  along with
• Communication skills OR
• Presence of stereotyped behavior, interests, and
  activities
• But criteria are not met for any other PDD

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Retts Disorder
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Childhood Disintegrative Disorder
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What are ASDs?

• Autism Spectrum Disorders
• Continuum comprised of autism, Aspergers, and
  PDD-NOS (Volkmar Klin, 2005)
• the concept of autism is evolving from the
  singular autistic disorder into the plural
  autistic spectrum disorders (ASDs) (Filipek,
  2005, p.535)
• Wing (1997) said that attempts to differentiate
  b/w these disordes have been arbitrarydifficult
  to apply and unhelpful in clinical practice (p.
  1761)

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DSM V

• Proposed Revision of Autism Diagnosis
• http//www.dsm5.org/ProposedRevisions/Pages/propos
  edrevision.aspx?rid94

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Alex 18 Months Diagnosed with Autism
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First Year of Intervention
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Prevalence

• Terminology
• Incidence the number of new cases of disease in
  a defined group of people over a specific time
• Prevalence the number of existing disease cases
  in a defined group of people during a specific
  time period
• Prevalence of ASD has continued to increase since
  first survey in 1966 why?
• Increases in requests for service
• Changes in diagnostic criteria
• Increased assessment opportunities
• Better awareness by pediatricians, teachers,
  parents
• An actual increase in cases?

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CDC Statistics

• Occur in all racial, ethnic, and socioeconomic
  groups
• Four times more likely to occur in boys than in
  girls
• Parents who have a child with an ASD have a 28
  chance of having a second child who is also
  affected.

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CDC Statistics - ASDs

• In 2003, 62 of the children who had an ASD had
  at least one additional disability
• Of those children, 68 had mental
  retardation/intellectual impairment
• 8 had epilepsy lower than previous
• In 1997, 18-42
• Other associated features
• Hyperactivity
• Short attention span
• Impulsivity
• Aggressiveness
• Self-injury
• Unusual responses to touch, smell, sound, and
  other sensory input.
• Abnormal eating habits (e.g., selectivity, pica)
• Abnormal sleeping habits.
• Abnormal moods or emotional reactions.
• Gastrointestinal issues such as chronic
  constipation or diarrhea 

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CDC Statistics - ASDs

• Some children with ASDs show hints of future
  problems within the first few months of life.
• In others, symptoms may not show up until 24
  months or later.
• Studies have shown that one third to half of
  parents of children with ASDs noticed a problem
  before their childs first birthday, and nearly
  8090 saw problems by 24 months.
• Some children with ASDs seem to develop normally
  until 1824 months of age and then they stop
  gaining new language and social skills, or they
  lose the skills they had.
• Children with ASDs develop at different rates in
  different areas of growth.
• Splinter skills
• Delays in one area and age-appropriate in another
  and in some cases even advances
• Inconsistent in how skills get developed
• Can read but cant tell you what sound a b makes

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CDC Statistics - ASDs

• Can often be detected as early as 18 months.
• But national average age of diagnosis is between
  4 and 5
• While all children should be watched to make sure
  they are reaching developmental milestones on
  time, children in high-risk groupssuch as
  children who have a parent or  brother or sister
  with an ASDshould be watched extra closely

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Autism and Developmental Disabilities Monitoring
(ADDM) Network

• The ADDM Network is a group of programs funded by
  the Centers for Disease Control and Prevention
  (CDC) to determine the prevalence of ASDs in US
  communities.
• The ADDM Networks first two ASD prevalence
  reports were released
• in the February 9, 2007, issue of the Morbidity
  and Mortality Weekly Report Surveillance
  Summaries.
• 2000 6.7 per 1,000 for 8-yr olds
• 2002 6.6 per 1,000 8-yr olds
• Thats about 1 in 150 children in these
  commuynicites
• The prevalence was much lower (3.3 per 1,000) in
  Alabama and higher (10.6 per 1,000) in New Jersey
  in 2002. (About 1 in 94)
• Prevalence stayed the same from 2000 to 2002 in
  four of the six sites with data for both years.
• It rose slightly in Georgia and significantly in
  West Virginia, indicating the need for tracking
  prevalence over time.

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New Prevalence Rates

• http//www.nytimes.com/2009/12/19/health/19autism.
  html
• http//www.cdc.gov/ncbddd/autism/index.html

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Current Prevalence Rates

• Nationwide
• One in 110 children is estimated to have autism
  spectrum disorders nationwide.
• In Missouri
• 934 students diagnosed in 1997
• 5,777 students in 2009
• Since 1992, autism prevalence has increased at an
  average of 22 each year

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Prevalence of ASD has continued to increase since
first survey in 1966 why?

• Increases in requests for service
• Changes in diagnostic criteria
• Increased assessment opportunities
• Better awareness by pediatricians, teachers,
  parents
• An actual increase in cases?

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Ideally, what does the diagnostic process look
like?

• Assess all characteristics/abilities
• 3 major areas, adaptive behavior, IQ
• Assess in multiple ways with multiple sources
• Interview, observation, checklist/rating scales
• Parent, teacher, professional examiner
• Assess over time with multiple observations in
  multiple settings
• Home, school, daycare
• Structured, unstructured

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Clinical vs. Educational Diagnosis

• Clinical diagnosis conducted by psychologist,
  neurologist, neuropsychologist
• Without a clinical diagnosis, a child may still
  qualify for special ed services according to
  federal and state autism disability definition
• Educational diagnosis conducted by school
  personnel, usually a team, consisting of people
  who are familiar with the child.
• Definition of Autism drawn from the Individuals
  with Disabilities Education Act (IDEA)
• Federal law which regulates eligibility,
  assessment, and intervention of educational
  services for children with disabilities

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IDEA definition of Autism

• A developmental disability significantly
  affecting verbal and nonverbal communication and
  social interaction, generally evident before age
  3, that adversely affects a child's educational
  performance.
• Other characteristics often associated with
  autism are engagement in repetitive activities
  and stereotyped movements, resistance to
  environmental change or change in daily routines,
  and unusual responses to sensory experiences.
• The term does not apply if a child's educational
  performance is adversely affected primarily
  because the child has a serious emotional
  disturbance as defined below.

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Videos

• Warning Signs of Autism What Parents Should Look
  For http//www.autismspeaks.org/video/index.php
• Autism Research Today
• http//www.msnbc.msn.com/id/21134540/vp/32584906
  32584906

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Etiology Parental Pathology

• Initial theory
• Autism considered an emotional disturbance
  inherited from parents
• Kanner (1943) inborn autistic disturbances of
  affective contact
• No empirical support

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Etiology Psychodynamic Theory

• Eveloff (1960) parents are cold, detached,
  ritualistic
• Bruno Bettelheim (1967)
• Coined term refrigerator mothers
• No empirical support

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Etiology Genetic Evidence

• Strong evidence for genetic component, but nature
  of the component is unknown
• Doesnt look like a single gene
• Monozygotic twin concordance high, but less than
  100

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Etiology Neurotransmitters

• Serotonin
• Some studies have found higher levels in children
  with ASD
• Opioids
• Display properties similar to morphine
• Administration can result in stereotypy,
  insensitivity to pain, reduced socialization
• Some studies have found higher levels in children
  with ASD

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Etiology Vaccines

• http//scienceblogs.com/insolence/2010/08/penn_tel
  ler_deconstruct_the_anti-vaccine.php
• Warning!!!!

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Etiology Vaccines

• Vaccines
• Thimerosal - Preservative used in MMR vaccine
  used to contain mercury
• Wakefield et al. (1998)
• 12 children with PDD and gastrointestinal disease
• Purpose was to look at relationship b/w these
• Participants were selected b/c they had been
  referred to a pediatric gastroenterology dept for
  tx of intestinal problems (e.g., diarrhea, pain,
  bloating)
• Onset appeared to be near time of MMR vaccination
• TheoryMMR led to impaired intestinal functioning
• Permeability of the intestines increased
• Resulted in excess absorption of peptides from
  food
• The peptides have opioid effects
• Opioid excess led to brain dysfunction, and
• Concluded that ASD was caused by MMR vaccine

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Etiology Vaccines

• Wakefield Study
• Methodological Issues
• Didnt discuss specific diagnoses of participants
  (or how obtained)
• The exact onset of intestinal problems wasnt
  known
• Evidence for link b/w behavior changes and MMR
  was based on report
• Correlational study only
• Ethical Problems
• Financial and scientific conflicts that Dr.
  Wakefield did not reveal in his paper.
• For instance, part of the costs of Dr.
  Wakefields research were paid by lawyers for
  parents seeking to sue vaccine makers for
  damages.
• Dr. Wakefield was also found to have patented in
  1997 a measles vaccine that would succeed if the
  combined vaccine were withdrawn or discredited.

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Etiology Vaccines

• In 2004, 10 of the 13 authors on the Wakefield et
  al. study published an article in the same
  journal (The Lancet) retracting the conclusions
  made in the original article
• http//www.childrensimmunisation.com/images/upload
  ed/Docs/times_21-02-2004.pdf
• http//www.oregon.gov/DHS/ph/acd/flu/public/FluMMR
  autism.pdf
• In 2010, the Lancet retracted the study
  altogether
• http//www.nytimes.com/2010/02/03/health/research/
  03lancet.html

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Etiology Vaccines

• Article on Autism and Vaccines written by
  Catherine Maurice for ASATs newsletter
• http//asatonline.org/pdf/summer2009.pdf

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Etiology Vaccines

• In May, 2010, Lancet was banned on practicing
  medicine in Great Britain due to unprofessional
  conduct
• http//www.nytimes.com/2010/05/25/health/policy/25
  autism.html?adxnnl1emceta1adxnnlx1274810492-w
  QC8ONIFU4ua40vpZ2qyFw
• http//www.aolhealth.com/2010/05/24/uk-bans-doctor
  -who-linked-autism-to-vaccine/?ncidwebmaildl1sms
  _ssemail

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Etiology

• CDC - Vaccines
• http//www.cdc.gov/ncbddd/autism/vaccines.htm
• ASAT summary of the vaccine controversy
• http//www.asatonline.org/pdf/newsletter_preview.p
  df
• Videos
• What Causes Autism?
• http//www.autismspeaks.org/video/index.php
• February (2009) court case
• http//www.cnn.com/2009/HEALTH/02/11/autism.vaccin
  es/index.htmlcnnSTCVideo

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Sowhats the cause of autism?

• No one cause of autism has been identified
• Genetic influences are likely most important risk
  factor
• But not only cause (MZ twin concordance lt 100)
• Cause is likely multifactorial
• Physiology and environment are ALWAYS interacting
  from day 1
• May be several types of autism with different
  causes