Autistic Spectrum Disorders: AKA PDD

Autistic Spectrum Disorders: AKA PDD James H. Johnson, Ph.D., ABPP University of Florida

Pervasive Developmental Disorders: Old and New Labels • 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 • atypical psychosis, • child psychosis, • symbiotic psychosis, • childhood schizophrenia, and • infantile autism

Evolution in the Classification of PDD • Prior to 1980 and the development of DSM III. there was no adequate classification system for the diagnosis of these disorders. • In DSM II there was no category appropriate for more severe forms of child psychopathology apart from “Childhood Schizophrenia”. • This category was very general and not sufficient for the diagnosis of the full range problems now considered under the heading of PDD

DSM II Criteria for Childhood Schizophrenia • Symptoms appear before puberty. • The conditions may be manifested by autistic, atypical and withdrawn behavior; • Failure to develop an identity apart from the mothers with general unevenness, gross immaturity, and inadequacy of development. • These developmental defects may result in mental retardation, which should also be diagnosed. • Although some children met criteria for this disorder most with severe psychological problems did not.

DSM III: A New Category for PDD • In DSM III an attempt was made to provide more adequate diagnostic categories for classifying more serious forms of child psychopathology. • Here two primary diagnostic categories were provided, as were more objective diagnostic criteria and specific decision rules for making diagnoses.

PDD: General Characteristics of the Category • Pervasive Developmental Disorders considered within DSM IV differ in a variety of ways • severity of impairment, • age of onset, • likely etiological factors involved • They are similar in reflecting core features that define the general diagnostic category. • They are seen as disorders characterized by pervasive impairments in several areas, including; • deficits in reciprocal social interactions, • deficits in communication skills, and • the presence of stereotyped behaviors/interests/activities

Developmental - Yes; Psychotic - No • At one time, conditions now referred to as Pervasive Developmental Disorders were thought to be reflective of Child Psychosis. • As these disorders generally bear little relationship to the psychotic conditions of adulthood (e.g. Schizophrenia, Bipolar Disorder), they are now referred to as "developmental" rather than "psychotic" disorders.

“Pervasive” vs “Specific” Developmental Disorders • These "pervasive" developmental disorders 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. • Children with these conditions often display distorted rather than simply delayed development.

DSM III: the Original PDD Classification • In the initial development of DSM (DSM III), only three categories of Pervasive Developmental Disorders were included; • Autism • Childhood Onset Pervasive Development Disorders. • There was also a more general category of “Atypical Pervasive Developmental Disorder” that could be used for children not diagnosable, using criteria for the other two categories.

DSM III: Autism Criteria • Onset before 30 months • Pervasive lack of responsiveness to other people • Gross deficits in language development • If speech present, peculiar speech patterns (e.g.echolalia, pronoun reversal) • Bizarre responses to various aspects of the environment – resistance to change; peculiar interests in or attachment to animate or inanimate objects. We will discuss Autism in more detail later.

DSM III: Childhood Onset PDD Diagnostic Criteria • A profound disturbance in social relationships and multiple oddities, all developing after 30 months of age and before 12 years (to separate it from Autism and Schizophrenia). • The disturbance in social relationships is gross and sustained, with such symptoms as lack of appropriate affective responses, inappropriate clinging, asocial behavior and lack of peer relationships.

DSM III: Childhood Onset PDD Diagnostic Criteria – cont. • Oddities of behavior include; • Sudden excessive anxiety • Constricted or inappropriate affect • Resistance to change in the environment • Insistence on sameness • Oddities in motor movement • Speech abnormalities • Hyper or hypo-sensitivity to sensory stimuli and • Self mutilation

Childhood Onset PDD: Associated Features • Bizarre ideas and fantasies and preoccupation with morbid thoughts and interests. • Pathological preoccupation with, and attachment to, objects such as always carrying a string, rubber band, straw, etc. • While seemingly representing an advance in attempting to be more objective in making diagnostic judgments, this classification approach changed in 1987 with DSM III –R.

PDD and DSM III – R: Moving Forward or Backward • In DSM III – R this category was changed dramatically. • The Childhood onset PDD category was eliminated. • Only the category of Autism was retained with this nature of the autism criteria being modified in several ways including; • Removing the age-of-onset criterion • Broadening the autism criteria thus distorting the traditional conceptualization of autism.

PDD and DSM III – R: Moving Forward or Backward – cont. • This broadening of the autism criteria came at a time when research was suggesting that it was important to start looking at subtypes of autism. • The changes resulted in many cases, that would have been diagnosed as COPDD being classified as autism. • Research suggested that diagnoses using these new criteria • Did not correspond to DSM III diagnoses of Autism or • Relate closely to clinician views of autism. • This prompted major changes in the PDD system. • Modifications were made for DSM IV. • DSM IV is more similar to DSM III than DSM III-R!

DSM IV: Current PDD Disorders • Several disorders are included under the present day DSM IV heading of Pervasive Developmental Disorders. • Asperger's Disorder • Autistic Disorder • Rett Disorder • Childhood Disintegrative Disorder • PDD (NOS) • Asperger’s Disorder, Autism, and PDD (NOS) are frequently also referred to as Autistic Spectrum Disorders (Gillis & Romanczyk, 2008)

The first published account of this disorder was by Austrian psychiatrist Hans Asperger in 1944 who initially referred to the condition as "autistic psychopathy". It is interesting to note that Dr. Asperger’s own preoccupations, interests and social aloofness suggest that he may himself have had an autistic spectrum disorder (Lyons & Fitzgerald, 2007) Asperger used the term "autistic" in the technical sense to refer to an abnormality of personality rather than features of infantile autism. However, more recent authors have commented on the similarities between these disorders. Indeed, there is some debate as to whether this disorder is actually distinct from autistic disorder. Asperger's Disorder: The Least Severe of the Severe Disorders

Essential Features • Essential features include • severe impairments in social interactions • restricted and repetitive patterns of interests, activities and/or behaviors • that result in impairment. • No clinically significant delays in cognitive development, language development • While not 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: Social Impairments • In autism, social impairments seem to result from an intense desire to avoid social interactions. • The social impairment in Asperger’s seems to result more from a lack of social skills and lack of social perspective taking. • These children seem to have a marked inability to understand and use rules which typically guide social behavior.

Asperger’s: Social Impairments • The child with Asperger’s may show significant problems with; • nonverbal behaviors such as maintaining appropriate physical proximity to others while interacting, • making and sustaining eye contact, and • appropriately using gestures, facial expression and other nonverbal behaviors to regulate social interactions.

Egocentricity of Social Behaviors • Social behavior often appears egocentric and self-centered, • Here, the child may frequently pursue his/her 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.

Restricted/Repetitive Behaviors • Restricted and repetitive patterns of behaviors, interests, or activities are often striking and may be manifest in a variety of ways. • 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.

Restrictive Patterns of Interest • Children with this disorder often 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 amount 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 • This results in significant impairment.

Aperger’s vs Autism • Unlike other PDD’s, in Asperger's Disorder, there is no clinically significant delay in cognitive development or language. • The child may learn to speak at a normal age and typically acquires a command of grammar (Children with autism have problems with this). • They may, however, show marked peculiarities in language. • They may invent words, use pronouns incorrectly, or repeat words or phrases over and over in a stereotyped manner. • These children are often extremely concrete and literal with a poor understanding of sarcasm or irony (Wiznitzer (2009). • May have big problem with idioms. • The content of speech is often overly pedantic, often consisting of long one-sided discussions about the child's favorite topic.

Asperger’s vs. High Functioning Autism • Is Asperger’s disorder is a separate disorder or just a variant of autism in higher functioning individuals. • Some evidence suggests that children with Asperger’s and high functioning autism are more alike than different and that Asperger’s may simply be a variant of autism (Frith, 2004). • However, children with Asperger’s and high functioning autism seem to show distinct patterns of social impairment with • children with Asperger’s being rated as “socially active but odd” and • those with autism rated as “aloof and passive” (Ghaziuddin, 2008)

Epidemiology • While there is little good data regarding prevalence, children meeting criteria for Asperger's Disorder are quite rare. • In a total population study of children between ages 7-16 in Goteborg, Sweden the minimum prevalence of Asperger's Disorder was found to be 36/10,000. • The disorder appears more common in males than in females. • Sex ratios ranging from 3.75 : 1 to 9:1 are reported.

Asperger’s: Etiology • Regarding etiology, the disorder was originally considered to have a genetic basis (Asperger, 1944). • While no formal studies firmly documenting a genetic etiology have been published, case study findings are available. • For example, in an early study Wing (1981) found that, 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.

Asperger’s: Etiology • Providing tentative support for some sort of biological etiology, Wing (1981) found that almost half of the 34 cases she studied had a history of pre-, peri-, or post-natal complications (e.g., anoxia) sufficient to cause neurological impairment. • Although not definitive, support for the role of biological factors comes from the fact that these children sometimes often show evidence of nonspecific neurological symptoms. • Research findings have also suggested that children with Asperger’s display abnormalities of the cerebellum and limbic system that are not unlike those found in autism (Mash and Wolfe 2007). • More research will be necessary to determine the most important contributors to this disorder.

Asperger’s: Prognosis • Given their higher level of functioning (due to a lack of basic cognitive and language deficits) the prognosis is Asperger’s appears much better than with other PDD’s. • Early studies by Wing (1981) presented case reports of individuals who were able to engage in gainful employment and function in a simi-independent manner. • A recent study found that 27% of those with Asperger’s had good adult outcomes and 26 % had restricted or poor outcomes with a very restricted life with no occupation and no friends (Mash and Wolfe 2007) • Obviously, prognosis is intimately related to treatment and management approaches designed to deal with the child's difficulties.

Treatment of Asperger’s • At present, no treatment has been shown to modify the basic underlying impairment shown by children with this condition, • Behavioral approaches designed to enhance the child's ability to function in social situations, along with an educational program tailored to meet his or her specific needs should be beneficial. • Psychotherapy, while not likely to remediate the child's basic difficulties, may be useful later on as the child becomes aware of the degree to which social skills limitations make it difficult to function without experiencing personal distress.

Infantile autism was first described by Leo Kanner (l943) in his classic paper " Autistic Disturbances of Affective Contact", which was published in the, now extinct journal, The Nervous Child. Autism

Autistic Disorder • In this seminal article, Kanner highlighted the defining characteristics of 11 children seen in his child psychiatry practice at Johns Hopkins University. • Kanner believed that these 11 children displayed a type of disorder different from any that had been described prior to that time. • His views regarding this disorder have heavily influenced present day views of the disorder, emphasized a number of features

Nature of the Disorder • 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 or so. • 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.

Defining Social Characteristics • 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”. . • This may be reflected in early life by a failure 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.

Defining Social Characteristics • Their problems in relating to others may be displayed by the failure of the child to respond to parents or others. • In some instances children may treat parents no differently from others and may show almost no response when a parent returns home, even after being gone for some time. • Sometimes these children are thought to be deaf because of their lack of responsiveness. • This problem of emotional responsivity prompted Kanner to describe the disorder as a primary disturbance of affective contact.

Social Aloofness as a Core Feature • Kanner suggested that the outstanding fundamental disorder is “the children’s inability 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 Language Impairments • All autistic children show evidence of a severe language disorder. • Many remain mute. • Those that develop speech typically show unusual features such as echolalia (the repetition of what someone else has said, just as it is said) or pronominal reversal (failure to use pronouns correctly ‑ referring to oneself as "you" and to others as "I"). • Even though some autistic children develop fairly large vocabularies, they usually cannot use speech to communicate with others.

Autistic Language Impairments • Kanner noted that although some of his 11 cases developed language, they were no better able to communicate than were those who remained mute. • Speaking autistic children often have no difficulty in naming objects and sometimes seem to have a facility 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 materials. • There is usually minimal evidence of spontaneous speech that serves a communicative function

The Desire for Sameness • Kanner and others have noted that autistic children seem to display an "anxious desire for the maintenance of sameness. • This refers to the fact that such children often get upset when things in their environment are changed ‑ when furniture is moved, when routines are changed, or when toys the child has left in a particular position are moved. • This may result in a catastrophic reaction 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.

Other Associated Features • In addition to the characteristics suggested, by Kanner, other behaviors are also found in some autistic children. • Many autistic children show stereotyped behaviors. • They may mouth objects, spend long periods of time flapping their arms and hands, rock, or display other apparently self‑stimulating behaviors. • The may sometimes appear either under or over responsive to environmental stimuli, or both. • Sometimes this under responsiveness is reflected in an apparent insensitivity to pain and in associated self‑injurious behaviors.

Prevalence of Autism • Although autism has, from the beginning, been seen as a rare disorder it has been difficult to determine its exact frequency of occurrence. • This is because investigators have often; • used different criteria for diagnosis, • because the disorder has frequently been confused with other severe disorders of childhood, and • because 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

Prevalenceof Autism • A review of studies conducted since the mid 1980's has, however, suggested higher prevalence figures. • The few studies using DSM criteria have reported rates on the order of 10 per 10,000 (Classic Autism). • Prevalence rates for Autism Spectrum Disorders • Recently it has been suggested that somewhere between 1 in 500 to 1 in 166 children have an ASD! Center for Disease Control and Prevention (CDC) • It is now being suggested that as many as 1 child per 150 (or more) may have an autistic spectrum disorder (Yeargin-Allsopp et al , 2003) • Other research has suggested that the prevalence for subtypes of autistic spectrum disorder are approximately 22 per 10,000 for autism, 33 for 10,000 for pervasive Developmental disorder NOS, and10 per 10,000 for Asperger’s disorder (Fombonne, et al , 2006) • The disorder is more frequent in boys than in girls, with sex ratios ranging from 2.0 to 1 to 5.7 to 1.

Autistic Success Stories • In a classic paper entitled "How far can autistic children go in matters of social adaptation?" Kanner (l973) reported on a follow‑up of some 96 autistic children seen prior to l953. • Although the majority did not fare as well, 11 of the 96 achieved what he described as a favorable outcome. • Here 3 obtained college degrees. Three went to junior college. At time of follow-up one other was reported to be doing well in college. The other four did not go beyond high school or special education.

Autistic Success Stories • The occupations of these grown‑up autistics included accountant, duplicating machine operator, lab technician, bank teller, along with 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. • Kanner found outcome to be unrelated to having received psychiatric treatment. • The single best predictor seemed to be having useful speech by age 5

Prognosis of Autism • In reviewing early follow‑up studies of autistic children DeMyer, et al (1981) suggested that as many as 60 to 70 percent live a life of complete or simi‑dependence, at home or in an institution. • Only about 1 to 2 per‑cent seemed to have achieved normal levels of independence, while others displayed a borderline level of functioning. • A better prognosis seemed to be associated with an IQ greater than 60.

Prognosis of Autism & Autistic Spectrum Disorders • Studies reviewed by Gillberg, et al (1992) suggest: • Autism associated with severe mental retardation diagnosed before age 5 carries a gloomy prognosis in respect of psychosocial adaptation. • Autism associated with mild mental retardation or near average intelligence levels has a more variable prognosis. • About half do poorly psychosocially in adulthood and do not hold jobs or lead independent lives in other ways. • However, a significant proportion of cases in this group has a relatively favorable prognosis and can be self-supporting as adults. • Only a few are likely ever to be married or engage in marriage-like relationships.

Prognosis of Autism & Autistic Spectrum Disorders • In very high functioning cases with autism or Asperger’s syndrome, the overall prognosis is much better. • Oddities of social style, communication and interests are likely to remain, but some in this group hold down jobs and many get married and have children. • There is much less detail with regard to the outcome picture in the high-functioning group than in the those with concomitant mental retardation. Gilberg (1992).

What about High Functioning Autism • Not a diagnostic category • Term used in different ways • Relates to those with autistic features but who have higher level language skills and may be normal in terms of cognitive functioning • Difficulties in distinguishing between this and Asperger’s disorder.

Etiology of Autism • Views regarding the causes of autism can generally be classified as psychogenic or biogenic in nature. • Psychogenic theorists, citing early reports which characterized the parents of autistic children as cold, aloof, obsessional, refrigerator like, and in other less than positive terms (see Kanner, l943), have emphasized the role of parental variables in the development of autism. • Indeed, some clinicians such as Bettelheim (l967) have suggested that negative maternal attitudes are of major importance in the development of this disorder.

Etiological Perspectives • For the most part, research designed to link family variables to autism has provided little support for psychogenic views. • DeMyer, et al (1981) have noted that, in sharp contrast to early portrayals of parents of autistic children as "refrigerator" personalities, the last decade of investigation has found these parents to be similar to those with children exhibiting other severe childhood disturbances. • "... 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).

Autistic Spectrum Disorders: AKA PDD