intro overview

1. Overview of Autism

2. 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

3. 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

4. History of Autism
 Rutter (1968)
 Said the term autism led to confusion!
 Argued autism was different than schizophrenia
 Higher M:F 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

5. 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

6. Pervasive Developmental Disorders
Come under section in DSM-IV-TR entitled…
 Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence
 Include:
 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
 Others: separation anxiety disorder, selective mutism, reactive
attachment disorder of infancy or early childhood, stereotypic
movement disorder, childhood, or adolescence - NOS

7. DSM Category: PDDs
Pervasive Developmental Disorders
Childhood
Autistic Rett’s
Disintegrative
Disorder Disorder
Disorder
PDD-
Asperger’s
Not Otherwise
Disorder
Specified
• PDDs are characterized by severe and pervasive impairment in 3 main areas
• Social interaction
• Communication
• Repetitive and restricted behaviors

8. 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

9. 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

10. 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

11. 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 that’s 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

13. 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

14. Rett’s Disorder

15. Childhood Disintegrative Disorder

16. What are ASDs?
• Autism Spectrum Disorders
• Continuum comprised of autism, Asperger’s,
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 disorders have
been “arbitrary…difficult to apply and
unhelpful in clinical practice” (p. 1761)

17. DSM V
• Proposed Revision of Autism Diagnosis
• http://www.dsm5.org/ProposedRevisions/P

18. 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?

19. 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
2%–8% chance of having a second child who
is also affected.

20. 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

21. 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 child’s first birthday, and nearly
80%–90% saw problems by 24 months.
• Some children with ASDs seem to develop normally until 18–24 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 can’t tell you what sound a “b” makes

22. 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
groups—such as children who have a parent
or brother or sister with an ASD—should
be watched extra closely…

23. 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 Network’s 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
• That’s about 1 in 150 children in these communities
• 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.

24. New Prevalence Rates
• http://www.nytimes.com/2009/12/19/healt
• http://www.cdc.gov/ncbddd/autism/index.h

25. 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

26. 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?

27. 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

29. 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

30. 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.

31. Etiology: Psychodynamic Theory
 Eve off (1960) – parents are cold, detached,
ritualistic
 Bruno Bettelheim (1967)
 Coined term “refrigerator mothers”
 No empirical support

32. Etiology: Genetic Evidence
 Strong evidence for genetic
component, but nature of the
component is unknown
 Does not look like a single gene
 Monozygotic twin concordance high,
but less than 100%

33. 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

34. Etiology: Vaccines
 http://scienceblogs.com/insolence/2010
 Warning!!!!

35. 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
 Theory…MMR 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

36. Etiology: Vaccines
 Wakefield Study
 Methodological Issues
 Did not discuss specific diagnoses of participants (or how
obtained)
 The exact onset of intestinal problems was not 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. Wakefield’s 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.

37. 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/uploaded/D
 http://www.oregon.gov/DHS/ph/acd/flu/public/FluMMRau
 In 2010, the Lancet retracted the study
altogether
 http://www.nytimes.com/2010/02/03/health/research/03

38. Etiology: Vaccines
 Article on Autism and Vaccines
written by Catherine Maurice for
ASAT’s newsletter:
 http://asatonline.org/pdf/summer2009.pdf

39. 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/healt
 http://www.aolhealth.com/2010/05/24/uk-b

40. Etiology
 CDC - Vaccines
 http://www.cdc.gov/ncbddd/autism/vaccines.htm
 ASAT – summary of the vaccine controversy
 http://www.asatonline.org/pdf/newsletter_preview.pdf
 Videos
 What Causes Autism?
 http://www.autismspeaks.org/video/index.php
 February (2009) court case
 http://www.cnn.com/2009/HEALTH/02/11/autism.vac

41. So…what’s 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 < 100%)
 Cause is likely multifactorial
 Physiology and environment are ALWAYS
interacting from day 1
 May be several types of autism with different
causes