In this chapter you have learned:
- Psychotic disturbances have been examined since the early 20th century. Bleuler applied the term schizophrenia to psychotic problems. Initially autism and childhood schizophrenia were seen as similar disorders. In 1943, Leo Kanner identified autism and a year later Hans Asperger described a similar group of children.
- Autism is currently understood as a pervasive developmental disorder characterized by impaired social interaction, disturbed communication, and restrictive repetitive behaviors and interests (the triad of impairments). Onset must occur before age 3 and significantly disturb the child’s ability to function. Children with autism may be less visually responsive, may be less likely to respond to their name, and may show aversion to being touched. They may avoid eye contact and fail to engage appropriately with others. Deficits in joint attention may be evident. They may be less likely to imitate others. Although they may demonstrate normal attachment to their parents, their interactions may not be reinforcing to others. Communication deficits are often evident with approximately 50% of these children remaining mute. When speech is present, echolalia and pronoun reversals and difficulties with pragmatics are not uncommon. Hyperlexia-where single word reading is extraordinary but comprehension is problematic is noted in some cases. Odd behaviors, obsessive or rigid behaviors and interests and stereotyped motor behaviors are typical. Oversensitivity to certain sounds, coupled with under sensitivity to other sounds is also reported. These children have difficulty switching their focus or attention. About 75% will demonstrate significant intellectual impairment. Higher IQ is associated with higher functioning and better outcomes. Uneven cognitive abilities are common with significant weaknesses in verbal skills and relative strengths in memory and visual spatial skills. Splinter skills-or abilities that are higher than expected may be noted. Savant skills (those noted in the movie Rainman) are often associated with autism, but only occur in approximately 5-10% of children with this diagnosis. Adaptive behavior deficits in communication and social skills are typical.
- The prevalence rate of autism and autism spectrum disorders have increased significantly over the years. This may be due to an actual increase, better diagnostic measures, increased awareness or broader diagnostic criteria. Boys receive the diagnosis at a rate of 3.5-4:1. As the level of intellectual impairment increases the ratio between boys and girls becomes more equal. Social class appears to be unrelated to autism. The progression of the disease is complex and may be critical to diagnosis. Many parents note problems from birth, while others indicate a regression of abilities that begins around age 2. In childhood, some improvements may be noted such as a decrease in repetitive movement and an increase in communication, but other issues such as obsessive interests may arise. In adolescence, improvements may continue or deterioration into behavioral problems may arise. Adolescence is a time of high risk for the development of seizure disorders. It is estimated that as many as one-half to two-thirds of these individuals fail to achieve independent living. Lower IQ and lack of language have been associated with poor outcomes.
- Folks with autism demonstrate problems with theory of mind or the ability to understand the desires, intentions, beliefs, and feelings of others. This is likely related to the social and communication deficits these individuals experience. They also tend to exhibit weak central coherence or a tendency to focus on parts of a stimulus rather than the whole picture. Executive functions are problematic and may mimic the problems noted with other disorders. They have particular problems with shifting attention and being cognitively flexible.
- Several areas of the brain have been identified as problematic including temporal lobe-limbic system, the frontal lobes and the cerebellum. There is some evidence that toddlers, but not infants, with autism have exceptionally large brains. However, large brains have not been consistently noted in adolescence and adulthood. Other research shows smaller brains in adolescence leading some to posit that the ability of the brain to form appropriate connections and adequately prune ineffective connections is a problem. Problems with serotonin and dopamine have also been noted.
- At one time the “refrigerator” mother was implicated as the cause of autism-this theory has since been debunked. Other theories have included exposure to viruses in the second trimester of fetal development and exposure to mercury in the MMR vaccine. Neither of these theories has held up well under scrutiny. Autism is associated with some genetic disorders such as fragile X and tuberous sclerosis. Genetic research indicates a higher concordance rate in monozygotic twins, higher rates of autism spectrum disorders in the families of probands, higher rates of other behavioral and social problems in the families of probands, and higher rates of problems in biological families rather than adoptive families. Chromosomes 7, 2 and 15 have been implicated in some cases.
- In addition to autism, the DSM notes Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorder Not Otherwise Specified as pervasive development disorders. Asperger’s disorder is a heavily researched and controversial diagnosis. There is some debate as to whether or not Asperger’s is simply high functioning autism. These children still exhibit problems in social interaction and preoccupations with interests or activities, but they do not exhibit language delays or cognitive impairments. Their adaptive behavior is also normal (except in social areas). Rett’s disorder is significantly more common in females and has been linked to a gene on the X chromosome. These children will exhibit normal development for the first few months of life and then begin to regress in distinctive ways. They will significant intellectual impairment and autistic like behaviors-although they may be more interested in others socially. However, their communication and behavioral problems persist into adulthood and the prognosis is poor. Children with Childhood Disintegrative Disorder (aka Heller’s Syndrome) are characterized by normal development for the first two years of life. Symptoms must occur by age 10 and include problems with expressive and receptive language, social and adaptive behavior deficits, loss of bowel and bladder control, and/or inappropriate play and loss of motor skills. These children are more likely to have abnormal EEGs and seizures, as well as adaptive behavior and intellectual impairments. Their prognosis is poor. Pervasive Developmental Disorder NOS is also called atypical autism. Individuals who do not meet all of the criteria for autism or present with unusual patterns of symptoms or an unclear history may be given this diagnosis.
- To assess autism the clinician should get a thorough developmental, family and medical history. Consultation with a medical doctor to rule out other disorders and determine if there is an associated diagnosis or genetic cause is a must. Direct observations paired with standardized tests of intelligence, development, adaptive behaviors, and language are required. There are several standardized measures of autistic behaviors including the Checklist for Autism in Toddlers, the Childhood Autism Rating Scale, and the Autistic Diagnostic Observation Schedule.
- There are a number of controversial treatments for autism that have not been empirically supported such as megavitamins, hugging therapy, auditory training, visual training, psychomotor skill patterning, and facilitated communication. Pharmacological treatments may include antipsychotic medications to reduced problematic behaviors. However both typical and atypical antipsychotic medications have side effects and more research is needed. Behavioral interventions such as those created by Lovaas can be quite effective, but they are intensive and expensive. The basic goals of the Lovaas method include reducing maladaptive behaviors that interfere with learning, teach imitation and compliance, train basic behaviors, improve language and communication, and enhance academic preparation and peer relationships. According to research on another popular model (TEACCH) intensive treatments should be given for many hours a day and in many environments, they should begin as early as possible, they should be applied in carefully controlled situations with highly trained staff, they should include techniques for generalization and maintenance, parents should be heavily involved and there is often variation in outcome.
- Schizophrenia differs from autism in that the children have hallucinations (erroneous perceptions) and/or delusions (false beliefs). These children may also have better language abilities and higher IQs in general when compared to children with autism. Hallucinations, delusions, disorganized speech and disorganized motor behavior are considered positive symptoms whereas, flat affect, poverty of speech, and avolition are negative symptoms. Diagnosing schizophrenia before the age of 7 or 8 is very difficult. Many children will exhibit non-psychotic symptoms before the onset of psychosis. This is known as insidious or gradual onset. Hallucinations and delusions are very common in childhood schizophrenia. Auditory hallucinations are the most common. As the child reaches adolescence, delusions become more complex and adult like. These children will often exhibit thought disorder or evidence that they cannot organize their thoughts. Motor abnormalities such as awkwardness, delays, poor coordination, and odd postures have been noted. These kids may display a lack of social interest, shyness, withdrawal and isolation. They may be moody, anxious, and depressed. Childhood schizophrenia is very rare and occurs in less than 1% of the population. Is often diagnosed more frequently in males and may occur more frequently in lower SES groups. Full recovery is rare, less than 25% will experience full recovery.
- Irregularities of hands, face, head and feet have been associated with schizophrenia which suggests genetic or prenatal problems during the second trimester. Smaller brain volume in frontal, temporal-limbic, thalamic and cerebellum have also been frequently reported. Enlargement of the ventricles in the brain, neuronal malformations and misplacement, and poor connections have been noted as well. Low reactivity of the autonomic nervous system and dysfunction of neurotransmitters such as serotonin, dopamine, GABA and glutamate have also been heavily researched. Genetic data indicate that the risk is high for immediate family members. Monozygotic have a 45% concordance rate compared to 17% for dizygotic twins. A number of chromosomes have been linked to schizophrenia but not consistently. Exposure to toxins during the second trimester has been identified as a risk factor, as has oxygen deprivation during childbirth. An old theory, the “schizophrenogenic” mother has not held up under scrutiny. However, family influences can impact the outcome of these individuals. Families that exhibit communication deviance have been linked to greater impairment. Parental expression of criticism and hostility or expressed emotion has been linked to poorer outcomes. The vulnerability stress model posits that the person has an organic vulnerability (faulty genes, prenatal insult, etc.) and then when exposed to environmental stressors, develops the disease. The neurodevelopmental hypothesis indicates that the early development of the brain is impaired and critical circuits are damaged, but that the full evidence of the damage may not be evident until later developmental periods. Issues associated with synaptic pruning may be the primary problem.
- Assessment should include historical information, data on pregnancy, childbirth and early development, assessment of positive and negative symptomology, intellectual, language and adaptive functioning, a physical examination including EEG and laboratory tests, and structured diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia. Treatment typically includes antipsychotic medications which address positive symptoms more effectively than negative symptoms, psychosocial interventions to educate the child and family about the diagnosis and build skills for coping and adjustment, and educational and social interventions.
