Understanding Autism (presentation)

1. Understanding
Autism
Dr Khalid Mansour
Locum Consultant Psychiatrist
St Andrews Hospital
2011

2. What really is that
Confusing concept
First-hand experience is
essential
Too many schools of
thinking
Electiveness is
unavoidable
Two professionals to
diagnose
My way of
understanding autism:
3 different sources

3. UNDERSTANDING AUTISM
1. Historical Developments of
the Concept of Autism

4. HISTORY:
Kanner’s Infantile Autism
1943: The distinction between
autism & LD
Asperger’s Syndrome : The
concept of mild autism.

5. HISTORY:
 Lorna Wing:
 Separating autism from schizophrenia
 Diagnostic triad: impairment of social
development, social communication and social
play.
 Autistic Spectrum Disorder (via Asperger’s): Mild
to severe autism > normal to severe autism
 Uta Frith and Simon Baron-Cohen:
 Theory of mind studies > Empathy & The Sally
Ann Test (the Emotional Dimension)
 Asperger’s Syndrome & High Functioning
Autism.
 Speech Therapy studies: Semantic Pragmatic
Disorder.

6. HISTORY:
Forensic Studies
Forensic aspects of autistic spectrum disorders.
Associations with cruelty to animals, fire setting,
regressive paedophilia, regressive sexual assaults,
violence to carers (especially mothers)
“Extreme” stress management > Asperger's
 Gary McKinnon Nicky Reilly

7. HISTORY:
Other Neuro-psychological
Studies:
Co-morbidity/association studies:
Learning Disability syndromes,
ADHD, epilepsy, etc.
The Broader Autism Phenotype
(BAP)> “Autistic Traits”
Mirror Neurones (Giacomo
Rizzolatti) > mechanism for
empathy
Triune Brain Theory (Paul
MacLean)

8. HISTORY:
Prevalence Studies:
Early studies (1980s): 4-6/10000
Now >1% life time prevalence (>schiz and >LD)
High rate of misdiagnosis: schiz, BAD, D&A, PD, etc
In general adult services: look into the treatment
resistant patients (bed blockers).

9. HISTORY:
ICD-10 & DSM-III:
International recognition for Asperger’s
Diagnostic Criteria (?)

10. DSM-IV: Pervasive Developmental Disorders:
 Classification
Autistic Disorder
Rett's Disorder
Childhood Disintegrative Disorder
 Asperger’s Disorder
Pervasive Developmental Disorder NOS
 Diagnostic criteria:
(I) A total of six (or more) items from (a), (b), and (c),
with at least two from (a), and one each from (b) and (c)
(II) Delays with onset prior to age 3 years:
(III) The disturbance is not better accounted for by Rett's
Disorder or Childhood Disintegrative Disorder

11. History (1): DSM-IV Diagnostic Criteria:
(A) qualitative impairment in social interaction:
 Poor nonverbal behaviors: eye-to-eye gaze
 Poor peer relationships
 Lack of spontaneous seeking to share enjoyment, interests, or
achievements
 Lack of social or emotional reciprocity
(B) qualitative impairments in communication:
 Delay in the development of spoken language
 Marked impairment in sustain a conversation
 Idiosyncratic language
 Lack of social imitative play
(C) restricted repetitive and stereotyped patterns of behavior, interests and
activities:
 Stereotyped and restricted patterns of interest
 Inflexible nonfunctional routines or rituals
 Stereotyped and repetitive motor mannerisms
 Preoccupation with parts of objects

12. DSM-IV Diagnostic Criteria: Problems:
Mainly for severe autism in childhood
No Autistic Spectrum (categorical classification)
> PDD-NOS (?)
Inappropriate inclusion of rare neurological
disorders like Rett’s and Childhood
Disintegrative Disorder syndrome
Poor appreciation of the emotional dimension
like > Nothing about “Theory of Mind” or
empathy.

13. Autistic Spectrum
ASPERGER
SYNDROME
RETT
SYNDROME
ATYPICAL
AUTISM
HELLERS
SYNDROME
PDD
NOS
AUTISM
KAMMER’S
SYNDROME
PDD – (ICD-10 & DSM-IV) model

14. Autistic Spectrum
ASPERGERS
SEVERE
AUTISM
ASD – Early Model
High Functioning
Autism

15. Autistic Spectrum
NORMALITY
ASPERGER
SEVERE
AUTISM
ASD – New Model
Narcissistic
personality
disorder
High Functioning
Autism

16. HISTORY (2): The Media
The Rain Man movie: Kim Peak - Idiot
Savant

17. HISTORY: Conclusions
1. A “Developmental Disability” that is
 Starts in childhood
 Pervasive
 Regressive
 Not corrected by retraining or change of environment
1. Core “Emotional” as well as “Social” dimensions:
2. Not categorical disorder: a Spectrum Disorder like LD
3. Associated with other regressive neurological disorders e.g.
 Avoiding direct eye contact,
 rocking,
 regressive OCD (e.g. hoarding, body fluids, etc),
 LD,
 speech Disorders,
 pica,
 Epilepsy, etc.

18. UNDERSTANDING AUTISM
2. Neuropsychological Studies:

19. Triune Brain Theory (Paul MacLean)
Senior Research Scientist
National Institute of Mental health
1913 - 2007

20. Triune Brain Theory (Paul MacLean)
Three brains in one: Specialised
but integrated
Social Brain: Neocortex
Emotional Brain: Limbic System
Objects/physical world Brain: Brain
Stem, Cerebellum & basal ganglia
(Reptilian Brain)

21. HOW DOES THE BRAIN WORK:
Systems: Triune Brain Theory (Paul MacLean)

22. AUTISTIC BRAIN:

23. Dysfunctional “Social Brain”:
 Social inadequacy:
 Aloofness,
 Awkwardness
 Passivity
 Poor understanding of social reality
 Social inappropriateness
 Poor social communication
 Poor fitting in social groups
 Treating people like objects or even preferring
objects over people

24. Dysfunctional “Emotional Brain”:
 Lack of understanding of emotions
 Poor reciprocation of emotions
 Poor emotional attachment
 Self-centeredness
 Lack of empathy
 Poor self awareness
 Lack of remorse or guilt when commit
inappropriate behaviour

25. Reptilian/other Brain Dysfunctions
LD
ADHD
OCD
Avoiding eye to eye contact
Existential (not stress related) anxiety
Epilepsy
Involuntary Motor Disorders
Rocking
Epilepsy, Pica

26. UNDERSTANDING AUTISM
(3) Direct Clinical Observations:

27. Physiological Coping Behaviour:
Control the Environment: (blind man
analogy: “Stay in control, stay safe”:
Higher dependency on carers
Restrict environment
Restricted interests: “Idiot Savant”
Rigid adherence to safe routines
Avoidance of changes

28. “Idiot Savant”

29. Pathological Coping Behaviour:
Severe Social Attitudes
 Severe social isolation
 Misuse of Alc &/or drugs to be able to mix with others
 Multiple regressive obsessional control of environment:
 Obsessional saving of body fluids
 Exaggerated hoarding obsessions
 Exaggerated emptying obsessions
 Exaggerated orderliness
 Poor coping – poor problem solving:
Violence
Fire setting
Sexual assault (opportunistic / childish assault of
vulnerable others in the house hold.

30. Pathological Coping Behaviour:
Regressive Emotional Reactions
Severe existential anxiety with poor
Coping with stress > panic, rage,
aggression
“Catastrophic reactions” in repsonse to
change
“Hostile Dependence” on carers (including
Physical aggression
Excessive blaming
Hypochondriasis

31. Routine and Habit Disorders:
 Routines
 Functional complex behaviours (e.g. Cleaning the
house on Saturday, drive to work in the morning,
visiting mum on Sunday)
 In autism:
 Regressive
 Rigid
 Poor adaptability when challenged > panic / rage
 Habits:
 Dysfunctional routine (e.g. drug and alcohol abuse,
stealing, violence)
 Develop mainly through learning and/or
environmental influence.

32. UNDERSTANDING AUTISM
(4) Proposed Formulations

33. (1) Proposed Diagnostic Criteria of Autism
(1) Essential Features:
 Poor development of SOCIAL intelligence / skills:
(Pervasive, Regressive, Since childhood & not creected by
training)
Social inappropriateness
Dysfunctional social aspects of play, verbal communication & non-
verbal communication
Social inadequacy (Aloof, Awkward or Passive)
 Poor development of EMOTIONAL intelligence / skills:
(Pervasive, Regressive, Since childhood & not creected by
training)
Self-centredness with poor self awareness
Poor empathy (dysfunctional theory of mind)
Lack of emotional reciprocity
Poor emotional awareness
Poor emotional aspects of play, verbal communication & non-verbal
communication

34. Proposed Diagnostic Criteria of Autism
(2) Compensatory Features:
 Restricting environments
 Restricting interests
 Islets of exceptional interests
 tendency to keep rigid control over environment
 Rigid routines or rituals
(3) Associated features:
 Existential (not stress related) anxiety
 Poor development of speech
 Poor eye to eye contact
 OCD like symptoms and rituals
 motor mannerisms
 Preoccupations with parts of objects
 Pathological habits

35. (2) Asperger Syndrome and
High Functioning Autism
Highly controversial
Different schools different views
This model:
High Functioning Autism: basic social and
emotional skills are compromised + better
coping due to high IQ.
Asperger syndrome: basic social and
emotional skills are okay except for:
Lack of imagination: “ability of prediction”
i.e. emotional and social skills can not be
transferred to unfamiliar situations
especially under stressful conditions.
“Hostile Dependence” on carers

36. PROPOSED CLINICAL THEORY:
Imagination Disorder
Imagination: ability to apply skills from the familiar
situation to the unfamiliar ones.
Main function of imagination is Prediction
Crucial for better emotional, social or physical
intelligences.
When ones lack emotional and social prediction abilities,
this leads to:
Reasonable performance in familiar sittings and with
support by regular carers
Deterioration in performance in new (unfamiliar)
situations especially under stress.
New situation: higher potential for emotional/social
awkwardness and/or regression in such situations
(Staggering Autism)

37. Stages of Intelligence and Autism
Stages of skill/intelligence Severe
Autism
High
Functionin
g Autism
Asperger
syndrome
Narcissistic
personality
disorder
Monitoring target data
X Yes Yes Yes
Understand / analyse data X
Yes Yes Yes
Developing an appropriate
response
X X
Yes Yes
Imitating appropriate
response
X X
Yes Yes
Mastering the skill in
unfamiliar situations
(imagination disorder)
X X X Yes
Mastering the skill under
stress
X X X
Yes
independence from carers
(No Hostile Dependence)
X X X X

38. (5) Observations about Management:

39. (3) Management:
Clinical vs Social Care
Clinical  social care.
Supporting the family too.
Social protection of patients (1/2 policing)
Improving quality of life
Public awareness (politics).
39

40. (3) Management:
Compensatory Approach
A “Deficit Disorder”
Realistic Expectation: patient is not
going to change much
Better Tolerance: especially re hostile
dependence.
Compensatory Approach: patients do
not change: carers and environment
change to compensate for patient's
deficits.

41. Management: Family Model of Care
(with or without School Model)
(Avoid disciplinarian models e.g. military, police or prison)
Most effective and most advanced
Promote socialisation
Promote maturity
Convenient:
Individualised
Familiarity
Predictability
Positive Support / training (Mum’s magic)
Safest model: Positive Boundaries System
HUMAN FACTOR IS CENTRAL
Consistency of staffing
Personalised relationship with staff (managers’ jealousy
syndrome)
41

42. (3) Management: Environment
High 3S environment:
Structure: Clear roles, clear authorities, clear time
tables, clear choices, predictable system, trustworthy.
Support:
Avoid pressure: Asperger patient can develop
erroneous thinking and extreme coping
mechanisms under pressure.
Continuous coaching (Borrowed Conscience):
Asperger patients can imitate staff but can not
transfer their skills to new situations. Staff need not
to get tired from repeating the lessons time after
time.
Supervision (Long-term): direct and indirect for
safety and support (expensive)

43. (3) Management: Rehabilitation
Rehabilitation is Essential not a luxury: for quality of
life and prevention of further loss of skills
Individualisation of care is essential: no “one-size-fits-
all”.
One-to-one care is common in ASD wards.
Normalisation AMAYC: use of community settings and
community themes
HF ASD patients can do Bridging: e.g. use physical
intelligence to compensate for lack of emotional or social
intelligence
Hospital Made Stability can not be easily extended to a
new and different environment unless it has the same
basic characteristics of the hospital environment (3S).

44. Management: Medications
 Illnesses with clear pathology need to be
promptly treated (e.g. epilepsy), though can
sometimes be confused with behavioural
disorders.
 For behavioural disorders: Behavioural /
Environmental Management should be given
priority:
 Meds are usually symptomatic: “No Cure”
 “better No-Meds”.
 Emergency Meds are better than regular meds
 In some cases meds are the best intervention
available to reduce suffering

45. Management: Routine a Habit Disorders
Respect patients’ routines and coping
mechanisms even if maladaptive.
Replace / modify them is better than suppress
them.
Induce minimum changes if possible:
removing routines is not the issue but
socialising them through channelling
Use “routines” for therapy: try to format
therapeutic elements into routines (opposite of
institutionalisation)

46. Management: Emergencies
 Good multidisciplinary reviews all times
 Avoid Overmedicalisation: most changes in autism
ward are due to
 Simple Physical illnesses: e.g. constipation, dental
pains, hyperacidity, etc
 Environmental changes e.g. routines or staff
changes.
 Side effects of medications
 Use of PRN is not bad but is needs to be a smart use
(as you do with your own kids at home):
 Avoid fear of using PRN as it might prolong suffering
 Avoid abuse of PRN: PRN for patient’s good not for staff good

47. Management:
Dealing with Difficult Families
Common problem: avoid “rivalry with families”.
Families deal with a lot of things (think as if the
patient is your own child):
Broader Autism Phenotype (BAP): high autistic traits in
families.
Guilt of giving away one’s own child to strangers to look
after.
Guilt of dying and leaving them alone in life
Be accommodating to families AMAYC but
also maintain clear boundaries: this is more
likely to initiate trust.
We must protect our patients from bad
treatment (intentional or not) by families too.

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