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
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
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
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
Pervasive Developmental DisordersCome 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
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
Diagnostic Criteria for AutisticDisorder (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
DSM Criteria for an Autism Diagnosis: Social InteractionMust 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
DSM Criteria for an Autism Diagnosis: CommunicationMust meet 1 of the following:Delay in, or total lack of, the development of spokenlanguage (not accompanied by an attempt tocompensate through alternative modes ofcommunication)Marked impairment in ability to initiate or sustainconversation with othersStereotyped and repetitive use of languageLack of varied, spontaneous make-believe play orsocial imitative play appropriate to developmental level
DSM Criteria for an Autism Diagnosis: RestrictedRepetitive and Stereotyped Patterns of Behavior,Interests, and ActivitiesMust 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
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
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)
DSM V• Proposed Revision of Autism Diagnosis• http://www.dsm5.org/ProposedRevisions/P
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?
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.
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
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
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…
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.
New Prevalence Rates• http://www.nytimes.com/2009/12/19/healt• http://www.cdc.gov/ncbddd/autism/index.h
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
Prevalence of ASD has continued toincrease 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?
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
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
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 childs 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 childs educational performance is adversely affected primarily because the child has a serious emotional disturbance as defined below.
Etiology: Psychodynamic Theory Eve off (1960) – parents are cold, detached, ritualistic Bruno Bettelheim (1967) Coined term “refrigerator mothers” No empirical support
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%
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
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
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.
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
Etiology: Vaccines Article on Autism and Vaccines written by Catherine Maurice for ASAT’s newsletter: http://asatonline.org/pdf/summer2009.pdf
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
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
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