1、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
2、type have been referred to by a variety of labels such as atypical psychosis, child psychosis, symbiotic psychosis, childhood schizophrenia, andinfantile autism,Evolution in the Classification of PDD,Prior to 1980 and the development of DSM III. there was no adequate classification system for the di
3、agnosis 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 C
4、riteria 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 The conditions may be manifested by autistic, atypical and withdrawn behavior; Failure to develop an identity apart from the mothers with general unevenness, gross immaturity, and inadequacy of development.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 defec
5、ts 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 mo
6、re 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
7、 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 recipro
8、cal 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 disord
9、ers 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
10、 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 developm
11、ent. 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 Develop
12、ment 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 d
13、eficits 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.
14、,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
15、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
16、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 wi
17、th, 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 Backw
18、ard,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
19、 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
20、 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
21、 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. Aspergers Disorder Autistic Disorder Rett Disorder Childhood Disintegrative Disorder PDD (NOS) Aspergers Disorder, Au
22、tism, and PDD (NOS) are frequently also referred to as Autistic Spectrum Disorders (Gillis & Romanczyk, 2008),Aspergers Disorder: The Least Severe of the Severe Disorders,The first published account of this disorder was by Austrian psychiatrist Hans Asperger in 1944 who initially referred to the con
23、dition as “autistic psychopathy“. It is interesting to note that Dr. Aspergers 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 abno
24、rmality 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.,Essential Features,Essential features includ
25、e 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 Aspergers Disorder, children with this c
26、ondition are often delayed in meeting major motor milestones (e.g., crawling, walking) and are frequently characterized as clumsy.,Aspergers: Social Impairments,In autism, social impairments seem to result from an intense desire to avoid social interactions. The social impairment in Aspergers seems
27、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.,Aspergers: Social Impairments,The child with Aspergers may show significant problems with; nonverbal be
28、haviors 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 appear
29、s 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 a
30、s 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 c
31、ertain 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
32、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, t
33、he child may have little understanding of the facts that they learn This results in significant impairment.,Apergers vs Autism,Unlike other PDDs, in Aspergers Disorder, there is no clinically significant delay in cognitive development or language. The child may learn to speak at a normal age and typ
34、ically 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 concret
35、e 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 childs favorite topic.,Aspergers vs. High Functioning Autism,Is Aspergers disorder
36、 is a separate disorder or just a variant of autism in higher functioning individuals. Some evidence suggests that children with Aspergers and high functioning autism are more alike than different and that Aspergers may simply be a variant of autism (Frith, 2004). However, children with Aspergers an
37、d high functioning autism seem to show distinct patterns of social impairment withchildren with Aspergers 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
38、 criteria for Aspergers Disorder are quite rare. In a total population study of children between ages 7-16 in Goteborg, Sweden the minimum prevalence of Aspergers 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 ar
39、e reported.,Aspergers: 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
40、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.,Aspergers: Etiology,Providing tentative support for some sort of biological etiology, Wing (1981) found that almost ha
41、lf 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 nonspecifi
42、c neurological symptoms. Research findings have also suggested that children with Aspergers 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
43、disorder.,Aspergers: Prognosis,Given their higher level of functioning (due to a lack of basic cognitive and language deficits) the prognosis is Aspergers appears much better than with other PDDs. Early studies by Wing (1981) presented case reports of individuals who were able to engage in gainful e
44、mployment and function in a simi-independent manner. A recent study found that 27% of those with Aspergers 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 t
45、o treatment and management approaches designed to deal with the childs difficulties.,Treatment of Aspergers,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 childs ability to functio
46、n 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 childs basic difficulties, may be useful later on as the child becomes aware of the degree to which social skills limitations ma
47、ke it difficult to function without experiencing personal distress.,Autism,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.,Autistic Disorder,In this semin
48、al 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 di
49、sorder 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.,
