10
Autism and Childhood-Onset Schizophrenia
Chapter Outline:
I.
II.
III.
General Description and Historical Background of Autism
A.
Autistic disorder or autism is a severe developmental disorder characterized by
abnormalities in social functioning, language, and communication, and unusual
interests and behaviors
B.
Autism is the most common and most studied pervasive developmental disorder
(PDD); characterized by significant impairments in social and communication
skills, and stereotyped patterns of interests and behaviors
C.
Autism and childhood-onset schizophrenia were previously lumped together as a
single condition, but are now seen clearly as distinctly different disorders
D.
In 1943, psychiatrist Leo Kranner described children who withdrew into a shell,
disregarded people, avoided eye contact, lacked social awareness, had limited
language, displayed stereotyped motor movements and showed preservation of
sameness as having a disorder called early infantile autism; he believed autism
resulted from an inborn inability to form loving relationships with other people
and described parents of these children as being cold and detached
E.
Autism is now recognized as a biologically-based lifelong developmental
disability that is present in the first few years of life
DSM-IV-TR : Defining Features
A.
Main features of DSM-IV-TR diagnostic criteria:
1.
Impairments in social interaction
2.
Impairments in communication
3.
Restricted repetitive and stereotyped patterns of behavior, interests, and
activities
B.
Delays or abnormal functioning in social interaction, social communication, or
symbolic or imaginative play prior to age 3
C.
Autism is a spectrum disorder, which means that its symptom patterns, range of
abilities, and characteristics are expressed in many different combinations and in
any degree of severity
D.
Three critical factors contribute to the spectrum nature of autism:
1.
Children with autism may possess any level of intellectual ability
2.
Children with autism vary in the severity of their language problems
3.
The behavior of children with autism changes with age
Core Deficits of Autism
A.
Social impairments
1. From a young age children with autism show deficits in imitating others,
orienting to social stimuli, sharing a focus of attention with others,
understanding other people’s emotions, and engaging in make believe play
2. Social expressiveness and sensitivity to others’ social cues are limited, rarely
share experiences or emotions with other people
3. Impairments in joint social attention- the ability to coordinate one’s focus of
attention on another person and an object of mutual interest; show little desire
to share interest and attention with another person
IV.
4. Process social information in unusual ways- may have difficulty imitating
others or orienting to social versus nonsocial stimuli, may overemphasize
parts of the face, don’t prefer speech over nonspeech sounds (as typically
developing children do)
5. Show slightly lower but comparable rates of secure attachment to their
mothers as normal controls
6. Deficit in ability to form attachments is not global, but is in their ability to
understand and respond to social information
7. Problems in processing and expressing emotional information contained in
body language, gestures, facial expressions, or voice
B.
Communication impairments
1.
Use protoimperative gestures to express needs, but not protodeclarative
gestures to direct visual attention of others to objects of shared interest
2.
May use instrumental gestures but not expressive gestures
3.
About 50% of children with autism do not develop any useful language
4.
Use qualitatively deviant forms of communication- rhythm and intonation
of speech often unusual, and may use incoherent and irrelevant speech,
pronoun reversals, echolalia
5.
Profound impairments in pragmatics-appropriate use of language in social
and communicative contexts
C.
Repetitive behaviors and interests
1.
Show narrow patterns of interests such as a fascination with arithmetic,
repetitive behaviors such as lining up objects, or stereotyped movements
such as rocking- seem driven to perform and maintain these behaviors
2.
Common and persistent self-stimulatory behaviors- repetitive body
movements or movements of objects
Associated Characteristics of Autism
A.
Intellectual Deficits and Strengths
1.
About 70% of children with autism have mental retardation, with
particular weaknesses in verbal IQ
2.
About 25% display splinter skills and 5% have savant abilities
B.
Sensory and Perceptual Impairments
1.
Include oversensitivities or undersensitivities to certain stimuli,
overselective and impaired shifting of attention to sensory input, and
impairments in mixing across sensory modalities
2.
Sensory dominance-tendency to focus on certain types of sensory input
over others
3.
Stimulus overselectivity- selective focus on one feature while ignoring
other equally important features
C.
Cognitive Deficits
1.
Deficits in processing social-emotional information
a.
Difficulty understanding social situations
b.
Impairments in the ability to understand others’ and their own
mental states (theory of mind)
2.
General deficits
a.
Deficits in executive functions
b.
V.
VI.
Lack of drive for central coherence (i.e., they tend to process
information in bits and pieces rather than looking at the big
picture)
D.
Physical Characteristics
1.
Less than 10% of children with autism have a co-occurring medical
condition that may play a causal role in their autism
2.
Development of epilepsy in 25% of individuals with autism, with onset
usually in late adolescence or early adulthood
3.
Abnormally large head circumference in about 20% of individuals
E.
Family Stress- In addition to experiencing the inherent stress and demands
involved in caring for a child with autism, parents of children with autism may
experience frustration and delays before receiving help; also may experience
social ostracism from friends or strangers
F.
Accompanying Disorders and Symptoms
1.
Most often associated with mental retardation and epilepsy
2.
Additional behavioral and psychiatric symptoms may include
hyperactivity, learning disabilities, anxieties and fears, mood problems,
and self-injurious behavior
G.
Differential Diagnosis
1.
Children with mental retardation but not autism do not display deficits in
joint social attention or theory of mind, and are often able to display social
behaviors appropriate for their mental age
2.
Compared to children with developmental language delays, children with
autism use more atypical forms of language, display less spontaneous
social conversation, and show greater impairment in nonverbal
communication
Prevalence and Course of Autism
A.
Occurs in about 16 children per 10,000
B.
Occurs in all social classes and in all cultures
C.
Approximately 3 to 4 times more common in boys than in girls, although no
gender differences among those with autism and profound mental retardation
D.
Extreme male brain (EMB) theory of autism focuses on the idea that those with
autism are more “systemizing” than “empathizing” and that males are presumed
to show more systemizing abilities and females more empathizing abilities
E.
Deficits become more noticeable around age 2, although elements are usually
present at a much earlier age
F.
Most children show gradual improvement with age, although they are likely to
continue to experience many problems
G.
Only a few adults with autism achieve a high level of independence; most remain
dependent on family and support services
H.
Usually a chronic and lifelong condition, especially for those with severe or
profound mental retardation
Causes of Autism
A.
Problems in Early Development- premature birth, bleeding in pregnancy, toxemia,
viral infection or exposure, and a lack of vigor after birth have been identified in a
minority of children with autism
B.
VII.
Genetic Influences
1.
Individuals with autism have an elevated risk of about 5% for gene
anomalies; 25% of children with tuberous sclerosis have autism
2.
Family and twin studies suggest that the heritability of an underlying
liability to autism is above 90%; non-autistic relatives of individuals with
autism display higher-than-normal rates of social, language, and cognitive
deficits that are similar in quality to those found in autism, but are less
severe
3.
Possible locations on different chromosomes for susceptibility genes for
autism have been suggested, but actual susceptibility genes have not yet
been identified
C.
Brain Abnormalities
1.
Higher rates of epilepsy and EEG abnormalities in about 50% of
individuals with autism provide general evidence of abnormal brain
functioning
2.
Observed deficits suggest the involvement of multiple regions of the brain
at both cortical and subcortical levels
3.
Brain imaging studies suggest abnormalities in the frontal lobe cortex,
cerebellum, and the medial temporal lobe and related limbic system
structures
4.
Neuroimaging studies of brain metabolism suggest decreased blood flow
in the frontal and temporal lobes
5.
About 1/3 of individuals show elevated levels of whole blood serotonin
D.
Autism as a Disorder of Brain Development- support for presence of a pervasive
abnormality in brain development in autism that produces generalized
impairments in complex information-processing abilities; may involve
dysfunction of a brain system specialized for social cognition
Treatment of Autism
A.
Most treatments are directed at maximizing the child’s potential and helping the
child and family cope more effectively with the disorder
B.
Treatments for low-functioning children emphasize elimination of harmful
behaviors and efforts to teach the child self-help skills, compliance with simple
requests and rules, basic social and emotional behaviors, communication of needs,
and appropriate play; as they grow older the focus is on teaching domestic and
work-related skills
C.
Goals for high-functioning children include the same as those for low-functioning
children, as well teaching language fluency, age-appropriate social interactions
with normal peers, and the behaviors and skills expected in typical classrooms
D.
Most effective treatments are highly structured and skills-oriented, tailored to the
individual child, involve and support the family, and involve early intervention
E.
Initial stages of treatment focus on building rapport and teaching learning
readiness skills through discrete trial training and incidental training
F.
Disruptive and interfering behaviors must be eliminated before the child is able to
learn more adaptive forms of social interaction and communication
G.
Teaching appropriate social behavior includes teaching expression of affection,
imitation, sharing, and turn taking, and may be done through interactions with
normal or mildly handicapped peers and/or reward systems for social initiations
H.
Teaching appropriate communication may make use of operant speech training or
sign language training
I.
Early intervention efforts are often carried out at home and in the preschool,
provide direct one-to-one work with the child for 15 to 40 hours per week,
actively involve the family, and involve efforts to include the child in interactions
with normal peers; most children benefit from early intervention
VIII. Other Pervasive Developmental Disorders (PDD)
A.
Asperger’s Disorder (AD)
1.
Characterized by major difficulties in social interaction and by unusual
patterns of interest and behavior in children with relatively intact cognitive
and communication skills
2.
The main differences between AD and autism appear to be higher verbal
mental age, less language delay, and greater interest in social contact in
children with AD
3.
Estimated prevalence is about 2.5 per 10,000, but likely to be higher; boys
are more likely to be affected
4.
The higher intellectual functioning in children with AD suggests better
long-term outcome than for autism
5.
Brain abnormalities in the cerebellum and limbic system are similar to
those for autism, but less severe
6.
On-going debate about whether or not AD simply describes higherfunctioning individuals with autism, as well as whether AD should be
viewed as a disorder or as an extreme on a continuum of social behavior
B.
Rett’s Disorder
1.
A severe neurological developmental disorder characterized by
deceleration of head growth, loss of previously acquired purposeful hand
skills with the subsequent development of stereotyped hand movements
(hand-wringing or hand-washing), loss of social engagement, appearance
of poorly coordinated gait or trunk movements, severely impaired
language development, and severe psychomotor retardation
2.
Occurs in about 1-4 per 10,000 females; mostly female cases reported to
date; severe neurological disorder caused by specific X-linked gene
mutations found in more than 80% of those affected
3.
Most experience severe or profound mental retardation, epileptic seizures,
motor handicaps, and difficulties with communication; girls with Rett’s
commonly have apraxia, and their brains are 12-34% smaller than other
children’s brains
4.
Long-term prognosis is poorer than for that of autism
C.
Childhood Disintegrative Disorder
1.
Characterized by a significant loss of previously acquired language, social
skills, and adaptive behavior prior to age 10; regression follows a period
of apparently normal development
2.
IX.
Abnormalities include impairment in social interaction and/or
communication, and restricted, repetitive, and stereotyped patterns of
behavior, interests, and activities, including motor stereotypes and
mannerisms
3.
Only occurs in about .2 per 10,000 children
4.
The symptoms, degree of impairment, and outcomes for children with this
disorder are similar to those for children with autism, with the exception
of age of onset and a period of normal development, typically for the first
2 to 4 years of life; however, inclusion of CDD and Rett’s disorder with
other PDDs has been questioned
D.
Children with Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS) display the social, communication, and behavioral impairments associated
with PDD, but do not meet the criteria for other PDDs, schizophrenia, or other
disorders
Childhood-Onset Schizophrenia (COS)
A.
Historically, the term “childhood schizophrenia” was applied to a diverse mix of
children with little in common other than their experience of a profound and
chronic disturbance in early childhood; term applied to children who today would
be diagnosed with autism or some other PDD
B.
In comparison to autism, COS is associated with a later age of onset, less
intellectual impairment, less severe social and language deficits, hallucinations
and delusions, and periods of remission and relapse
C.
COS is not distinct from adult schizophrenia, but rather is a more severe form;
however, schizophrenia may be expressed differently at different ages
D.
DSM-IV-TR: Defining Features
1.
Delusions (disturbances in thinking), hallucinations (disturbances in
perception), disorganized speech, disorganized or catatonic behavior,
“negative” symptoms (i.e., flat affect, alogia, avolition)
2.
Signs of disturbance must persist for at least 6 months
E.
Related Symptoms and Comorbidities
1.
High comorbidity with conduct problems and depression
2.
Despite the historical association between autism and schizophrenia,
children with schizophrenia do not show an elevated risk for autism or
other PDDs
3.
90% of children show a clear history of behavioral and psychiatric
disturbances before the onset of psychosis
F.
Prevalence
1.
Extremely rare in children under age 12 years of age; estimated prevalence
.14 to 1.0 child per 10,000
2.
Boys have an earlier age of onset; twice as common in boys, although
gender differences disappear in adolescence
G.
Causes
1.
Current views regarding causes are based on a vulnerability-stress model
that emphasizes the interplay among vulnerability, stress, and protective
factors, in the context of developmental maturation of brain circuitry
2.
H.
Preliminary evidence suggests a strong genetic contribution to
schizophrenia in childhood, even more so than for adults
3.
COS appears to particularly associated with family stress; parents have
high scores of communication deviance
Treatment
1.
COS is a chronic disorder with a bleak long-term outcome
2.
Current treatments emphasize use of antipsychotic medications in
combination with psychotherapeutic, and social and educational support
programs
3.
Psychosocial treatments, such as social skills training and family
intervention, and educational supports are also important