Autism and Other Autism Spectrum Disorders (ASDs) or Pervasive Developmental Disorders (PDDs)

Transcription

1 June 11, 2008 Autism and Other Autism Spectrum Disorders (ASDs) or Pervasive Developmental Disorders (PDDs) Institute for Development of Mind and Behavior Masataka Ohta MD (

2 OUTLINE Concept and Diagnosis of Autism and other ASD including Behavioral Problems Problems Biology of Autism Developmental Psychopathology of Autism Treatment of Autism Cognitive Developmental Therapy Comorbidity and Medication Family Support Programs

3 Earlier Descriptions about Autism Spectrum Disorders Kanner L., 1943 Autistic Disturbances of Affective Contact (1944 Early infantile autism) Asperger, H., 1944 Autstisch Psychopathen im Kindersalter

4 Three myths of autism on psychoanalytic theories 1. Autism ; defense against parents esp.mother. 2. good or excellent potential intelligence. 3. no brain biological problems.

5 Collapse of the three myths and Appearance of new concept Collapse of the myths and Development of a new concept as brain dysfunction Defined as behavioral syndrome at present

6 Historical Change of Terminology for Autism DX System Terms Higher Category 1968 DSM-II childhood type Schizophrenia 1978 ICD-9 infantile autism Psychosis 1980 DSM-III infantile autism PDD 1987 DSM-III-R autistic disorder PDD 1991 ICD-10 childhood autism PDD 1994 DSM-IV autistic disorder PDD 2000 DSM-IV-TR autistic disorder PDD ICD: International Classification of Diseases (WHO) DSM: Diagnostic and Statistical Manual of Mental Disorders (APA) PDD: Pervasive developmental disorder

7 Diagnostic Criteria of Childhood Autism Qualitative impairments in reciprocal interaction Qualitative impairments in communication Restricted, repetitive, and stereotyped patterns of behavior, interests and activities Developmental abnormalities must have been present in the first 3 years for the diagnosis to be made (ICD-10 WHO, 1994; DSM-IV-TR APA, 2000) ( See the attached paper )

8 Abnormal Behaviors frequently associated with Autism In Childhood hyperactivity, sleep disturbance, oversensitivity to sounds, abnormalities in eating etc After Adolescence inertia, obsessive-compulsive disorder(ocd) like behavior, catatonia, mood disorders (depression, bipolar disorders, mood swings self-injurious behavior(sib), aggressive behaviors,

9 Pervasive Developmental Disorders(ICD-10) Childhood autism A typical autism Rett's syndrome Other childhood disintegrative disorder Overactive disorder associated with mental retardation and stereotyped movements Asperger's syndrome Other pervasive developmental disorders Pervasive developmental disorder, unspecified

10 ICD-10-DCR (1993) Pervasive Developmental Disorders Other PDD Overactive Childhod Autism Rett Asperger syndrome Atypical Autism Desintegrative Unspecified DCR: Diagnostic Criteria for Research

11 Pervasive Developmental Disorders(DSM-IV-TR) Autistic disorder Rett's disorder Childhood disintegrative disorder Asperger's disorder Pervasive developmental disorder NOS

12 DSM-IV -TR (2000) Pervasive Developmental Disorders Overactive Atutistic disorder Rett PDDNOS I ncl udi ng At ypi ca l Aut i s m Asperger syndrome Desintegrative

13 Early Symptoms of Autism See the table on the resume

14 Associated Behavioral Problems Infancy to childhood; sleep disturbances, hyperkinesis, peculiarities in perception (ex. oversensitivity to sounds) Puberty to young adulthood Inertia, obsessive-compulsive disorder(ocd), self-injurious behavior(sib), aggressive behaviors, mood swings

15 Intelligence and cognition Since autism is a behavior syndrome, each autistic child have different intelligence Cognitive skills are usually uneven Intelligence develops with age

16 Social Interaction Types in Adults with ASD Aloof Subgroup Passive Subgroup Active-but-Odd subgroup Subgroup with Stilted Interaction (Wing, L. 1992)

17 Wing s Subgroups and Ohta Staging III-2> III-1< Total (%) Aloof (45.8) Passive (25.0) Active-Odd (29.2) Total p< χ2= df=2

18 Present Social Situation Male Female Unknown Total % Employed Public/private workshop Institution (Autism Society Japan 1992)

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20 Prevalence of PDDs Previous Present reports abroad Typical Autism 4, 5~7 17~40 Other PDDs 2 ~5 27~46 All PDDs 6, 7~12 63~67 Ratio of + MR 75~80% 22~49% (Per 10,000 child population)

21 Biology of Autism

22 Developmental Psychopathology in Autism

23 Major Findings on Standard Psychological Tests 1. autistic children reject tasks not due to "autistic shell", but due to difficulty of tasks 2. Wechsler tests show a characteristic profile 3.relatively few autistic children obtain IQ scores within normal range, and most function at a severely retarded level 4. IQ scores are remarkably stable, regardless clinical changes in behavior 5. obtained IQ scores are predictive of later adjustment

24 Three Crisis Points of Cognitive Development in Preschooler 1. differentiation of "means" and "end" in Nonsymbolic period or Sensory-motor period 2. finding of "name", that is, every things have their own names 3. formation of basic concepts, including concepts of relationships such as comparison, spatial concepts

25 STAGE OF COGNITIVE DEVELOPMENT (Ohta s Staging)

26 STAGE OF COGNITIVE DEVELOPMENT (Ohta s Staging) Stage I Stage I-1 Stage I-2 Stage I-3 Stage II Non-symbolic representation Non active requesting behaviors Crane phenomenon" most frequent behavior Various request behaviors including speech, gesture and/or pointing Emergence of symbolic functioning Stage III Explicit existence of symbolic functioning Stage III-1 Understanding "object names" Stage III-2 Understanding "concepts of relationship" Stage IV End of the preoperational period

27 Language Decoding Test (LDT)

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31 1. Pick up the dog. 2. Put the button on the box. 3. Put the scissors next to the blocks. 4. Put the box on the button. 5. Put the blocks next to the scissors. 6. Put the button into the box.

32 Algorithm of Ohta Staging Evaluation LDT-R 1 (identifying objects by name) No credit Stage I* Credit (accomplish 4 tasks or more) LDT-R2 (identifying objects by use) No credit Credit (accomplish 4 tasks or more) Stage II LDT-R 3 (three-circle comparison) No credit Stage III-1 Credit (accomplish both tasks) LDT-R4 (spatial relationships) No credit Stage III-2 Credit (accomplish tasks #1~#3 and one of task #4 or # 5) LDT-R5 (conservation of quantities) No credit Stage IV-1 Credit (accomplish all tasks) LDT-R6 (concept of inclusion) No credit Stage IV-2 Credit (accomplish this task) Stage V or over * Stage I is divided three substages according to crane phenomenon

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36 Ohta Staging and Mean Mental Age (MA) on Binet Test Stage VI Stage III-2 Stage III-1 StageII Stage I MA (months) (Mean Calendar Age 87.3/35.4 months; N=90) (Mutoh et al. 2003)

37 Status of Employment at the Examination HSG* LSG Total Competitive Jobs 13(50.0) 1( 4.5) 14(29.8) Not employed 12(46.2) 21(95.5) 33(70.2) Unknown 1( 3.8) Total 26(100) 22(100) 47(100) (p= χ2=10.43 df=1) *HGS: High Stage Group (StageIII-2 or more) LSG: Low Stage Group (Stage III-1 or less)

38 Treatment of Autism

39 Historical Review of Treatment for Autism Treatment based on psychoanalytic or dynamic theories were denied as essential treatment Behavioral approaches Cognitive behavioral approaches Cognitive developmental approaches

40 Two Facets of Treatment for Autistic Individuals Environment modulation (indirect treatment) Direct treatment

41 Modern Principles of Psychoeducational Approaches Developmental perspective Difficult to facilitate learning under free situations Appropriate tasks and structured settings Programs reducing abnormal behavior must combine with those enhancing adaptive behaviors Non-aversive approach To make entirely programs under consideration of three dimensions; 1. to facilitate development of basic cognition including emotion, 2. to facilitate adaptive behaviors, 3. to reduce or control abnormal behaviors

42 Cognitive Developmental Therapy (See an another paper)

43 Two Major Assumptions in CDT

44 Three primary aims of the Cognitive Developmental Therapy

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46 Developmental Goals of Stage I to stimulate various sensations & to integrate between sensations to differentiate means and goals to foster basic communication abilities to facilitate abilities to understand that everything has a name

47 CDT and Abnormal Behavior Appropriate Understanding of their mind and Appropriate Approach on the Basis of Ohta s Staging Reduce and /or Prevent Abnormal Behavior

48 Comorbidity and Psychopharmacotherapy in ASDs

49 Two types of psychiatric and behavioral problems Non-specific; hyperactivity aggressiveness, SIB, explosiveness, excitability etc. Super-imposed psychiatric conditions or Comorbidity; epilepsy, Tourette' syndrome, obsessivecompulsive disorders, mood disorders (ex. depression), catatonia, etc.

50 Psychopharmacologic agents Antipsychotics sedative hypnotics stimulants antianxiety drugs mood stabilizers antidepressants anticonvulsants others

51 Side effects of Antipsychotics Sedation Parkinsonism Tardive dyskinesia Weight gain

52 Family Support Programs parents are not the etiological agent supportive approaches facilitating coping skills in terms of three primary aims