June 22, 2011 Autism and Other Autism Spectrum Disorders (ASD) or Pervasive Developmental Disorders (PDD) Institute for Development of Mind and Behavior Masataka Ohta MD (Email: mohta-dmb@nifty.com)
OUTLINE Concept and Diagnoses of Autism and other ASD/PDD Developmental Psychopathology of Autism and Ohta Stageing Treatment of Autism including Cognitive Developmental Therapy
Concept and Diagnoses of Autism and other ASD/PDD
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
Three myths of autism based on psychoanalytic theory 1. Autism ; defense against parents esp.mother. 2. good or excellent potential intelligence. 3. no brain biological problems.
Declining of the three myths and Appearance of new concept Declining of the myths and Development of a new concept as brain dysfunction Defined as behavioral syndrome at present
Historical Change of Terminology for Autism in Official Diagnostic Systems 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 AS 1994 DSM-IV autistic disorder PDD AS 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 disorders AS: Asperger Syndrome (cf http://www.dsm5.org)
Diagnostic Criteria of [Childhood] Autism/Autistic Disorder Qualitative impairments in social 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)
Abnormal Behaviors frequently associated with Autism In Childhood hyperactivity, sleep disturbance, oversensitivity to sounds, abnormalities in eating etc After Adolescence inertia, self-injurious behavior(sib), aggressive behaviors, catatonia, obsessive-compulsive disorder(ocd) like behavior, mood disorders (depression, bipolar disorders, mood swings ),
Pervasive Developmental Disorders ICD-10 Childhood autism A typical autism Rett's syndrome Other childhood disintegrative disorder Asperger's syndrome Overactive disorder associated with mental retardation and stereotyped movements Other pervasive developmental disorders Pervasive developmental disorder, unspecified DSM-IV-TR Autistic disorder Rett's disorder Childhood disintegrative disorder Asperger's disorder Pervasive developmental disorder NOS
Intelligence and Cognition Since autism is a behavior syndrome, each autistic child have different intelligence Cognitive skills are usually uneven Intelligence develops with age
Savant Syndrome (By T. Ueda)
Early Symptoms of Autism I 1.Delayed speech and other speech problem Ⅲ-1 1.Not good a t forming interpersonal relationship 2.Poor response to others 3.Poor relationship in peer group/situation 4.Ignorring verbal comments as if deaf III-2 1. Restlessness and hyperactivity (Ohta et al. 1987)
Social Interaction Types in Adult Life Aloof Subgroup Passive Subgroup Active-but-Odd subgroup Subgroup with Stilted Interaction (Wing, L. 1992)
Wing s Subgroups and Ohta Staging III-2> III-1< Total (%) Aloof 4 18 22 (45.8) Passive 9 3 12 (25.0) Active-Odd 13 1 14 (29.2) Total 26 22 48 p<.00001 χ2=22.014 df=2
Present Social Situation Male Female Unknown Total % Employed 56 9 3 68 18.4 Public/private workshop 75 14 5 94 25.5 Institution 172 37 8 207 56.1 300 50 16 369 (Autism Society Japan 1992)
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 ~100~ Ratio of + MR 75~80% 22~49% (Per 10,000 child population)
Etiology of ASD
Cumulative Ratio of Epilepsy in Course of Autism Year Ratio(%) Number of subjects Number of subjects with epilepsy Mean age of subjects (Range) Keyakinosato 1993 33.3 60 20 25yr (18-38yr) Kawasaki et al. 1988 30.1 209 63 14 (10-22) Shimizu et al. 1987 25.0 100 25 14 ( 5-27) Gillberg et al. 1987 26.1 23 6 - (16-23) Kobayashi et al. 1985 14.4 90 13 16 (12-27) Matsumoto et al. 1982 12.1 91 11 14 ( 9-22) Lotter et al. 1974 20.0 30 6 - (16-18) Rutter et al. 1974 28.1 64 18 22 Kanner 1971 18.2 11 2 - (29-39)
Ratio of Concordance in Twin Studies of Autism Reporters Year MZ DZ Folstein & Rutter 1977 4/11 (0.36) 0/10 (0) Steffenburg et al 1989 10/11 (0.91) 0/10 (0) Ritvo et al 1985 22/23 (0.96) 4/17 (0.24) Smalley et al 1988 9/11 (0.82) 2/9 (0.22) Wakabayashi et al 1981 3/8 (0.39) 0/2 (0) Total 48/64 (0.75) 6/48 (0.13) (Nakane 1998)
Developmental Psychopathology in Autism
Major Findings on Standard Psychological Tests 1. autistic children reject tasks not due to "autistic shell", but due to difficulty of tasks 2. IQ scores of autistic children distribute from within normal range to severely retarded level ; recently, ratio of autistic children with normal intelligence are gradually increasing. 3. Wechsler tests show a characteristic profile in their course of development 4. IQ scores are remarkably stable, regardless clinical changes in behavior 5. obtained IQ scores are predictive of later adjustment
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, everything has its own name 3. formation of basic concepts, including concepts of relationships such as comparison, spatial concepts Children are acquired concept of Inclusion about 7 to 8 years (Piaget)
STAGE OF COGNITIVE DEVELOPMENT (Ohta s Staging)
STAGE OF COGNITIVE DEVELOPMENT (Ohta s Staging) Stage I Non-symbolic representation Stage I-1 Stage I-2 Stage I-3 Non active requesting behaviors Crane phenomenon" most frequent behavior Various request behaviors including speech, gesture and/or pointing Stage II 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 Intuitional thinking (4,5-7,8yrs) (End of the preoperational period)
Language Decoding Test Revised (LDT-R) (See Annex 1)
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.
LDT-R 5 1) Are there more black marbles or white marbles? 2) Are there more black marbles or white marbles? 3) Repeat #2; Are there the same numbers of black marbles or white marbles? LDT-R6 Which is more, all the marbles or the black marbles?
Algorithm of Ohta s 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 Credit (accomplish both tasks) Stage III-1 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 Credit (accomplish all tasks) Stage IV-1 LDT-R6 (concept of inclusion) No credit Credit (accomplish this task) Stage V or over Stage IV-2 * Stage I is divided three substages according to crane phenomenon
III-2 IV 8.3% 0%
Crane symptom (Stage I-2)
Ohta Staging and Mean Mental Age (MA) on Binet Test Stage VI Stage III-2 Stage III-1 StageII Stage I MA (months) 0 20 40 60 80 100 (Mean Calendar Age 87.3/35.4 months; N=90) (Mutoh et al. 2003)
WISC Profile in Autism (Stage III-2 to IV) (Lincoln et al 1995)
Status of Employment at the Examination for Pension (at 20 years old) 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=0.0012 χ2=10.43 df=1 HSG: high Ohta s stage group(iii-2 or more) LSG:low Ohta s stage group(iii-1 or less) (Ohta et al 1999)
IQ Difference between Persons with and without Competitive Jobs in HSG Jobs N 13 12 No Jobs Mean IQ 41.8 46.2 n.s. SD 13.1 20.4 Range 23-84 20 ー 62
Treatment of Autism
Historical Review of Treatment for Treatment based on psychoanalytic Autism or dynamic theories were denied as essential treatment Behavioral approaches Cognitive behavioral approaches Cognitive developmental approaches Psychopharmacotherapy
Two Facets of Treatment for Autistic Individuals Environment modulation (indirect treatment) Direct treatment
Modern Fundamental Principles of Psycho-educational 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
Cognitive Developmental Therapy (See Annex 2)
Two Major Assumptions in CDT First, if autistic children were given appropriate tasks, they would learn these tasks spontaneously; Second, if we arranged the tasks appropriately in the order of cognitive development. As the result of the learning, we could restore specific cognitive disorder of autistic children or at least facilitate their cognitive development. These two assumptions were verified through the nationwide experience.
Three primary aims of the Cognitive Developmental Therapy 1. to help overcome or compensate for the primary disabilities and to facilitate cognitive development 2. to facilitate development of adaptive skills 3. to reduce or prevent maladaptive behaviors
Genetic Factors Environmental
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
(1994/6/2)
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
Comorbidities and Psychopharmacotherapy in ASDs
Psychiatric and Behavioral Problems as Targets for Psychotropic Medicine Non-specific; hyperactivity, aggressiveness, Self injurious behavior (SIB), explosiveness, excitability etc. Reaction to Stress, and Adjustment Disorders Super-imposed psychiatric conditions or Comorbidities; epilepsy, intellectual disability, ADHD Tourette syndrome, obsessive- compulsive disorders, mood disorders (ex. depression), catatonia etc.
Psychopharmacologic agents antipsychotics sedative hypnotics stimulants antianxiety drugs mood stabilizers antidepressants anticonvulsants others
Side effects of Antipsychotics Sedation Parkinsonism Tardive dyskinesia Weight gain
Family Support Programs parents are not the etiological agent supportive approaches facilitating coping skills in terms of three primary aims
Thank you for your attention