1: Introduction Flashcards
50 years ago, people that has specific disorders were often considered to have intellectual impairment.
Older adults with ASD would of had an initial diagnosis of intellectual impairment, as people weren’t really able to diagnose ASD all that well 20-30 years ago. There is a similar sort of pattern with children with disorders like Williams Syndrome. We all know children with dyslexia, apparently prisons are full of people with problems like dyslexia who are intelligent people that have difficulties with very specific aspects of learning.
Neurodevelopmental Disorders research encompasses different disciplines:
Neurodevelopmental Disorders research encompasses different disciplines: Molecular Biology (levels at the cell), Behavioural genetics, Developmental Neurobiology, Neuroimaging (small but growing in NDD), Cognitive Science and Developmental Psychology. These various groups give us a rich broad view of what is going on with these children with NDD. There are different research instruments and techniques are brought to the study of Neurodevelopmental Disorders: MRI / fMRI (important in enabling us to understand the difference between emotion recognition and other aspects of social cognition), EEG / TMS, Genetics, Epidemiology, Clinical reports (important in developing an understanding of these disorders). Neuroimaging has its limitations. Dorothy Bishop, suggests you cannot diagnose specific language impairment using neuroimaging. It’s a very useful and important tool but it doesn’t give us all the answer. Experimental studies are good if there is a child with a very discreet problem e.g. auditory working memory, this will have a knock on effect for the language and literacy etc. but we get it in quite a discreet way. When we think about social cognition in things like the Sally Ann experimental test has been very influential. A standardised test to see whether a child that has got a normal IQ (perfectly bright child) is really dyslexic/language impairment. The we would use a standardised language test that may tell us that the child has a language age of 8 years old but this child is a perfectly bright 10-year-old. Therefore, the language test will help diagnose a specific language disorder in that child.
Historical changes in conceptualising neurodevelopmental disorders.
Historical changes in conceptualising neurodevelopmental disorders. Diagnosis is this process of identifying and determining the nature or cause of a disease or injury through evaluation of the patient history examination, and how they are at this moment in time and a review of the laboratory data. The opinion derived from such an evaluation e.g. the ADOS will give data about how that child has done in that particular clinical interview but no diagnostician would make a diagnosis purely based in these results. They bring evidence from different kinds of areas. A comfortable child might do well on the ADOS but when the same child is seen playing with its peers in the playground, you then may see there are many more
In diagnosis for all psychological / psychiatric disorders, this process involves the identification and evaluation of behaviours, thoughts and feelings.
In diagnosis for all psychological / psychiatric disorders, this process involves the identification and evaluation of behaviours, thoughts and feelings. If they can describe their thoughts and feelings this would be important. The most important thing is that it has a negative impact on an individual’s life. There is a lot of discussion about the amount of people being diagnosed with ASD (it might be true that we’ve diagnosed people that we consider to be a little bit eccentric 20-30 years ago). A person who is eccentric but having a perfectly good life, why do they ned to be diagnosed. The clinician might only give a diagnosis if in enabled the child to access something that would help it (HFA may be doing well but they may receive more time in exams etc.). This may be environmental too, if a child is in a school where there are lots of helpful people around that might influence whether a child goes for a diagnosis. The official system for classifying these psychological disorders is prepared by the American Psychiatric Association (APA) Diagnostic and Statistical Manual (DSM).
In 1840 was the first documentation of “idiocy / insanity”.
In 1840 was the first documentation of “idiocy / insanity”. Abnormal behaviours were often described in a very superstitious way and it was only then where we started to think about them in a scientific way. In 1880 there were 7 categories of mental illness and then post-WWII there was something of a proliferation because there were people with very bad experiences in WWII. Early on there was a greater variation in how people were diagnosed. However, mental health is on the same page in a universal way because of the Diagnostic and Statistical Manual: Mental Disorder (DSM-I) in 1952. DSM development: DSM-I :1952, DSM-II: 1968, DSM-III : 1980, DSM-III-R (twiddling, no major changes): 1987, DSM-IV : 1994, DSM development V-TR: 2000 and finally the current DSM-5: 2013.
The term autism was used as a symptom of schizophrenia. Kanner (1943) was the first to describe autism
The term autism was used as a symptom of schizophrenia. Kanner (1943) was the first to describe autism as a syndrome/disorder in an extraordinary sensitive and perceptive way which he didn’t really get very much wrong in terms of describing them. He thought that their main problem was a difficultly in communicating, he described 11 children with autistic disturbance of affective contact (emotional contact with other people), he believed that their inability to communicate was their main difficulty. He further noted a profound lack of social engagement early in life; communication problems, unusual responses to their environments, hated changes in routine, echolalia, etc. Echolalia is not unique to ASD, we see it other disorders e.g. blind children. But Kanner was the first to describe it in terms of developmental disorder.
Development of a Diagnostic Category: Rutter (1978) outlined an official account of autism
Development of a Diagnostic Category: Rutter (1978) outlined an official account of autism grounded in Kanner’s description that went in DSM-III. By this time people had begun to do research also encompassed research findings. people like Lorna Wing were working in clinics where there were lots of children with ASD. Description became first official category definition of autism (DSM-III:1980). In the DSM-IV-TR (2000), the description slightly changed Pervasive Developmental Disorders which reflects the research that happened. There was a disorder called Autistic Disorder which had a triad of impairments in social interaction, communication and restricted interests and behaviours. Furthermore, there was Asperger syndrome, Rett’s Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). These disorders remained until the current DSM-5.In DSM-IV, to have infantile autism, the child would have to have had an onset prior to 30 months. 1) Socialisation, 2) Communication, and 3) Restricted interests/repetitive behaviours.
There can be a strong feeling a child has ASD by a lack of pointing and lack of eye contact etc.
There can be a strong feeling a child has ASD by a lack of pointing and lack of eye contact etc. well within the first year. If the child is developing completely normally for the first two and a half years and suddenly stops speaking, it is not ASD according to DSM-IV. There also needs to be a certain number of things happening in all these three areas, they have to show deficits in socialisation and communication and restricted interests. This is one of the reasons that DSM-V was changed because there are a huge number of children with PDD-NOS (majority of children got this diagnosis) who would get this diagnosis because they do not show restricted interests. They might meet criterion for socialisation and communication but not on the 3rd axis or they might meet it on the first and third axis but not the second. A child that meets criteria on the 1st and 2nd but not on the 3rd would not receive a diagnosis of ADS but they could be massively more handicapped than a child who has meet criteria who meets all 3 but is quite mild. This resulted in very handicapped children unable to receive a diagnosis yet diagnosed children who were doing well. Therefore, it was a very rational decision in DSM-5 to make this change.
Hans Asperger (1944) was working in NAZI Germany and released a paper the year after Kanner but did not have great communication with people outside.
Hans Asperger (1944) was working in NAZI Germany and released a paper the year after Kanner but did not have great communication with people outside. There are definite similarities between the two papers thus you can tell its the same disorder but the emphasis is quite different. The people Asperger described had better language and cognitive skills than Kanner’s people. When Lorna Wing started working with children who were very different with ASD, she started using Aspergers as a way of distinguishing brighter children. However, she regretted it later on in life and said she’d opened a pandora’s box because it didn’t work very well. Mostly because there are some children that meet criteria for ASD yet use single words by the time they are 18months, use 2 word phases by the time they are two and a half and thus have a normal language acquisition. The difference between those that have a normal language trajectory and a person with ASD with delayed speech is non-existent by adulthood. A HFA person who has acquired language late, is often indistinguishable from someone that has been talking from early on. This is why DSM-5 lost this category because the research didn’t support this distinction between HFA and AS. AS is culturally very important, people identify with being Aspis. Asperger Syndrome is characterised the by same triad of impairments as autistic disorder but without delayed language criteria (30 months) DSM-IV. Language and early cognitive abilities preserved, at least early in life.
Retts syndrome in DSM-IV
Retts syndrome in DSM-IV is only seen in females who have a brief period of normal development (around 6 months) and then everything went wrong, all functions that were supposed to be increasing decreased, followed be decelerted head growth, loss of purposeful hand movements and the development of psychomotor retardation. Theres a failure of language development. There is a much higher proportion of males to females with ASD, but this may be due to the fact that we are not as good at recognising females with ASD. ASD presents differently in girls, they are much more verbal etc.
Childhood Disintegrative Disorder
Childhood Disintegrative Disorder has a very different developmental trajectory, about 2 years there is a fairly normal development which is very different to autism, the biggest problems are in those very early years and then a dramatic deterioration e.g. a loss of language, social skills, and sensorimotor co-ordination occurs after around 2 years of normal development. For a long time people used to talk about having children who had language early on but then lost their language (videos of children when younger).
PDD-NOS (Pervasive Developmental Disorder not otherwise specified)
PDD-NOS (Pervasive Developmental Disorder not otherwise specified) are children that wouldn’t make criterion for ASD. They were the most neglected group of children. If 100 children came to clinic, 70 might get PPD-NOS diagnosis but grant bodies would only fund research with the ASD children, therefore we knew so little about these children. Sub-threshold cases. Individuals show marked impairments in social interaction communication and/or stereotyped behaviours but did not meet criteria for any of the other PDD categories. PDD-NOS was the most common condition but the least studied. All subgroups off PDD and all other categories have been removed from the DSM-5 because there was lack of genetic and psychological evidence for current subgrouping, clinicians were inconsistent in diagnosing ‘high- functioning autism’ and Asperger syndrome (for a good reason: there are counties in England where the local did not provide supply for a child with AS but will for a child with HFA).
Another massive problem is that people with ASD have really bad sensory problems
Another massive problem is that people with ASD have really bad sensory problems (e.g. hyperacusis: sounds), given that children have high levels of stress, this is to helpful. Can either be under sensitive or over sensitive (hypo or hypersensitivity). Its complexity random which way it goes, some children have auditory, vestibular, tactile, visual problems. Some people only have auditory problems, there is not really a one profile of sensory problems in ASD. Some children with ASD won’t eat food of certain colour (green food etc.). DSM-V included sensory abnormalities and this was really the work done by Sue Leekham who really looked at sensory problems and saw that at some level and within some modality it seems pretty universal. An infant with hyperacusis (an intolerance of everyday sounds) they spend a lot of time covering their ears which is not great for language acquisition. If a child has a problem with visual, they will most likely avoid looking at somebody eyes/face. Therefore, its really interfering with their normal developmental trajectory in terms of language acquisition and learning about faces etc.
In the DSM-5 ‘Additional needs / difficulties’ also identified
In the DSM-5 ‘Additional needs / difficulties’ also identified and high, moderate or mild impairment documented is now documented. Furthermore, the triad of impairments detailed in DSM- IV were collapsed into a dyad of impairments in DSM-V. Now there is 1) socio-communicative impairment and 2) restrictive, repetitive behaviours. The rationale for this change is that social and communicative impairments show a high level of overlap and are difficult to distinguish (unable to separate them) and present under one category in the DSM-5 (2013) Autism Spectrum Disorder.
Therefore, we have moved from a triad to a dyad of impairments in DSM-5.
Therefore, we have moved from a triad to a dyad of impairments in DSM-5. In the new criteria of 1) Socio-communicative impairment across contexts as evidenced by all three of the following: how do we operationalise that in diagnosis and what are we losing for: socio-emotional reciprocity (e.g. child is happy when others are happy), nonverbal behaviours used for social interactions (gestures/paralinguistic actions) aren’t seen in ASD even in HFA and deficits in developing and maintaining relationships (in ADOS: why do you mean by friend to test if they have a concept of friendship). 2) Restricted and repetitive interests and behaviours and activities. At least two of the following: stereotyped, repetitive speech, motor movements or use of objects e.g. body twisting, same phrase repeatedly, excessive adherence to routines, ritualised patterns of verbal/non-verbal behaviour (lining up of objects) or excessive resistance to change (teenager sleeping in toddler bed, not wanting to change bedding which is partially due to the smell of the detergent). Highly restricted, fixated interests that are abnormal in intensity or focus. ADOS: stereotypical behaviour: spinning wheels as opposed to creative play behaviour in typically developing children. ASD have very good concentration when they are interested in something (e.g. name of every star etc.).
