The New Face of AutismReconceptualizing the Symptoms and Impairments in Autism Spectrum DisordersSam Goldstein Ph.D. Assistant Clinical Professor of Psychiatry University of Utah Affiliate Research Professor of Psychology George Mason University

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GoalsBriefly discuss the historical theories of Autism Spectrum Disorders (ASD).Define ASD.Briefly discuss syptoms of ASD by age.Briefly discuss a core theory of ASD.Briefly review hypothesized causes.Introduce data from the largest epidemiological sample collected of normal children and those with ASD.

Kanners Description (1943)Inability to relate in ordinary ways to people.Disinterest in parents and people.Excellent rote memory skills.Language difficulties including but not limited to: mutism, echolalia, pronoun reversal, literalness, poor social language.Lack of spontaneous activity.A wide range of cognitive skills.

Kanners Description (1943)Self absorbed facination with the inanimate environment.Pronounced resistance to change in routine.Purposeless repetitive movements.Isolated interest and proficiency in meaningless tasks with endless repetition.

Gillbergs DescriptionImpaired social interaction.Self absorbed behavior.Odd interests and routines.Speech and language problems inspite of seemingly competent superficial language skills.Non-verbal communication problems.Motor clumsiness.

Autism is increasingly referred to as a spectrum disorder in which individuals can present problems ranging from total impairment to near reasonable functioning.

In the DSM model Autism Spectrum Disorder (ASD) is referred to as the Pervasive Developmental Disorders (PDD)s.

The Pervasive Developmental Disorders (PDDs) are a group of conditions that share certain clinical features but appear to have diverse etiologies and natural courses.

The term PDD emphasizes the pervasiveness of disturbances over a wide range of different domains affecting the normal unfolding and development of multiple competencies.

PDDsOnset in infancy or early childhood.Typical patterns of delays and deviance in social, affective and communicative development.Expanding recognition and interest in the clinical and educational realms.Spectrum, continuum or syndrome?

Core DSM and ICD Autistic SymptomsImpaired social relations.Impaired communication skills.Impaired behavior.

The social development of autistic children is qualitatively different from other children.

In normal children perceptual, affective and neuroregulatory mechanisms predispose young infants to engage in social interaction from very early on in their lives.

Young autistic children:

Have little interest in the human face.Lack differential preference for speech sounds.Lack imitative capacity.Lack interest in physical comfort.Dont attach to caretakers well.

Symptoms Present Before 24 Months: Failure To -Orient to nameAttend to human voiceLook at face and eyes of othersImitateShow objectsPointDemonstrate interest in other children

Symptoms Present Before 36 MonthsUse of others body to communicate or as a toolStereotyped hand/finger/body mannerismsRitualistic behaviorFailure to demonstrate pretend playFailure to demonstrate joint attention

Joint AttentionBehaviors that focus the attention of the self and others on the same object (e.g. pointing,sharing emotion, etc.)Develops between 6 and 9 monthsPrecursor of more advanced social and communication skills

Joint AttentionThis abnormality thought to be one of the earliest signs of autismPresent in children with developmental delays absent autismThis ability when present in preschoolers with autism predicts better prognosis for language development

Pretend Play in AutismLimited, often absentWhen present usually characterized by: repetitive themes, rigidity, isolated acts, one-sided play, limited imagination.

Theory of MindA new line of research has proposed that the social deficits in autism represent a specific, innate cognitive capacity to attribute mental states to others and oneself and use these to explain and predict another persons behavior.

One in four autistic children experience physical problems including epilepsy.

Up to eighty percent of autistic children experience intellectual deficits.

Level of cognitive functioning and useful language by five years of age are the best predictors of outcome.

Autism occurs at a greater than chance rate with:

Fragile XTuberous sclerosisNeurofibromatosisWilliams syndromePhenylketonuriaCongenital rubella

Idiopathic Autism90% of cases.Genetics plays an important role.Autism occurs more frequently in monozygotic than dizygotic twins.The rate of autism among siblings is significantly higher than the general population.No single causative gene has been identified.At least five or more genes interact.Genes on chromosomes 7 and 15 look promising.

The Autism Spectrum Rating Scale Project (Goldstein and Naglieri)A normative look at autistic symptoms, behaviors and impairments,

ASRS Data Collection ProcedureSite coordinators from across the U.S. collected data between October 2006 and October 2008.Over 5,000 children were sampled at home and at school.

Normative data was stratified to match the U.S. Census on race/ethnicity, parental education level, and geographic location.

Standard procedures were followed:informed consent obtainedspecific instructions given to ratersraters debriefed upon completion

ASRS Standardization Samples

ASRS StructureDSM-IV-TR AlgorithmValidity ScalesPositive ImpressionNegative ImpressionInconsistency IndexTreatment ScalesPeer SocializationAdult SocializationSocial/Emotional ReciprocityAtypical LanguageStereotypyBehavioral RigiditySensory SensitivityAttention

Sample Items: ASRS ScalesPrincipal Axis Factoring with Direct Oblimin rotation.

Classification AccuracyClassification accuracy (predicting ASD vs. General Population group membership) of responses on the ASRS Parent (6-18).

Important ConclusionsAutism Spectrum Disorder represents a unique, measurable condition distinct from normal behavior and development.DSM-IV requires revision.ASD is best represented by a 3 factor model with associated symptoms and behaviors.

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Discriminant Function Analyses (DFA) were conducted in order to determine if scores on the ASRS could accurately predict group membership into the ASD or matched general population group (gen pop group matched to ASD group on age, gender, and race/ethnicity). The grouping variable in all DFAs was the actual group membership of the respondent. The predictors included the ASRS scales. N for each group was 80.

Overall correct classification rate: the percentage or proportion of correct classifications.Sensitivity: the ability of the ASRS scores to correctly detect clinical cases in a population (i.e., the proportion of target clinical youth predicted to belong to this group by the ASRS).Specificity: the ability of the ASRS to correctly identify general population cases (i.e., the proportion of general population youth predicted to belong to the general population group).PositivePredictive power (PPP): the percentage of youth identified by the ASRS as having a disorder who, in fact, have that disorder. NegativePredictive power (NPP): the percentage of youth identified by the ASRS as not having a disorder who, in fact, do not have that disorder. FalsePositive rate: the percentage of youth identified as having a disorder who, in fact, do not have the disorder.False-negative rate: the percentage of youth identified as not having a disorder who, in fact, do have that disorder.