Presentation on theme: "The Triad of Impairments Past, Present and Future"— Presentation transcript:
1 The Triad of Impairments Past, Present and Future Dr Judith GouldDirectorThe NAS Lorna Wing Centre for Autism
2 Development of the Concept of the Autism Spectrum Lotter (1960) in his Middlesex prevalence study, used Kanner’s criteria very strictly applied in a total population of children of all levels of ability.Wing and Gould (1979), in their Camberwell study, looked for any kind of strange behaviour in a total population of children identified as having any kind of special need. This group was selected because virtually all the children Lotter identified were known to have special needs.A group fitting Kanner’s criteria were identified, with the same prevalence as found by Lotter.A few children fitting Asperger’s criteria were also identified. This group was very small because the mainstream children in the area were not screened.(continued)
3 ContinuedThere were many more children who did not fit Kanner’s or Asperger’s criteria but who had all kinds of mixtures of features of these “syndromes”.It was found that impairments of social interaction, communication and imagination could occur in a very wide range of manifestations. But, however they were manifested, there was a strong tendency for them to cluster together and to be associated with a narrow, repetitive pattern of activities. It was very difficult to draw neat boundaries between the named “syndromes” and those with the triad of impairments who did not fit into a “syndrome”.The concept of a spectrum of autistic disorders fitted the findings better than the categorical approach. This does not imply a smooth continuum from the most to the least severe. All kinds of combinations of features are possible.
4 WING AND GOULD (1979) Camberwell study Group fitting Kanner’s criteria – 4.9 in 10,000Group fitting Asperger’s criteria – 1.7 in 10,000(mainstream children in the area were not screened)Group with mixtures of features – 15.4 in 10,000(The groups overlapped with each other. Clinical pictures on the borderlines could be classified differently by different workers)
5 WING AND GOULD (1979) Camberwell study What held all these groups together was a triad of impairments of:social interactioncommunication andimagination.There was a strong tendency for these impairmentsa) to cluster togetherb) to be associated with a narrow, repetitive pattern of activities.
6 The triad and the repetitive activities could be shown in a wide range of different ways
7 Social Impairment Different manifestations: * # Aloof, indifferent PassiveActive but odd, bizarreOver-formal, stiltedSociable with 1 person – problems with groups(* Kanner # Asperger
8 Social Communication Impairment (verbal and non-verbal) Different manifestations:*#No communicationCommunicates own needsRepetitive, one sidedFormal, long-winded, literal(* Kanner # Asperger)
9 Imagination Impairment Different manifestations:*#Handles objects for simple sensationsHandles objects for practical usesCopies pretend play of othersLimited “pretend” play; repetitive, isolatedInvents own imaginary world – but rigid, stereotyped(* Kanner # Asperger
10 Repetitive Activities Different manifestations*#Bodily movementsFascination with sensory stimuliSimple, object directedRoutines involving objectsRoutines in space or timeVerbal routinesRoutines related to special skillsIntellectual interests(* Kanner # Asperger
11 Other Features Often Present With The Triad Untypical patterns of:Language comprehension / useResponses to sensory stimuliMovement and postureAttention / level of activityEating / drinking / sleepingMoodBehaviour
12 Factors Affecting the Clinical Picture The way the triad is manifestedAssociated featuresAssociated disabilities: developmental, physical, psychiatricThe overall level of abilityAgeGenderPersonality and temperamentEnvironmentEducation
13 Evidence For A Spectrum Many people show mixtures of features of different sub-groupsOne person can show different features in different environmentsOne person can show different features at different agesMembers of the same family can show different featuresIdentical twins or triplets can show different featuresThe same basic principles underlie methods of education and care for whole spectrum
14 Conditions That May Be Associated With The Spectrum Attention deficit/hyperactive disorderTourette’s syndromeDevelopmental receptive language disorderDyspraxiaDyslexiaDAMP syndromeGeneralised learning disabilityEpilepsyTuberous sclerosisFragile XPhenylketonuria (untreated)Rett’s syndromeWilliams’ syndromeSotos’ syndromeCornelia de Lange syndromeTurner’s syndromeKleinfelter’s syndromeNeurofibromatosisDown’s syndromeObsessive-compulsive disorderCatatonia / Parkinsonism“Psychotic” states in response to stressAnxietyAffective disordersSchizophrenia – rareAny other developmental, physical or psychiatric condition
15 The Importance of the Social Impairment Leo Kanner 1943Present from birthGenetic:-“We must assume that the children have come into the world with innate inability to form the usual, biologically provided affective contact with people”
16 Social Withdrawal Lorna Wing 1964 “Social withdrawal is an important characteristic of autistic children which perhaps is related to the inability to communicate in speech. A mother often senses this in her child almost from birth. Later the mother notices that the child does not attract her attention to things going on around – indeed her child appears oblivious of them”This is now referred to as lack of joint-referencing.
17 The Social Impairment is the Key to Diagnosis In children and adults with severe or profound learning disabilities the level of development may be too low for communication and imagination.But, interest in other humans is present virtually from the beginning of life.
18 The Social Impairment is the Key to Diagnosis Children and adults with extremely high levels of cognitive ability may be verbally articulate with good imagination but have learned social skills through their intellect rather than by social intuition.
19 Revision of the Triad of Impairments Social InteractionSocial CommunicationSocial ImaginationThe Triad is usually associated with repetitive patterns of activities
20 The reason for selecting social impairment as the only defining feature of autism spectrum disorders is purely practical and not related to any causal theory.
21 Research Neuropathology underlying social impairment Biology of the social instinctCauses:Genetic, pre-natal environment, post-natal environmentNeurological relationships to other conditionsPhysical – Phenylketonuria, Tuberose SclerosisDevelopmental – ADHD, Tourette’s, DyspraxiaPsychiatric – Anxiety, Depression, OCDEffective methods of helping and support
22 Change in ThinkingAttempts to define sub-groups among autism spectrum disorders by behavioural features and arbitrary age-based cut-off points – related to current International Diagnostic Systems.Apart from the lack of the social instinct untypical behaviours are found to varying degrees in all diagnostic sub-groups, in all developmental disorders and to some extent in typical development.
23 Dimensions Versus Categories In clinical practice, it is extremely difficult to define the boundaries between different diagnostic categories, whatever the criteria used.The clinical pictures found in those with autistic spectrum disorders fit better with the concept of multiple dimensions than with the concept of separate, definable categories.Individual needs are more accurately assessed from the profile of levels on different dimensions than from assigning a categorical diagnosis.
24 Key Similarities and Methods of Supporting all People within the Autism Spectrum What can a person with severe learning disability and typical autism have in common with someone brilliant in a chosen field and whose behaviour fits Asperger’s descriptions?Everyone with an autism spectrum disorder has a number of specific problems in coping with everyday lifeAll have difficulties following subtle, unwritten rules that govern social lifeAll need other people to communicate with them in clear and easily understandable termsAll are helped if complex, shifting ideas are explained in concrete terms eg with visual illustrationsAll have difficulty comprehending the passage of time
25 ContinuedAll have, to varying degrees difficulty working out the consequences of their own and other peoples’ actionsAll need more time than most other people to process informationAll need to be informed clearly in advance with careful explanations if plans are changedDifficulties caused by over sensitivity to various kinds of sensory input are very common