1. Autism Spectrum Disorder and Childhood-Onset Schizophrenia6
Autism Spectrum Disorder and Childhood-Onset Schizophrenia

2. Autism Spectrum Disorders (ASD)
A complex neurodevelopmental disorder characterized by abnormalities in social behavior, language and communication skills, and unusual behaviors and interests

3. Description and History
ASD refers to pervasive developmental disorders (PDDs) characterized by significant impairments in social and communication skills, and by stereotyped patterns of interests and behaviors

4. Description and History (cont’d.)
Kanner (1943) coined the term “early infantile autism” to describe young children with autistic symptoms
Asperger (1944) defined a milder form of autism ► Asperger’s disorder
Autism is a biologically-based lifelong neurodevelopmental disability present in the first few years of life

5. DSM-5 Defining Features of ASD
Impairments in social interaction
Impairments in communication
Restricted repetitive and stereotyped patterns of behavior, interests, and activities

6. DSM-5 Diagnostic Criteria for ASD
Table 6.1 DSM-5 Diagnostic Criteria for Autistic Disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

7. DSM-5 Diagnostic Criteria for ASD (cont’d.)
Table 6.1 DSM-5 Diagnostic Criteria for Autistic Disorder
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association.

8. Autism Across the Spectrum
Three factors contribute to the spectrum nature of autism
Children with autism may differ in level of intellectual ability, from profound disability to above-average intelligence
Children with autism vary in the severity of their language problems
The behavior of children with autism changes with age

9. Core Deficits of ASD Debate about core deficits of ASD
Several deficits likely affect the child’s:
Social-emotional development
Language development
Cognitive development
These aspects of development are interconnected

10. Social Interaction Impairments
Deficits in social and emotional reciprocity
Unusual nonverbal behaviors
Social imitation, sharing focus of attention, make-believe play
Limited social expressiveness
Atypical processing of faces and facial expressions
Joint attention

11. Communication Impairments
One of the first signs of language impairment is inconsistent use of early preverbal communications
Use protoimperative gestures rather than not protodeclarative gestures
Miss other declarative gestures, such as showing gesture
About 50% do not develop any useful language

12. Instrumental and Expressive Gestures
Figure 6.1 Instrumental and expressive gestures. Children with ASD may use gestures to get others to do things for them but not to convey feelings
Photo Credits (a) © 2012 Karin Dreyer Photography/Jupiterimages Corporation (b) © 2012 Image Source/Jupiterimages Corporation (c) © 2012 Michaela Begsteiger/ Jupiterimages Corporation (d) © 2012 Digital Vision/Jupiterimages Corporation.

13. Communication Impairments (cont’d.)
Those who begin to speak may regress between months
Children with ASD who develop language usually do so before age 5
Qualitative language impairments
Pronoun reversals
Echolalia
Perseverative speech
Impairments in pragmatics

14. Difficulty with Pragmatic Use of Language
Figure 6.2 Children with ASD have difficulty with the pragmatic use of language
Photo Credits 2012 PhotoAlto/Eric Audras/jupiterimages Corporation

15. Restricted and Repetitive Behaviors and Interests
Stereotyped body movements
Repetitive sensory and motor behaviors
Insistence on sameness behaviors
Self-stimulatory behavior
Different theories
A craving for stimulation to excite their nervous system
A way of blocking out and controlling unwanted stimulation from environment that is too stimulating
Maintained by sensory reinforcement it provides

16. Associated Characteristics of ASD
Children with ASD display a number of associated characteristics
Intellectual deficits and strengths
Sensory and perceptual impairments
Cognitive and motivational deficits
Medical conditions and physical characteristics

17. Intellectual Deficits and Strengths
About 70% of autistic children with autism have co-occurring intellectual impairment
A common pattern is low verbal scores and high nonverbal scores
About 25% have splinter skills or islets of ability
5% (autistic savants) display isolated and remarkable talents

18. Drawing of a Horse by Nadia, Age 5
Figure 6.3 Drawing of a horse by Nadia at age 5.
Source Nadia A Case of Extraordinary Drawing Ability, , 1977, Selfe, 1 figure only. Copyright Elsevier 1977.

19. Sensory and Perceptual Impairments
Oversensitivities or undersensitivities to certain stimuli
Overselective and impaired shifting of attention to sensory input
Impairments in mixing across sensory modalities
Sensory dominance
Stimulus overselectivity

20. Cognitive and Motivational Deficits
Deficits in processing social-emotional information
Difficulty in situations that require social understanding
Do not understand pretense or engage in pretend play
Deficit in mentalization or theory of mind (ToM) - difficulty understanding others’ and their own mental states
Do not understand false-belief tests

21. General Deficits
Executive functions (higher-order planning and regulatory behaviors)
Weak drive for central coherence (strong human tendency to interpret stimuli in a relatively global way to account for broader context)
Do well on tasks requiring focus on parts of stimulus

22. Embedded Figure Test
Figure 6.4 Embedded Figures Test children with autism perform relatively well on tasks that require attention to details of a figure rather than the overall pattern.
Source From A Manual for the Embedded Figures Test by H. A. Witkin, P. K. Oltman, E. Raskin, and S. A. Karp, pp. 21–26. Consulting Psychologists Press, Inc. Copyright © 1971 by Stephen Karp. Reprinted by permission of S. A. Karp

23. What is Specific to ASD?
Lack of ToM is one of the most specific to ASD
Deficits in processing socio-emotional information and executive functioning deficits are less specific to ASD

24. Are Cognitive Deficits Found in All ASD?
A single cognitive abnormality cannot explain all the deficits present in in children with ASD
There is a view that children with ASD have an underlying impairment in social motivation

25. Medical Conditions and Physical Characteristics
About 10% of children with ASD have a coexisting medical condition
Motor and sensory impairments, seizures, immunological and metabolic abnormalities
Sleep disturbances occur in 65%
Gastrointestinal symptoms occur in 50%
About 20% have a significantly larger- than-normal head size—more common in those who are higher functioning

26. Accompanying Disorders and Symptoms
Two most common disorders
Intellectual disability
Epilepsy
Other disorders - ADHD, conduct problems, anxieties and fears, and mood problems
May engage in extreme and sometimes potentially life-threatening self-injurious behaviors (SIB)

27. Prevalence and Course of ASD
Worldwide: 100 children per 10,000 may suffer from some form of autism
Autistic disorder - 22 of 10,000
PPD-NOS - 33 of 10,000
Asperger’s disorder - 10 of 10,000
One million or more individuals in the United States
Occurs in all social classes and identified worldwide

28. Age of Onset
Most often identified by parents in the months preceding child’s second birthday
Diagnosis is made in preschool period or later
Earliest point in development for reliable detection period is from months
Diagnoses made around 2-3 years are generally stable
AAP recommends that all children be screened at months

29. Course and Outcome
Children with ASD may develop along different pathways
Often gradual improvements with age,
Likely to continue to experience many problems
Symptoms may worsen in adolescence
Complex obsessive-compulsive rituals may develop in late adolescence and adulthood

30. Causes of ASD
It is now generally accepted that autism is a biologically based neurodevelopmental disorder with multiple causes
Problems in early development
Genetic influences
Brain abnormalities
A disorder of risk and adaptation

31. Problems in Early Development
Children with ASD experience more health problems during pregnancy, at birth, or immediately following birth
Prenatal and neonatal complications have been identified in a small percentage of children with ASD
Examples: parental age, in vitro fertilization, and maternal use of drugs

32. Genetic Influences Chromosomal and gene disorders
Fragile-X anomaly occurs in 2-3% of children with ASD
ASD individuals have a 5% elevated risk for chromosomal anomalies
About 25% of children with tuberous sclerosis have ASD

33. Family and Twin Studies
15-20% of siblings of individuals with ASD have the disorder
Broader autism phenotype
Concordance rates
70-90% in identical twins
Near 0% for fraternal twins
Heritability of an underlying liability for ASD is 90%

34. Molecular Genetics
Points to particular areas on many different chromosomes as possible locations for genes for ASD
Causally implicated but not a direct cause
ASD is likely to be a complex genetic disorder
Expression of ASD genes may be influenced by environmental factors occurring primarily during fetal brain development
Epigenetic dysregulation may be a factor

35. Brain Abnormalities
Behavioral features of ASD may result from abnormalities in brain structures
Lack of normal connectivity and communication across brain networks
Multiple brain regions may be involved

36. Brain Abnormalities – Biological Findings
Cerebral gray and white matter overgrowth Structural abnormalities:
In the cerebellum and medial temporal lobe and related limbic system structures
Decreased blood flow in the frontal and temporal lobes
Elevated blood serotonin in 33% of cases
Atypical patterns of connectivity in default mode network

37. ASD as a Disorder of Risk and Adaptation
The relationship between the child’s early risk for ASD and later outcomes
Is mediated by alterations in how the child interacts with and adapts to his or her environment
Different children will follow different developmental pathways

38. Treatment of ASD There are about 400 different treatments for ASD
There is no known cure
Treatment goals
Minimize core problems
Maximize independence and quality of life
Help the child and family cope more effectively with the disorder

39. Overview of Treatment Strategies
Engaging children in treatment
Decreasing disruptive behaviors
Teaching appropriate social behavior
Increasing functional, spontaneous communication
Promoting cognitive skills
Teaching adaptive skills to increase responsibility and independence

40. Treatment Strategies: Initial Stages
Initial stages focus on building rapport and teaching learning-readiness skills
Discrete trial training involves a step-by-step approach to presenting stimulus and requiring a specific response
Incidental training strengthens behavior by capitalizing on naturally occurring opportunities

41. Early Intervention Intensive 25 hours a week and 12 months a year
Low student-teacher ratio
High structure
Family inclusion
Peer interactions
Generalization

42. Medications Many children with ASD receive psychotropic medications
Antidepressants, stimulants, and tranquilizers/ antipsychotics
Benefits are limited
Variable from child to child
Core deficits of these children are not altered
Risks, benefits, and costs must be carefully evaluated

43. Childhood-Onset Schizophrenia (COS)
Schizophrenia is a neurodevelopmental disorder of the brain - expressed in abnormal mental functions and disturbed behavior
Characterized by severe psychotic symptoms bizarre delusions, hallucinations, thought disturbances, grossly disorganized behavior or catatonic behavior, extremely inappropriate or flat affect, and significant deterioration or impairment in functioning

44. Childhood-Onset Schizophrenia (cont’d.)
COS is a rarer and possibly more severe (not distinct) form of schizophrenia
Key features
Occurs during childhood
Has a gradual, rather than sudden onset
Is likely to persist into adolescence and adulthood
Has profound negative impact on developing social and academic competence

45. DSM-5 Positive and Negative Symptoms
Positive symptoms
Delusions
Hallucinations most common for children are auditory - occur in 80% of cases with onset prior to age 11
40 to 60% experience visual hallucinations, delusions, and thought disorder
Negative symptoms
Slowed thinking, speech, movement; emotional apathy; and lack of drive

46. DSM-5 Diagnostic Criteria for Schizophrenia
Table 6.2 Diagnostic Criteria for Schizophrenia
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association.

47. DSM-5 Diagnostic Criteria for Schizophrenia (cont’d.)
Table 6.2 Diagnostic Criteria for Schizophrenia
Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association.

48. Precursors and Comorbidities
Gradual onset
Almost 95% have history of behavioral, social, and psychiatric disturbances before onset of psychosis
Developmental precursors
Other symptoms/disorders
70% meet criteria for another diagnosis - most commonly mood disorder or ODD/CD
COS and ASD may not be linked

49. Prevalence Extremely rare in children under age 12
Dramatic increase in adolescence, with a modal onset around 22 years of age
Estimated prevalence is less than 1 per 10,000 children
COS has an earlier age of onset in boys by two to four years
Gender differences disappear in adolescence

50. Causes of COS Neurodevelopmental model Biological factors
Defective neural circuitry increases a child’s vulnerability to stress
Biological factors
Strong genetic contribution
Molecular genetic studies have identified several potential susceptibility genes
CNS dysfunction and improvements with medication suggest it is a disorder of the brain

51. Causes of COS (cont’d.) Environmental factors
Familial disorder and nongenetic factors may play a role through interaction with a genetic susceptibility
High communication deviance
Stress, distress, and personal tragedy experienced by families of children with schizophrenia

52. Treatment of COS
COS is a chronic disorder with a poor long-term prognosis
Current treatments emphasize use of antipsychotic medications combined with psychotherapy and social and educational support programs
Medications help control psychotic symptoms
There can be serious side effects