Autism Frontiers: Clinical Issues and Innovations - Hardcover

Bruce K. Shapiro, M.D. Professor of Pediatrics, The Johns Hopkins University School of Medicine; The Arnold J. Capute, M.D., M.P.H. Chair in Neurodevelopmental Disabilities; Vice President, Training, Kennedy Krieger Institute, 707 North Broadway, Baltimore, MD 21205

Pasquale J. Accardo, M.D., is Professor of Pediatrics at Virginia Commonwealth University in Richmond. He received his medical degree from Downstate Medical Center, Brooklyn, New York; completed his pediatric residency at James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, and obtained his developmental pediatrics training at the John F. Kennedy Institute for Handicapped Children (now called the Kennedy Krieger Institute), an affiliate of Johns Hopkins University School of Medicine, Baltimore, Maryland. He is subcertified in neurodevelopmental disabilities in pediatrics by the American Board of Pediatrics. Dr. Accardo is the author and editor of several books including Attention Deficit Hyperactivity Disorder: The Clinical Spectrum (York Press, 2001); Austim: Clinical and Research Issues (York Press, 2000), and Developmental Disabilities in Infancy and Childhood, Second Edition, Volumes I and II (Paul H. Brookes Publishing Co., 1996).

Excerpted from the Preface of Autism Frontiers: Clinical Issues and Innovations, edited by Bruce K. Shapiro, M.D., & Pasquale J. Accardo, M.D.

Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Preface

In 1943, Leo Kanner described 11 children with a unique behavioral disorder that came to be known as autism. In addition to describing the cardinal characteristics of the syndrome—"impairment of social interaction manifesting an inability to relate themselves in the ordinary way to people and situations . . ." (p. 242) and behavior dominated by profound aloneness, impaired language development, and restricted, stereotypic behavior—Kanner noted that these children showed many other dysfunctions. He distinguished this disorder from intellectual disability (ID) and schizophrenia, disorders with which he was familiar.

In the 1970s, the diagnosis of autism had to be proved beyond a reasonable doubt. Children with the diagnosis of autism had to meet the criteria of Kanner and be significantly impaired. Occasionally, a child would receive the diagnosis of mental retardation and "autistic features." The operational diagnosis, however, was mental retardation. It was the best forecaster of outcome and the behavioral dysfunction could be managed in segregated special education settings.

Dr. Arnold Capute was among those who questioned the specificity of the autism diagnosis (Capute, Derivan, Chauvel, & Rodriguez, 1975). He felt that autism was not a unique condition and that the diagnosis did not add to the management of the patient, to our understanding of the mechanism of dysfunction, or to the prognosis. From his work with developmental assessment, he recognized the developmental aspects of symptoms of autism and the need to distinguish them from more typical development. For example, pronomial reversal and echolalia was associated with language development in children younger than 30 months. His extensive clinical experiences caused him to question the validity of an autism diagnosis. He knew that restricted, stereotypic behavior was not uncommon in children with severe ID and that perseveration was seen often in children with cerebral palsy and other brain injury. Finally, the close linkage between language and social interaction caused him to question whether deficient socialization could exist as an independent factor. Subsequent studies have validated this viewpoint.

In the 1980s, the focus on early identification and early intervention extended to autism. As the diagnostic criteria were applied increasingly to younger children, the diagnostic margins blurred. Autism moved from a categorical to a dimensional disorder. During this epoch, there was an increased appreciation of the role of pragmatics in developmental language disorders. Frequent debates centered on whether the child had a developmental language disorder or autism.

The authors of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV; American Psychiatric Association, 1994) recognized the dimensional nature of autism and changed the diagnostic criteria from "significant impairment" to "qualitative abnormalities." Unfortunately, they failed to appreciate that all neurodevelopmental disorders are on a spectrum. Every child with a neurodevelopmental disorder has elements of every dysfunction. Children with attention–deficit/hyperactivity disorder (ADHD) have motor coordination deficits. Those with speech–language impairments have academic difficulties. Children with motor coordination disorders have language deficits. All neurodevelopmental dysfunction is associated with impairments in social interactions.

Since the early 1990s, there has been an explosion of interest in the area of autism. This is in part fueled by the increased number of children who have been diagnosed with autism, the desperation of these children's parents and grandparents to find effective treatment, and the parallel explosion in genetics and neuroscience that generates the hope that understanding the mechanism of autism will make it possible to learn how to treat or prevent it.

The current state of affairs is confused. Absolute proof is no longer required to establish the diagnosis. The boundaries of autism extend into ID, ADHD, and receptiveexpressive language disorders (Howlin, Mahwood, & Rutter, 2000). Indeed, the term autism spectrum disorders (ASDs) has become the default diagnosis for a variety of reasons. The parental stigma is less, the outcome is more hopeful, and resolution of symptoms has been documented.

ABOUT THE BOOK

Autism Frontiers: Clinical Issues and Innovations is based on the Spectrum of Developmental Disabilities conference. This conference, marking its 30th year in 2008, focuses on an aspect of neurodevelopmental disabilities. It brings together experts to provide an interdisciplinary focus on neurodevelopmental and related disorders. Presentations address the public health aspects, diagnostic issues, neuroscience advances, developmental aspects, and current management strategies. Speakers blend current research with clinical expertise to delineate the boundaries of our knowledge in diagnosis, research, and management.

The 2006 conference focused on autism from a number of perspectives and helped clarify the state of knowledge. It addressed the epidemiology and concomitant implications for service provision, diagnostic criteria and overlaps, and clinical management and treatment. Autism Frontiers: Clinical Issues and Innovations explores three clinical aspects of autism: diagnosis, management, and associated dysfunctions. It is not a textbook about autism but a compendium of chapters that examines aspects of this disorder, reflects current thinking on the topic, and identifies the limits of clinical knowledge.

Shapiro, Menon, and Accardo synthesize a large body of material to derive a clinical approach to ASDs that can be employed in a primary care setting. Lock uses his experiences in delivering early intervention services to children with ASDs to demonstrate the overlaps in diagnosis and service delivery needs. Rapin expands upon these findings and addresses the milder end of the autism spectrum. In her discussion of Asperger syndrome, the syndrome of nonverbal learning disability, and "Einstein children," she illustrates the rigor of thought and method needed to establish disorders as distinctive entities. She provides a neurologist's insights to gene–behavior interactions.

Language issues are addressed in separate chapters by Mantovani, Shapiro, and Turner. Mantovani addresses the dual clinical entities of regression and seizures and distinguishes isolated language regression from more generalized regression. He reviews the relationship between ASDs and epilepsy and concludes that epileptic encephalopathy is rare. He provides clinical suggestions to guide the ordering of electroencephalograms in children with ASDs. Shapiro focuses broadly on language dysfunction in preschool children. He notes that these disorders have effects on function in cognitive, academic, social/behavioral, and motor function. In this chapter, he raises the question of the specificity of the diagnosis of receptive–expressive language disorder. Turner takes a novel approach to the language of children with ASDs and addresses the impact of nonliteral language on pragmatics. She reviews humor, irony, inferencing, and figurative language. She also addresses the interactive aspects of conversation and notes how children with ASDs have difficulty with being conversational partners. The implications of these findings for function, assessment, and treatment are discussed.

Landa and Accardo each address the possibility of earlier diagnosis of ASDs. Early identification is a prelude to early intervention. Landa reviews the possibility of identifying children between 12 and 36 months. She posits that ASDs can be detected by 14 months of age. Her chapter also provides an approach to intervention that can be used for toddlers who have been identified as having ASDs. Accardo speaks to the issues of early identification and diagnosis, notes the early overlaps between ASDs and other developmental disorders, and uses this knowledge to propose a two–level screen that would be easily adapted to well–child care of 18– to 24–month–olds.

Egel focuses on treating the primary behavioral dyfunctions of autism in the classroom. His discussion recognizes the important role that school plays in the lives of children with ASDs. His chapter operationalizes some of the precepts discussed by Turner. Oswald, Coutinho, Johnson, Larson, and Mazefsky address the special issues that children with Asperger syndrome encounter in the classroom. They present qualitative data derived from a project that investigated the implementation of a teambased approach to supporting students with Asperger syndrome in the classroom. They illustrate the barriers and challenges that confront students and provide suggestions for clinicians who interact with school personnel, students with Asperger syndrome, and students' families in school settings.

Myers, in a comprehensive review of psychopharmacology of ASDs, makes the important point that there is no drug therapy that addresses the core symptoms of ASDs. His chapter outlines the spectrum of challenging behaviors that may be encountered by clinicians who care for children and adults with ASDs. He underlines the need for individualization of pharmacologic approaches and reinforces the primacy of educational and behavioral approaches for the management of ASDs.

Challman addresses attempts to treat ASDs with complementary and alternative medicine (CAM). He reviews the rationale for the popularity of various CAM approaches and provides a reasoned approach that professionals can share with parents who ask about CAM. Challman also notes that the placebo effect plays a prominent role in determining therapeutic effectiveness in both CAM and traditional intervention. Finally, he notes that interventions must be proven both safe and effective.

Pandey, Wilson, Verbalis, and Fein raise the provocative question, "Can autism resolve?" They review the literature and amplify it with their own experience based on longitudinal studies. They conclude that some children may eventually lose their diagnosis, but residual difficulties in attention, language, and socialization may persist in children who have achieved an "optimal" outcome.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Capute, A.J., Derivan, A.T., Chauvel, P.J., & Rodriguez, A. (1975). Infantile autism. I: A prospective study of the diagnosis. Developmental Medicine and Child Neurology, 17(1), 58-62.

Howlin, P., Mawhood, L., & Rutter, M. (2000). Autism and developmental receptive language disorder—a follow–up comparison in early adult life. II: Social, behavioural, and psychiatric outcomes. Journal of Child Psychology and Psychiatry, 41(5), 561-578.

Kanner, L. (1943). Autistic disturbances of affective contact. The Nervous Child, 2, 217-250.