Autistic Spectrum Disorders
Kenneth Towbin & Ann Wagner
National Institute of Mental Health, NIH
About the Lecture
In 1943, Leo Kanner described eleven children with deviations from typical child development he termed "autistic disturbances of affective contact." Kanner emphasized a constellation of symptoms including profound unresponsiveness to social overtures, abnormal expression of social relatedness, severe limitations of both language and nonverbal communication, and persistent engagement in repetitive behavior. Many also displayed marked distress when confronted with changes in routine. This "first cut" formulation has come to be known as "classic autism" or "Kanner's autism". Current science suggests that there is a group of disorders that include Classic Autism but go beyond Kanner's first descriptions. This broader group, which is often viewed as a "spectrum" of disabilities ranges from a group of individuals with profound impairment in both social and cognitive abilities, to those with relatively milder social learning deficits and normal or above normal intelligence. In our discussion we will focus on the phenomenon of this spectrum of disorders, with the goal of giving the audience an idea of what it might be like to raise or live with someone with this disorder, and some insight into what the experience might be like for someone with a social learning disability. We will present an overview of what is known thus far about causes of the disorder. Although there is no cure or one best treatment for autism spectrum disorders yet, there are interventions that can reduce symptoms and promote adaptive functioning. Some of these will be discussed too.
About the Speaker
Kenneth Towbin is a Board Certified child and adolescent psychiatrist who is currently Chief of Clinical Child and Adolescent Psychiatry in the Mood and Anxiety Disorders Program at the National Institute of Mental Health. Prior to his work at NIMH, Dr. Towbin was the Medical Director of the Autism/PDD Clinic at Children's National Medical Center, working along with Dr. Wagner. As two parts of a critical trio of disciplines, they fashioned an integrated, multidisciplinary team procedure dedicated to the diagnosis and assessment of children with complex social learning disorders. Ann Wagner is a clinical psychologist, and is Chief of the Autism/PDD Intervention Research Program at the National Institute of Mental Health. Prior to her current position at the NIMH, she was Program Director of the Autism/PDD Clinic at Children's National Medical Center in Washington, DC. Dr. Wagner holds Master's degrees in education and psychology, and attained a Ph.D. in Clinical Psychology from Michigan State University in 1991.
President McDiarmid called the 2138th meeting to order at 8:17 p.m. on, December 14, 2001. The Recording Secretary read the minutes of the 2137th meeting and they were approved. The speakers for the evening were Kenneth Towbin and Ann Wagner, National Institute of Mental Health, NIH. The title of their presentation was “Autistic Spectrum Disorders”. Mr. Towbin began with the original clinical description of autism. In 1943, Leo Kanner described children with certain characteristic deviations from typical child development he termed “autistic disturbances of affective contact”, or autism. Today, these symptoms fall within a class of disabilities referred to as “autistic spectrum disorders”, including Asperger syndrome, pervasive developmental disorder, Rett syndrome, and childhood disintegrative disorder. Autism is a biological disorder of social learning and reciprocity that is usually evidenced by an onset of symptoms before age 3. There is an impairment of reciprocity behavior, or understanding of motivation of others. There are deficits in non-verbal communication and in processing personal relationships. There are limitations in empathy, or reading emotional context, in showing, sharing and emotional sharing. There are impairments of language skills and delays in language acquisition, deficits in the ability to sustain conversation, and repetitive or idiosyncratic language. There are deficits in socially imitative or imaginary play, dedication to non-functional routines, restricted or narrow interests, repetitive behaviors or stereotypies, and preoccupations with parts of objects. Epidemiological studies of autism estimated in 1960 there were 4 affected individuals per 10,000, in 1966-1988 4.3 per 10,000, and in 1988-1998 7.2 per 10,000. These numbers led to discussions of a “rising epidemic” of autism in the 90's. However, these numbers may be an abuse of statistics, and reflect more changes in diagnostic criteria that changes in prevalence. Before 1982, investigators created their own criteria based on Kanner's definitions. Since 1990 investigators have employed standard tests, improved diagnostic methods, improved record keeping, structured interviews and structured observations. There does seem to have been an inverse relationship between estimates of prevalence and the size of the sample. There have been some investigations of sporadic, apparent “outbreaks” of autism. Twin and family studies indicate a concordance of 70-82%, depending on the definition standard. The recurrence risk in siblings is 2-6% rather than 0.05%. Genetic analysis indicates no single gene is responsible, but rather there are 2-10 independent, or 2-6 epistatic (interacting) loci, with an affected individual inheriting 2-5 predisposing genes. Suspect genes have been placed on all but six chromosomes. Especially implicated are 2q and 7q, particularly the 7q22-31 region associated with language disorders, 15q11-13 the Angleman region, and 16p13 the NMDA receptor and TSC2 genes. There is a high incidence of ASD associated with tuberous sclerosis. The typical neuropathologies of autism are a large head circumference, with no evidence of atrophy by MRI. Increased brain volume suggests dysgenic rather than degenerative processes. The presence in the hippocampal region of tightly packed cells with stunted dendrites suggests miswired cells. There is increased white matter in cerebellar neocortical gray matter, and slowed cerebellar growth. Ms. Wagner described the neuropsychology in pervasive developmental disorder (PDD). Typically there is a split in the verbal and performance IQ's; verbal is less than the spatial in classic autism, and the spatial is less than the verbal in Asperger's. Developmental patterns that are clear at age 2 to 3 are changed and not so clear at age 9 to 10. In older, normal IQ patients there is less of a split in verbal and performance IQ. The psychological “theory of mind” is the ability to appreciate others' thoughts and feelings and predict their behavior. PDD patients have relatively defective “theory of mind” as evidenced by “false belief” tasks, inability to produce pretend play, difficulty in assessing causes of emotion, what is accidental or intended, and difficulty in understanding or engaging in deception or non-literal statements. This defective “theory of mind” is presumed to be neurological and is considered a developmental delay, rather than a complete absence of the skill. Early symptoms are problems with “joint attention”, such as “oh, look” requests, problems with sustaining and shifting attention, and poor “executive” functions. These attention difficulties are different from “attention deficit disorder”. The problem with joint or social attention is consistently recognized by parents and teachers, and it affects daily living skills as well as academics Children with PDD have an advantage in tasks where the context is a distractor, such as embedded figures, but they are less likely to be helped by contextual clues. They have a tendency to fail to use context in reading ambiguous words. There is a correlation between central coherence ability and “theory of mind” proficiency There have been few population based follow-up studies on the course of the disorder. 10-15% make exceptionally good progress and can obtain college degrees. Challenges include pubertal changes associated with increased social complexity and discontinuity of services, risk of depression or anxiety, especially in Asperger's, and 40% institutionalization. Although there is no cure for autism spectrum disorders, there are interventions that can reduce symptoms and promote adaptive functioning. These helpful interventions include pivotal response therapy, family support and training in behavioral controls. There is substantial private and public funding for research on these disorders. At the NIH, for example, several institutes contribute to autism research including the NIMH, NICHD (Child Health and Human Development), NIDCD (Deafness and Commuication Disorders) and NINDS (Neurological Diseases and Stroke). The total funding from all NIH institutes is over $60 million. Mr. Towbin and Ms. Wagner kindly answered questions from the floor. President McDiarmid thanked them for the society, and welcomed them to its membership. The President made the announcements about the next meeting, parking, and refreshments, and adjourned the 2138th meeting to the 181st Annual Business Meeting of the Society at 9:28 p.m. Attendance: 39 Temperature: 17.8°C Weather: partly cloudy Respectfully submitted, John S. Garavelli Recording Secretary