Autism Part 1

“Our two year-old son is a beautiful boy but we have become concerned. He still does not speak, actually, he doesn’t really look at you when you speak or appear to have any interest in what you say. We had his hearing tested by our physician and nothing appeared wrong. Our son does not initiate play with other children nor does he actually appear to have any interest in his peers. While he is a loving little boy, he does not really hug you back. Someone suggested that we have him tested for autism and we’re scared. Is he autistic? What do we do?”

Autism refers to a neuro (brain) developmental disorder that affects an estimated 1/166 to 1/500 children each year in the United States with an annual growth rate in diagnoses of 10 – 17%. Staggering statistics? Surely, but even more importantly notice the incidence of 1/166 to 1/500. Why the significant range?

I recall being horrified (as a youth) when Dalton Trumbo in Johnny Got His Gun indicted the United States government when he revealed that their own offices could not provide an accurate statistic on the number of soldiers who died in Vietnam, often missing the number by thousands. Were the lives lost so insignificant? I now find myself in a somewhat similar position. Why the significant variability or range in estimates of the incidence of autism? Why doesn’t someone know how many children have autism? Are the children with autism lost and insignificant? Hmmmm…

The answer may lie in the fact that autism is not a thing but rather the diagnosis refers to a constellation of symptoms/problems with a developmental onset or emerging during first three years of life. The diagnostic criteria or symptoms/problems required for the diagnosis of autism reads something like a Chinese Restaurant menu including “A total of six (or more) items from (1), (2) and (3) with at least two from (1), and one each from (2) and (3)”… that should clear everything up. Want to know what criteria (1), (2) and (3) are? Google Autism Disorder DSM.

But what are the core or essential characteristics of autism? Hmmm… the answer is that the symptoms vary as a function of age. What is normal in a one-year old may be abnormal in a four year-old.

• Early signs (during the first 6-12 months of life) of an autism spectrum disorder may include poor eye contact during parent-child interactions, an absence of cooing/babbling, an absence of reciprocal smiling and apparent indifference to others that may include tactile sensory features ranging from recoiling from touch to requirements for swaddling/holding close.
  
• During the 12 – 24 month age range, symptoms of a potential autism spectrum disorder include persistence of early signs along with no attempts to speak with associated gestural communications, limited communicative intent, limited play, repetitive body movements (ie., hand flapping, rocking, etc.), fixation on objects (ie., moving fans, prisms, balls, etc.), resistance to change and a tendency for the child to become overwhelmed in high stimulation settings.
  
• Later (age 24 months+) emerging features of a potential autism spectrum disorder include (in addition to persistence of other symptoms noted previously) a lack of initiation to engage in reciprocal play with peers, limited play, emergence of over-select behaviors (ie., lines up objects, requirements for sameness, etc.) and difficulties following the gaze of others. In addition, emergence of exaggerated fear responses ranging from extreme rage to total indifference (ie., to pain) is often observed.

So, does your child have an autism spectrum disorder? I do not know but I tend to have infinite faith in the gut feelings of mothers. If a mother informs me that she has fears that something may be amiss in the development of her child, I generally believe that something may be wrong. The answer? Sorry if I sound repetitive on this… but… you may wish to consider an evaluation to shed some light on the fears. So, if it is an autism spectrum disorder, what causes it? Hmmmm… let me think about that one (see you next week)…

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

M&M’s and a Spray Bottle

“Our four year-old daughter has always been slow… slow to sit up, slow to walk (she never really crawled but sort of GI-Joe’d it across the floor), slow to talk (she has only a couple single words that sort of telegraphically communicate her wants)… and potty training?… it seems like it will never happen with no progress during the past year. She was diagnosed with mental retardation.”

“The most recent problems have been eating non-food items, she eats every piece of fuzz on the carpet, self-stimulation, self-abuse, she hits her head on the floor when frustrated, some biting and rocking. When recently seen by a professional (psychologist, physician, therapist, etc.), it was recommended that we initiate a behavior modification (operant conditioning) program in which we reward her with preferred items (attention, M&M’s, touches, etc.) when she displays positive behaviors, ignore her (extinction) when she is engaged in negative behaviors that are not physically injurious and spray her with a water solution (punish her) when she is engaged in self-injurious or aggressive behaviors. After two months, our daughter has shown a dramatic increase in physical aggression and has learned to adeptly avoid sprays to the face while we have felt like total failures as parents while our child appears to fear our presence. What do we do?”

First things first. The diagnostic system adopted by the American Psychiatric Association and utilized by the American Psychological Association is an “axial” system that is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM for short). Numerous versions and revisions have been completed across time that reflect changes in our understanding of various symptom complexes.

The axial system has five axes that include: Axis I (Clinical disorders that may be the focus of clinical attention or treatment), Axis II (Personality disorders and mental retardation including factors that may mediate symptom expression), Axis III (General medical conditions that are potentially relevant to understanding and treating Axis I and II problems), Axis IV (Psychosocial and environmental problems or stressors that may affect symptom/problem severity and Axis V (Global Assessment of Functioning or the clinician’s judgment of the individual’s overall level of functioning).

My take on the process? Axis IV and V are so poorly correlated among observers to be irrelevant or meaningless (this opinion may not be shared by others). Axis I is analogous to the current weather conditions (it is raining, it is snowing, it is a thunderstorm, etc.). Axis II is analogous to the severity of the weather conditions or associated factors (28 degrees, high winds, etc.) and Axis III is analogous to the underlying cause of the current weather conditions (a cold front from Canada merging with a warm front from the Gulf of Mexico) that cause or contribute to the Axis I (thunderstorm) and Axis II (high winds) diagnoses.

For your daughter the Axis I diagnosis is the presenting symptoms/problems or what you are seeking assistance in addressing. Axis I diagnoses may include Pica (eating non-food items) and a Disruptive Behavior Disorder (self-abuse, aggression). To discover that your child has been diagnosed with Pica or a Disruptive Behavior Disorder is not particularly enlightening (particularly since you told the professional what those symptoms were). The Axis II diagnosis of mental retardation is similarly unenlightening, it simply refers to the degree to which your child’s cognitive, behavioral, adaptive living and social development deviates from the average or middle of the bell curve. You said “slow” or “delayed”… the IQ score simply provides an estimate of how much (IQ = 60 = 40% delay relative to peers, IQ = 55 = 45%, got the idea, 100 – IQ = % delay).

To discover that you finished fifth in a race does not provide insight into how to improve your running speed.

In contrast, the Axis III diagnosis refers to biological and/or neurological factors that underlie or are the cause of the Axis I and II diagnoses. Axis III diagnoses could potentially include maldevelopment of myelinated axonal connections from limbic to frontal regions secondary to premature birth, frontal lobe disconnection secondary to perinatal hydrocephalus, stroke involving the left middle cerebral artery, shear strain injury secondary to high force trauma to the head, etc. The Axis III diagnosis is designed to identify the “hardware” (computer analogy) limitations or factors that contribute to, drive or cause the presenting symptoms (Axis I).

Does your daughter have mental retardation? No… she may show a slow (retardation) rate or incomplete development of skills. What do we do?” Hmmm… give me a week to think on that one.