A five to fifteen year follow-up study of infantile psychosis. II. Social and behavioural outcome

The activities and participation of adolescents with autism spectrum disorders in Singapore: findings from an ICF-based instrument

BACKGROUND

This study sought to describe the activities and participation of adolescents with autism spectrum disorders (ASD) in Singapore and to examine the suitability of the Activity and Participation component of the International Classification of Functioning, Disability and Health for achieving this purpose. This information may guide the development of intervention programmes for adolescents and adults as well as the provision of a means to document meaningful outcomes.

METHODS

Parents of 20 adolescents with ASD attending special schools in Singapore were interviewed using the Vineland Adaptive Behavioural Scales - Second Edition and the Activities and Participation Rating Scale (APRS), which was developed for this study.

RESULTS

The adolescents with ASD were rated to have more difficulties with participation than with the engagement of activities. Individual domain analyses indicate no difficulties with mobility and mild difficulties with self-care. The performance of general tasks and demands were rated as less problematic than domestic, major life areas, communication and interpersonal interactions. The adolescents with ASD were rated to have more difficulties in communication and community environments than in at home. In addition, analysis of associations between the APRS and Vineland Adaptive Behavioural Scales - Second Edition reveal a pattern of strong relationships between sub-tests.

CONCLUSION

This study highlights the imperative for researchers and practitioners alike to develop a focus on strengths, generalisation and the quality of life of adolescents with ASD. The APRS also shows promise in helping document outcomes for adolescents with ASD in Asia and further development of this instrument is needed.

Brain plasticity and disease: a matter of inhibition

One major goal in Neuroscience is the development of strategies promoting neural plasticity in the adult central nervous system, when functional recovery from brain disease and injury is limited. New evidence has underscored a pivotal role for cortical inhibitory circuitries in regulating plasticity both during development and in adulthood. This paper summarizes recent findings showing that the inhibition-excitation balance controls adult brain plasticity and is at the core of the pathogenesis of neurodevelopmental disorders like autism, Down syndrome, and Rett syndrome.

Autism spectrum disorders

The term autism spectrum disorder refers to a constellation of symptoms involving impairments in social interaction and communication, and restricted, repetitive behaviours and interests. This article highlights the disorder among professionals who may come into contact with people with autism spectrum disorder.

Autism and epilepsy: historical perspective

Autism spectrum disorders (ASD) and epilepsy co-occur in approximately 30% of individuals with either ASD or epilepsy. While there is no single unifying ASD-epilepsy phenotype, understanding potential commonalities in subgroups of children with an ASD-epilepsy phenotype will help us disentangle the pathophysiology of both ASD and epilepsy. Throughout this brief historical perspective we selectively review critical trends in ASD-epilepsy research and highlight challenges to clinical and research efforts including terminology, heterogeneity of both ASD and epilepsy, and lack of careful characterization of children affected with both ASD and epilepsy. These complex issues continue to burden research on the diagnosis, neurobiology and management of children with ASD and epilepsy. A key concept that has emerged during the past 40 years is the strong association between intellectual disability and a higher prevalence of epilepsy in individuals with ASD. In addition, the two peaks of seizure onset, one in early childhood and one in adolescence and continuing through adulthood may be unique to individuals with ASD. The overlap of language and autistic regression to epilepsy, EEG epileptiform activity, sleep, and to epileptic encephalopathies such as Landau-Kleffner syndrome continue to be controversial areas of research and of clinical interest. An emerging consensus is that shared developmental genetic, molecular and pathophysiological mechanisms exist and account for the common co-occurrence of ASD and epilepsy.

Relative clinical utility of three Child Symptom Inventory-4 scoring algorithms for differentiating children with autism spectrum disorder vs. attention-deficit hyperactivity disorder

OBJECTIVE

The present study compared three separate Child Symptom Inventory-4 (CSI-4) scoring algorithms for differentiating children with autism spectrum disorder (ASD) from youngsters with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Parents/teachers completed the CSI-4, a DSM-IV-referenced rating scale, for 6 to 12-year-old clinical referrals with ASD (N = 186) and ADHD (N = 251). Algorithms were based on either all CSI-4 items (forward logistic regressions) or the 12 DSM-IV symptoms of pervasive developmental disorder (PDD) included in the CSI-4.

RESULTS

ROC analyses indicated generally good to excellent values for area under the curve, sensitivity, specificity, and positive predictive power. Algorithms for parent ratings were superior to teacher ratings. The algorithm based solely on PDD symptoms evidenced the greatest generalizability.

CONCLUSION

Although algorithms generated from regression analyses produced greater clinical utility for specific samples, the PDD-based algorithm resulted in greater stability across samples.

Language outcomes of toddlers with autism spectrum disorders: a two year follow-up

Thirty-seven children 15-25 months of age received clinical diagnoses of autism spectrum disorder (ASD) and were re-evaluated two years later. All subjects were judged to have retained a diagnosis of ASD at the follow-up evaluation. Communication scores for the group as a whole during the first visit were significantly lower than nonverbal IQ. However, by the second visit, verbal and nonverbal scores were no longer significantly different. The group was divided into two subgroups, based on expressive language (EL) outcome at the second visit. The two groups were similar in the second year of life in terms of expressive communication skills and autistic symptoms, except for a trend toward more stereotypic and repetitive behavior in the worse outcome group. By the second visit, however, the groups differed significantly on all standard measures of expression and reception, as well as on autistic symptomotology and nonverbal IQ. When assessed during their second year, children who ended up in the better outcome group showed higher average nonverbal cognitive level, receptive language (RL) scores, number of sounds and words produced, use of symbolic play schemes, and response to joint attention bids. Regression analysis revealed that the variables for which significant differences between the two outcome groups in their second year of life were found provided significant prediction of EL outcome at age four. Stepwise regression identified RL and presence of stereotypic and repetitive at the first visit as significantly associated with EL outcome. Implications of these findings for early identification and intervention are discussed.

Economic cost of autism in the UK

Autism has lifetime consequences, with potentially a range of impacts on the health, wellbeing, social integration and quality of life of individuals and families. Many of those impacts are economic. This study estimated the costs of autism spectrum disorders (ASDs) in the UK. Data on prevalence, level of intellectual disability and place of residence were combined with average annual costs of services and support, together with the opportunity costs of lost productivity. The costs of supporting children with ASDs were estimated to be pound 2.7 billion each year. For adults, these costs amount to pound 25 billion each year. The lifetime cost, after discounting, for someone with ASD and intellectual disability is estimated at approximately pound 1.23 million, and for someone with ASD without intellectual disability is approximately pound 0.80 million.

Interventions to Improve Communication

Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words. However, the limitation of these methods in maintenance and generalization of skills suggests that many children with autism will need to have these methods supplemented with less adult-directed activities to increase communicative initiation and carry over learned skills to new settings and communication partners. Providing opportunities for mediated peer interactions with trained peers in natural settings seems to be especially important in maximizing the effects of this intervention.

Association of a monoamine oxidase-a gene promoter polymorphism with ADHD and anxiety in boys with autism spectrum disorder

The aim of the present study was to examine the association between a variable number tandem repeat (VNTR) functional polymorphism in the promoter region of the MAO-A gene and severity of ADHD and anxiety in boys with ASD. Parents and teachers completed a DSM-IV-referenced rating scale for 5- to 14-year-old boys with ASD (n = 43). Planned comparisons indicated that children with the 4- versus 3-repeat allele had significantly (p < 05) more severe parent-rated ADHD inattention and impulsivity, and more severe teacher-rated symptoms of generalized anxiety. Our results support a growing body of research indicating that concomitant behavioral disturbances in children with ASD warrant consideration as clinical phenotypes, but replication with independent samples is necessary to confirm this preliminary finding.

Young Adult Outcome of Autism Spectrum Disorders

To learn about the lives of young adults with ASD, families with children born 1974-1984, diagnosed as preschoolers and followed into adolescence were contacted by mail. Of 76 eligible, 48 (63%) participated in a telephone interview. Global outcome scores were assigned based on work, friendships and independence. At mean age 24, half had good to fair outcome and 46% poor. Co-morbid conditions, obesity and medication use were common. Families noted unmet needs particularly in social areas. Multilinear regression indicated a combination of IQ and CARS score at age 11 predicted outcome. Earlier studies reported more adults with ASD who had poor to very poor outcomes, however current young people had more opportunities, and thus better results were expected.

Antipsychotic medication for childhood-onset schizophrenia

BACKGROUND

Childhood-onset schizophrenia is schizophrenia with onset prior to the age of 13 years. Although it is rare, people who suffer from schizophrenia at an early age appear to have a clinically severe form of the illness with poor long-term prognosis. Antipsychotic medication is one way of managing this rare but serious mental illness.

OBJECTIVES

To examine the effects of antipsychotic medication for childhood-onset schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2006 and February 2007), inspected references of all identified studies for further trials and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials involving children and young people with a diagnosis of childhood onset schizophrenia (i.e. with a diagnosis of schizophrenia before the age of 13) comparing any antipsychotic drug with another antipsychotic or placebo.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality assessed and extracted data from trials. We excluded data where more than 50% of participants in any group were lost to follow up. For homogenous dichotomous data we calculated random effects, relative risk (RR) and its 95% confidence interval (CI) and, where appropriate, number needed to treat (NNT) on an intention-to-treat basis. For normal continuous data we calculated the weighted mean difference (WMD).

MAIN RESULTS

From a total of 2062 citations, we identified six relevant trials. We categorised trials into three comparisons: atypical versus typical, atypical versus atypical and typical versus typical antipsychotic drugs. The only comparison to find any differences between treatment groups was atypical versus typical antipsychotic drugs. A few results from one study favoured the atypical antipsychotic clozapine over haloperidol in treating treatment resistant childhood-onset schizophrenia (n=21, WMD CGAS 17.00 CI 7.74 to 26.26; n=21, WMD Bunney-Hamburg Psychosis Rating Scale -3.60 CI -6.64 to -0.56). Participants on clozapine, however, were three times more likely to have drowsiness (1 RCT, n=21, RR 3.30 CI 1.23 to 8.85, NNH 2 CI 2 to 17) and half of the children receiving clozapine had neutropenia (1 RCT, n=21, RR 12, CI 0.75 to 192.86).

AUTHORS' CONCLUSIONS

There are few relevant trials and, presently, there is little conclusive evidence regarding the effects of antipsychotic medication for those with early onset schizophrenia. Some benefits were identified in using the atypical antipsychotic clozapine compared with haloperidol but the benefits were offset by an increased risk of serious adverse effects. Larger, more robust, trials are required.

What happens to children with PDD when they grow up? Prospective follow-up of 219 children from preschool age to mid-childhood

OBJECTIVE

To describe the psychological development of children with pervasive developmental disorders over a period of 3 years and to identify the factors linked to their developmental paths.

METHOD

The study was a collaborative and prospective follow-up study of 219 preschoolers. Retrospective data and enrollment data were collected at the beginning of the study and 3 years later.

RESULTS

We observed high variability in the short-term outcomes of preschoolers. In line with previous research, our results showed that intellectual, linguistic and adaptive functioning were useful for predicting outcome. The severity of a child's autistic symptoms appears to be related to his or her future development. These variables can therefore be used as predictors of outcome for preschoolers with autism.

CONCLUSION

Developmental and symptom changes in young children with autism should not be overlooked and need to be assessed regularly in view of choosing suitable servicing programs.

Predictors of expressive vocabulary growth in children with autism

PURPOSE

The purpose of this exploratory study was to examine the variability and predictors of expressive vocabulary development in children with autism and very delayed language.

METHOD

This study involved 35 children with autism whose initial chronological ages were between 20 and 71 months and whose initial expressive vocabularies were less than 60 words. Their expressive vocabularies were measured at baseline and at 6, 12, and 24 months following the start of intervention using the MacArthur-Bates Communicative Developmental Inventory (L. Fenson et al., 1993).

RESULTS

A cluster analysis revealed 4 distinct patterns of expressive vocabulary development over 2 years. The number of words said, the presence of verbal imitation skills and pretend play skills with objects, and the number of gestures to initiate joint attention at baseline were all associated with the cluster of children who demonstrated the most rapid expressive vocabulary growth over time. The 2 clusters of children who demonstrated the least vocabulary growth had the most significant developmental delays and autism severity at 6 months, but not at baseline.

CONCLUSIONS

This study confirms the heterogeneity in language development in young children with autism and, consistent with other reports, confirms that specific prelinguistic skills are predictive of development.

Predictors of language acquisition in preschool children with autism spectrum disorders

In 118 children followed from age 2 to 5 (59 with autism, 24 with PDD-NOS and 35 with non-spectrum developmental disabilities), age 2 and age 3 scores of non-verbal ability, receptive communication, expressive communication and socialization were compared as predictors of receptive and expressive language at age 5. Non-verbal cognitive ability at age 2 was generally the strongest predictor of age 5 language, while at age 3 communication scores were a stronger predictor of age 5 language for children with autism. Early joint attention as well as vocal and motor imitation skills were more impaired in children who did not develop language by age 5 (but had relatively strong non-verbal cognitive skills) than in children who did develop language by 5.

Follow-up of children diagnosed with pervasive developmental disorders: stability and change during the preschool years

Forty-one children with pervasive developmental disorders (PDDs) receiving eclectic services were assessed twice during their preschool years. Measures were compared over time for the whole group and for diagnostic subgroups: Childhood autism (CA group) and Other PDDs group. The mean intelligence quotient/developmental quotient (IQ/DQ) of the whole group was stable (P = 0.209) and scores on the Childhood Autism Rating Scale (CARS) decreased (P = 0.001). At time 2, the CA group was more impaired than the other PDDs group: autistic symptoms were more severe (P = 0.01), adaptive behavior scores were lower (P = 0.014), and a trend for lower IQ/DQs (P = 0.06). Children in this study seemed to fare better than reported in previous follow-up studies on children with autism.

ADHD symptom subtypes in children with pervasive developmental disorder

OBJECTIVE

Compares DSM-IV ADHD subtypes in large samples of 3-to-5 and 6-to-12 year old children with pervasive developmental disorder (PDD) vs. nonPDD clinic referrals.

METHOD

Parents and teachers completed a DSM-IV-referenced rating scale.

RESULTS

ADHD subtypes were clearly differentiated from the nonADHD group and showed a differential pattern of co-occurring psychiatric symptoms (more pronounced for teacher- than parent-defined subtypes and older than younger children) that was similar in both PDD and nonPDD samples. The Combined type had more severe oppositional, aggressive, and PDD symptoms than Inattentive type and were from less advantaged homes than other subtypes. Hyperactive-Impulsive type was least impaired.

CONCLUSION

Findings support the notion that ADHD may be a clinically meaningful syndrome in children with PDD.

Episodic psychiatric disorders in teenagers with learning disabilities with and without autism

BACKGROUND

Mental health problems in people with learning disabilities and autism are poorly understood.

AIMS

To investigate the prevalence of episodic psychiatric disorders in a sample of teenagers with learning disabilities with and without autism.

METHOD

Teenagers with learning disabilities living in one geographical area were identified. Those with autism were matched to those without. A semi-structured investigator-based interview linked to Research Diagnostic Criteria was used to assess prevalence and type of episodic disorders.

RESULTS

Significantly more individuals with autism had a lifetime episodic disorder, most commonly major depression. Two individuals with autism had bipolar affective disorder. Other episodic disorders with mood components and behaviour change were also evident, as were unclassifiable disorders characterised by complex psychiatric symptoms, chronicity and general deterioration. Antipsychotics and stimulants were most frequently prescribed; the former associated with episodic disorder, the latter with autism.

CONCLUSIONS

Teenagers with learning disabilities and autism have higher rates of episodic psychiatric disorders than those with learning disabilities alone.

Forty-two-years later: the outcome of childhood-onset schizophrenia

This paper describes the long-term course of 76 patients who had been consecutively admitted to the Department of Child and Adolescent Psychiatry, Philipps University, between 1920 and 1961 with a suspected diagnosis of childhood-onset schizophrenia. By means of a consensus analysis of available data in accordance with ICD-10 criteria, the diagnosis of schizophrenia was confirmed in only 50% of the original sample (n = 38, childhood-onset schizophrenia group); whereas the rest of the sample were allotted other diagnoses (n = 38, non-schizophrenia group). A follow-up investigation was conducted, interviewing all available patients, if possible, or their first-degree relatives or doctors. In the childhood-onset schizophrenia group, age at onset (mean +/- S.D.) was 12.7 +/- 2.5 (range 5-14) years and age at follow-up was 55.0 +/- 4.8 (range 42-62) years. The outcome of this group was poor. According to the Global Assessment Scale (GAS), only 16% had a good (GAS score 71-100) and 24% had a moderate (GAS score 41-70) outcome. In the 16 childhood-onset schizophrenia patients who could be personally investigated at follow-up, 10 (62.5%) displayed severe or moderate depressive symptoms according to the BPRS depressive score. The death rate (including suicide) was significantly higher in the schizophrenia group (n = 15; 39.5%) than in the non-schizophrenia group (n = 7; 18.4%). A comparison of the life-time diagnoses of the total sample (n = 76) at follow-up with the ICD-10 diagnoses made retrospectively revealed a diagnostic stability in 69 (91%) and a change of diagnosis in 7 (9%) cases, among them 4 who were originally diagnosed as having childhood-onset schizophrenia.

Advances in drug treatments for children and adolescents with autism and other pervasive developmental disorders

Autism is a disorder characterised by abnormalities in language and social development, and repetitive behaviours. Antipsychotics, including haloperidol and risperidone, are the most widely studied drugs for reducing symptoms in children and adolescents with autism. When administered at relatively low dosages, antipsychotics have been shown to reduce repetitive behaviours (stereotypies) and social withdrawal, as well as a number of related symptoms, such as hyperactivity, aggression, self-abusive behaviour, temper tantrums, lability of mood and irritability. Adverse effects of antipsychotics include sedation, dizziness, increased appetite, weight gain, changes in the electrocardiogram parameters, drooling, hyperprolactinemia and a risk of drug-related dyskinesias. Other agents have been less well studied for the treatment of autism, but there are suggestive data regarding their safety and efficacy. Of these agents, a number have been investigated, based on theories about the aetiology of autism, including SSRIs and naltrexone, although the efficacy of these agents has been limited. Stimulant drugs have been shown to reduce hyperactivity and improve focus, but they may cause behavioural worsening, weight loss and stereotypies de novo. Secretin is a treatment that has received much media attention after reports of efficacy from small open studies, but all controlled studies have failed to show any benefit. In autism, alternative treatments have also been used, but none have shown benefit in well-designed studies.

Comparison of DSM-IV symptoms in elementary school-age children with PDD versus clinic and community samples

This study compares DSM-IV symptoms in children (ages 6 to 12 years) with pervasive developmental disorder (PDD), clinic controls, and community-based samples. Parents/teachers completed the Child Symptom Inventory-4 for four samples: PDD (N = 284/284) and non-PDD psychiatric clinic referrals (N = 189/181) and pupils in regular (N = 385/404) and special (N = 61/60) education classes. The PDD group received higher symptom severity ratings than the regular education group, but was similar to the non-PDD clinic sample. Screening prevalence rates were highest for ADHD, ODD, and generalized anxiety disorder. PDD subtypes exhibited differentially higher rates of psychiatric symptoms. The magnitude of rater and gender differences in symptom severity ratings was modest. Clinic-referred children with PDD exhibit a pattern of psychiatric symptoms highly similar to nonPDD clinic referrals. Although much additional research is needed on comorbidity, these symptoms have important treatment implications.

Clinical variables at age 2 predictive of mental retardation at age 5 in children with pervasive developmental disorder

This study attempted to find clinical variables evaluated at age 2 that would predict mental retardation (MR, IQ/cognition-adaptation developmental quotient [C-A DQ]<70) at age 5 in 57 children with pervasive developmental disorder (PDD). About two-thirds of subjects had MR at both initial and outcome evaluations. The C-A DQ at initial evaluation was significantly lower in mentally retarded PDD (MRPDD) than in high-functioning (IQ >or= 70) PDD (HFPDD). MRPDD changed less than HFPDD in IQ/C-A DQ between ages 2 and 5. The C-A DQ at age 2 was a potent predictor for MR at age 5 and the total score and three item scores of Childhood Autism Rating Scale-Tokyo Version evaluated at age 2 were also useful in predicting MR at age 5.

Striatal volume on magnetic resonance imaging and repetitive behaviors in autism

BACKGROUND

The repetitive behaviors seen in autism phenotypically resemble those seen in obsessive-compulsive disorder (OCD) and Tourette Syndrome (TS), disorders in which structural and functional abnormalities of the basal ganglia (BG) are present and correspond to the severity of repetitive behaviors.

METHODS

Seventeen subjects with autism by DSM-IV and Autism Diagnostic Interview (ADI) and 17 matched controls completed a 1.5 T magnetic resonance image (MRI) of the brain. Two blinded researchers, with good inter-rater reliability, outlined the right and left caudate and putamen. Autistic and control BG volumes covaried for total brain volume were compared using analysis of covariance. BG volumes within the autistic group were correlated with the ADI Repetitive Behavior scores (ADI-C domain).

RESULTS

Right caudate volume controlled for total brain volume was significantly larger in autistic subjects than in controls. In addition, right caudate and total putamen volumes correlated positively with repetitive behavior scores on the ADI-C domain, particularly the higher order OCD-like repetitive behaviors.

CONCLUSIONS

Increased right caudate volume in autism is of interest, since this has also been observed in OCD patients. Increased volume of the right caudate and total putamen positively correlated with greater repetitive behaviors, supporting the hypothesis of BG dysfunction associated with repetitive behaviors in autistic adults.

Trajectory of development in adolescents and adults with autism

This article seeks to elucidate the trajectory of development in adolescents and adults with autism. Prospective, retrospective, and cross-sectional studies are reviewed to reveal the manifestation of and changes in the core symptoms of autism in adolescence and adulthood. Comparing children with adolescents and adults, modest degrees of symptom abatement and improvement in skills have been documented in multiple studies, as are increases in verbal and decreases in performance IQ. Nevertheless, most individuals do not attain normative outcomes in adulthood and continue to manifest significant degrees of symptomatology and dependency. However, a small sub-group (about 15%) has more favorable adult outcomes.

Comparison of childhood disintegrative disorder and disintegrative psychosis not diagnosed as childhood disintegrative disorder

To clarify the difference of Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) childhood disintegrative disorder (CDD) from International Classification of Diseases (9th revision; ICD-9) disintegrative psychosis (DP), 10 CDD children (mean age, 7.7 years) and 18 DP children (mean, 6.5 years) not diagnosed as CDD divided into DSM-IV autistic disorder (DP-AD; n = 11) and pervasive developmental disorders not otherwise specified (DP-PDDNOS; n = 7) were compared on 31 variables not directly related to the normalcy before regression. The CDD, DP-AD, and DP-PDDNOS groups did not differ significantly in 28 variables. The DP-PDDNOS group met significantly a smaller number of items in criterion A of DSM-IV autistic disorder criteria than the CDD and DP-AD groups, both of which did not differ significantly in this respect. The CDD group tended to be more abnormal in auditory responsiveness and verbal communication than the DP-PDDNOS group. While CDD is distinct from DP-PDDNOS, its validity apart from AD with regression remains to be studied.

Autism Research: Lessons from the Past and Prospects for the Future

The paper uses both the author's experience of research training, and the empirical studies of autism in which he participated over the last 40-plus years, to derive research lessons and to consider the needs and prospects for future research. Attention is drawn to: the importance of mentors; the need to use technologies in a hypothesis-testing fashion; the important of possible creative/innovative leaps and of recognition of the unexpected; the need to ask challenging questions and to recognize when the original ideas were mistaken. There is great value in broadening the scientific strategies used to investigate a particular condition and much is to be gained by deliberately seeking parallels with other conditions.

Psychiatric symptoms in preschool children with PDD and clinic and comparison samples

OBJECTIVE

This study describes and compares the severity of DSM-IV symptoms in preschool children with diagnosed pervasive developmental disorder (PDD), clinic controls, and two community-based samples.

METHOD

Parents (/and teachers) completed the early child inventory-4 (ECI-4), a DSM-IV-referenced rating scale for four samples: PDD (n = 172/160) and nonPDD psychiatric clinic referrals (n=135/101) and youngsters in regular (n=507/407) and special (n =64/140) early childhood programs. Children ranged in age from 3 to 5 years old.

RESULTS

With the exception of conduct problems, the PDD group generally received higher symptom severity ratings than the regular early childhood group, but the pattern of differences compared with the other two groups often varied by type of symptom and informant. Teachers rated the PDD and nonPDD clinic groups as having equally severe ADHD and oppositional defiant disorder symptoms. Teachers rated the PDD group as having more severe anxiety and depression symptoms than parents. The Asperger group was rated by both informants as more oppositional than the autism and PDDNOS subgroups. Teachers rated males in the regular early childhood sample as having more severe ADHD and aggressive symptoms than females, but this was not the case for the PDD sample.

CONCLUSION

Preschoolers with PDD exhibit more severe DSM-IV psychiatric symptoms than children in regular and special early childhood programs, and to some extent nonPDD psychiatric referrals. The concept of comorbidity warrants further exploration, as does informant-specific syndromes as validators of diagnostic constructs.

Comparative study of early childhood high-function autism and developmental mixed receptive-expressive language disorder

Verbal cognitive profile and general social functioning were compared between two groups of children aged 5 to 7 years, one with high-function autism and the other with developmental mixed receptive-expressive language disorders. The two groups, totaling 50 children, were matched for age and non-verbal IQ (mean, 90). Both groups had impaired verbal cognitive profile and social adaptive functioning, with no statistically significant differences between the two groups. The implications of our findings are discussed. Current preschool and early childhood medical-educational intervention programs in Taiwan must design and implement curricula in which children with language delay, whether autistic or/not, can develop essential social skills.

Adult outcome for children with autism

BACKGROUND

Information on long-term prognosis in autism is limited. Outcome is known to be poor for those with an IQ below 50, but there have been few systematic studies of individuals with an IQ above this.

METHOD

Sixty-eight individuals meeting criteria for autism and with a performance IQ of 50 or above in childhood were followed up as adults. Their mean age when first seen was 7 years (range 3-15 years); at follow-up the average age was 29 years (range 21-48 years). Outcome measures included standardised cognitive, language and attainment tests. Information on social, communication and behavioural problems was obtained from the Autism Diagnostic Interview (ADI).

RESULTS

Although a minority of adults had achieved relatively high levels of independence, most remained very dependent on their families or other support services. Few lived alone, had close friends, or permanent employment. Communication generally was impaired, and reading and spelling abilities were poor. Stereotyped behaviours or interests frequently persisted into adulthood. Ten individuals had developed epilepsy. Overall, only 12% were rated as having a 'Very Good' outcome; 10% were rated as 'Good' and 19% as 'Fair'. The majority was rated as having a 'Poor' (46%) or 'Very Poor' (12%) outcome. Individuals with a childhood performance IQ of at least 70 had a significantly better outcome than those with an IQ below this. However, within the normal IQ range outcome was very variable and, on an individual level, neither verbal nor performance IQ proved to be consistent prognostic indicators.

CONCLUSIONS

Although outcome for adults with autism has improved over recent years, many remain highly dependent on others for support. This study provides some information on prognostic indicators, but more fine-grained research is needed into the childhood variables that are associated with good or poor outcome.

Autism spectrum disorders: early detection, intervention, education, and psychopharmacological management

Our understanding and treatment of children with autism have changed dramatically since Leo Kanner first formally documented the disorder in 1943. With reference to the historical context, this paper reviews recent research addressing 4 major issues: early detection, intervention, education, and psychopharmacological management of children with autism and related (autistic) spectrum disorders (hereafter, "autism"). We conclude from our review of the evidence that, in the absence of additional, more compelling data, the clinical usefulness of existing screening instruments remains questionable. However, the potential importance of such research is underscored by the clear benefits of early behavioural intervention: despite differences in orientation, outcomes for children with autism can be significantly enhanced with early intensive intervention. Although many questions remain (notably, What are the critical therapeutic components? For whom? For what domains of development? For what level of intensity and duration?), interventions shown to be effective are all carefully planned, engineered, monitored, and designed to target specific skill domains. Including children with autism in regular classes within the public school system poses several challenges, the most pressing of which is the large number of school personnel who need to be trained in evidence-based teaching and behavioural management practices. Finally, psychotropic drugs may help to reduce some symptoms, but they are neither curative nor a substitute for other forms of support and intervention.

Parental identification of early behavioural abnormalities in children with autistic disorder

The aim of the study was to identify early behavioural abnormalities in children later diagnosed with autistic disorder. Accurate identification of such deficits has implications for early diagnosis, intervention and prognosis. The parents of 153 children with autistic disorder completed a questionnaire asking them to describe early childhood behaviours of concern and to recall the age of onset. Core deficit-linked behaviours were then identified and the ontogeny of their development was noted. Behaviour categories were: (1) gross motor difficulties, (2) social awareness and play deficits, (3) language and communication difficulties, and (4) unusual preoccupations. The findings supported the notion that the nature and prevalence of these deficits depend on age. Consistent with past research, there was a significant interval between parents first noticing abnormalities and the making of a definitive diagnosis. The implications for this delay are discussed.

Predictors of outcome among high functioning children with autism and Asperger syndrome

BACKGROUND

The objective of this paper is to assess the extent to which measures of cognitive abilities taken in an inception cohort of young high functioning children with autism and Asperger syndrome predict outcome roughly two and six years later.

METHOD

Children who received a diagnosis of autism or Asperger syndrome (AS) and who had a nonverbal IQ score in the 'non-retarded' range were included in the inception cohort. Measures of language and nonverbal skills were taken when the children were 4-6 years of age and outcome assessments were completed when the children were 6-8 and 10-13 years of age. The three outcome measures consisted of scales of adaptive behaviours in socialisation and communication and a composite measure of autistic symptoms (abnormal language, abnormal body and object use, difficulties relating to others, sensory issues and social and self-help difficulties).

RESULTS

The explanatory power of the predictor variables was greater for communication and social skills than for autistic symptoms. The power of prediction was stable over time but did differ by PDD subtype. In general, the association between language skills and outcome was stronger in the autism group than in the AS group.

CONCLUSIONS

These results support the emphasis of early intervention programmes on language but more work needs to be done on understanding variables that influence outcome in social skills and autistic behaviours, particularly in those with AS.

Stability and change among high-functioning children with pervasive developmental disorders: a 2-year outcome study

This study prospectively compared the 2-year outcome of children diagnosed with autism or Asperger syndrome at age 6-8 years in terms of symptoms from the Autism Diagnostic Interview. Significant differences were seen in the three-domain summary scores of social interaction, communication, and repetitive activities, with the Asperger syndrome group demonstrating fewer and/or less severe symptoms at both times. There was a trend for the trajectories to come together over time on the socialization and communication domains, but not the repetitive activities domain. Differences were not attributable to IQ. Analysis of individual items indicated that the autism group improved over time on seven items and showed increased symptom severity on three items. On the other hand, the Asperger syndrome group improved on only two items and showed increased symptom severity on six items. Results suggest that the two PDD subtypes represent similar developmental trajectories, although the Asperger syndrome group maintains its advantage. Educational and clinical implications of the results are discussed.

Social impairment in the "Care in the Community" cohort: the effect of deinstitutionalization and changes over time in the community

This paper presents data from a longitudinal collaborative study of The Care in the Community Sample (Cambrdige, Hayes, Knapp, Gould, & Fenyo, 1994; Cambridge et al., 2001; Knapp et al., 1992). The aim of the study was to investigate how social impairment changes are related to the move from institutional to community care using some preliminary analysis of the above data. A measure of social impairment using the Skills and Behavior Interview from the most recent follow-up of this cohort was found to be consistent with Wing's definition of social impairment, when applied to the cohort 12 years after deinsitutionalization. This measure was then used to retrospectively identify social impairment in the same sample (of approximately 250 people) at baseline (in the institution), at 1 year and at 5 years in the community. Prevalence data pointed to high levels of social impairment in the sample (50.1%) in institutions but the decrease to 39.8% after 1 year in the community was not significant (although conversation and social mixing and initiation of conversation and social interaction did improve over time). Once in the community, social impairment in general did not change over time, although there was a significant decrease in conversation and social mixing, non-verbal communication and initiation of conversation and social interaction. These results are compared to other research findings and the implications and limitations of the study discussed.

Frühkindlicher Autismus: Alter bei Beginn und frühe Abbauprozesse

Zusammenfassung: Fragestellung: Das Alter bei Beginn autistischer Auffälligkeiten und frühe Abbauprozesse im sozialen oder sprachlichen Bereich werden bei Kindern mit frühkindlichem Autismus als Hinweis auf eine spezielle Untergruppe angesehen. Angaben zur Häufigkeit variieren in den verschiedenen Arbeiten. Ziel der Untersuchung ist es, an einer klinischen Stichprobe festzustellen, wie häufig ein Beginn nach dem ersten Lebensjahr oder Abbauprozesse im sozialen und sprachlichen Bereich beobachtet werden und mit welchen weiteren Auffälligkeiten sie kombiniert sind. Methode: Den Akten von 101 Kindern, die seit 1993 mit der Diagnose eines frühkindlichen Autismus in einer Spezialambulanz untersucht wurden, entnahmen wir die Diagnosen auf den sechs Achsen des multiaxialen Klassifikationssystems, Angaben zum Alter bei Beginn der Auffälligkeiten bzw. des Abbaus und zum Alter bei der 1. Untersuchung. Ergebnisse: 75% der Kinder werden als von Anfang an auffällig beschrieben. 14 der 101 Kinder zeigten einen Abbau im sozialen Bereich und 21 Kinder einen Verlust sprachlicher Fähigkeiten. Ein Zusammenhang mit dem IQ oder dem Sprachentwicklungsstand bei der Untersuchung wurde nicht gefunden. Kinder mit Abbauprozessen hatten häufiger eine Epilepsie als Kinder ohne berichtete Abbauprozesse. Schlussfolgerungen: Die vorhandenen Daten berechtigen zu der Hypothese, dass der verspätete Beginn der autistischen Symptomatik, insbesondere aber der Verlust von Fähigkeiten, ein Hinweis auf eine spezielle Untergruppe innerhalb der autistischen Kinder ist. Diese Symptome sollten unbedingt zu einer genauen diagnostischen Abklärung einer epileptischen Genese führen.

Changes in social impairment for people with intellectual disabilities: a follow-up of the Camberwell cohort

The skills and social impairments of a total population of children with severe intellectual disabilities and/or autism from Camberwell, South London (Wing and Gould, 1978 and 1979), were assessed using the Handicaps, Behaviours and Skills schedule, and they were reassessed when they were adolescents and young adults (Shah, 1986). Changes in social impairment over time are presented here. As Shah (1986) had found with a smaller sample, social impairment remained relatively stable over time: on a simple "socially impaired" versus "sociable" dichotomous grouping, 93% did not change social group. Within the socially impaired group, there was a significant increase in impairment over time (i.e., people who were passive at Time 1, were aloof at Time 2). Implications of these results and predictions for a further follow-up study are discussed.

Genetics of autism: complex aetiology for a heterogeneous disorder

Since autism was first recognized as a disorder in 1943, speculation about its aetiology has ranged from biological to psychological and back again. After twin studies during the 1970s and 1980s yielded unequivocal evidence for a genetic component, aetiological research in autism began to focus primarily on uncovering the genetic mechanisms involved. The identification of chromosomal abnormalities and Mendelian syndromes among individuals with autism, in conjunction with data from genome screens and candidate-gene studies, has helped to refine the view of the complex genetics that underlies autism spectrum conditions.

Antiepileptic drugs: affective use in autism spectrum disorders

Antiepileptic drugs are widely administered to individuals with autistic spectrum disorders. There are several reasons for the use of antiepileptic drugs in autistic spectrum disorders, including the high incidence of epilepsy in these individuals, the anecdotal reports suggesting an improvement of communication and behavior in autistic subjects with epileptic discharges, and the increased awareness that some disruptive behaviors may be manifestations of an associated affective disorder. In this study, data on the current use of antiepileptic drugs in the treatment of autism, and on the association of affective disorders with epilepsy and autism, are reviewed. The evidence supporting the hypothesis that there may be a subgroup of autistic children with epilepsy and affective disorders that preferentially respond to antiepileptic drugs is still very preliminary, and further investigations with double-blind controlled studies are needed. Although the role of antiepileptic drugs at the present time is not established, there is evidence that autism, epilepsy, and affective disorders commonly co-occur, and that they may share a common neurochemical substrate, which is the common target of the psychotropic mechanism of action of different antiepileptic drugs.

Social and psychiatric functioning in adolescents with Asperger syndrome compared with conduct disorder

Lack of standardized phenotypic definition has made outcome studies of Asperger syndrome (AS) difficult to interpret. This paper reports psychosocial functioning in 20 male adolescents with AS, defined according to current ICD-10 criteria, and a comparison group of 20 male adolescents with severe conduct disorder. Subjects were gathered from clinical referral. Evaluation used standardized interviewer rated assessments of social functioning and psychiatric morbidity. The AS group showed severe impairments in practical social functioning despite good cognitive ability and lack of significant early language delay. High levels of anxiety and obsessional disorders were found in AS; depression, suicidal ideation, tempers, and defiance in both groups. Results are compared with those from other studies. Relevance to clinical ascertainment and treatment is discussed.

Autism and developmental receptive language disorder--a comparative follow-up in early adult life. I: Cognitive and language outcomes

In this paper we compare adult outcome in a group of young men with autism and a group with developmental receptive language disorders. The two groups were first assessed in early childhood, when aged 7 to 8 years of age. Although matched at that time for nonverbal IQ (mean 92-93) and expressive language ability, the Autism group was significantly more impaired on most measures of social and communication skills and stereotyped behaviours. A later follow-up, in mid-childhood, suggested that although the groups were still quite distinct, social and behavioural problems had become more apparent in the Language group. The current study was completed when the participants were aged, on average, 23 to 24 years. The findings indicated that verbal IQ and receptive language scores had improved significantly more in the Autism group than in the Language group over time. Moreover, although the Language group were less severely impaired in their social use of language, many showed a number of abnormal features in this domain. There were no differences between the groups on tests of reading or spelling. Discriminant function analysis, which had clearly distinguished between the groups as children, now showed much greater overlap between them. Regression analysis indicated that although early language ability appeared to be related to outcome in the Autism group, in the Language group there was little association between measures of childhood functioning and later progress. The implications of these findings for understanding the nature of the underlying deficit in autism and the relationship between the two disorders are discussed.

Autism and developmental receptive language disorder--a follow-up comparison in early adult life. II: Social, behavioural, and psychiatric outcomes

This paper focuses on general social functioning in two groups of young men, one with autism and one with developmental receptive language disorders, who were first assessed at the ages of 7-8 years. At that time, although matched for nonverbal IQ (mean 92-93) and expressive language, the Language group showed significantly fewer social and behavioural problems. At follow-up, when aged on average, 23 to 24 years, the Autism group continued to show significantly more impairments in terms of stereotyped behaviour patterns, social relationships, jobs, and independence. However, problems in all these areas were also common in the Language group. Many still lived with their parents, few had close friends or permanent jobs, and ratings of social interaction indicated abnormalities in a number of different areas. On a composite measure of social competence only 10% of the Language group was assessed as having severe social difficulties compared to 74% of the Autism group. Nevertheless, 65% were rated as having moderate social problems and only 25% were rated as being of near/normal social functioning. Two individuals in the Language group, but none in the Autism group, had also developed a florid paranoid psychosis in late adolescence. As in the follow-up of cognitive and linguistic functioning (see Mawhood et al., 2000, this volume, pp. 547-559), discriminant function analysis, which had clearly distinguished between the groups as children, now showed much greater overlap between them. Regression analysis indicated that although early language ability appeared to be related to outcome in the Autism group, there was little association between any measures of childhood functioning and prognosis in the Language group. Theoretically, these findings have implications for our understanding of the nature of autism and other pervasive language disorders, and of the relationship between them. Practically, they demonstrate the very persistent problems experienced by individuals with developmental language disorders, and their need for much greater help and support than is presently available.

Changes in skills for people with intellectual disability: a follow-up of the Camberwell Cohort

The skills of a total population of children with severe intellectual disability and/or autism from Camberwell, South London, UK, and the initial follow-up data, taken when the subjects were adolescents and young adults (Shah 1986), are described in the present study. Changes in skills over time are presented within the categories of communication, self-care, and educational and cognitive skills, as assessed by the Handicaps, Behaviours and Skills schedule. The results indicated that skills had improved in many areas between times 1 and 2, but that this improvement was more noticeable for the children who had been youngest at time 1. The implications of these results and predictions for a further follow-up study are discussed.

Anwendbarkeit der Child Behavior Checklist bei entwicklungsgestörten Kindern

Zusammenfassung: Frage: Die Child Behavior Checklist (CBCL) wird in großen, unausgelesenen Stichproben verwendet, um Verhaltensauffälligkeiten bei Kindern und Jugendlichen zu erfassen. In der hier vorgelegten Arbeit wird untersucht, inwieweit sich die CBCL eignet, um die bei einer Stichprobe entwicklungsgestörter Kinder typischerweise auftretenden Probleme zu erfassen. Methodik: Es wurden zwei Stichproben entwicklungsgestörter Kinder, bei denen Schwierigkeiten im Bereich der Sprache und der Kommunikation bestanden, untersucht. Es handelte sich um 34 Kinder mit einem frühkindlichen Autismus und 34 alters-, geschlechts- und intelligenzparallelisierte Kinder mit einer spezifischen Sprachentwicklungsstörung. Bei den zwei Stichproben wurde im Rahmen der routinemäßigen Abklärung der Symptomatik die CBCL ausgefüllt. Ergebnisse: Die Hälfte der sprachgestörten Kinder hatten im CBCL-Gesamtscore Werte im klinischen Bereich. Bei diesen Kindern sind die Probleme vor allem auf den Skalen «Aufmerksamkeitsstörungen», «Soziale Probleme» und «Zurückgezogenheit» anzutreffen. Etwa zwei Drittel der autistischen Kinder werden auf den oben genannten Syndromskalen als auffällig eingestuft. 32 der 34 autistischen Kinder erreichen auf der Skala V «Schizoid/Zwanghaft» auffällige Werte, während dies nur für ein sprachgestörtes Kind der Fall ist. Die Einzelitem-Analyse zeigt, daß in beiden Stichproben überdurchschnittlich häufig über entwicklungsbezogene Probleme (Sprechprobleme, Einnässen…) berichtet wird. Schlußfolgerungen: Die CBCL ist geeignet, um die bei entwicklungsgestörten Kindern charakteristischen Verhaltensauffälligkeiten zu erfassen. Diese Auffälligkeite n werden sowohl auf der Ebene der Syndromskalen wie auch durch Einzelitems erfaßt. Hohe Werte auf der Skala «Schizoid/Zwanghaft» sollten bei diesen Kindern Anlaß zu einer gezielten diagnostischen Abklärung eines frühkindlichen Autismus geben.