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

The Environmental Rating Scale (ERS): a measure of the quality of the residential environment for adults with autism

This study used classical test theory to assess the psychometric properties of the Environmental Rating Scale (ERS), a measure specifically designed to assess the treatment programs in residential settings that serve individuals with autism. Results of the confirmatory factor analysis support the presence of a single factor represented by the total score. The reliability of the measure was demonstrated by assessments of the internal consistency, stability, and interrater reliability. Preliminary analysis of the validity of the ERS indicates that this measure discriminates between treatment settings designed specifically for individuals with autism and those designed for other populations of developmentally handicapped clients and family homes. The ERS was also significantly positively correlated with a measure of the caregiver's knowledge about autism and a visitor's global impression of the desirability of the setting as a place to live.

Behavioral characteristics of 187 young adults with autism

A survey was conducted on the present behavioral characteristics of 187 cases of adult autism in patients over 18 years of age employing Achenbach's Child Behavior Checklist (CBCL). When their behavioral characteristics were evaluated in relation to Present Language Developmental Level (PLDL) and Present Adaptive Level (PAL), it was seen that greater variation in behavior characteristics was seen among those exhibiting increasingly lower PLDL and PAL scores. Behavior characteristics reminiscent of depression were noted even among those exhibiting high PLDL. Behavior pointing to obsession was found in common among almost all cases of autism irrespective of PLDL or PAL. Psychotic symptoms such as hallucinations and delusions were absent in most cases. The results of the present study were indicative not only of the significance of obsessive behavior in autism, but also its significance in terms of delving further into the psychopathology of the disorder.

Prognosis in autism: do specialist treatments affect long-term outcome?

Many different treatments have been claimed to have a dramatic impact on children with autism. This paper reviews what is known about the outcome in adult life and examines the limitations and advantages of a variety of intervention approaches. It concludes that there is little evidence of any "cure" for autism, but appropriately structured programmes for education and management in the early years can play a significant role in enhancing functioning in later life.

A comparison of speaking and mute individuals with autism and autistic-like conditions on the Autism Behavior Checklist

The item, total, and subscale scores on the Autism Behavior Checklist (ABC) were compared for 155 mute and 335 speaking individuals with autism spectrum disorders. Although no significant difference was observed between the groups on the ABC total score, the mute group demonstrated significantly more pathology on 21 of 57 items and 3 of 5 subscales. The speaking group obtained significantly higher scores on only 8 items and 1 subscale (Language). The appropriateness of providing greater pathology scores on expressive language items to speaking, rather than to mute, individuals is called into question. The authors speculate whether the expressive language items are weighted too heavily, in regard both to the Language subscale and to the ABC total score. If the expressive language items were removed, the mute group would have significantly higher ABC total scores and therefore a greater degree of autism severity.

Longitudinal examination of the behavioral, language, and social changes in a population of adolescents and young adults with autistic disorder

This follow-up study evaluates the behavioral, language, and social outcomes in a population of autistic patients initially examined in childhood. We evaluated 102 (63%) of the 163 eligible subjects, including 54 adolescents (12-17 years of age) and 45 adults (> or = 18 years of age). Three patients had died in the interim. Behavior difficulties continued to be a problem in 69% of adolescents and adults. Thirty-five percent of adolescents and 49% of adults engaged in self-injurious behavior, and slightly more than 50% of adolescents and adults exhibited some stereotypic behaviors. Over 90% of both adolescents and adults had persisting social deficits. Language improved with age, although only 35% achieved normal or near-normal fluency. Comprehension also improved, although only 29% of subjects had achieved normal or near-normal comprehension of oral language. At the time of last follow-up, 28% of all patients and 53% of adults were living in residential placement. Only 11% of adults were employed on the open market, all in menial jobs; an additional 16% were employed in sheltered workshops. The social, behavioral, and language deficits identified in early life in autistic children tend to persist into adolescence and young adulthood.

Course of behavioral change in autism: a retrospective study of high-IQ adolescents and adults

OBJECTIVE

The course of behavioral change in autistic behaviors has received little attention in previous research but is a potentially important parameter for study in autism.

METHOD

Autistic behaviors were systematically examined in 38 high-IQ adolescent and adult autistic individuals at their current age (13 through 28 years) and retrospectively at age 5 years using a standardized interview for autism.

RESULTS

Significant change over time in autistic behaviors, generally in the direction of improvement, was detected. The proportion of subjects showing improvement in communication and social behaviors was found to be significantly higher than the proportion showing improvement in ritualistic/repetitive behaviors. Five of 38 subjects who met DSM-IV criteria for autistic disorder at age 5 years no longer met criteria at their current age, although all five continued to have substantial impairment.

CONCLUSIONS

The study of patterns of behavioral change over time in autism has practical implications for both diagnosis and prognosis as well as potential importance in defining biologically meaningful subgroups and clarifying fundamental mechanisms underlying this disorder.

Restlessness: the anatomy of a neuropsychiatric symptom

OBJECTIVE

The aim of this paper is to review the literature on restlessness and related syndromes in order to examine the different causes and clinical descriptions, and to present a pathogenetic model that would incorporate its diverse aetiology.

METHOD

A literature search was undertaken with restlessness, agitation, akathisia, hyperactivity, fidgetiness and jitteriness as key words.

RESULTS

Causes of restlessness are diverse, and its distinction from other descriptions, such as agitation and hyperactivity, is poorly defined in the literature. Detailed descriptions of the syndromes are therefore lacking. The neuroanatomical basis of restlessness may consist of abnormalities in the cortico-subcortical neuronal circuits, the complex regulation of which may explain why different causes often lead to a common end result.

CONCLUSIONS

The terms used to describe restlessness and related disorders should be standardised, and the clinical manifestations investigated pedantically. Human and animal studies should investigate the pathophysiology so that intervention can be based on the underlying mechanisms.

Language and communication in autistic disorders

Communication problems form one of the key diagnostic criteria for autism, but there is a wide variety of manifestations. The theory that autistic individuals are unable to represent mental states can shed light on both the nature and range of communication impairments. This theory predicts that the specific communication deficit lies in the use of language to affect other minds. Language is not special in this respect, and is important only in so far as it may be used to give evidence of a speaker's thoughts and intentions. Thus, in autism, language level would be expected to relate strongly to performance on standard tests of theory of mind. Normal language acquisition appears to build upon the ability to recognize and orient towards ostensive behaviour. For this reason, it may not be necessary to postulate additional language impairments in order to explain the almost universal prevalence of language delay in children with autism. Autism, then, provides a model for studying the important distinction between language and communication, and demonstrates the vital part which mind-reading plays in normal human verbal and non-verbal interaction.

Thought disorder in childhood

OBJECTIVE

This paper delineates the evolution of the concept of thought disorder and presents a developmental/neurobehavioral theory of the main components of formal thought disorder in childhood-onset schizophrenia.

METHOD

A review of past and recent clinical, cognitive, and linguistic studies of thought disorder in childhood-onset schizophrenia presents the main features and changes in the thought disorder concept.

RESULTS

The review emphasizes that, in the past, this term was used to describe a variety of clinical manifestations in a heterogenous group of children because of the lack of distinction between childhood schizophrenia and infantile autism. The studies that have been conducted during the past 15 years, however, have demonstrated well-defined clinical components of thought disorder and their cognitive/information processing, linguistic/pragmatic, and biological correlates.

CONCLUSIONS

A functional conceptualization of formal thought disorder in childhood-onset schizophrenia is presented in light of the theoretical and clinical implications of the reviewed studies.

Autism: fifty years on from Kanner

It is now 50 years since Leo Kanner first described autism as a distinctive pattern of symptoms in some children with severe developmental problems. Since then the assessment and diagnosis of children with pervasive disorders of development has been refined and much is known about the phenomenology and epidemiology. Autism is a biological disorder of the central nervous system (CNS) of unknown cause. It is associated with a number of organic disorders such as epilepsy and has comorbidity with other psychiatric disorders such as tic disorder. Cognitive abnormalities in social interactions, affect and language are present but there is still debate regarding which of these, if any, is the primary cognitive deficit. Special education and behavioral management has led to modest but important developmental improvement in many children with autism. Autism remains a life-long condition but patterns of symptoms change and skills develop from childhood into adult life.

Language acquisition after mutism: a longitudinal case study of autism

This longitudinal case study challenges the assumption that individuals with autism who have severely restricted speech and language skills have a poor prognosis for further development of expressive oral language. The study follows the development of a woman with autism from mutism at age 10 to acquisition of a range of spoken and written language skills at age 26. The intervention in which the woman participated and her skills pre- and post-intervention and at two follow-up assessments are documented. The results support the hypotheses that speech and language development may proceed after mutism associated with limited verbal imitation and phoneme production skills, that some skills may plateau or decline, and that both spoken and written language may become viable forms of communication.

Psychological assessment of adolescents and adults with autism

This paper reports the results of a small follow-up study on 17 autistic adolescents and young adults who are also intellectually retarded. The aim is to examine how far scores on the Psychoeducational Profile (PEP) predicts scores on the Adolescent and Adult Psychoeducational Profile (AAPEP) 5 years later. One subscale eye-hand coordination significantly predicts the scores on three subscales of the AAPEP: Vocational Skills, Independent Functioning, and Vocational Behavior. Imitation predicts Interpersonal Behavior. Fine Motor predicts Leisure Skills and Cognitive Performance predicts Functional Communication. Results are interpreted in terms of the implications for educational intervention programs with autistic adolescents and adults.

The influence of age and sex on the onset and early course of schizophrenia

A new standardised interview for the retrospective assessment of onset and early course of schizophrenia (IRAOS) was used to study the influence of age and sex on time of onset and psychopathology before first admission in 267 schizophrenic patients admitted for the first time. Mean age at onset, according to various operationalised definitions, differed by three to four years between the sexes. The age distribution at the earliest sign of mental disorder showed an early and steep increase until the age of 25 in males, and a delayed and smaller increase in females, with a second peak in women aged 45-79. Schizophrenia began with negative symptoms in 70% of cases, appearing two to six years before admission, and all positive symptoms appearing up to two years before. Both positive and negative symptoms accumulated exponentially. The early course of the disease was similar across age groups, except there was a longer period of negative symptoms before first admission in late-onset schizophrenia in women. The few significant age differences in symptoms were presumably due to general age-dependent reaction patterns like anxiety and depression or the cognitive development of personality, as indicated by an increase in fully elaborated positive symptoms, especially systematised paranoid delusions, with age.

A follow-up study of 201 children with autism in Kyushu and Yamaguchi areas, Japan

A follow-up survey was conducted on 201 young adults with autism who were 18 or older (mean age, 21.5). All had participated previously in intensive therapeutic camping or had therapeutic involvement at medical consultation agencies to evaluate their outcome. Their social outcome was better than that previously reported in Japan. Although 31.5% had shown marked deterioration during adolescence, 43.2% had shown marked improvement during that period. Possible factors contributing to these results are discussed.

Autistic social dysfunction: some limitations of the theory of mind hypothesis

This study examined the extent to which the social disabilities found in autism can be accounted for by the "Theory of Mind" hypothesis. Items related to social development from the Vineland Adaptive Behavior Scales were administered to 29 CA-, MA- and IQ-matched pairs of young autistic and non-autistic, developmentally disabled children. These items were evaluated in relation to expected ages of acquisition based on the Vineland standardization database. Our results indicate that the social dysfunction in autism affects very basic and early emerging social behaviors which are typically present prior to the time at which even the earliest precursors of a theory of mind apparently emerge.

A follow-up study of high-functioning autistic children

Fifty-eight high-functioning autistic children were assessed during preschool and early school years and followed over a period of 8 years. Early and current psychometric and language tests, parent interviews concerning autistic symptomatology, and direct observations were examined as predictors of the Vineland Adaptive Behavior Scales and scores on standardized achievement tests. Verbal skills emerged as the strongest predictor of social-adaptive functioning. Clear, positive relationships also emerged between intellectual functioning, and academic attainment. Early non-verbal IQ also showed a positive relationship with outcome. Academic performance appeared considerably stronger than in earlier studies.

Young autistic children's listening preferences in regard to speech: a possible characterization of the symptom of social withdrawal

Autism is a childhood disorder diagnosed primarily in the presence of severe social unresponsiveness in the first 3 years of life (Volkmar, 1987). Since speech exerts a prepotent attraction on the attention of normally developing infants, hence facilitating social engagement, we designed a technique to examine whether this inborn reaction could be at fault in young autistic children. They were given a choice between their mothers' speech and the noise of superimposed voices (a sound effect obtained in a busy canteen). Data were obtained utilizing a specially designed automated and computerized device which recorded the children's responses in their own homes. In contrast to comparison groups of mentally retarded and normally developing children who showed the expected strong preference for their mothers' speech, the autistic children actively preferred the alternative sound or showed a lack of preference for either audio segment. These results suggest that such abnormal reactions to speech are a feature of these children's overall disregard to people.

Delayed visual maturation and autism

Three boys are described with a mixed developmental disorder, which so far appears to have a relatively good prognosis. Each boy presented in early infancy with visual unresponsiveness, which spontaneously resolved. This delayed visual maturation was accompanied or followed by severe autistic impairment, general developmental delay, hypotonia and clumsiness. Subsequent progress has been unexpectedly favourable, with striking improvements in language, play, social interest and social competence. Widespread, patchy delay in brain maturation could possibly account for this combination of delayed visual maturation and autism, with a good prognosis.

A longitudinal study of language acquisition in autistic and Down syndrome children

Findings from a longitudinal study of language acquisition in a group of autistic children are presented. Six autistic subjects and six children with Down syndrome, matched on age and MLU at the start of the study, were followed over a period of between 12 and 26 months. Language samples were collected in the children's homes while they interacted with their mothers. Samples of 100 spontaneous child utterances from the transcripts were analyzed using the following measures: MLU, Index of Productive Syntax, lexical diversity, and form class distribution. The results indicate that the majority of these autistic children followed the same general developmental path as the Down syndrome children in this study, and normal children reported in the literature, in the acquisition of grammatical and lexical aspects of language, and confirm previous findings suggesting that autism does not involve a fundamental impairment in formal aspects of language.

Echolalia and comprehension in autistic children

The research reported in this paper investigates the phenomenon of echolalia in the speech of autistic children by examining the relationship between the frequency of echolalia and receptive language ability. The receptive language skills of 10 autistic children were assessed, and spontaneous speech samples were recorded. Analysis of these data showed that those children with poor receptive language skills produced significantly more echolalic utterances than those children whose receptive skills were more age-appropriate. Children who produced fewer echolalic utterances, and had more advanced receptive language ability, evidenced a higher proportion of mitigated echolalia. The most common type of mitigation was echo plus affirmation or denial.

The autistic child's theory of mind: a case of specific developmental delay

In previous tests of the lowest level of a "theory of mind" (i.e. first-order belief attribution), 80% of autistic children were found to be impaired relative to a non-autistic mentally-handicapped control group. The present study examines the 20% of autistic children who have a theory of mind at the lowest level, and tests their ability to use a theory of mind at higher levels (i.e. second-order belief attribution). This autistic subgroup, in comparison to Down's Syndrome and normal control groups, was found to be severely impaired at the higher level. Autism is discussed as a possible case of specific developmental delay.

Social and pragmatic deficits in autism: cognitive or affective?

Autism is characterized by a chronic, severe impairment in social relations. Recent studies of language in autism also show pervasive deficits in pragmatics. We assume, uncontroversially, that these two deficits are linked, since pragmatics is part of social competence. This paper reviews the literature describing these deficits, and then considers two different psychological theories of these phenomena: the Affective theory and the Cognitive theory. Although the Affective theory makes better sense of the results from emotional recognition tasks, the Cognitive theory predicts the particular pattern of impaired and unimpaired social skills in autism, as well as the pragmatic deficits. These two theories might usefully be integrated in the future.

Validity and reliability of the Childhood Autism Rating Scale with autistic adolescents

The validity and reliability of the Childhood Autism Rating Scale (CARS) for autistic adolescents was tested. In the first study, CARS scores for autistic children and adolescents (matched on nonverbal IQ, sex, and ethnicity) were compared. In the second study, a group of nonautistic, handicapped adolescents were administered the CARS and these scores were compared with those of a group of autistic adolescents (matched on age, nonverbal IQ, sex, and ethnicity). The CARS clearly discriminated the two adolescent groups, suggesting that the scale may be an adequate measure of autism in adolescence. Although the CARS total score did not discriminate the younger from older autistic subjects, some interesting age-related differences emerged for specific items. A recommendation is made for elimination of one of the items on the CARS that negatively correlates with the CARS total score for both autistic groups.

Tourette's disorder coupled with infantile autism: a prospective study of two boys

In a longitudinal study, two boys in the Outpatient Psychiatric Clinic at Tokyo University were found to exhibit Tourette's disorder in addition to the original diagnoses of infantile autism. This paper addresses problems of applying the diagnostic criteria of DSM-III in terms of voluntary tic suppression in diagnosing patients with both disorders. Differences between motor tics and stereotyped movements in patients with both infantile autism and Tourette's disorder have been clearly distinguished. This may enable us to identify more autistic individuals with Tourette's disorder by focusing on these differences. In contrast to Burd et al.'s findings and implications, these two boys have not manifested spurts in language and social relationships nor have their conditions significantly improved, despite the development of Tourette's disorder.

Parental perception of behavioral symptoms in Japanese autistic children

A diagnostic questionnaire was used to study the abnormalities that parents first noticed, the ages at which parents first noticed these early symptoms, and the main problems the parents complained about in the first consultation. In this study, parents of 141 autistic children below the age of 12 were employed. Approximately 71% of the parents noticed abnormalities in their autistic children by the age of 2 1/2 years. Parents of older autistic children tended more often to report symptoms of mental retardation, ritualistic behavior, and self-injury. This study showed that the Japanese peak of abnormal social behavior, including autistic symptoms as reported by parents, was from the ages of 3 years to approximately 9 years, compared with the U.S. and European peak of 3 to 6 years.

Nonverbal communication and play correlates of language development in autistic children

The aim of this study was to determine the social and cognitive correlates of language acquisition in autistic children. Functional and symbolic play skills were shown to be associated with language abilities in a sample of young autistic children (mean CA 54.5 months), thereby replicating previous findings. Certain types of nonverbal communication skills were also shown to be significant correlates of language development in this group of autistic children. These involved the ability to use gestures to coordinate visual attention between social partners with respect to objects or events. The play and nonverbal communication variables were not significantly correlated, suggesting that these variables reflect independent psychological factors associated with language development in young autistic children.

The criteria for early use of nonvocal communication systems with nonspeaking autistic children

Criteria to differentiate nonspeaking subjects from speaking autistic preschool-age children were examined. The data on several developmental features previously recorded at 4 1/2 years of age were compared between 10 nonspeaking and 10 speaking children who were followed until late childhood. Total DQ, subscale DQs of intellectual, self-care, and motor ability, and several speech production features (variety of phone categories, distortion in vowels, and disappearance of babbling) were the most distinctive indices between the two groups. We believe that an early use of a nonvocal communication system by autistic children with these features results in more successful outcomes than before.

Cognitive disorders of infantile autism: a study employing the WISC, spatial relationship conceptualization, and gesture imitations

Sixteen autistic children with WISC Performance IQs of 70 or above were analyzed to determine their conceptions of spatial relations, size comparisons, and gesture imitations through the use of the WISC, an originally devised Language Decoding Test (LDT), and a modified Gesture Imitation Test (GIT). WISC results were replicated as in previous studies. The autistic children showed an inability to acquire concepts of size comparison and spatial relationships through verbal instructions. They often gave peculiar responses (partial imitations), which seem to be related to their inability to integrate another person's body as a whole through visual input. These findings support the notion that the basic cognitive deficit is an impairment of symbolic-representational functioning, including language and body images, which results from a combination of delay and deviation of the symbolic-representational function.

Autistic children exposed to simultaneous communication training: a follow-up

Fourteen originally mute, low-functioning autistic children, exposed to intensive simultaneous communication training, were followed up 1 to 4 years later. Psychometric testing, communication assessment, and teacher and parent interviews were employed. Results showed that at least half of the children who had become verbal by program termination remained verbal at follow-up. Higher-functioning and verbal children performed overall better than their lower-functioning and mute peers. Children exposed longer to the intensive program and those exposed to good schooling after termination fared better at follow-up, as did those whose parents were more involved in their training. Yet teachers and parents employed mainly speech rather than signs to communicate with these children, despite the children's difficulty with speech. Compared to the verbal children, who recalled signs and words equally well, the mute children recalled signs better than words. The findings are discussed for their relevance to choice of communication training with different subgroups of autistic children.

The organic etiology of infantile autism: a critical review of the literature

Various theories have been provided in the literature regarding the etiology of infantile autism. It seems that the biological causation dominates the thinking of mental health practitioners and researchers irrespective of discipline. Areas of research include the following: neuropathological studies of the brain, autopsies, electroencephalograms, epileptic seizures, brain lateralization, studies in asymmetry; neurochemistry; genetics; and pre-, peri- and postnatal factors. A critical analysis of these studies has indicated that the evidence of organic factors tends to be rather weak and furthermore has been found to be contradictory. It is felt that the major problem lies in the fact that a large number of investigators include in their sampling children with various mental and physical disabilities and label them autistic. In general, there seems to be little information regarding the selection and little background information is offered on these children. It is suggested that a standardized and world wide diagnostic system be constructed which will provide objective etiological results.

Variables relating to the mental development of children with infantile autism

Among 54 variables studied in 194 autistic children, nine variables--meaningful words, pointing, eating without assistance, crane symptoms (maneuvers of letting a person manipulate an object by grasping his or her hand and bringing it close to the object), echolalia, changing clothes without assistance, speech loss (loss of once-emerged meaningful words before 30 months of age), establishment of toilet-training and diagnosis of MBD--were correlated significantly to the children's mental development levels with absolute values of Kendall's tau b over 0.2. A discriminant analysis showed that three positive correlates, i.e., meaningful words, pointing and echolalia, and a negative correlate, i.e., crane symptoms, were important in distinguishing between young autistics with and without unfavorable mental development and possible poor outcomes.

Conceptual problem-solving in highly verbal, nonretarded autistic men

Nine highly verbal, nonretarded men, ages 18 to 39, with clearly documented childhood diagnoses of infantile autism were studied with the Wisconsin Card Sorting Test, a measure of conceptual problem solving sensitive to frontal system dysfunction, and with a measure of social-adaptive functioning. Their performances were compared with 10 controls matched for age, sex, education, and IQ, as well as with published norms for various groups of brain-damaged patients. Significant deficits in the formulation of rules and significant perseverative tendencies were documented in the autistic sample. No significant correlation between these deficits and social-adaptive deficits was seen. These findings were discussed with respect to the heterogeneity of the autistic disorder and Damasio's hypothesis concerning frontal-subcortical dysfunction in autism.

The use of nonvocal communication techniques with autistic individuals

Studies reporting the use of sign languages and symbol systems with autistic children and young people are reviewed. The studies suggest that signs and symbols can be used in communication by individuals who are above and below the age of five, mute and mentally handicapped. The communication skills developed may, in some cases, be complex, and speech may develop in the context of sign or symbol programmes. However, problems concerned with the description of subjects, methods and outcome of studies mean that many conclusions can only be supported tentatively by existing data.

The functional neuroanatomy of infantile autism

Infantile autism is a behavioral syndrome consisting of specific disturbances of social relating and communication, language, response to objects, sensory sensitivity and motility. The uniqueness of this syndrome suggests one underlying pathophysiologic mechanism, although multiple etiologies, which could activate or replicate such a mechanism, have been demonstrated. Review of considerable experimental evidence and clinical observation suggests that the symptomatology of autism, including the disturbances of social relating and communication, can best be explained as a disorder of sensory modulation. This in turn suggests a neurophysiologic mechanism consisting of dysfunction of a cascading series of neurophysiologic levels or interacting neuronal loops in the brainstem and diencephalon which subserve modulation of sensory input. Some of those same systems modulate motor output in response to sensory input, and their dysfunction may release the abnormal perseverative motility of infantile autism. Other experimental evidence and clinical observations stress the language deficits of autism and implicate dysfunction of cortical structures. Brainstem and diencephalic centers project rostrally to telencephalic structures and these, in turn, modify brainstem and diencephalic function. Theories of rostrally and caudally directed sequences of pathoneurophysiologic contributions to the system dysfunction in autism are compared. It is concluded that the symptoms of autism can best be explained in terms of dysfunction of brainstem and related diencephalic behavioral systems and their elaboration and refinement by selected higher neural structures.

Schizophrenia in children under 16 years

Schizophrenic children admitted as inpatients to a child psychiatric unit over a 10-year period were reviewed in terms of demographic characteristics, clinical features, and social adaptation using the DSM-III as a frame of reference. Ten children who were first seen at least 1 year previously were followed up and reassessed as regards clinical status and level of adaptive functioning. As in other studies, outcome was related to age at onset, premorbid level of adaptation, rapidly of onset, clinical subtype, and presence of affective symptoms. However, deterioration following the active phase of the illness occurred in only four cases. The outcome in childhood schizophrenia may be more favorable than generally assumed, but there is a need for longer and larger studies of carefully diagnosed groups.

Childhood autism: deficits of communication and symbolic development. I. Distinctions from language disorders

The present paper reviews, outlines, and explores the literature concerned with the speech-language disorder of childhood autism. The problems of communication of the autistic child are compared and contrasted with those of children with a variety of other language disorders (e.g. receptive developmental dysphasia). Based upon the review of normal preverbal communicatory and symbolic development, it is concluded that childhood autism involves a pervasive language disorder encompassing communication in general, as well as certain symbolic-representational abilities necessary for language. An overview of the attempts to teach speech to autistic children in then undertaken with special emphasis on the possible implications of developmental knowledge for these training pursuits. Finally, the role of neurologic substrates in the language and communication disorder of autism is presented.

The communicative function of question production in autistic children

Six children diagnosed as autistic and who also were reported to be using questions inappropriately in their conversations with adults were each placed in a conversational context in which the adult responses to their questions were systematically varied. The dependent variable was the occurrence and amount of appropriate conversational continuation associated with each type of adult response. Differential listener response did affect the occurrence of conversational continuation and to a lesser degree the amount of continuation. These data were interpreted to support the hypothesis that repetitive questioning in this population serves the communicative function of conversation initiation. Furthermore, it appears that the autistic conversants lack the conversational management skills to maintain the conversation following the listener's answer to the question.

Infantile autism and the temporal lobe of the brain

Studies are reviewed that support the hypothesis that infantile autism results from a neuropathology of the temporal lobes of the brain. First, there are parallels between symptoms noted in autism and those found in the Kluver-Bucy and amnesic syndromes. Second, there is a similarity between developmental dysphasia and autism. Third, the formation of cross-modal associations may be deficient in autistic children, a symptom resembling aspects of Geschwind's disconnection syndromes. Finally, a large number of organic factors have been associated with the development of autism, some of these having specific implications for temporal lobe involvement. It is concluded that the main autistic symptoms are most consistent with a neurological model involving bilateral dysfunction of the temporal lobes. Individual differences in the extent of bilateral involvement and/or other coexistent neuropathologies could contribute to the heterogeneity of the autistic population.