Current concepts: infantile autism and the pervasive developmental disorders

The pervasive developmental disorders (PDD), as exemplified by infantile autism, are a group of severe childhood neuropsychiatric disorders of early onset in which multiple areas of social, communicative, and cognitive development are disturbed. Although these disorders often are associated with some degree of mental retardation and various medical and neurological abnormalities, they are distinctive in their course and outcome, and in the patterns of development deficit. These conditions, which are expressed as the final behavioral syndrome, probably have many different causes. Whereas organic factors clearly are implicated, no precise etiological mechanisms have been established. Management of these disorders includes appropriate educational and behavioral intervention. Efforts are needed to define these disorders more precisely, and to identify relevant subgroups, to further studies of pathophysiology.

A critical review of DSM-III in the developmental disorder of childhood

This paper presents a summary and critical review of the DSM-III diagnostic system for childhood psychiatric disorders with particular reference to developmental disorders. The rational for a multiaxial system, explicit diagnostic criteria, and a phenomenological approach are outlined. Criteria for mental retardation, infantile autism, and specific developmental disorders are reviewed. While this system is an advance over previous schemes many problems are also evident. These include a lack of specificity of the criteria, inconsistencies in criteria, and placement on the axes of mental disorders.

Age of recognition of pervasive developmental disorder

In DSM-III, pervasive developmental disorder is divided into two major categories: infantile autism and childhood onset pervasive developmental disorder. The criteria differ, primarily, in the age of onset. The authors studied 129 patients who had received diagnoses of pervasive developmental disorder or a related disorder and found only five cases of apparent childhood onset pervasive developmental disorder. These five patients were behaviorally indistinguishable from those with other diagnoses. Practically, age of onset may be more appropriately termed "age of recognition," and its use as a major diagnostic criterion for such disorders may not be justified.

Compliance, 'negativism', and the effects of treatment structure in autism: a naturalistic, behavioral study

Nineteen autistic individuals were observed in their familiar residential environment using a time-sample technique. Rates of stereotyped and self-injurious behaviors, the direction of the subject's gaze (at staff, task or elsewhere) and the number of requests made to a subject by staff were a function of treatment structure, as defined by the staff: child ratio. While patterns of compliance in response to different types of requests were observed, subjects were generally compliant. The data do not support the notion that autistic children are unusually 'negativistic'. The utility of ecologically valid observations and the need for normative data are discussed.

Computed tomographic brain scanning in four neuropsychiatric disorders of childhood

CAT scans were performed in 66 patients with neuropsychiatric disorders of childhood (infantile autism, attention deficit disorder, Tourette's disorder, and language disorder) and a control group of 20 medical patients. Ventricular volume and brain density were determined by quantitative, computer-based methods by researchers blind to the patients' diagnoses. There were no significant differences among diagnostic groups or between neuropsychiatric patients and medical control patients in total ventricular volume, right-left ventricular volume ratio, ventricular asymmetries, ventricle-brain ratios, or brain density.

The experience of infantile autism: a first-person account by Tony W

A first-person account of the experience of autism is presented by a 22-year-old man who was first evaluated at the Yale Child Study Center at 26 months of age. His history and current status are reviewed. Factors related to outcome and diagnostic issues are discussed. Such accounts may be helpful in guiding research.

Inappropriate uses of stimulant medications

The utility of stimulant medications in the treatment of attention deficit disorder (ADD) has been demonstrated repeatedly. Over 500,000 children receive these medications in the United States each year. The drugs, however, may be used inappropriately in cases where a presumptive diagnosis of "hyperactivity" is mistakenly made on the basis of nonspecific increases in activity levels or when an initial sedative response is taken as diagnostic confirmation of ADD. In this series of six cases, stimulant medications had been used inappropriately to manage a range of developmental problems. The importance of a careful diagnostic evaluation before instituting stimulants, careful monitoring, and a consideration of their risks are emphasized.

Platelet imipramine binding in autistic subjects

Previous reports of elevated platelet serotonin (5-HT) concentrations in autistic subjects suggest that platelet 5-HT uptake might be altered in autism. Parameters of 3H-imipramine (IMI) binding were measured in 11 drug-free autistic subjects and 10 normal volunteers. Similar means (+/- SD) for Bmax (autistics, 1350 +/- fmole/mg protein; normals, 1590 +/- 206 fmole/mg protein) and Kd (autistics, 0.98 +/- 0.10 nM; normals, 0.94 +/- 0.13 nM) were found in the two groups. The normal number (Bmax) and affinity (Kd) of the IMI binding site in autistic subjects suggest that the regulation of 5-HT uptake is not different in autism.

A hierarchical analysis of patterns of noncompliance in autistic and behavior-disturbed children

A reanalysis of data from an experimental study of autistic negativism is presented. Subjects were autistic, behavior-disturbed, or normal and ranged in age from 5 to 12 years. There were nine subjects per group. Experimental conditions consisted of a verbal request for a verbal response, a nonverbal request for a nonverbal response, and a verbal request for a nonverbal response. Data were reanalyzed by dichotomizing subjects as either compliant or noncompliant on the basis of the number of correct responses; scalogram analysis was then performed on the dichotomized data. The children's responses to the messages formed a cumulative, unidimensional hierarchy based on the individual patterns of responses, with verbal requests for verbal responses eliciting the least compliance and verbal requests for nonverbal responses the most. Implications of the hierarchy for a developmental theory of autistic negativism and the relationship of task demands to compliance are discussed.

Group therapy in the management of manic-depressive illness

Because patients with bipolar affective illness have generally been viewed as poor candidates for psychotherapy, many clinicians have relied on lithium prophylaxis as the major treatment modality. However, even with lithium prophylaxis many patients still relapse, often in settings providing little support for maintenance treatment. This report presents the results of a long-term therapy group composed exclusively of bipolar manic-depressive patients, many of whom had histories of poor adherence ot lithium maintenance. The group met weekly and was conducted with an interpersonal, interactional "here and now" format. Patients attended an average of 47 sessions. Members were initially somewhat aloof and remote and minimized their problems. Over the course of their participation, members became more open and began to discuss their concerns about their illness and lithium maintenance treatment; during this time they functioned much as members in any long-term psychotherapy group. In the two-year period prior to entering the group, patients averaged 16.8 weeks of hospitalization; in the subsequent two-year period they averaged 3.6 weeks of hospitalization. Groups of this kind may offer a simple, cost-effective adjunct to lithium maintenance treatment and may provide the advantages and opportunities of psychotherapy to a group of patients generally seen as resistant to such approaches.

High attrition rates in commercial weight reduction programs

The management of obesity is increasingly dominated by nonprofessional self-helping groups. Little information about the efficacy of these groups is available from independent sources. In a study of 108 women enrolled in a commercial weight reduction program, we found very high attrition rates; 50% of the members dropped out in six weeks and 70% in 12 weeks. Similar attrition rates have been reported in five other programs in three different countries. Very high attrition rates diminish the effectiveness of commercial weight reduction programs, and they suggest caution in the interpretation of data based on weight losses of persons who remain in these programs.