Outcome and prognostic factors in infantile autism and similar conditions: a population-based study of 46 cases followed through puberty

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.

[Kanner autism. Course of the disorder in the 2nd and 3rd decade in 18 patients with special reference to social adjustment. Results of a qualitative retrospective study]

The development of Kanner autism in 18 patients (mean age 28 years) in their second and third decade was explored and recorded with respect to factors affecting social competence in adulthood. To validate the diagnoses, we used the Childhood Autism Rating Scale (CARS). A version of the Vineland Adaptive Behavior Scales (VABS) was employed to assess social adaptation. On average, the individuals showed socially adaptive skills typical for healthy children at the age of 4 years and 3 months. Seventy-two percent of the autistic persons showed a characteristic pattern: they scored highest in daily living skills and lowest in social skills, especially in interpersonal relationships, where they performed at an average age equivalent of only 2 years and 7 months! Correlation analysis was conducted between developmental factors due to the disorder on the one hand and socially adaptive skills on the other. It showed, among other results, that positive developmental tendencies during adolescence are related to better social adaptation in adulthood ( r=0.57).

Preschool children with autism spectrum disorders in Taiwan: follow-up of cognitive assessment to early school age

In this study, we longitudinally followed into childhood a cohort of preschool children, initially diagnosed as autistic or non-autistic with developmental delay, to evaluate the stability of cognitive assessments performed during the preschool period. The consistency in group means and intra-individual stability of developmental quotients (DQ) and non-verbal intelligence quotients (IQs) were compared for these two groups, which were matched by chronological age, initial non-verbal IQ/DQs, initial test given, and length of follow-up interval. The case group comprised 16 autistic children with average age at initial assessment of 3 years 8 months. The control group comprised 16 non-autistic developmental delayed children with average age at initial assessment of 3 years 11 months. Mean DQ/non-verbal IQ at initial assessment was 73.9+/-23.9 for the case group and 80.3+/-23.2 for the control group. ANOVA yielded no significant effect of time or time x diagnosis interaction (F=0.183, P=0.675). The absolute difference in scores and group means were equivalent for both groups of children, with no difference in patterns of change. Correlations between DQ/non-verbal IQs at initial assessment and follow-up were significant and high for the two groups (autistic group: r=0.87; control: r=0.77). Intellectual functioning can be a valid measure in Taiwanese preschool children with autism, and has an equivalent meaning for children with autism and for non-autistic children with developmental delay. Though the follow-up period is too short for definite prognostic conclusions to be drawn, we think that non-verbal intelligence should be an essential assessment for preschool oriental autistic children so that sound expectation and treatment plan can be made.

Learning disability

Learning disability is common, affecting 1-2.5% of the general population in the Western world, and encompasses many different conditions. It usually leads to major functional impairment and lifelong need for support and interventions, not the least important of which are medical and health-care services. Rapid progress is being made in the understanding of the cause and pathogenesis of many learning disability syndromes, and these advances are likely to improve targeted interventions in the next decade. Many countries have abolished a learning disability specialty for medical professionals, but there is a great need to revive this niche of medical knowledge. We know little about quality of life and effects on families of people with learning disability, and research is needed to address these issues.

Screening for autism spectrum disorder in adult psychiatric outpatients in a clinic in Taiwan

Patients with adult autism spectrum disorder (ASD) continue to suffer from impairment in socialization and communication skills, and a proportion of them may develop psychiatric symptoms. It is thus likely that physicians in adult psychiatric departments may see a number of patients with ASD. Identification of patients with ASD is helpful and important for rehabilitation. This study estimated the prevalence of ASD among adult psychiatric outpatients in a Taiwanese medical center. A total of 660 patients were screened with Nylander and Gillberg's "Autism Spectrum Disorder in Adult Screening Questionnaire." Patients with high scores then underwent a diagnostic clinical interview conducted by child psychiatrists. Four patients (0.6%) were found to have ASD.

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.

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.

Outcome research in Asperger syndrome and autism

This article presents findings from the outcome literature on autism, Asperger syndrome (AS), and related disorders. The discussion of outcome principally focuses on life adaptation, but also considers outcome in AS in relationship to other diagnostic groups and across time. The current research in this area is neither substantial nor systematic. Thus, in this examination of the literature, the goal is to highlight salient findings, but also to put forward questions that might direct meaningful research in this area for the future and to consider implications for treatment.

Prospective long-term follow-up of patients with pervasive developmental disorders

We conducted a 12-year prospective study of children with pervasive developmental disorders from North Dakota. In a prospective longitudinal follow-up study, of 59 patients, we found 52 patients with pervasive developmental disorders (88%). Ten (17%) declined to participate. We collected data on 42 (71%) of the original cohort. Of the 42 subjects, 1 died (1.7%). The other 41 were followed up for 492 person-years. Severity scores for the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) declined 20% and for DSM-IV 23%. Global Assessment of Functioning improved 19%, and the average number of comorbidities decreased 45%. Thirty-seven percent of patients improved in all four measures, whereas only 5% improved in only one measure. Pervasive developmental disorders are developmental disorders with a long-term course of limited improvement for most patients. Male subjects demonstrated substantially more variability in improvement but, overall, demonstrated more improvement than female subjects.

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.

Behavioral phenotypic variation in autism multiplex families: evidence for a continuous severity gradient

Recent genetic investigations of autism have studied multiplex families, typically including families with multiple siblings who meet criteria for a diagnosis of autism. However, little is known about the specific behavioral characteristics of siblings with autism in these multiplex families. We investigated the behavioral phenotypic variability and similarity of 351 siblings with autism in 171 multiplex families using cluster analysis and correlations. The results of cluster analyses showed that the individuals with autism could be characterized on a severity gradient: a continuum based on severity of symptoms and impairment as measured by Autism Diagnostic Interview-Revised (ADI-R) scores, verbal-nonverbal status, and nonverbal IQ scores. Clusters based on scores from the ADI-R for the autism diagnostic criteria of the DSM-IV and nonverbal IQ scores still represented a severity gradient when the effects of verbal-nonverbal status were removed. The severity gradient was shown to be heritable, with a sib correlation of 30% or a heritability of 60%. In summary, in a sample of 171 autism multiplex families, there was no evidence of discrete behaviorally defined subgroups of affected individuals or families characterized by distinct patterns of behavioral symptoms. Rather, the clusters could be characterized along a single, heritable, continuous severity dimension.

Update on the epidemiology and prognosis of pediatric epilepsy

Epilepsy is among the most common serious neurologic disorders in childhood. Epidemiologic studies over the past few decades have greatly increased current knowledge of the incidence and prognosis of seizures. Newer epidemiologic studies have used population- or community-based cohorts, and careful attention has been given to etiology and specific epilepsy syndromes, the two most important factors affecting prognosis. Risk of epilepsy is highest in patients with an associated serious neurologic abnormality, such as mental retardation or cerebral palsy. More than two thirds of patients with childhood-onset epilepsy ultimately achieve remission. Of those attaining remission on medications, approximately 70% remain seizure free when medications are discontinued. Mortality is increased in patients with epilepsy, but the increased mortality risk in childhood-onset epilepsy is primarily seen in patients with neurologic abnormalities or intractable epilepsy. Although long-term seizure outcomes are generally favorable, childhood-onset epilepsy is associated with adverse long-term psychosocial outcomes, even in patients attaining remission. This review summarizes recent data on the epidemiology and prognosis of pediatric epilepsy.

Understanding and listening to people with autism

This article continues the learning disability supplement's examination of autism (see Aylott, 2000a,b) by exploring how a lack of knowledge and understanding of positive aspects of autism among non-autistic people (neuro typicals) has led to many adults with autism having negative life experiences. It calls for all staff working with people with autism to find ways to 'think' and 'feel' in autism. It is only when this has been achieved that any of us will be able to listen effectively to people with autism; this hopefully may result in life experiences for people with autism being more of a positive than a negative encounter.

Interventions to facilitate communication in autism

The purpose of this article is to discuss research opportunities arising from the current literature in the area of communication. Six general themes are discussed, including (a) increasing spontaneity, initiations, and the variety of functions of language verbal and nonverbal children with autism exhibit; (b) assessing and teaching precursors relating to positive outcome; (c) the importance of family involvement in intervention programs; (d) best practices for implementation of communicative interventions; (e) the interrelationship between language and other behavioral symptoms of autism; and (f) the social and pragmatic use of language. These areas are discussed in terms of improving assessment and intervention practices to produce greater long-term communicative outcomes for individuals with autism.

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.

Epilepsy in adolescents and young adults with autistic disorder

Since the first description by Kanner (1943) the association between autistic disorder (AD) and epilepsy has been observed in 4-42% of patients. Some authors reported that seizures prevailed in adolescence but a systematic investigation has never been undertaken. We examined retrospectively 60 patients divided into two groups (with and without epilepsy and EEG paroxysmal abnormalities) with AD unrelated to a congenital or acquired encephalopathy (mean age 17 years 2 months). The aim was to investigate epilepsy, EEG paroxysmal abnormalities and possible etiological factors. The prevalence of epilepsy was 38.3%, much higher than that in a normal population of a similar age (6.6 per thousand). The prevalence of EEG paroxysmal abnormalities without epilepsy was 6.7%, higher than that in a population of adolescents and adults with psychiatric pathologies (2. 6%). Seizure onset was after age 12 years in 66.7% of cases. The most common type of epilepsy was partial in 65.2% and four patients (17.4%) had a benign childhood epilepsy with centro-temporal spikes. At the last observation 44.4% of patients had been seizure-free for 2 years or more. There were no organic factors influencing the development of epilepsy but familial and personal antecedents, mental retardation and CT scan/MRI data may suggest an early brain dysfunction responsible for AD and epilepsy.

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.

The screening and diagnosis of autistic spectrum disorders

The Child Neurology Society and American Academy of Neurology recently proposed to formulate Practice Parameters for the Diagnosis and Evaluation of Autism for their memberships. This endeavor was expanded to include representatives from nine professional organizations and four parent organizations, with liaisons from the National Institutes of Health. This document was written by this multidisciplinary Consensus Panel after systematic analysis of over 2,500 relevant scientific articles in the literature. The Panel concluded that appropriate diagnosis of autism requires a dual-level approach: (a) routine developmental surveillance, and (b) diagnosis and evaluation of autism. Specific detailed recommendations for each level have been established in this document, which are intended to improve the rate of early suspicion and diagnosis of, and therefore early intervention for, autism.

Childhood disintegrative disorder

Childhood disintegrative disorder (CDD) is a clinical syndrome characterized by disintegration of mental functions and regression of acquired language and intellectual functions after a period of normal development typically of 3 to 4 years. Although recognized for many years, research on this condition is less advanced than that in autism. Epidemiological data are limited but the condition is much less common than autism. The relationship of this condition to autism remains the topic of debate. Neuropathological and other medical conditions are sometimes associated with the disorder but contrary to earlier belief this is not typical. Collaborative research would facilitate our understanding of this condition.

The natural history of somatic morbidity in disintegrative psychosis and infantile autism: a validation study

In order to study the validity of disintegrative psychosis (DP) as defined in ICD-9, we compared the natural history of somatic morbidity of 13 patients given this diagnosis in childhood with a control group of 39 patients with infantile autism (IA) matched for gender, age, IQ and social class. Average follow-up time was 22 and 23 (11-33) years, respectively. Significantly more DP patients (85 versus 41%) had been admitted to a non-psychiatric hospital during the follow-up period. They also had significantly more admissions (3.6 versus 1.0) and stayed longer in hospital (78 versus 4 days) than patients with IA. Three of the DP individuals had an associated medical disorder and made extensive use of somatic services during the follow-up period. Altogether the DP group had utilised the medical health care system more than patients with IA suggesting that they had more medical symptoms than the IA group. On the whole our findings suggest that individuals with DP and IA should be conceptualised as essentially distinct and should be studied separately as regards aetiology, pathophysiology, course and treatment.

Chromosomal disorders and autism

Many cases of autism appear to be caused by several abnormal genes acting in concert. The literature on chromosomal aberrations in autism is reviewed, with a view to finding potential gene markers for the neuropsychiatric disorder. Most of the chromosomes have been implicated in the genesis of autism. However, aberrations on the long arm of Chromosome 15 and numerical and structural abnormalities of the sex chromosomes have been most frequently reported. These chromosomes appear to hold particular promise in the search for candidate genes.

Autism and Clostridium tetani

Autism is a severe developmental disability believed to have multiple etiologies. This paper outlines the possibility of a subacute, chronic tetanus infection of the intestinal tract as the underlying cause for symptoms of autism observed in some individuals. A significant percentage of individuals with autism have a history of extensive antibiotic use. Oral antibiotics significantly disrupt protective intestinal microbiota, creating a favorable environment for colonization by opportunistic pathogens. Clostridium tetani is an ubiquitous anaerobic bacillus that produces a potent neurotoxin. Intestinal colonization by C. tetani, and subsequent neurotoxin release, have been demonstrated in laboratory animals which were fed vegetative cells. The vagus nerve is capable of transporting tetanus neurotoxin (TeNT) and provides a route of ascent from the intestinal tract to the CNS. This route bypasses TeNT's normal preferential binding sites in the spinal cord, and therefore the symptoms of a typical tetanus infection are not evident. Once in the brain, TeNT disrupts the release of neurotransmitters by the proteolytic cleavage of synaptobrevin, a synaptic vesicle membrane protein. This inhibition of neurotransmitter release would explain a wide variety of behavioral deficits apparent in autism. Lab animals injected in the brain with TeNT have exhibited many of these behaviors. Some children with autism have also shown a significant reduction in stereotyped behaviors when treated with antimicrobials effective against intestinal clostridia. When viewed as sequelae to a subacute, chronic tetanus infection, many of the puzzling abnormalities of autism have a logical basis. A review of atypical tetanus cases, and strategies to test the validity of this paper's hypothesis, are included.

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.

Validity of childhood disintegrative psychosis. General findings of a long-term follow-up study

BACKGROUND

Empirical evidence for the validity of the diagnostic label disintegrative psychosis is sparse. The issue of whether it is a separate form of infantile autism is unresolved.

METHOD

To investigate the validity of disintegrative psychosis as defined in ICD-9, the natural history of 13 cases were compared with 39 matched cases of infantile autism on various outcome variables. Average follow-up time was 22 (11-33) years.

RESULTS

Statistically significant differences were found between the two groups in terms of number of admissions to non-psychiatric departments, occurrence of comorbid epilepsy, social style, and score on the Global Assessment of Functioning scale. In most other areas assessed there was a tendency, although statistically insignificant, towards a better outcome in the infantile autism comparison group.

CONCLUSIONS

Our findings provide some support for maintaining a diagnostic category of disintegrative psychosis as distinct from infantile autism.

The long-term course of autistic disorders: update on follow-up studies

The majority of children with autism show deviance and socially or psychiatrically handicapping conditions throughout life. Only a small proportion of those with classical childhood autism lead independent adult lives. Others, particularly those with 'high-functioning' autism and so-called Asperger syndrome will improve enough to live an independent adult life. The level of mental retardation and other comorbid conditions (such as medical syndromes and other neuropsychiatric disorders, including epilepsy) is important in predicting outcome. An IQ below 50 around school age predicts severe restriction of social and adaptive functioning in adult life. The absence of communicative speech at 5-6 years of age is indicative of a poorer long-term overall outcome. There is a clear co-variation between IQ and level of communication, but probably there is some prognostic factor in language development apart from this. Measures of flexibility and cognitive shifting abilities tend to be good predictors of social outcome in a few studies. There is a continued need for prospective, longitudinal studies of children with autism spectrum disorders, particularly in Asperger syndrome. The role of interventions of various kinds needs to be addressed in such studies.

The outcome in children with childhood autism and Asperger syndrome originally diagnosed as psychotic. A 30-year follow-up study of subjects hospitalized as children

This follow-up study reports data on 18 children fulfilling the ICD-10 criteria for childhood autism (n = 9) and Asperger syndrome (n = 9). In connection with the present study the original child psychiatric records were reassessed according to the ICD-10 criteria. The children were followed over a period of 30 years. The mean age at the time of study was 38 years. The results show that in adulthood the autistic patients had a poorer outcome than children with Asperger syndrome as regards education, employment, autonomy, marriage, reproduction and the need for continuing medical and institutional care. Particular attention is given to pharmacotherapy and the relationship between the childhood disorder and psychiatric morbidity in adult life.

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.

A comparative study of Asperger syndrome with high-functioning atypical autism

To test the validity of Asperger syndrome (AS) as defined in ICD-10, 26 patients (age range, 3.5 to 12 years) with AS and 16 patients (age range, 3 to 11.5 years) with high-functioning (IQ > 90) ICD-10 atypical autism (HAA) were compared on 64 clinical variables including obstetric risk factors, early developmental landmarks, IQ, autistic symptoms on the CARS-TV, epileptic EEG abnormalities and epilepsy. AS did not differ significantly from HAA on all but total and four item scores (i.e. imitation, visual responsiveness, auditory responsiveness and non-verbal communication) on the CARS-TV, in which AS scored significantly lower than HAA. A discriminant function based on imitation and auditory responsiveness predicted 76.2% of the 42 cases. The small difference from HAA indicates that AS is better to be regarded as the highest-functioning end of the PDD spectrum, rather than a valid subtype of PDD. However, the autistic symptom profile less distorted in AS than HAA may warrant a further study on its validity.

Regression in pervasive developmental disorders: seizures and epileptiform electroencephalogram correlates

BACKGROUND

Approximately one third of the parents of children with pervasive developmental disorders or autistic spectrum disorders reports an early regression of unknown cause in their children's language, sociability, and play. Seizures or an epileptiform electroencephalogram (EEG) are associated with language regression in acquired epileptic aphasia (Landau-Kleffner syndrome) and some other pediatric epileptic syndromes. The importance of epilepsy or epileptic EEGs as contributors to autistic regression is not known.

METHOD

Subjects were 482 boys and 103 girls on the autistic spectrum seen consecutively in consultation by one child neurologist. Data on autistic regression, seizures, sleep EEGs, and cognitive function were entered prospectively into a data base.

RESULTS

Of the 585 children, 176 (30%) had a history of regression, and 66 children (11%) had a history of epilepsy, defined as two or more unprovoked seizures. Among 392 children with available sleep EEGs, the EEG was epileptiform in 59% of the 66 epileptic children and 8% of the 335 nonepileptic children. Regression had occurred equally among children without seizures and in those with epilepsy. Regression was associated with an epileptiform EEG in 14% of 155 nonepileptic children who had undergone a regression, as opposed to 6% of 364 children with neither regression nor epilepsy. Mean age at regression was 21 months. There was no difference in the proportion of children with epilepsy or epileptiform EEGs who had regressed before or after 2 years of age. Approximately half of the epileptiform discharges were centrotemporal, whether or not the child was epileptic or had regressed. Children with lower cognitive function were more likely to have undergone regression than those with better cognitive skills (34% vs 20%).

CONCLUSION

Epilepsy or epileptiform EEGs occur in a significant minority of autistic children with a history of regression and in a smaller minority without regression. Prompt recognition of regression and recording of prolonged sleep EEGs is recommended, even though information on the potential efficacy of antiepileptic treatment to improve language and behavior in autistic children with epilepsy or an epileptiform EEG is still lacking.

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.

Embryological origin for autism: developmental anomalies of the cranial nerve motor nuclei

The underlying brain injury that leads to autism has been difficult to identify. The diagnostic criteria of the disease are not readily associated with any brain region or system, nor are they mimicked by vascular accidents, tumors, or degenerative neurological diseases occurring in adults. Fortuitously, a recent report of autism induced by thalidomide exposure provides evidence that the disease originates by an injury at the time of closure of the neural tube. The human data suggest that the initiating lesion includes the motor cranial nerve nuclei. To test this hypothesis, we first examined motor nuclei in the brainstem of a human autistic case. The autopsy brain exhibited near-complete absence of the facial nucleus and superior olive along with shortening of the brainstem between the trapezoid body and the inferior olive. A similar deficit has been reported in Hoxa-1 gene knockout mice in which pattern formation of the hindbrain is disrupted during neurulation. Alternatively, exposure to antimitotic agents just after neural tube closure could produce the observed pattern of deficits. Thus, the lesions observed in the autopsy case appear to match those predicted by the thalidomide cases in both time of origin and central nervous system (CNS) location. To produce similar brain lesions experimentally, we exposed rat embryos to valproic acid, a second teratogen newly linked to autism. Dams received 350 mg/kg of valproic acid (VPA) on day 11.5 (the day of neural tube closure), day 12, or day 12.5 gestation. Each treatment significantly reduced the number of motor neurons counted in matched sections of the earliest-forming motor nuclei (V, XII), and progressively later exposures affected the VIth and IIIrd cranial nerve nuclei. All treatments spared the facial nucleus, which forms still later. Counts from the mesencephalic nucleus of trigeminal, the dorsal motor nucleus of the vagus, and the locus ceruleus were not affected by exposure to VPA, even though these nuclei form during the period when exposure occurred. Despite its effects on the motor nuclei, valproic acid exposure did not alter the further development of the brain in any obvious way. Treated animals were robust and had no external malformations. The autopsy data and experimental data from rats confirm that CNS injuries occurring during or just after neural tube closure can lead to a selective loss of neurons derived from the basal plate of the rhombencephalon. The results add two new lines of evidence that place the initiating injury for autism around the time of neural tube closure.

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.

Autism and medical disorders: a review of the literature

The authors reviewed all the population studies on autism published in the English language with particular reference to the rate of medical disorders. Seven studies met criteria for inclusion in the survey. The mean of possibly autism-related medical disorders in persons with autism across these studies was 24.4%. There was a trend for higher rates of medical disorders among subjects with severe mental retardation. The evidence in respect of atypical autism was equivocal, and the overall prevalence of medical disorders in this group was similar to that found in typical autism.

Autism and epilepsy (and tuberous sclerosis?) in two pre-adolescent boys: neuropsychiatric aspects before and after epilepsy surgery

We report on two pre-adolescent boys with a combination of severe seizure disorders and severe-moderate autism who underwent brain surgery for their epilepsy at the ages of 9 and 10 years, respectively. Both boys became seizure-free and initially improved dramatically with regard to autism symptoms. One of the boys continued to improve, but the other had a relapse to his pre-operative state in conjunction with his pubertal growth spurt. Several years after surgery, one of the boys remained much improved with respect to his autism. The other subject showed some improvement with respect to self-injury and aggression, and had slightly lower scores on screens for autism symptoms than in the year preceding epilepsy surgery. The histopathological examination of the brain tissue that was removed at surgery suggested a diagnosis of tuberous sclerosis in both cases.

Autism: towards an integration of clinical, genetic, neuropsychological, and neurobiological perspectives

Autism constitutes one of the best validated child psychiatric disorders. Empirical research has succeeded in delineating the key clinical phenomena, in demonstrating strong genetic influences on the underlying liability, and in identifying basic cognitive deficits. A range of neurobiological abnormalities has also been found, although the replicability of specific findings has not been high. An understanding of the causal processes leading to autism, and accounting for the marked variability in its manifestations, requires an integration across these different levels of enquiry. Although this is not yet possible, a partial integration provides a useful strategy for identifying key research questions, the limitations of existing hypotheses, and future research directions that are likely to prove fruitful. The research findings for each research level are critically reviewed in order to consider how to move towards an integration across levels.

EEG features and epilepsy in patients with autism

Epileptic seizures are frequently reported (4-32%) in autism. These values are higher than in the normal population of children and adolescents (0.5%). In the literature there is no uniform description of epilepsy in autism. We examined 106 patients with autistic disorder divided into three groups on the basis of presence or absence of EEG paroxysmal abnormalities (PA) and / or epilepsy including febrile convulsions (FG). Our patients presented an autistic syndrome unrelated to clear congenital or acquired encephalopathy. The prevalence of epilepsy and EEG PA was 23.6% and 18.9%, respectively. Significant differences between the three groups appeared for (i) familial antecedents for epilepsy / FC and neurologic and psychiatric diseases (P < 0.004), (ii) a different proportion between the three groups for mental retardation (P < 0.03), (iii) and EEG fast activity (P < 0.04). Our patients showed several types of epilepsy, including idiopathic forms with seizure onset after the age of 10 in 45% of cases. Seizures were mainly partial, not frequent and controllable by anti-epileptic drugs. PA were mostly focal and multifocal and in 45% of cases were typical of benign childhood partial epilepsy with centro-temporal spikes. The higher incidence of epilepsy and EEG PA is apparently not related to organic pre-, peri- and postnatal antecedents or cerebral lesions. On the contrary, genetic factors responsible for autism and epilepsy seem important in the genesis of these two disorders.

Relationships between mental disorders in childhood and adulthood

Research findings on continuities and discontinuities in psychopathology between childhood and adult life are reviewed with respect to major depressive disorders, anxiety states, obsessional conditions, anorexia nervosa, conduct disorders, hyperkinetic disorders, autism, specific developmental disorders of language and schizophrenia. The findings are used to consider both the conceptual issues and possible mediating mechanisms.

The high-functioning autistic experience: birth to preteen years

A retrospective chart review of 15 children with high-functioning autism was conducted for the years 1981 through 1992. The purpose of the study was to describe the experience of children with high-functioning autism from infancy through preadolescence. Chart data included clinic staff records, parent letters, academic program records, service records, and comments from the children themselves. The findings of this study support the proposition that children with autism who have an IQ above 70 follow a varied but improving course over time. All 15 children met the DSM-III-R criteria for autism when first evaluated. By middle elementary school, however, none of the children in this study met the DSM-III-R criteria for autism, although they continued to have various language disturbances, social skill deficits, and unique behavioral qualities.

Autism as a strongly genetic disorder: evidence from a British twin study

Two previous epidemiological studies of autistic twins suggested that autism was predominantly genetically determined, although the findings with regard to a broader phenotype of cognitive, and possibly social, abnormalities were contradictory. Obstetric and perinatal hazards were also invoked as environmentally determined aetiological factors. The first British twin sample has been re-examined and a second total population sample of autistic twins recruited. In the combined sample 60% of monozygotic (MZ) pairs were concordant for autism versus no dizygotic (DZ) pairs; 92% of MZ pairs were concordant for a broader spectrum of related cognitive or social abnormalities versus 10% of DZ pairs. The findings indicate that autism is under a high degree of genetic control and suggest the involvement of multiple genetic loci. Obstetric hazards usually appear to be consequences of genetically influenced abnormal development, rather than independent aetiological factors. Few new cases had possible medical aetiologies, refuting claims that recognized disorders are common aetiological influences.