How far can autistic children go in matters of social adaptation?

Natural language acquisition and gestalt language processing: A critical analysis of their application to autism and speech language therapy. AUTISM & DEVELOPMENTAL LANGUAGE IMPAIRMENTS 2024;9:23969415241249944. [PMID: 38784430 PMCID: PMC11113044 DOI: 10.1177/23969415241249944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and Aim

Recently, there has been a lot of interest surrounding the term gestalt language processor (GLP) which is associated with Natural Language Acquisition (NLA): a protocol intended to support the language development of autistic people. In NLA, delayed echolalia is presumed raw source material that GLPs use to acquire language in a stage-like progression from delayed echolalia to spontaneous speech. The aim of this article is to evaluate NLA in light of relevant literatures to allow scrutiny of NLA claims.

Main contributions

First, we review the notion of gestalt language and situate it in the broader literature on language styles to update understanding of its significance. We then review the links from gestalt language processing to autism and identify definitional and conceptual problems and clarify the construct 'episodic memory'. We discuss the 'raw material view of delayed echolalia' and identify theoretical and empirical shortcomings. Finally, we review Blanc's language stages and their accompanying assessment and language support recommendations and challenge their validity.

Conclusions & Implications

The term 'gestalt language processor' is definitionally and conceptually troubled, the assertion that autistic people are GLPs is misleading and unhelpful, and evidence is lacking that GLP represents a legitimate clinical entity. The theoretical basis of NLA lacks empirical support. NLA stages are implausible and their accompanying assessment and support recommendations lack justification. We recommend the use of alternate, individualized, theoretically-sound, evidence-based, neurodiversity-affirming supports that are sensitive and responsive to the heterogeneity that defines autism.

Developmental diversity: Putting the development back into research about developmental conditions

The dominant discourse surrounding neurodevelopmental conditions such as autism and ADHD emphasizes biological explanations. Neurodevelopmental conditions are conceived as different types of brains, the result of different types of genes. This way of thinking is present both in medical research and in clinical practice. Indeed, it is widely acknowledged that the idea of having a biological diagnosis helps people see beyond blame and guilt. It aids acceptance. However, simplistic approaches to biology risks neglecting the experiences and stories of autistic people in favor of finding etiological causes. At the same time, there is growing awareness that risks, functioning, and resilience are not solely defined by genes and brains but have a cultural and experiential component as well. Furthermore, atypical cognitive trajectories are not straightforwardly associated with poor outcomes. In this paper we describe the concept of developmental diversity as an alternative to more categorical approaches to neurodevelopmental conditions. We explore how dynamic models of life offer possibilities to look at neurodevelopmental conditions differently: rather than seeing autistic people as people with fundamental flaws in their genes or software faults in their brains that have to be explained, autism appears as a phenomenon that exists in interaction with the context, as a meaningful reaction to the environment. We explore what it would mean for research to go from a diagnosis-based approach to a developmental diversity approach that will define wellbeing and functioning in a more granular way across developmental trajectories. We argue that this would mean incorporating lived experiences into biological research and going beyond genes-environment dichotomies. Next to yielding a more complete picture on the phenomenon of autism, we describe how an approach that takes developmental diversity as a starting point offers a new way to look at existing challenges of autism research, such as how to deal with the significant overlap between diagnosis. Our hypothesis is that thinking with developmental diversity rather than categorical difference both represents an opportunity for a more inclusive society, and fundamentally can alter the way we perform research. As such, it is in line with requests of neurodiversity and disability movements.

A Systematic Review of Passing as Non-autistic in Autism Spectrum Disorder

While long described in anecdotal accounts of the lived experiences of autistic individuals, the phenomenon of behaving in ways that appear inconsistent with the presence of autism (or passing as non-autistic; PAN) has recently seen a dramatic increase in scrutiny in the published scientific literature. Increased research attention has coincided with a proliferation of methods, definitions, measures, and population assumptions associated with PAN. To date, however, no review has sought to systematically identify and synthesize the literature on PAN. This systematic review reflects the state of the PAN literature as of May 2020. Ninety articles were screened, 66 were identified for evaluation, and 46 met inclusion criteria and were reliably coded for study characteristics and participant characteristics. Results reveal that the PAN literature includes a relatively even mix of qualitative, quantitative, and mixed-method studies, and that a variety of terms are used for PAN (with masking and camouflage being the most frequent). Sample sizes varied widely (from one to 832 participants), with 63.06% of participants being categorized as autistic. Nearly all studies reported methods for confirming autism diagnoses, with community and clinical diagnoses being most common. The majority of studies reported participant gender, with slightly more females included than males on average, but fewer than half of all studies compared PAN across genders. Nearly all studies reported participant age, demonstrating a wide range of 2 to 79 years, with a mean age of 23.85. Conversely, only 23.91% of studies provided participant race or ethnicity data. Nearly all studies formally or informally excluded participants with intellectual disability. Finally, measures of internalizing symptoms, which are often thought to be linked to PAN, were reported in only 17.4% of studies. Implications for gaps in understanding of PAN and future directions for the field are discussed.

Implications of Applying "Clinically Significant Impairment" to Autism Assessment: Commentary on Six Problems Encountered in Clinical Practice

The addition of 'clinically significant impairment' (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, Author, 2013) to the diagnostic criteria for autism in DSM-5 attempts to establish a threshold for the condition. However, the increased prominence of the neurodiversity paradigm and social model of disability runs counter to the idea that characteristics of autism are fundamentally impairing. Consequently, diagnostic criteria for autism are becoming misaligned with the contemporary views of 'disorder' and 'disability'. In this commentary, we outline six clinical issues that arise from this misalignment during diagnostic assessment for autism, and the tension this creates in making diagnostic decisions. We conclude by considering ways the 'clinically significant impairment' criterion could be changed, and the implications this would have on clinical practice, and the concept of autism.

Auditory Pitch Perception in Autism Spectrum Disorder Is Associated With Nonverbal Abilities

Atypical sensory perception and heterogeneous cognitive profiles are common features of autism spectrum disorder (ASD). However, previous findings on auditory sensory processing in ASD are mixed. Accordingly, auditory perception and its relation to cognitive abilities in ASD remain poorly understood. Here, children with ASD, and age- and intelligence quotient (IQ)-matched typically developing children, were tested on a low- and a higher level pitch processing task. Verbal and nonverbal cognitive abilities were measured using the Wechsler's Abbreviated Scale of Intelligence. There were no group differences in performance on either auditory task or IQ measure. However, there was significant variability in performance on the auditory tasks in both groups that was predicted by nonverbal, not verbal skills. These results suggest that auditory perception is related to nonverbal reasoning rather than verbal abilities in ASD and typically developing children. In addition, these findings provide evidence for preserved pitch processing in school-age children with ASD with average IQ, supporting the idea that there may be a subgroup of individuals with ASD that do not present perceptual or cognitive difficulties. Future directions involve examining whether similar perceptual-cognitive relationships might be observed in a broader sample of individuals with ASD, such as those with language impairment or lower IQ.

Autism Spectrum Disorders: In Theory and Practice

Autism is a prevalent and strongly genetic brain-based disorder. Early focus in the field on the relevance of psychogenic factors led to the blaming of parents for the occurrence of the disorder, and as a result mainstream research on psychotherapeutic approaches has until recently been limited. Although psychoanalytic approaches continue to be considered of limited relevance for these individuals, dynamic theory is both informative and informed by conceptual approaches to the understanding of autism. Theory of mind in particular is a prominent model for understanding the core deficits of autism and bears strong resemblance to the concept of mentalization. Although cognitive-behavioral and social skills interventions may form the cornerstone of psychotherapy for individuals with autism, the formation of a treatment alliance remains crucial and may require a particular willingness for flexibility on the part of the therapist.

Cognitive enhancement therapy for adults with autism spectrum disorder: results of an 18-month feasibility study

Adults with autism experience significant impairments in social and non-social information processing for which few treatments have been developed. This study conducted an 18-month uncontrolled trial of Cognitive Enhancement Therapy (CET), a comprehensive cognitive rehabilitation intervention, in 14 verbal adults with autism spectrum disorder to investigate its feasibility, acceptability, and initial efficacy in treating these impairments. Results indicated that CET was satisfying to participants, with high treatment attendance and retention. Effects on cognitive deficits and social behavior were also large (d = 1.40-2.29) and statistically significant (all p < .001). These findings suggest that CET is a feasible, acceptable, and potentially effective intervention for remediating the social and non-social cognitive impairments in verbal adults with autism.

The effects of aging on the BTBR mouse model of autism spectrum disorder

Autism spectrum disorder (ASD) is a complex heterogeneous neurodevelopmental disorder characterized by alterations in social functioning, communicative abilities, and engagement in repetitive or restrictive behaviors. The process of aging in individuals with autism and related neurodevelopmental disorders is not well understood, despite the fact that the number of individuals with ASD aged 65 and older is projected to increase by over half a million individuals in the next 20 years. To elucidate the effects of aging in the context of a modified central nervous system, we investigated the effects of age on the BTBR T + tf/j mouse, a well characterized and widely used mouse model that displays an ASD-like phenotype. We found that a reduction in social behavior persists into old age in male BTBR T + tf/j mice. We employed quantitative proteomics to discover potential alterations in signaling systems that could regulate aging in the BTBR mice. Unbiased proteomic analysis of hippocampal and cortical tissue of BTBR mice compared to age-matched wild-type controls revealed a significant decrease in brain derived neurotrophic factor and significant increases in multiple synaptic markers (spinophilin, Synapsin I, PSD 95, NeuN), as well as distinct changes in functional pathways related to these proteins, including “Neural synaptic plasticity regulation” and “Neurotransmitter secretion regulation.” Taken together, these results contribute to our understanding of the effects of aging on an ASD-like mouse model in regards to both behavior and protein alterations, though additional studies are needed to fully understand the complex interplay underlying aging in mouse models displaying an ASD-like phenotype.

Age of first words predicts cognitive ability and adaptive skills in children with ASD

Acquiring useful language by age 5 has been identified as a strong predictor of positive outcomes in individuals with Autism Spectrum Disorders (ASD). This study examined the relationship between age of language acquisition and later functioning in children with ASD (n = 119). First word acquisition at a range of ages was probed for its relationship to cognitive ability and adaptive behaviors at 52 months. Results indicated that although producing first words predicted better outcome at every age examined, producing first words by 24 months was a particularly strong predictor of better outcomes. This finding suggests that the historic criterion for positive prognosis (i.e., "useful language by age 5") can be updated to a more specific criterion with an earlier developmental time point.

Differential diagnosis between schizophrenia and autism in adulthood: a case report

The clinical distinction between autism spectrum disorders (ASD), also called pervasive developmental disorders (PDD), and schizophrenia is often difficult to make. Here we describe a case of an adult patient presenting with a diagnosis of schizophrenia based on a history of functional deterioration and presumed persecutory delusions. A psychiatric and psychological assessment conducted from a developmental perspective, in association with direct observation and neuropsychological evaluation for intellectual disabilities and autism, led to a diagnosis of PDD not otherwise specified, with revision of the initial diagnosis of schizophrenia.

Early childhood predictors of the social competence of adults with autism

Longitudinal research into adult outcomes in autism remains limited. Unlike previous longitudinal examinations of adult outcome in autism, the twenty participants in this study were evaluated across multiple assessments between early childhood (M = 3.9 years) and adulthood (M = 26.6 years). In early childhood, responsiveness to joint attention (RJA), language, and intelligence were assessed. In adulthood, the parents of participants responded to interviews assessing the adaptive functioning, autistic symptomology and global functioning of their children. RJA and early childhood language predicted a composite measure of adult social functioning and independence. Early childhood language skills and intelligence predicted adult adaptive behaviors. RJA predicted adult non-verbal communication, social skills and symptoms. Adaptive behaviors changed with development, but symptoms of autism did not. Additional factors associated with adult outcomes are discussed.

Validation of proposed DSM-5 criteria for autism spectrum disorder

OBJECTIVE

The primary aim of the present study was to evaluate the validity of proposed DSM-5 criteria for autism spectrum disorder (ASD).

METHOD

We analyzed symptoms from 14,744 siblings (8,911 ASD and 5,863 non-ASD) included in a national registry, the Interactive Autism Network. Youth 2 through 18 years of age were included if at least one child in the family was diagnosed with ASD. Caregivers reported symptoms using the Social Responsiveness Scale and the Social Communication Questionnaire. The structure of autism symptoms was examined using latent variable models that included categories, dimensions, or hybrid models specifying categories and subdimensions. Diagnostic efficiency statistics evaluated the proposed DSM-5 algorithm in identifying ASD.

RESULTS

A hybrid model that included both a category (ASD versus non-ASD) and two symptom dimensions (social communication/interaction and restricted/repetitive behaviors) was more parsimonious than all other models and replicated across measures and subsamples. Empirical classifications from this hybrid model closely mirrored clinical ASD diagnoses (90% overlap), implying a broad ASD category distinct from non-ASD. DSM-5 criteria had superior specificity relative to DSM-IV-TR criteria (0.97 versus 0.86); however sensitivity was lower (0.81 versus 0.95). Relaxing DSM-5 criteria by requiring one less symptom criterion increased sensitivity (0.93 versus 0.81), with minimal reduction in specificity (0.95 versus 0.97).

CONCLUSIONS

Results supported the validity of proposed DSM-5 criteria for ASD as provided in Phase I Field Trials criteria. Increased specificity of DSM-5 relative to DSM-IV-TR may reduce false positive diagnoses, a particularly relevant consideration for low base rate clinical settings. Phase II testing of DSM-5 should consider a relaxed algorithm, without which as many as 12% of ASD-affected individuals, particularly females, will be missed. Relaxed DSM-5 criteria may improve identification of ASD, decreasing societal costs through appropriate early diagnosis and maximizing intervention resources.

Local vs. global approaches to reproducing the Rey Osterrieth Complex Figure by children, adolescents, and adults with high-functioning autism

Individuals with autism have an atypical pattern of visual processing. Various studies have provided evidence that individuals with autism perceive the details of stimuli before the gestalt, the reverse of the typical pattern of visual processing. This study used the Rey Osterreith Complex Figure (ROCF) task and an objective scoring system to examine local/global processing approaches to its reproduction in 37 individuals diagnosed with high-functioning autism (HFA) compared to 49 age-, IQ-, and gender-matched typically developing controls (TD). The sample was divided into children (aged 8-14 years) and adolescents/adults (aged 15-47 years) to assess age effects. Results showed no difference in overall performance on the ROCF between HFA and TD children. TD participants displayed improved organizational and planning skills with age and a shift to global processing approaches, but there were no differences in performance between children and adolescents/adults with HFA. There was no evidence of enhanced local processing in either HFA group. These findings suggest that HFA individuals with average IQ scores do not have the clinically demonstrable evidence of the enhanced local processing thought to reflect increased local brain connectivity in more severely autistic individuals. The deficient global processing of the HFA adults reflects dependence of performance on impaired strategic problem-solving abilities, which has been demonstrated to result from under development of neural connectivity between visuo-spatial and frontal brain regions in HFA adults.

Social skills training for adolescents with Asperger syndrome and high-functioning autism

The effectiveness of a social skills training group for adolescents with Asperger syndrome and high-functioning autism (AS/HFA) was evaluated. Parents of six groups of adolescents (n = 46, 61% male, mean age 14.6) completed questionnaires immediately before and after the 12-week group. Parents and adolescents were surveyed regarding their experience with the group. Significant pre- to post-treatment gains were found on measures of both social competence and problem behaviors associated with AS/HFA. Effect sizes ranged from .34 to .72. Adolescents reported more perceived skill improvements than did parents. Parent-reported improvement suggests that social skills learned in group sessions generalize to settings outside the treatment group. Larger, controlled studies of social skills training groups would be valuable.

Trajectory of development in adolescents and adults with autism

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

Treating the core features of autism: are we there yet?

A wide variety of nonestablished treatments have been proposed as "cures" for the core features of autism and are used frequently despite having largely escaped scientific scrutiny. In contrast, a growing body of empirical evidence supports the use of a few forms of theory-based and empirically validated treatment for some aspects of the core features of autism. These include behavioral/psychoeducational interventions and specific forms of medication treatment, which can produce significant improvements in communication, social interaction, and problem behaviors that both maintain over time and generalize across settings. While there is no doubt that treatment and educational services for persons with autism have improved over the past 6 decades, it also appears that significant issues remain with respect to (1) the routine application of validated treatments for the majority of cases with autism, (2) the resistance to even validated forms of treatment for a substantial minority of cases with autism, and (3) the extent to which validated treatments effectively treat the specific core features of autism that are most disabling for persons with autism and their families.

Automatic attention cueing through eye movement in 2-year-old children with autism

Automatic attention cueing by perceived changes in gaze direction was studied in 2-year-old children with autism and typically developing (TD) controls using a visual attention cueing paradigm. In Experiments 1 and 2 the cue consisted of an eye movement (Eyes) and a nonbiological movement (SimEyes), respectively. The results suggest that visual attention in children with autism and their TD counterparts is cued by perceived eye movement. Thus, although in naturalistic situations toddlers with autism do not follow the gaze of others, they are sensitive to directional cues inherent in eye movement. Cue-specific differences in performance related to the level of engagement and cue-processing time may suggest reliance on different underlying strategies for gaze processing in autism.

A capacidade do bebê para estar só e o isolamento autista

O tratamento preventivo das perturbações precoces com o risco de evolução Autista é discutido nesse texto como uma ação paradoxal do ponto de vista psicanalítico. A prevenção implica na perpetuação do pensamento psiquiátrico kraepeliano sobre a evolução obrigatória de um conjunto de sintomas de uma referida doença. Ao mesmo tempo enfatiza-se a necessidade do tratamento precoce de bebês com isolamento patológico.

Identifying early intervention targets for children with autism in inclusive school settings

This study assessed play and social behavior of young children with autism in inclusive school settings to identify important targets for intervention. Data were collected for five children with autism and for typically developing peers. All children with autism received intervention in one-on-one settings but did not have individual education plan goals that provided systematic intervention for developing play and social skills in their school settings. Results indicated the children with autism and their typically developing peers played with a comparable number of stimulus items (e.g., toys), but the children with autism engaged in these activities for shorter durations. Both children with autism and their typically developing peers engaged in similar levels of social interaction with adults. However, the children with autism rarely or never engaged in social interactions with their peers, whereas the typically developing peers frequently engaged in social interactions with other children. The results suggest important targets for intervention.

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.

Sociosexual knowledge, experience, attitudes, and interests of individuals with autistic disorder and developmental delay

Thirty-one individuals, 15 with autistic disorder and 16 with developmental delay, male and female, were asked to select from a series of drawings depicting sexually relevant activities and to define them. In addition they were asked to describe their sexual experiences, attitudes, and interests, using a semistructured interview format. Ability to select through pointing out sexually relevant body parts or activities was not different by level of functioning, group, or gender. There were differences in providing a sociosexual label, however, with better performance for those with developmental delay and for the higher functioning. No differences were evident for sexual experiences, likely because of the considerable variability across subjects and types of activity, with some individuals reporting very many and others very few. As to attitudes, individuals with autistic disorder endorsed more sexual activities than those with developmental delay. Higher knowledge of sexuality terms and activities was inversely related to their endorsement. Literalness and perseveration were evident in the responses of some, primarily those with autistic disorder. Results are discussed for their relevance to the reliability and validity of information on sexual awareness among the developmentally disabled. Suggestions for future research are offered.

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.

Wechsler IQ profiles in diagnosis of high-functioning autism

A Wechsler Intelligence Scale profile characterized by VIQ < PIQ with lowest subtest score on Comprehension and highest on Block Design has been associated with autism. Recently, this profile has been applied to assess the accuracy of diagnosis in research samples and for differentiating autism from similar disorders in high-functioning individuals. Universality of this profile, however, has not been sufficiently demonstrated. We therefore examined WISC-R and WAIS-R profile characteristics in 81 rigorously diagnosed high-functioning (VIQ and FSIQ > 70) children (n = 45) and adults (n = 36) with autism. Analysis of the profiles in these groups did not reveal the presumed typical VIQ < PIQ pattern. The typical subtest pattern was found, but the magnitude of profile variability was small. We concluded that individuals with autism can demonstrate a wide range of ability levels and patterns on the Wechsler scales, without a single characteristic prototype. Use of IQ score profiles in the diagnosis and differential diagnosis of autism in high-functioning individuals is not considered valid.

A preliminary 31P MRS study of autism: evidence for undersynthesis and increased degradation of brain membranes

In this pilot study, brain high energy phosphate and membrane phospholipid metabolism were investigated in the dorsal prefrontal cortex of 11 high-functioning autistic adolescent and young adult men (the age range is 12-36 years) and 11 age-, gender-, IQ, race- and socioeconomic status-matched normal controls using in vivo 31P nuclear magnetic resonance spectroscopy (MRS). The autistic group had decreased levels of phosphocreatine and esterified ends (alpha ATP + alpha ADP + dinucleotides + diphosphosugars) compared to the controls. When the metabolite levels were compared within each subject group with neuropsychologic and language test scores, a common pattern of correlations was observed across measures in the autistic group, but not in the control group. As test performance declined in the autistic subjects, levels of the most labile high energy phosphate compound and of membrane building blocks decreased, and levels of membrane breakdown products increased. No significant correlations were present with age in either group or with IQ in the control group, suggesting that these findings were not the consequence of age or IQ effects. This pilot study provides tentative evidence of alterations in brain energy and phospholipid metabolism in autism that correlate with the neuropsychologic and language deficits. The findings are consistent with a hypermetabolic energy state and undersynthesis of brain membranes and may relate to the neurophysiologic and neuropathologic abnormalities in autism.

Asperger's syndrome: three cases and a discussion

The recently revived academic interest in and controversy over the subject of Asperger's syndrome is briefly discussed. Gillberg & Gillberg's operational criteria for its definition are used to isolate three cases of the syndrome presenting over a single year to a mental handicap service. The cases are described in detail. Common themes and associations with the available literature are discussed. In all three cases, the struggle for clarity in the syndrome's nature or specificity in the literature is also reflected in aspects of their clinical management.

Neuropsychological functioning in nonmentally retarded autistic individuals

To investigate several neurobiological theories we evaluated the neuropsychological functioning of 15 non-mentally retarded autistic adolescents and young adults and 15 controls matched on age, gender, IQ, and race. The autistic subjects were found to perform less well than controls on measures of abstraction involving cognitive flexibility, verbal reasoning, complex memory, and complex language comprehension in the absence of significant differences on measures of attention, associative memory, and the rule-learning aspects of abstraction. These findings are most consistent with a generalized abnormality in complex information processing and would not support theories purporting fundamental deficits in attention or information acquisition.

Improving social skills and disruptive behavior in children with autism through self-management

The literature suggests that children with autism typically are unresponsive to verbal initiations from others in community settings, and that such unresponsiveness can lead to problematic social interactions and severely disruptive behavior. The present study assessed whether self-management could be used as a technique to produce extended improvements in responsiveness to verbal initiations from others in community, home, and school settings without the presence of a treatment provider. The results showed that children with autism who displayed severe deficits in social skills could learn to self-manage responsivity to others in multiple community settings, and that such improvements were associated with concomitant reductions in disruptive behavior without the need for special intervention. The results are discussed in terms of their significance for improved development of social skills in children with autism.

The relationship between existing residential services and the needs of autistic adults

Existing residential services for adults with autism vary in size, location, and source of funding. Most service options have been designed for individuals with handicaps other than autism and therefore have difficulty addressing the needs of all but the highest functioning autistic adults. This paper provides a review of the characteristics of autism that affect adaptation to residential settings. A description of existing residential options based on the combined experiences of Great Britain and North Carolina is presented, and directions for future research are then discussed.

A follow-up study of high-functioning autistic children

It is well known that IQ is an important prognostic variable in the outcome of autistic children. There are, however, very few data available on the outcome of nonretarded autistic children as adults. We identified 16 such probands from records and followed them up between 11 and 27 years since discharge from a center specializing in the assessment of autistic children. There were 12 males and 4 females, average age was 26, and mean IQ was 92 (range 68-110). Although the majority were functioning poorly in terms of occupational-social outcome and psychiatric symptoms, a surprising number (4) had a very good outcome and might be considered recovered. The severity of early autistic behavior was a poor predictor of outcome, but neuropsychologic measures of nonverbal problem solving were highly correlated with outcomes. The results of the study indicate that a small percentage of nonretarded autistic children can be expected to recover to a substantial degree.

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.

New perspectives in autism, Part II: The differential diagnosis and neurobiology of autism

The clinical spectrum of autism spans a broad range of functions, but the core symptoms remain the same regardless of the intelligence of the child: the autistic type of social deficit that ranges from a lack of inclination to relate to extreme difficulty with the mechanics of social interactions, a global communication deficit that involves both verbal and nonverbal modes, and a severe cognitive deficit involving concept formation (abstraction) that is combined with an exceptional memory for factual information. These symptoms may vary dramatically in severity, but the basic deficits are identifiable regardless of IQ. Under-recognition of autism is a major problem at all IQs, but especially in patients with IQs above 50. No drugs have been found to significantly improve the core deficits in autism. Antipsychotics should be avoided except for short-term use. Antidepressants, anxiolytics, and anticonvulsants are important in the treatment of depression, affective modulation, situation-related stress, and seizures. Intensive social skills training is assuming a prominent role in behavior modification programs, and success with higher-functioning autistic children suggests that outcome can be improved by intensive training. The neurobiology of autism has also undergone dramatic changes. The psychogenic theories of etiology have been completely invalidated. Autism is now considered to be a neurological disorder resulting from an error in brain development. The precise location and nature of this deficit are still being actively debated and investigated. One theory emphasizes a dysfunction of the limbic system that results in an impairment in the acquisition of information. A second theory proposes a primary role for dysfunction of the cortical association network responsible for the processing of information.

Perspective-taking ability and its relationship to the social behavior of autistic children

A study was undertaken to assess the relationship between perspective-taking ability and the quality of social behavior in autistic children. Sixteen autistic children ranging from 6 to 14 years of age were administered three types of perspective-taking tasks (perceptual, conceptual, and affective), as well as the Peabody Picture Vocabulary Test and the Leiter International Performance Scale. Two measures of social behavior were taken: the Vineland Social Maturity Scale and the Social Behavior Rating Scale, designed for the present study. It was found that perspective-taking ability was significantly correlated with both measures of social skills, whereas receptive vocabulary and nonverbal intelligence were not. These results suggest that the social impairments of autistic children may be related to specific deficits in social cognition.

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.

Managing the behavior of adults with autism in the job setting

The purpose of the study was to facilitate the adjustment of adults who are severely disabled by autism to the job setting. Three cases are presented that illustrate the use of on-the-job training procedures to manage behavior problems of adults with autism. In two cases aggressive and oppositional behavior were eliminated or reduced in frequency, and in a third case production rate was increased. The feasibility of on-the-job training of adults with autism is discussed, and expanded research into vocational training programs is recommended.

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.

Social skills training with verbal autistic adolescents and adults: a program model

An ongoing social skills training program was implemented with 15 verbal autistic adolescents and adults. The major long-range goals were for the participants to have positive peer-related social experiences in a supportive atmosphere and to learn useful skills in this way. Short-term training objectives included how to meet other people, stay on a topic of conversation, ask questions, pay attention, and express one's feelings and emotions. Teaching techniques included modeling, coaching, and role-playing. Preliminary indications suggest that the main goals and training objectives were being accomplished and that clients were progressing in their conversational skills, their selection of relevant topics, and their perceptions of themselves. The implications of this program for the understanding and treatment of autistic adolescents and adults is described, as well as the viability of a social skills training model. The need for more research on this most important issue is highlighted.