Autism in dsm3 - Lecture notes 1-5 PDF

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lecture notes from spring 2020 course...

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In the DSM-III, the APA note that “[Infantile Autism] is apparently more common in the upper socioeconomic classes, but the reason for this is not clear” (American Psychiatric Association, 1980, p.89). Using information from the lecture videos presented in this course, along with article by Leo Kanner, come up with two possible explanations for how the APA came to this conclusion. Also, explain your reasoning for each explanation: what information or clues led you to your explanation, what assumptions are you making to get to your explanation and why are they likely, etc. DSM III published in 1980 Mental disorder: clinically significant behavioural or psychological syndrome, or pattern that occurs in an individual that is typically associated with either a painful syndrome (distress) or impairment in one or more important areas of functioning (disability). - Clinically significant means that the cases are severe and people who are suffering are reaching out to clinicians (psychiatrists are not diagnosing the general public) - Does not define what the important areas of functioning are (will change from disorder to disorder) APA caution: a common misconception is that a classification of mental disorders classifies individuals, when actually, it is the disorders that people have that are being classified. This is a way to not negate the individuals, but also are trying to mitigate how they are distancing themselves from the patients Autism diagnoses have increased a lot in the last 10-15 years and one of the primary reasons for that may be applied behavioural analysis (ABA therapy). The only disorder in the DSM that says that you need ABA therapy is for autism even though it is not exclusively effective in autism. ABA can be helpful for people with intellectual disabilities. So, with an intellectual disability, people can’t get coverage for ABA, even though they might benefit from it. DSM 3 – finally a separation between schizophrenia and autism Essential features of infantile autism in DSM 3: lack of responsiveness to other people, gross impairment and communicative skills, and bizarre responses to various aspects of the environment – all developing within the first 30 months of age (2.5 years) --- by today’s standards, that is late!! We can now reliably diagnose autism at around 18 months. According to DSM 3: symptoms/presentation of infantile autism are – - Lack of responsiveness, lack of interest in other people o Don’t tend to respond to other people o Don’t tend to respond to their own name  One of the investigations that parents are put through to find out if child has autism is a hearing test (they’ll do this test first because the child may be in their own little world or may just have hearing problems) o Lack of interest in people (playing with others in daycare situations) - Failure to cuddle, aversion to physical contact or affection (part of lack of responsiveness) - Lack of eye contact and facial responsiveness

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Failure to develop cooperative play and friendships o Hard for them to play pretend because they tend to take things very literally (in DSM 3 it was described that they have difficulty with figurative thinking)

Communication symptoms/presentation in DSM 3: - Language may be totally absent (we know now this is not true, even if they don’t speak, they may still be able to comprehend language – we also know that language can develop later) - Immature grammatical structure (trouble following grammatical rules and stringing sentences together) - Delayed or immediate echolalia (behaviour where they immediately repeat themselves or something they just heard or repeating something they’ve heard before) o One way this behaviour works: scripting! Children with autism may repeat lines from their favourite movies over and over again o Echolalia was seen as useless and dysfunctional, however, recent research shows otherwise. If they can’t form their own sentences, they may borrow other peoples. - Pronoun reversal o Severe end of spectrum (Kanner’s autism) o Kids may refer to themselves as “you” instead of “I” - Nominal aphasia o Word finding difficulties o Difficulty coming up with nouns - Inability to use abstract terms, metaphorical language o One of the reasons why autistic children do not do pretend play - Abnormal speech melody o Difficulty with proper intonation – different languages have different intonation patterns o A lot of autistic people speak in monotone and their voices may sound a little robotic – not sure why but it could be related to abnormal speech melody - Appropriate nonverbal communication is often lacking o People with autism do not express body language very well o Facial expressions don’t come across very well o They have difficulty reading other people, and because of this, they don’t know how to replicate that behaviour themselves. o This could be due to neuron deficits (certain neurons only fire when they can see things that they can mirror, ex. Social interaction) o They don’t interact as much as other people, so they aren’t exposed to the cues at the same frequency that other people are.

Behavioural symptoms: - Intolerance of change in environment or routine o At the time, this was seen as reactive and there was no explanation for it

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o Now there is some research that looks into how being in a routine helps minimize some cognitive load for certain functions, which allows them to function better for other things. Attachment to odd objects o Attachment to teddy bear: normal o Attachment to broken TV remote: odd Ritualistic behaviours involving motor acts o Stimming (shaking legs, arms, or pacing) may help to process information better and helps to focus. Standing in one place can cause anxiety and create nervous energy. o BUT in the 1980s, this was not seen as a functional behaviour (instead seen as ritualistic and repetitive and significant sign of the disorder) Fascination with movement o Fascinated by water and fans Fascination with parts of objects o Love to take things apart and look at the pieces, see what’s inside and try to rebuild it Inordinate interest in rote topics o They might watch the same YouTube video over and over again because they like the repetition or maybe they are focused on one thing Excellent long-term memory o Back-handed compliment

Associative features: - Mood liability (psychiatric term referring to mood swings) o In the 1980s, they believed that people had severe mood swings (this is not a feature of autism per se). It could be related to communication – if they feel frustrated and they can’t communicate how they feel, it could lead to meltdown. o Mood disorders and autism are not mutually exclusive (people with autism are often diagnosed with anxiety, depression, or bipolar) - Under responsiveness and Over responsiveness to sensory stimuli o Hyper and hypo sensitivity o In addition to the five senses: proprioception, which is knowing where your body is in relation to other objects around you. People who are hyposensitive to proprioception may be clumsy. o Also: hypo or hyper sensitive vestibular system (rolls and flips – roller coasters and car rides). Hyper sensitive people may get car sick - Rhythmic body movements o Stimming (constant body movement/rocking/shaking helps keep them centered) - Lack of appreciation of danger o Tend to react to some things without considering the outside consequences o Concept to external danger does not register at the time. - According to DSM 3: 40% of autistic children have IQ under 50

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o This qualifies for severe intellectual disability Only 30% of autistic children have an IQ of 70+ o Normal range is between 85 and 115 o Around 70-85 is a mild intellectual disability Intellectual functioning extremely variable o It is common for some autistic people to have low scores in a few areas and very high scores in other areas to the point where the average is almost meaningless. Substantial difficulty with tasks requiring abstract thinking

Course: - Some of these children eventually lead independent lives with minimal signs - 1/6 makes adequate social adjustment and is able to do some kind of regular work in adulthood - 1/6 makes only a fair adjustment - 2/3 of children remain severely handicapped and unable to lead independent lives - Factors related to long-term prognosis include IQ and development of language skills

Impairment: - The disorder is incapacitating - Special educational facilities are almost always necessary Complications: - 25% or more of cases develop seizures in adolescence or early adult life - Most of the children with an IQ below 50 develop seizures but only very few of those with normal intelligence do Prevalence: - As of 1980, the disorder was considered very rare (2-4 cases per 10,000) - Now, Canadian stats: 1 in 58 - It is apparently more common in the upper socioeconomic class but the reason for that is not clear. Sex ratio: - The disorder is three times more common in boys than in girls Predisposing factors: - In the past, certain familial interpersonal factors were thought to predispose to the development of this syndrome, but recent studies do not support this view Familial pattern: - The prevalence of infantile autism is 50 times as great in siblings of children with the disorder than the general population. Still true today (number may have changed)

Kanner: Donald’s family was very rich and was able to afford diagnoses and stuff.

Rich and educated plus stay at home moms. Many of the parents are also psychiatrists, so that could be a contributing factor as to why there were not as many cases back then. Perhaps the cases have increased because access to information on child care is much more accessible now.

In the DSM-III, the APA note that “[Infantile Autism] is apparently more common in the upper socioeconomic classes, but the reason for this is not clear” (American Psychiatric Association, 1980, p.89). Using information from the lecture videos presented in this course, along with article by Leo Kanner, come up with two possible explanations for how the APA came to this conclusion. Also, explain your reasoning for each explanation: what information or clues led you to your explanation, what assumptions are you making to get to your explanation and why are they likely, etc.

Reflection 1: I believe that one of the reasons why it seemed as though Infantile Autism was more common in the upper socioeconomic classes when the DSM-III was released is because there were cases that went undiagnosed. I came to this explanation because between the time Leo Kanner described ASD and the DSM-III was published, the Civil Rights Movement was happening in America. Although the family dynamics in the cases that Leo Kanner studied are each unique, all of them were financially stable and had the means to access therapy. Around the time of the Civil Rights Movement, minority groups were facing the repercussions of racial inequality, and this may have also impacted their ability to seek medical help and consequently, the autism data in DSM-III. Furthermore, because of racial inequality in the education system at the time, families from lower socioeconomic classes may not have had the benefit of high quality education to learn about what autism is and how to seek therapy. So, if they had children with autism, those children were not diagnosed. Secondly, I believe that another factor in why it seemed like Infantile Autism was more common in the upper socioeconomic classes is because many of the parents in the cases that Kanner used in his paper were a combination of stay-at-home mothers and psychiatrists. Although there is a slight overlap between this and the first explanation because both discuss education and wealth, it also means that the children’s mothers were able to spend time with them and observe their children enough to be able to write detailed descriptions of their behaviours for Kanner to look into. Moreover, being children of psychiatrists came with the privileged ability to be well connected with researchers and doctors to get their children assessed. In many cases, because the parents of families from lower socioeconomic statuses were most likely both working parents, and therefore been leading a life of reactive parenting rather than proactive parenting. For example, if their children possessed certain behaviours and

symptoms of autism, the parents may have reacted those behaviours and symptoms by accommodating and adapting rather than observing and seeking therapy. In Kanner’s paper, the parents were able to write up detailed descriptions of their children’s behaviours and their concerns. This enabled them to seek help and proceed with raising their children in a proactive manner....