spectrum disorders aka pdduniversity of florida自闭症又名pdd 佛罗里达大学课件

AutisticSpectrumDisorders AKAPDD JamesH Johnson Ph D ABPPUniversityofFlorida PervasiveDevelopmentalDisorders OldandNewLabels ThecurrentDSMIVcategoryofPervasiveDevelopmentalDisordersincludesseveralmoresevereformsofchildpsychopathology Historicallydisordersofthistypehavebeenreferredtobyavarietyoflabelssuchasatypicalpsychosis childpsychosis symbioticpsychosis childhoodschizophrenia andinfantileautism EvolutionintheClassificationofPDD Priorto1980andthedevelopmentofDSMIII therewasnoadequateclassificationsystemforthediagnosisofthesedisorders InDSMIItherewasnocategoryappropriateformoresevereformsofchildpsychopathologyapartfrom ChildhoodSchizophrenia ThiscategorywasverygeneralandnotsufficientforthediagnosisofthefullrangeproblemsnowconsideredundertheheadingofPDD DSMIICriteriaforChildhoodSchizophrenia Symptomsappearbeforepuberty Theconditionsmaybemanifestedbyautistic atypicalandwithdrawnbehavior Failuretodevelopanidentityapartfromthemotherswithgeneralunevenness grossimmaturity andinadequacyofdevelopment Thesedevelopmentaldefectsmayresultinmentalretardation whichshouldalsobediagnosed Althoughsomechildrenmetcriteriaforthisdisordermostwithseverepsychologicalproblemsdidnot DSMIII ANewCategoryforPDD InDSMIIIanattemptwasmadetoprovidemoreadequatediagnosticcategoriesforclassifyingmoreseriousformsofchildpsychopathology Heretwoprimarydiagnosticcategorieswereprovided asweremoreobjectivediagnosticcriteriaandspecificdecisionrulesformakingdiagnoses PDD GeneralCharacteristicsoftheCategory PervasiveDevelopmentalDisordersconsideredwithinDSMIVdifferinavarietyofwaysseverityofimpairment ageofonset likelyetiologicalfactorsinvolvedTheyaresimilarinreflectingcorefeaturesthatdefinethegeneraldiagnosticcategory Theyareseenasdisorderscharacterizedbypervasiveimpairmentsinseveralareas including deficitsinreciprocalsocialinteractions deficitsincommunicationskills andthepresenceofstereotypedbehaviors interests activities Developmental Yes Psychotic No Atonetime conditionsnowreferredtoasPervasiveDevelopmentalDisorderswerethoughttobereflectiveofChildPsychosis Asthesedisordersgenerallybearlittlerelationshiptothepsychoticconditionsofadulthood e g Schizophrenia BipolarDisorder theyarenowreferredtoas developmental ratherthan psychotic disorders Pervasive vs Specific DevelopmentalDisorders These pervasive developmentaldisordersaretobedistinguishedfrom SpecificDevelopmentalDisorders e g reading articulation arithmetic andlanguagedisorders Thisisbecausetheyarecharacterizedbyseveredisturbancesinmanybasicareasofdevelopment Theymayalsobereflectedinbehaviorshavingnocounterpartinnormaldevelopment Childrenwiththeseconditionsoftendisplaydistortedratherthansimplydelayeddevelopment DSMIII theOriginalPDDClassification IntheinitialdevelopmentofDSM DSMIII onlythreecategoriesofPervasiveDevelopmentalDisorderswereincluded AutismChildhoodOnsetPervasiveDevelopmentDisorders Therewasalsoamoregeneralcategoryof AtypicalPervasiveDevelopmentalDisorder thatcouldbeusedforchildrennotdiagnosable usingcriteriafortheothertwocategories DSMIII AutismCriteria Onsetbefore30monthsPervasivelackofresponsivenesstootherpeopleGrossdeficitsinlanguagedevelopmentIfspeechpresent peculiarspeechpatterns e g echolalia pronounreversal Bizarreresponsestovariousaspectsoftheenvironment resistancetochange peculiarinterestsinorattachmenttoanimateorinanimateobjects WewilldiscussAutisminmoredetaillater DSMIII ChildhoodOnsetPDDDiagnosticCriteria Aprofounddisturbanceinsocialrelationshipsandmultipleoddities alldevelopingafter30monthsofageandbefore12years toseparateitfromAutismandSchizophrenia Thedisturbanceinsocialrelationshipsisgrossandsustained withsuchsymptomsaslackofappropriateaffectiveresponses inappropriateclinging asocialbehaviorandlackofpeerrelationships DSMIII ChildhoodOnsetPDDDiagnosticCriteria cont Odditiesofbehaviorinclude SuddenexcessiveanxietyConstrictedorinappropriateaffectResistancetochangeintheenvironmentInsistenceonsamenessOdditiesinmotormovementSpeechabnormalitiesHyperorhypo sensitivitytosensorystimuliandSelfmutilation ChildhoodOnsetPDD AssociatedFeatures Bizarreideasandfantasiesandpreoccupationwithmorbidthoughtsandinterests Pathologicalpreoccupationwith andattachmentto objectssuchasalwayscarryingastring rubberband straw etc Whileseeminglyrepresentinganadvanceinattemptingtobemoreobjectiveinmakingdiagnosticjudgments thisclassificationapproachchangedin1987withDSMIII R PDDandDSMIII R MovingForwardorBackward InDSMIII Rthiscategorywaschangeddramatically TheChildhoodonsetPDDcategorywaseliminated OnlythecategoryofAutismwasretainedwiththisnatureoftheautismcriteriabeingmodifiedinseveralwaysincluding Removingtheage of onsetcriterionBroadeningtheautismcriteriathusdistortingthetraditionalconceptualizationofautism PDDandDSMIII R MovingForwardorBackward cont Thisbroadeningoftheautismcriteriacameatatimewhenresearchwassuggestingthatitwasimportanttostartlookingatsubtypesofautism Thechangesresultedinmanycases thatwouldhavebeendiagnosedasCOPDDbeingclassifiedasautism ResearchsuggestedthatdiagnosesusingthesenewcriteriaDidnotcorrespondtoDSMIIIdiagnosesofAutismorRelatecloselytoclinicianviewsofautism ThispromptedmajorchangesinthePDDsystem ModificationsweremadeforDSMIV DSMIVismoresimilartoDSMIIIthanDSMIII R DSMIV CurrentPDDDisorders SeveraldisordersareincludedunderthepresentdayDSMIVheadingofPervasiveDevelopmentalDisorders Asperger sDisorderAutisticDisorderRettDisorderChildhoodDisintegrativeDisorderPDD NOS Asperger sDisorder Autism andPDD NOS arefrequentlyalsoreferredtoasAutisticSpectrumDisorders Gillis Romanczyk 2008 Asperger sDisorder TheLeastSevereoftheSevereDisorders ThefirstpublishedaccountofthisdisorderwasbyAustrianpsychiatristHansAspergerin1944whoinitiallyreferredtotheconditionas autisticpsychopathy ItisinterestingtonotethatDr Asperger sownpreoccupations interestsandsocialaloofnesssuggestthathemayhimselfhavehadanautisticspectrumdisorder Lyons Fitzgerald 2007 Aspergerusedtheterm autistic inthetechnicalsensetorefertoanabnormalityofpersonalityratherthanfeaturesofinfantileautism However morerecentauthorshavecommentedonthesimilaritiesbetweenthesedisorders Indeed thereissomedebateastowhetherthisdisorderisactuallydistinctfromautisticdisorder EssentialFeatures Essentialfeaturesincludesevereimpairmentsinsocialinteractionsrestrictedandrepetitivepatternsofinterests activitiesand orbehaviorsthatresultinimpairment Noclinicallysignificantdelaysincognitivedevelopment languagedevelopmentWhilenotaspecificsymptomofAsperger sDisorder childrenwiththisconditionareoftendelayedinmeetingmajormotormilestones e g crawling walking andarefrequentlycharacterizedasclumsy Asperger s SocialImpairments Inautism socialimpairmentsseemtoresultfromanintensedesiretoavoidsocialinteractions ThesocialimpairmentinAsperger sseemstoresultmorefromalackofsocialskillsandlackofsocialperspectivetaking Thesechildrenseemtohaveamarkedinabilitytounderstandanduseruleswhichtypicallyguidesocialbehavior Asperger s SocialImpairments ThechildwithAsperger smayshowsignificantproblemswith nonverbalbehaviorssuchasmaintainingappropriatephysicalproximitytootherswhileinteracting makingandsustainingeyecontact andappropriatelyusinggestures facialexpressionandothernonverbalbehaviorstoregulatesocialinteractions EgocentricityofSocialBehaviors Socialbehavioroftenappearsegocentricandself centered Here thechildmayfrequentlypursuehis herownhighlypersonalizedinterestsinsocialencounterswithoutapparentawarenessthattheotherpersondoesnotsharesimilarinterests Behavioroccurringwithinthecontextoftwowaysocialinteractionsoftenappearsasinept naiveandpeculiar Restricted RepetitiveBehaviors Restrictedandrepetitivepatternsofbehaviors interests oractivitiesareoftenstrikingandmaybemanifestinavarietyofways Somemaybepreoccupiedwithspecificactivities e g spinningobjects orbecomeoverlyattachedtocertainobjectsorfamiliarplacesandbecomeintenselyupsetwhenseparatedfromthem Othersshowaninflexibleadherencetodailyroutines RestrictivePatternsofInterest Childrenwiththisdisorderoftenshowanextremeall consuminginvolvementinsomespecificareaofinterest Thechildmayspendmostofhis hertimelearningfactsrelatedtothearea Theymaycollectthingshavingtodowiththearea andspendanenormousamountoftimetalkingtoothersaboutthisareawhetherornottheyareinterested While investingagreatdealoftimelearningabouttheirareaofinterest thechildmayhavelittleunderstandingofthefactsthattheylearnThisresultsinsignificantimpairment Aperger svsAutism UnlikeotherPDD s inAsperger sDisorder thereisnoclinicallysignificantdelayincognitivedevelopmentorlanguage Thechildmaylearntospeakatanormalageandtypicallyacquiresacommandofgrammar Childrenwithautismhaveproblemswiththis Theymay however showmarkedpeculiaritiesinlanguage Theymayinventwords usepronounsincorrectly orrepeatwordsorphrasesoverandoverinastereotypedmanner Thesechildrenareoftenextremelyconcreteandliteralwithapoorunderstandingofsarcasmorirony Wiznitzer 2009 Mayhavebigproblemwithidioms Thecontentofspeechisoftenoverlypedantic oftenconsistingoflongone sideddiscussionsaboutthechild sfavoritetopic Asperger svs HighFunctioningAutism IsAsperger sdisorderisaseparatedisorderorjustavariantofautisminhigherfunctioningindividuals SomeevidencesuggeststhatchildrenwithAsperger sandhighfunctioningautismaremorealikethandifferentandthatAsperger smaysimplybeavariantofautism Frith 2004 However childrenwithAsperger sandhighfunctioningautismseemtoshowdistinctpatternsofsocialimpairmentwithchildrenwithAsperger sbeingratedas sociallyactivebutodd andthosewithautismratedas aloofandpassive Ghaziuddin 2008 Epidemiology Whilethereislittlegooddataregardingprevalence childrenmeetingcriteriaforAsperger sDisorderarequiterare Inatotalpopulationstudyofchildrenbetweenages7 16inGoteborg SwedentheminimumprevalenceofAsperger sDisorderwasfoundtobe36 10 000 Thedisorderappearsmorecommoninmalesthaninfemales Sexratiosrangingfrom3 75 1to9 1arereported Asperger s Etiology Regardingetiology thedisorderwasoriginallyconsideredtohaveageneticbasis Asperger 1944 Whilenoformalstudiesfirmlydocumentingageneticetiologyhavebeenpublished casestudyfindingsareavailable Forexample inanearlystudyWing 1981 foundthat ofthe34caseswiththisdisorderthatshestudied 5ofthe16fathersand2ofthe24mothershad toamarkeddegree behaviorresemblingthatobservedintheirchildren Asperger s Etiology Providingtentativesupportforsomesortofbiologicaletiology Wing 1981 foundthatalmosthalfofthe34casesshestudiedhadahistoryofpre peri orpost natalcomplications e g anoxia sufficienttocauseneurologicalimpairment Althoughnotdefinitive supportfortheroleofbiologicalfactorscomesfromthefactthatthesechildrensometimesoftenshowevidenceofnonspecificneurologicalsymptoms ResearchfindingshavealsosuggestedthatchildrenwithAsperger sdisplayabnormalitiesofthecerebellumandlimbicsystemthatarenotunlikethosefoundinautism MashandWolfe2007 Moreresearchwillbenecessarytodeterminethemostimportantcontributorstothisdisorder Asperger s Prognosis Giventheirhigherleveloffunctioning duetoalackofbasiccognitiveandlanguagedeficits theprognosisisAsperger sappearsmuchbetterthanwithotherPDD s EarlystudiesbyWing 1981 presentedcasereportsofindividualswhowereabletoengageingainfulemploymentandfunctioninasimi independentmanner Arecentstudyfoundthat27 ofthosewithAsperger shadgoodadultoutcomesand26 hadrestrictedorpooroutcomeswithaveryrestrictedlifewithnooccupationandnofriends MashandWolfe2007 Obviously prognosisisintimatelyrelatedtotreatmentandmanagementapproachesdesignedtodealwiththechild sdifficulties TreatmentofAsperger s Atpresent notreatmenthasbeenshowntomodifythebasicunderlyingimpairmentshownbychildrenwiththiscondition Behavioralapproachesdesignedtoenhancethechild sabilitytofunctioninsocialsituations alongwithaneducationalprogramtailoredtomeethisorherspecificneedsshouldbebeneficial Psychotherapy whilenotlikelytoremediatethechild sbasicdifficulties maybeusefullateronasthechildbecomesawareofthedegreetowhichsocialskillslimitationsmakeitdifficulttofunctionwithoutexperiencingpersonaldistress Autism InfantileautismwasfirstdescribedbyLeoKanner l943 inhisclassicpaper AutisticDisturbancesofAffectiveContact whichwaspublishedinthe nowextinctjournal TheNervousChild AutisticDisorder Inthisseminalarticle Kannerhighlightedthedefiningcharacteristicsof11childrenseeninhischildpsychiatrypracticeatJohnsHopkinsUniversity Kannerbelievedthatthese11childrendisplayedatypeofdisorderdifferentfromanythathadbeendescribedpriortothattime Hisviewsregardingthisdisorderhaveheavilyinfluencedpresentdayviewsofthedisorder emphasizedanumberoffeatures NatureoftheDisorder Unlikecertainotherseveredisordersofchildhood Kannerassumedautismtohaveanearlyonset Hebelievedthedisordertobepresentfromthebeginningoflife oratleasttobecomeobviousduringthefirstyearorso Indeed hereferredtoitasan inborndisturbance Hefeltthatthisearlyonsetservedtodifferentiatethedisorderfromotherproblems whichatthattime werejudgedtobemanifestationsofchildhoodpsychosis DefiningSocialCharacteristics Autisticchildrenhaveaprimarydisturbanceinsocialrelationshipsandanapparentinabilitytorelatetoothers Theyseemaloof oftenoblivioustothepresenceofothers andareoftendescribedasbeinginaworldoftheirown Likeinashell Happiestwhenleftalone Actingasthoughpeoplearen tthere Thismaybereflectedinearlylifebyafailuretoshowanticipatoryposturingwhentheparentattemptstopickthemupfromthecrib andthefailureoftheinfanttomoldhimorherselftothebodyoftheparent DefiningSocialCharacteristics Theirproblemsinrelatingtoothersmaybedisplayedbythefailureofthechildtorespondtoparentsorothers Insomeinstanceschildrenmaytreatparentsnodifferentlyfromothersandmayshowalmostnoresponsewhenaparentreturnshome evenafterbeinggoneforsometime Sometimesthesechildrenarethoughttobedeafbecauseoftheirlackofresponsiveness ThisproblemofemotionalresponsivitypromptedKannertodescribethedisorderasaprimarydisturbanceofaffectivecontact SocialAloofnessasaCoreFeature Kannersuggestedthattheoutstandingfundamentaldisorderis thechildren sinabilitytorelatethemselvesintheordinarywaytopeopleandsituationsfromthebeginningoflife Hegoesontonotethat thisisnotasinschizophrenicchildrenoradults adeparturefromaninitiallypresentrelationships itisnota withdrawal fromformerlyexistingparticipation Thereisfromthestart an extremealonenessthatwheneverpossibledisregards ignores shutsoutanythingthatcomestothechildfromtheoutside AutisticLanguageImpairments Allautisticchildrenshowevidenceofaseverelanguagedisorder Manyremainmute Thosethatdevelopspeechtypicallyshowunusualfeaturessuchasecholalia therepetitionofwhatsomeoneelsehassaid justasitissaid orpronominalreversal failuretousepronounscorrectly referringtooneselfas you andtoothersas I Eventhoughsomeautisticchildrendevelopfairlylargevocabularies theyusuallycannotusespeechtocommunicatewithothers AutisticLanguageImpairments Kannernotedthatalthoughsomeofhis11casesdevelopedlanguage theywerenobetterabletocommunicatethanwerethosewhoremainedmute Speakingautisticchildrenoftenhavenodifficultyinnamingobjectsandsometimesseemtohaveafacilityforlearningpreviouslyconstructedverbalmaterialssuchaspoems songs andlistsofthings Suchlearning however seemstobewithoutanyappreciationofthemeaningofthesematerials Thereisusuallyminimalevidenceofspontaneousspeechthatservesacommunicativefunction TheDesireforSameness Kannerandothershavenotedthatautisticchildrenseemtodisplayan anxiousdesireforthemaintenanceofsameness Thisreferstothefactthatsuchchildrenoftengetupsetwhenthingsintheirenvironmentarechanged whenfurnitureismoved whenroutinesarechanged orwhentoysthechildhasleftinaparticularpositionaremoved Thismayresultinacatastrophicreactionlastinguntilthingsarereturnedtotheirformerstate Thisdesireforsamenessmayleadsomechildrentodisplayawiderangeofritualisticbehaviors OtherAssociatedFeatures Inadditiontothecharacteristicssuggested byKanner otherbehaviorsarealsofoundinsomeautisticchildren Manyautisticchildrenshowstereotypedbehaviors Theymaymouthobjects spendlongperiodsoftimeflappingtheirarmsandhands rock ordisplayotherapparentlyself stimulatingbehaviors Themaysometimesappeareitherunderoroverresponsivetoenvironmentalstimuli orboth Sometimesthisunderresponsivenessisreflectedinanapparentinsensitivitytopainandinassociatedself injuriousbehaviors PrevalenceofAutism Althoughautismhas fromthebeginning beenseenasararedisorderithasbeendifficulttodetermineitsexactfrequencyofoccurrence Thisisbecauseinvestigatorshaveoften useddifferentcriteriafordiagnosis becausethedisorderhasfrequentlybeenconfusedwithotherseveredisordersofchildhood andbecausenotallchildrenwithautismcometotheattentionofresearchers Prevalencedatafromearlystudiessuggestedverylowratesofoccurrence typically4or5casesper10 000children andaslowas2per10 000for classic cases PrevalenceofAutism Areviewofstudiesconductedsincethemid1980 shas however suggestedhigherprevalencefigures ThefewstudiesusingDSMcriteriahavereportedratesontheorderof10per10 000 ClassicAutism PrevalenceratesforAutismSpectrumDisordersRecentlyithasbeensuggestedthatsomewherebetween1in500to1in166childrenhaveanASD CenterforDiseaseControlandPrevention CDC Itisnowbeingsuggestedthatasmanyas1childper150 ormore mayhaveanautisticspectrumdisorder Yeargin Allsoppetal 2003 Otherresearchhassuggestedthattheprevalenceforsubtypesofautisticspectrumdisorderareapproximately22per10 000forautism 33for10 000forpervasiveDevelopmentaldisorderNOS and10per10 000forAsperger sdisorder Fombonne etal 2006 Thedisorderismorefrequentinboysthaningirls withsexratiosrangingfrom2 0to1to5 7to1 AutisticSuccessStories Inaclassicpaperentitled Howfarcanautisticchildrengoinmattersofsocialadaptation Kanner l973 reportedonafollow upofsome96autisticchildrenseenpriortol953 Althoughthemajoritydidnotfareaswell 11ofthe96achievedwhathedescribedasafavorableoutcome Here3obtainedcollegedegrees Threewenttojuniorcollege Attimeoffollow uponeotherwasreportedtobedoingwellincollege Theotherfourdidnotgobeyondhighschoolorspecialeducation AutisticSuccessStories Theoccupationsofthesegrown upautisticsincludedaccountant duplicatingmachineoperator labtechnician bankteller alongwithseveralothertypesofunskilledwork Kannernotedthatalthoughthese11childrendidshowafavorableoutcome noneseemedtoshowanyinterestintheo