Q. Consider this video, what are the consequences of social deprivation in infancy? Video: Psychological Hazards in Infancy Good infant care can make the difference between growth and disaster If...

Q. Consider this video, what are the consequences of social deprivation in infancy?
Video:
Psychological Hazards in Infancy
Good infant care can make the difference between growth and disaster
If deprived of simple human contact, they become “human wrecks”

• will not be able to sit up


• attention only captured by own hands


• not able to crawl


• smaller


• people become of little interest


• “cycle of failure”: neglect leads to apathy, which makes him/her less attractive, leads to further neglect

Therefore, good infant care is essential
Especially attractive or lively babies will attract additional attention from busy caregivers

• Leads to cycle of growth: the more attention she gets, the more lively and attractive she becomes


• Will lead to a person who cares about others and approves of herself

Caregivers busy, may not know how important attention is
Caregivers need to respect babies’ natural sleep and digestion cycles, should not go by clock (will lead to better adaptation later in life)
Caregivers may put schedules (e.g. cleaning) over stimulation for children
Children need to be stimulated during the day for proper development

• may become bored, bang head, sleep too much


• netting may isolate children further


• not even given toys in cribs

With proper stimution and play, appropriate motor skills and coordination can develop

• more menally alert, curiousity


• twice as big


• twice as advanced motor skills


• attention needed for even normal physical growth

sometimes caregivers think it is safer/less trouble to have children off the floor, but

• becomes fully dependent on caregiver


• cribs and playpens can be used for too long

babies true vocation is exploration

• if cut off, development is stunted

holding children while feeding can be restraining for infants

• should be encouraged to do everything possible for themselves


• would be able to if given the opportunity/encouragement


• babies are then more independent (nurses free to go about other business)

hidden hazards (less obvious than “human wrecks”)

• if child not given chance to exercise own initiative


• need to be active, talkative “explorers” (at 1 year)


• if not, slow to develop speech


• distinguishing between self and others retarded


• little mastery of self and world (needs to be treated as an appropriate age, rather than someone younger)


• there will be different levels of development regardless of care


• if confined, the world holds less and less as child grows older


• can become bored (dangerous)


• becomes less interactive


• essentially being “held back”

FOCUS: difference bw emotionally neglected vs. attended-to children

• apathy (key symptom of reactive attachment disorder)


• growth (smaller)


• emotionally retarded


• self-stimulating (Autistic-like)


• rocking back and forth (Autistic-like)


• called “failure to thrive”


• critical period for “failure to thrive”


• needs to be first 2 years, if not, there will be permanent damage

Assessment, Diagnosis and Treatment

Diagnosis


Should not be static
(unfortunately this fact is not acknowledged)
The more info, the higher the validity
Diagnosis is based on assessment, and the treatment is based on the diagnosis
Somewhat like the process used with adults, but there are many differences (and there is a separate section of DSM – but adults can be diagnosed with these disorders and vice versa)
Diagnosis uses the same tool that one would with adults
Only 2 professions can use DSM (as a tool) to make diagnosis

DSM IV- TR
is the tool most widely used in North America and Canada, published by “A-Psy-A”

• medical tool devised by a group of physicians


• first introduced in 50s


• only 2 categories specific to children (expanded in each edition)


• now there are 10 child-related categories (with a subset of disorders in each)
  
  
  
  • e.g., autistic-like disorders (includes aspergers, rett’s syndrome)
  
  
  
  


• there will be a significant change in childhood disorders in DSM 5


• categories of disorders WILL NOT be on the midterm


• the rest of the world does not use this tool to diagnose psychiatric disorders


• poor validity (misdiagnosis), is quite high


• reliability fairly high


• negative correlation bw validity and diagnosis


• diagnosis helps with selection of treatment (PRO of diagnosis)


• stigmatization a by-product (CON)


• In all diagnoses, there is the subsection of NOS (not otherwise specified), useful for insurance (PRO) but decreases validity (CON)

Has 5 axes (dimensions)

• Axis 1: primary presenting complaint (answer to “what are you here for today?”), what will be treated first
  
  
  
  • DSM allows a psychologist to diagnose co-morbidity on axis 1
  
  
  • All other axes provide context for this axis
  
  
  
  


• Axis 2: disorders that are considered permanent, usually referred to as personality disorders
  
  
  
  • Can be treated, but generally don’t go away
  
  
  • Mental retardation is the only childhood disorder that can go on axis 2
  
  
  
  


• 
  Axis 3: relevant physical conditions (important because Autism often misdiagnosed as e.g. deafness)


• Axis 4: outside stressors
  
  
  
  • Most stressful for children: removal of caregivers
  
  
  • The number one job of an infant (psychologically) is to attach itself to a caregiver – if not accomplished, the consequences are dire
  
  
  
  


• Axis 5: global assessment of functioning
  
  
  
  • Over a 1-year period
  
  
  • Occupationally, recreationally, and in relationships
  
  
  • DSM asks for a scale from 1-100 (with 100 being very high functioning)
  
  
  • The lower the score, the poorer the prognosis (how the illness will progress)
  
  
  • If one is getting social support, the prognosis is much better than if not (so prognosis needs to take this into account)
  
  
  
  

ICD-10: International Classification of Diseases

• published by the WHO (division of UN)


• this is what the rest of the world uses


• trying to make compatible with DSM-5


• OHIP requires ICD-10 diagnosis “codes”

There is significant overlap between the two systems
Some are recognized by the other, and vice versa
Since 1995, efforts have been made to make these two tools completely compatible
Issues of diagnosis:

• problems of labelling (can be stigmatizing)

Efforts to devise classification systems only for children not widely used
Benefits of diagnosis:
1) Selection of treatment
2) Helps research of mental illness
3) comfort in knowing you have something that other people have (there is a reason you act the way you do)
Problems with diagnosis
1) stigmitization
2) constricting (should not be static, it can change – assessment should be ongoing)
What makes for a good classification system?
1) categories are clearly defined: DSM is quite good on this, but (in ICD as well) there is a significant overlap in categorical symptoms from one disorder to another (which can lead to misdiagnosis)
2) categories exist: the person being given the diagnosis actually HAS this set of symptoms, they are observed to occur together regularly (using stats, factor analysis; or using consensus among professionals)
3) reliability: test-retest, inter-rater (categories add to reliability, makes DSM quite reliable)
4) validity: categories clearly disciminable from one another (DSM mostly fails, has greater reliability than validity – significiant symptom overlap)
5) clinical utility: it’s useful – the DSM 4 is useful (similar to polygraph - has utility, but low validity)
Two types of diagnositic systems
Clinically derived (from consensus among professionals, DSM and ICD)
Empirically derived (from statistics – factor analysis)

• very poor utility
  
  
  
  • many syndromes have symptoms in common
  
  
  • e.g., for children – only two factors are “introversion and extroversion”
  
  
  • not sophisticated enough yet
  
  
  
  

Assessment


Should be an ongoing process

3 types:

• interview
  
  
  
  • structured and unstructured
  
  
  • most common in adults
  
  
  
  


• testing
  
  
  
  • more formal than the interview
  
  
  • cognitive and projective
  
  
  
  


• observational
  
  
  
  • just watching behaviour
  
  
  • most common for children
  
  
  
  

Components of assessment:
Referral

• parents may be reluctant to admit their child is disordered


• issues that do not affect others will often go unreferred


• the referral is important because it gives clues to how the problem is understood


• can be likened to a triage


• interviewer can tailor specifics of assessment to the referral (e.g. tests)


• child’s attitude is important to note, e.g. they can feel put-down or blamed
  
  
  
  • important for building rapport
  
  
  
  


• anger and anxiety important to note in a referral, clinician needs to have
  rapport:
  emotional relationship between two individuals
  
  
  
  • very, very important in client-patient relationship (in assessment as well as therapy)
  
  
  • part of the “art” of therapy
  
  
  • especially important with older adults and children
  
  
  
  


• need to assess child’s motivation for seeking treatment
  
  
  
  • e.g., conduct disorder: could be to avoid punishment
  
  
  
  

Formal assessment

• can be done by the same person as who did the referral


• observation most useful
  
  
  
  • children not as verbally sophisticated as adults are
  
  
  • two warnings: 1) you are observing this behaviour at one time and in one particular location, might not be completely translate across different situations (time and location) 2) one could commit observer bias: e.g., if referral is for ADD, there may be a bias in the observation to find ADD
  
  
  • does not require an interaciton
  
  
  
  

5 categories of observational behaviour:
1) appearance

• general appearance and attire can tell one a lot about physical, social, and interpersonal characteristics


• any observations and extremes in appearance (deformities, scars, bruises)
  
  
  
  • could be clues of abuse, fighting, epilepsy
  
  
  
  


• estreme thinness (could be anorexia)


• does appearance fit age?
  
  
  
  
  

2) emotional gestures and facial expressions (can be subtle, needs to be carefully attended to by therapist)

• children will let you know through body language e


• motions easy to detect and interpret if looked for


• specific attention to fear and anxiety

3) gross and fine motor acts

• chemical functioning and brain functioning


• physiological and psychological functioning


• extremely overactive (ADD, drugs, chemical imbalance) or underactive (sleep disorder, malnutrition)


• involuntary spasmodic movement (tic disorders like Tourette’s)


• doing this repeatedly/over and over

4) quality of relationships

• child being assessed presents with parent (could be part of axis 4 and 5)


• opportunity to view interactions bw children and parents

5) structure of verbalizations

• are verbalizations appropriate for age, socioeconomic status, schooling, intellectual functioning


• use of neologisms (made up words), incoherences (could be psychosis, brain damage), tangential speech (long-winded, full of irrelevant info – could be ADHD)


• what child thinks, can remember, what he/she feels


• confabulation (making things up – might be believed by child, could be psychosis or conduct disorder)

The interview
Questions are asked, and resposnses are required
Questions that are asked are based on referral (big problem with interview, because referrals can make questions too specific)

• Don’t want to miss any info that might be relevant


• Could be comorbid conditions not represented at referral


• Could be psychologist’s paradigm (e.g. psychoanalytic, behaviourist, etc.)
  
  
  
  • Could miss info from each other’s paradigms
  
  
  
  

Always asked in an interview: family history, present problems, identifying information
Building a rapport

• establishing rapport with children much more difficult than with adults


• should be in an non-threatening environment (play environment)


• freedom of movement for child important


• assess level of anxiety in child


• including parents makes child less anxious

Interviews can be structured or unstructured

• most therapists use a mixture of both


• unstructured more likely iwht children


• not useful for Autism, MR, very young children


• monitor cooperativeness and truthfulness of child at all times

Advantages to structured:

• thorough


• negatively affects rapport

unstructured advantages

• you pick the questions


• less questions


• more conversational


• less formal


• can miss things

The “art” part of interview

• must listen carefully, include important info and discard irrelevant info

Tests
Testing almost exclusive domain of psychologists\
Gather info not readily accessible from the interview:

• fantasies, memories, achievements, perceptions

Cognitive tests

• carefully standardized (e.g. Stanford-Binet)


• normative data

Stanford-Binet

• cognitive test


• First developed by Binet and Stanford U


• Yields intelligence quotient


• Asks children to perform tasks such as square, triangle; complete drawing; imitate examiner; define words;


• First cognitive test developed (and was for children)


• Primarily used to diagnose MR in children

WISC

• Cognitive test


• Most widely used cognitive test is the WISC (Weschler Intelligence Scale for Children)


• In fourth edition


• Most widely used for children


• Yields more sophisticated iq


• More sophisticated factor analysis


• Shorter than normal iq tests


• In order to build rapport, subsection is ended when there are 4 mistakes


• 3 different IQs:
  
  
  
  • verbal iq
  
  
  • performance iq
  
  
  • overall/general iq
  
  
  
  

PPVT (Peabody Picture Vocabulary Test)

• Graded set of cards (gets more sophisticated as it goes on)


• 4 drawings each card, child needs to indicate which drawing matches which word


• also been standardized


• relatively high correlation bw PPVT in WISC in younger children

Bayley Scale

• Looks at whether child has reached milestones


• Theory: relationship between reaching developmental milestones sooner than the norm will predict IQ later in life (not much reliability)


• Still used as a rough measurement

Personality inventories

• self reports (therefore always biased)


• have bias

MMPI

• not really used for children (too many q’s)


• not a projective test, referred to as an inventory


• more common for parents than children

Child Behaviour checklist

• another personality test (like MMPI)


• questions about childs thoughts/feelings


• not used directly with children

Projective tests

Rorschach test

• some standardization (Exner)
  
  
  
  • e.g. picking out a red spot and calling it blood indicator of psychosis
  
  
  
  


• no right or wrong answers


• can respond freely to these tests

Thematic Apperception Tests (TAT)

• introduced 1935


• responses are psychologically determined


• the stimuli are ambiguous enough htat the response will reflect the personality
  
  
  
  • ambiguity frees client to respond in a more honest way
  
  
  
  

Children’s Apperception Test (CAT)

• not widely used


• late 50s early 60s


• ambiguous situations and interactions, but in cartoons


• more like play and cartoons?
  
  
  
  • Research suggests this is not the case
  
  
  
  

Paper 2 Q. Based on the video, What accounts for the positive results of Lovaas' treatment? Why is it not universally applied?

This below article is related to lovaas treatment I guess, found from the google, but the thought paper should be basically based on the video.

Autism Treatment based on Applied Behavioral Analysis:
What Does the Current Research Tell Us?

By Richard Irwin (CTFEAT member)
Research has demonstrated that young children with autism can make dramatic progress in intensive treatment programs based on the principles of Applied Behavioral Analysis (ABA). In fact, some children who begin treatment by age 4 and continue treatment for at least two years progress so much that they become indistinguishable from typical children their age. The most thorough study of the effectiveness of behavioral intervention on children with autism was published in 1987 by Dr. O. Ivar Lovaas of UCLA (Lovaas, O.I. (1987) "Behavioral treatment and normal educational and intellectual functioning in young autistic children," Journal of Consulting and Clinical Psychology, 55, 3-9).
The study compared the progress made by three separate groups of children with autism: one experimental group and two control groups. The experimental group consisted of 19 children who were given an average of 40 hours per week of one-to-one behavioral intervention for a minimum of two years. The first control group consisted of 21 children who were given 10 hours or less per week of behavioral intervention, while the second control group consisted of 21 children not treated by Lovaas and his colleagues. A number of the children in the two control groups received a variety of other interventions as well. All children were diagnosed as autistic by professionals not associated with the study. In addition, the three groups of children were shown by a number of standard test measures to be virtually identical prior to treatment. The behavioral treatment addressed all the deficits normally associated with autism spectrum disorders: cognitive, social, behavioral and communication.
In the end, substantial and measurable differences were seen between the experimental group and the two control groups. The experimental group children, as a whole, showed an average gain of 20 IQ points while the two control groups showed no gain at all. Nine children in the experimental group (47%) successfully completed regular first grade without any supports and obtained IQ scores in the average to above average range. These nine children had an average gain of over 30 IQ points and by all measures were normal functioning.
Eight of the remaining ten children in the experimental group demonstrated substantial gains in all areas of development, but were unable to attend school without any support. They completed first grade in special education or language-delayed classes. The remaining two children were placed in classes for autistic or mentally retarded children..
In contrast, only one child in the two control groups completed regular first grade and had an IQ score in the average range. Of the children in the control groups, 53% were placed in classes for autistic or mentally retarded children, with the rest completing first grade in special education or language-delayed classes.
Lovaas and his colleagues published a follow-up study (McEachin, J.J, Smith, T., & Lovaas, O.I. (1993). "Long-term outcome for children with autism who received early intensive behavioral treatment," American Journal on Mental Retardation, 4, 359-372) in which they reevaluated the 9 best-outcome children from the original study when they were about 13 years old (These "children" are today, in 1998, an average of 26 years old since the data for this study was gathered in 1984-1985). In addition to measuring the IQ of these children at follow-up, two other tests, the Vineland Adaptive Behavior Scales and the Personality Inventory for Children, were used to evaluate this group. These tests are designed to detect any psychological disturbances and to determine if a child has the behaviors needed to cope with everyday life. All tests were administered by professionals who did not know the children’s personal or treatment histories.
The results of the follow-up study demonstrated that the gains made by these children persisted. Eight of the 9 children continued to succeed in normal education classes. One child had been placed in special education classes subsequent to the original study, but one child originally placed in special education classes had later been moved to regular education classes. The IQ scores of the 9 best-outcome children were the same as at the end of the original study. Independent examiners were given a mixed group of these best outcome children and typical children to test, using all the measures discussed above. The examiners were given no information whatsoever on the children being tested. These "blind" examiners could not distinguish the best-outcome children from their typical peers on measures of cognitive, academic, social or adaptive skills.
Dr. Jay Birnbrauer and Dr. David Leach of Murdoch University published the best effort thus far at replication of the original study by Lovaas (Birnbrauer, J.S. & Leach, D.J. (1993) "The Murdoch early intervention program after 2 years," Behaviour Change, 10, 63-74). They found that 4 of 9 children receiving behavioral treatment made significant progress and were approaching normal levels of functioning, while only 1 of 5 children receiving no behavioral treatment made significant progress. This study was limited in three ways. First, there was a limited number of children available for the study. Second, the children receiving behavioral intervention were only supplied 20 hours of treatment per week on average as opposed to the 40 hours per week supplied in the Lovaas study. Last, due to a lack of funding, the study was only able to continue for two years. Despite all this, the data is consistent with the results reported in the original Lovaas study.
Criticisms of the UCLA Studies
It is unlikely that any two studies in the field of autism have generated as much excitement and undergone as much scrutiny as the original behavioral intervention study published in 1987 and its follow-up published in 1993. A number of criticisms have been leveled at these two studies, some of which identify legitimate areas for improvement in the studies and some of which are no more that distortions of the truth. The following is a list of commonly seen criticisms of the Lovaas studies. This list is by no means comprehensive. It should be pointed out that five experts in the field of autism wrote commentaries which were published alongside the 1993 article. Each agreed that the 9 best-outcome children appeared to have made significant gains and that these gains could be attributed to the behavioral treatment.
Children were not randomly assigned to the experimental and control groups. This is absolutely true. The suggestion made by critics is that the experimental group was intentionally loaded with higher functioning children and all the lower functioning children were placed in the control group. In fact, distribution between the experimental and control groups was made solely on the basis of resource availability. If there were adequate resources to give a child 40 hours per week of one-to-one behavioral treatment, then the child was assigned to the experimental group. If these resources were not available at the time of referral, then the child was assigned to the control group receiving 10 hours or less of behavioral treatment. The children in the second control group were not assigned to this group by Lovaas and his colleagues but were part of a group being treated by other professionals. Lovaas and his colleagues could have assigned these children on a completely random basis; however, most reputable institutions consider it unethical to assign to groups in this manner. Most ethics review boards prefer children to be assigned based on the availability of treatment. More importantly, the three groups of children were shown by all test measures to be essentially identical prior to treatment, eliminating the argument that the study was rigged for success.
The children in the study were not representative of autistic children as a whole. Some critics have suggested that the children in the experimental group had abnormally high IQ scores at intake and were, therefore, high functioning children who would have done well regardless of treatment. This is just not true for several reasons. First, a recent publication comparing treatment programs ("The Effectiveness of Early Intervention," edited by M. J. Guralnick, (Paul H. Brookes Publishing Co., 1997)) listed the average IQ scores at intake for eight different programs, including the UCLA program. The average intake IQ scores reported for these programs were essentially identical. Second, the experimental group was shown to be identical to the two control groups prior to treatment and yet the two control groups did not make any significant progress. Third, there is no evidence in the literature that higher functioning children with autism make gains regardless of treatment.
Lovaas and his colleagues claimed they cured children of autism. Lovaas and his colleagues demonstrated that it was possible for children with autism to achieve "normal functioning" through intensive behavioral treatment. Nowhere in any of the literature published by the Lovaas group is the claim made that behavioral intervention is a cure for autism.
The best-outcome group did not achieve "normal functioning." Some critics have questioned whether the best-outcome group achieved normal functioning or just attained high functioning status, retaining some residual features of autism. In the 1993 follow-up study, a battery of test measures were used to determine cognitive, social, communicative and behavioral functioning. These test measures were applied to the best-outcome group as well as to typical children by professionals blind to the identity or background of the children. These professionals were unable to detect any evidence of autism.
The 1987 study relied heavily on the use of aversives. Aversives - a sharp "no" or a light slap on the thigh - were used as part of the treatment procedure in a few cases where children exhibited high rates of aggression and self-stimulatory behaviors. New methods, devised by Lovaas and other researchers, have replaced the use of aversives. Currently, no reputable program uses aversives.
Other treatment programs are just as effective. A chapter in a recently published book ("Early Intervention in Autism" by G. Dawson and J. Osterling, in The Effectiveness of Early Intervention," edited by M. J. Guralnick, (Paul H. Brookes Publishing Co., 1997)) reviewed eight early intervention programs for children with autism. Dawson and Osterling state that "there exists little evidence that the philosophy of the program is critical for ensuring a positive outcome as long as certain fundamental program features are present." However, the review is both misleading and factually incorrect in some instances. Of the eight programs reviewed, four (including the UCLA program) utilize the same intensive one-to-one behavioral (discrete trials) intervention used by Lovaas in his 1987 study, while a majority of the rest use behavioral intervention in one form or another. These facts were not made clear in the review. The four programs not using one-to-one behavioral teaching (LEAP, TEACCH, Colorado Health Sciences and Walden Preschool), have not published any data comparing outcomes of children in the program to those in control groups. Comments on the outcomes for these programs, as reported by Dawson and Osterling, are as follows:
TEACCH. It was reported that 4 year old autistic children gained 15-19 IQ points by 9 years of age. In fact, this gain was seen only by the most severely retarded autistic children. In the end, their IQ scores were still in the mentally retarded range. When all of the children examined were included in the comparison (severely retarded, mildly retarded and nonretarded), it was found that no gain in IQ was made from age 4 to age 9. Despite being in existence since 1972, and having published numerous articles in the field of autism, the faculty at TEACCH have yet to publish any peer-reviewed research supporting the effectiveness of their treatment approach. The only evidence offered to demonstrate the effectiveness of the TEACCH program are the results from some parent satisfaction surveys.
Colorado Health Science. According to Dawson and Osterling, this program resulted in the "doubling of developmental rate in several areas." This increase in developmental rate was determined by using a method known as prediction analysis. Prediction analysis attempts to determine what progress is due to treatment and not just the result of normal maturation. Prior to treatment, a child is tested to determine their skill levels in areas such as language or cognition. These measured skill levels are expressed, in months, as the developmental level of the child. For example, a 40 month old autistic child may be determined to have language skills equivalent to a 20 month old typical child prior to treatment.
The developmental level is divided by the child’s actual age to determine a baseline development rate. In the case given here, the child’s developmental rate for language is 0.5, the result of dividing the 20 month developmental level by the child’s actual age of 40 months. Prediction analysis says that this is the rate of development expected of an autistic child in the absence of any treatment. At an age of 50 months the child is expected to have language skills equivalent to a 25 month old typical child. This prediction is made by multiplying the child’s actual age by the development rate (0.5 x 50 months = 25 months).
After a period of treatment, the predicted developmental level is compared to the measured developmental level. If the measured developmental level is higher than the predicted developmental level, then the treatment is considered effective by prediction analysis. If at an actual age of 50 months the child was determined to have language skills equivalent to a 30 month old typical child, then the treatment would be considered effective because the skill level was greater than that predicted (25 months).
Prediction analysis is not always reliable and is not a rigorous evaluation of a treatment. In addition, though the children in the Colorado Health Science program made some progress in the areas of cognition, language, fine motor skills and social skills, these skills never came close to reaching age appropriate levels.
LEAP. Children in the LEAP program were described as making "significant" gains in language, cognitive and motor skills. Like the Colorado Health Science outcomes, these gains were based on a form of prediction analysis. It was also claimed that 50% of the LEAP children go on to placement in "regular education classrooms." However, it is not clear if these children required any supports in these classes. Placement in regular education classes can be a misleading statistic as the children could require extensive supports or none at all (as in the case of the 9 best-outcome children in the Lovaas study). Some school districts mandate full inclusion.
Walden Preschool. The Walden program also used school placement (86%) as fundamental proof of the treatment effectiveness. Walden also observed that language use tripled after treatment. However, if a child was using only a few words prior to treatment, this may not be a significant gain. No measures were taken to show if improvements were made in the areas of cognitive function, social skills and behavior.
In conclusion, none of these four programs have published treatment results that come close to matching those achieved by Lovaas and his colleagues. Most treatments today claim to be effective and to help autistic children "progress." However, since the basis for these claims can vary greatly, these treatments must be held to a higher standard. Parents should ask: What kind of outcomes, supported by peer-reviewed research, does this treatment produce? The goal should not be "any progress" but the maximum possible measurable progress that children with autism can make.

Video

The Behavioural Treatment of Autistic Children

· There will be a question from this video on the final exam

Autism starts at birth, or first 30 months

Lack social and self-help skills

Rarely play appropriately with toys

“Self-stimulation” (odd playing with toys, rocking)

Some have extreme tantrums, may injure themselves

Extremely inattentive and do not seek approval of others

Half are mute, the rest generally repeat what the person says (echolalia)

Deficits

Language

Emotional attchemnt

Attention

Toy play

Peer play

Self-help

Additional Symptoms

Self stimulation

Isolation

Aggression

Specific causes remain unclear

BF Skinner’s operant conditioning had large influence on behavioural treatment for autism

Lisa, 3 years old

· Likes to arrange and rearrange favourite objects

· Does not speak

· Does not play with toys

· Sitting is reinforced with food and praise, kisses on cheek a reinforcement for Lisa

· Tantrums are ignored and not reinforced (should extinguish)

· At first, Lisa would increase tantrums when they stopped being reinforced (“extinction burst”), but eventually diminished

· Using reinforcement, Lisa eventually learned to sit without needing a prompt

Study 1:

Treatment progress for Pamela, Ricky (case study, both tracked over many years):

o First month: nouns

o Second month: verbs

o Third month: prepositions

o Six months: social actions

o Eight months: conversations (e.g., “what’s your name”)

o Twelve months: social spontaneity

o Fourteen months: storytelling

o Eighteen months: significant improvements, but can be lost without constant reinforcement

Pamela (as adult), lives in hospital

· Able to carry out household tasks

· Lost most of speech from above treatment

Ricky lives at small teaching hospital

· Lost most of language skills, spontaneity

· Developed recreational skills

For both Ricky and Pam, lost most of their language from 14 months of treatment when treatment stopped

Beahaviour treatment

Promoted complex behaviour like language

Longer the treatment lasted, better the improvement

Stopped self-injury, etc.

BUT

Children never caught up

Regressed when treatment was removed

1970s:

Treated in community

Parents involved

Longer treatments

Study 2:

Scientific study to examine this treatment:

40 hours of treatment a week (10 hours in control group)

Longitudinal study

Before treatment:

· Rejected parental warmth

· Inattentive

· Severe tantrums

· Did not play with toys

· Not toilet trained

· Self-stimulation

· None played with peers

· Mute

In study, autistic children were taught:

· how to dress

· appropriate eating

· Games and play

· Imitation of gestures

· Imitation of speech

· Identification of objects

Chris, 11 years old:

· Difficulty with language

· Problems with attention

· Over 10-year period, had received over 1500 hours in treatment

· However, iq did not improve (extensive time in treatment does not always help)

· Adaptive and self-help skills DID improve

Val

· Iq raised from 34 to 54

· Able to be placed in developmentally delayed class

· Gained good conversational skills

Ian

· IQ rose 40 points to normal range

· 5 years after treatment, indistinguishable from friends

Results – those in the experimental group (but not control):

Gained an avg of 20 iq points

9/20 gained normal functioning (no one in the control did)

Those with normal functioning

· gained 37 iq points

· maintained normal functioning, IQ many years later

Neil

· IQ rose from MR to mentally superior range

· Gained language, was able to move treatment into home

· At 14, 9 years after treatment, he is indistinguishable from peers

· Enrolled in gifted program

This type of treatment (in the study) was much more cost-effective than a lifetime in supervised care

Additional notes on video:

· Can this treatment be considered a cure for autism? In medicine, a 50% (9/20 approx. 50%) success rate WOULD be considered a cure

· Treatment would be considered successful

· For Pamela and Ricky, treatment is removed because money runs out

o An example of AB-reversal (because treatment was started, removed, then started again)

o Unintentional experimental study where he/she serves as own control – very important, because it showed this behavioural technique is an effective treatment

· Study 2: efforts to replicate experiment, but very expensive

· Behavioural therapy counter-intuitive

· “Cured” children probably do have propensity towards Autism (because it is partially genetic)

Autistic Spectrum Disorders

This lecture corresponds to the lower left-hand box on the second page

Autism

Used to be called childhood schizophrenia

DSM 4“pervasive developmental disorders”

To be replaced with Autism Spectrum Disorders

Other Disorders in this category

Autism

Asberger’s

Disintegrative disorder (replaced childhood schizophrenia)

Rett’s

All under umbrella of “childhood psychoses” – loss of touch with reality

- Movement to place them all on different points in one “spectrum” in next DSM – some seem qualitatively different

Autism is frequently misdiagnosed as a physical condition early in development – e.g. deafness (because not responsive)

Severe autism:

· hallmark symptom #1: no social interaction

· because there is no interaction, it is extremely difficult to assess what information he/she is processing

· often co-morbid with mental retardation

o difficult to “tease apart” severe autism and MR

· Still difficult to diagnose childhood psychoses

DSM V considers labelling ADD, tic disorders, Autism, and Conduct Disorder as “neural developmental disorders,” because they all clearly have a neurological base

Significant overlap in Autism and “childhood schizophrenia”

v Pervasive is (possibly) being replaced with Autism Spectrum Disorders

v Childhood Mental Disorders will be replaced with “Neural Developmental Disorders”

Might create new personality disorder with “depressive personality disorder”

Schizophrenia: extremely difficult to diagnose in children because “delusions” are common in childhood (e.g. imaginary friends)

Infantile Autism

Leo Canner: first proposed term/diagnosis

“Extreme Autistic alone-ness”

· Acknowledgment of no social interaction

· Not interacting with their caregivers

· Do not include others in activities

· Do not react with pleasure or displeasure in the absence or presence of a caregiver

· Qualitatively different from child without Autism

· Unable to relate to people and wants to be left alone

· If interaction is forced, Autistic children tend to become distressed, have a ‘meltdown”

· Hallmark symptom #2: self-stimulation (unclear why they do this): e.g. staring at hands, objects, for hours; handwringing

· Likely to respond angrily, in an irritated manner to adult who reaches out to them

· Rarely make eye-contact

· Can be treated behaviourally (first step is teaching/conditioning a child to make eye contact)

· Hallmark #3: lack of eye-contact

· Behavioural therapy is typically done with positive reinforcement

· Those with Autism often the result of premature birth

· By the time the child is a toddler, can clearly see symptoms

· Tend to have a fondness for inanimate objects

· React violently to changes in environment

· Photographic memory

· Hallmark #4: poor speech

· Speech is acquired in only 50% of Autistic children

· Even those with moderate Autism can function (e.g. get a degree)

· Don’t seem to understand/feel pain in the same way

· Echolalia: will repeat back what person just said “parrot-like speech” (if autistic child develops speech, it tends to be echolalia, repetitive, “concrete” – e.g. one phrase will be used in every situation)

· Canner thought it was organic, despite lack of evidence

· Evidence suggests Autism is NOT a form of MR (have normal intelligence)

· Hallmark #5: stereotyped patterns of behaviour: e.g. moving a ball around in the same way for hours

· NOT a result of vaccinations

Subtypes of Autism

· Savant Syndrome:

o Excel at e.g., musical skill, memory; very specific areas of cognitive functioning

· Asbergers

o Asperger’s: “nerdiness” a form of Asbergers

o Clearly not MR

o Don’t understand sarcasm

o Sheldon form “Big Bang Theory” great example

Associated Characteristics of Autism

· Neurodevelopmental disorder

· Related to environmental causes

· Lower SES

· Parents tend to be “emotionally cold” – coldness could me genetic

· By 5, do become sligntly more social

o May become compulsive about routines

· More rare than depression, schizophrenia – occurs in 5-10 in 1000 children

· More prevalent in boys than girls (suggests biological origin)

· Again, seems to be a neurological disorder

· Evidence shows parents tend to be more intelligent

Genetics

· Twin studies difficult, due to rarity of Autism

· Seems to be 36% percent heritability (suggests strong genetic relationship)

· Caused by multiple genes

· Seems to be no reliable genetic markers

· Some research has shown increased serotonin, at the same level of other psychoses, therefore not indicative of Autism itself

Neurobiology

· CAT scans - can make 3D images

· MRI – can make better 3D pictures, and no radiation (expensive)

· fMRI – can show which parts of brains are active (extremely expensive)

· Left temporal lobes affected in those with autism

· Also, asymmetry in left side of the brain (makes sense because LH key in speech production)

Childhood Schizophrenia

Term used today is “disintegrative disorder”

“catch-all phrase” for all children with severely abnormal behaviour

different from adult schizophrenia

“Schizophrenia” thought of as involving delusions and hallucinations – actually, this is not typically seen in childhood psychoses

Typical onset between the ages of 2-11

Like autism, affective responses, cognitive functioning, social skills are all diminished

Profound decrease in people, events, and activities – loss of contact with other people and reality

Typically do not play with toys

Often have “flattened affect” – NO emotion

Bizarre body movements, can be repetitive like in Autism

Catatonic: “extreme movements,” also seen in schizophrenia

Strong genetic component

Behavioural treatments also effective

Inability to modulate sensory input (may be common to all ASD – autistic people often like to limit sensory input)

· However, some treatments are sensory overload (paradoxically)

Differences between Autism and Childhood Schizophrenia:

· List of differences in outline can be found in the outline on page 3

· Those with childhood schizophrenia tend to look pale

· Differences in alpha and beta wave functioning

· Less stiff than autistics

· Clumsy

· Do NOT see savants

Paper 3 Q,. Do you think it is useful to treat the parent of a child with ADHD?
Video is at the end of lecture notes which are scanned files.
And there is additional reading as well.