We start our review of each Autistic Spectrum syndrome by presenting the diagnostic criteria for each of the DSM-IV PDD disorders, as defined out by the American Psychiatry Association:
1. Autistic Disorder (click here for more details about autism)
(A) total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
1. qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
2. qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped patterns of interest that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
(d) persistent preoccupation with parts of objects
(B) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
(C) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
2. Asperger’s Syndrome
Symptoms of Asperger’s include: impaired ability to utilize social cues such as body language, irony, or other “subtext” of communication; restricted eye contact and socialization; limited range of encyclopedic interests; perseverative, odd behaviors; didactic, verbose, monotone, droning voice; “concrete” thinking; over-sensitivity to certain stimuli; and unusual movements.
Official DSM-IV criteria are similar to that for Autistic Disorder except do not include the “communication” problem areas: in other words, autistic people who talk well. [Many experts would argue that although verbal speech is preserved in Asperger’s, other communication problems certainly exist.]
(A) Qualitative impairment in social interaction, as manifested by at least two of the following:
1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
2. failure to develop peer relationships appropriate to developmental level
3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
4. lack of social or emotional reciprocity.
(B) Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
2. apparently inflexible adherence to specific, non-functional routines or rituals
3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
4. persistent preoccupation with parts of objects
(C) The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
(D) There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)
(E) There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.
(F) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
Listen to the speech pattern of kids with Asperger's
3. PDD-NOS (PDD-Not Otherwise Specified)
This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this category includes atypical autism --- presentations that do not meet the criteria for Autistic Disorder because of late age of onset, atypical symptomatology, or subthreshold symptomatology, or all of these.
4. Rett’s Disorder
The current DSM-IV criteria are given below. Thanks to the development of a new genetic blood test, though, we are finding Rett’s Disorder in children with much milder symptoms.
(A) All of the following:
1. apparently normal prenatal and perinatal development
2. apparently normal psychomotor development through the first 5 months after birth
3. normal head circumference at birth
(B) Onset of all of the following after the period of normal development:
1. deceleration of head growth between ages 5 and 48 months
2. loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing)
3. loss of social engagement early in the course (although often social interaction develops later)
4. appearance of poorly coordinated gait or trunk movements
5. severely impaired expressive and receptive language development with severe psychomotor retardation
5. Childhood Disintegrative Disorder (CDD)
(A) Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior.
(B) Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas:
1. expressive or receptive language
2. social skills or adaptive behavior
3. bowel or bladder control
4. play
5. motor skills
(C) Abnormalities of functioning in at least two of the following areas:
1. qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity)
2. qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of varied make-believe play)
3. restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and mannerisms
(D) The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by Schizophrenia.
(2) Expanded Autistic Spectrum Disorders
Next, we turn our attention to those Autistic Spectrum Disorders that are not included in DSM-IV:
High Functioning Autism
For some authors, this term is synonymous with Asperger’s syndrome. For others, it implies milder autism without retardation, or PDD-NOS.
Non-Verbal Learning Disabilities (NVLDs): trouble with the gestalt/integration of non-verbal information
NVLDs are a cluster of symptoms presumably related to poor ability to integrate information by the non-dominant hemisphere (typically the right hemisphere). Although rote verbal language is spared, non-verbal areas may be debilitating. These children have trouble with the ability to integrate it all together, i.e., to see the big gestalt picture rather than the details. In short, they can’t “see the forest for the trees.”
Although verbal communication is highly prized in school (good talkers, readers, and writers), up to 2/3 of communication actually occurs non-verbally. Thus, in the long run, the maladaptive learning of NVLD may be more destructive than typical LD. Estimates are that 0.1 to 1% of population has a NVLD, compared to 10% of population has a LD, although these numbers may be an artifact of who and how we test.
Difficulty integrating non-verbal information occurs in three main areas:
(1) Motoric integration problems:
Gross motor: clumsy, unbalanced walking leading to clinging behaviors, bumping in to things, fear of climbing, hesitant to explore physically, difficulty bike-riding, uncoordinated at sports.
Fine motor: using scissors, shoe tying (which she’ll talk herself through), poor handwriting using awkward and tight grip, finger agnosia.
(2) Visual-Spatial-Orientation integration problems, with inability to form visual images:
Resultant focus on detail rather than the important gestalt.
Labels everything verbally, since that is the only—albeit not always accurate—way she can process the visual/spatial information. For example, she may find her way home by counting houses and labeling landmarks verbally.
Unaware where she is in space, so unaware of where to place answers on the homework sheet, or how to navigate the school.
These elaborate “naming” strategies break down with changes in routine, leading to an inability to cope with change.
(3) Social/communication problems:
Trouble integrating non-verbal communication with verbal communication to achieve full social interaction.
The children do clearly appear to want social acceptance (vs. Asperger’s, where the children do not usually appear interested socially).
However, typically labeled as “annoying” because of their dependence on others, their constant speech, and their misinterpretation of social cues.
Very literal interpretation of others; concrete thinking; seeing the world in black and white; trouble understanding dishonesty; trouble seeing hidden meanings, prompting others to say “You know what I meant!”—when they didn’t.
Don’t read the social cues of give and take conversation, thus appearing self-centered, weird, or impolite.
NVLD symptoms change through the lifespan:
Symptoms as toddlers:
Uncoordinated (gross motor and fine motor).
Trouble with social interactions, non-verbal clues (such as a peer’s facial expression of “Enough is enough!”), and adjustments to change. They may appear “confused.”
Warning signal: You always have to tell the child, “I shouldn’t have to tell you that.” Obviously, with these kids, you do have to tell them. That’s how you know there is a problem.
Trouble with spatial orientation.
As a young child:
Often exceptional rote speech, memory, and reading skill, which the children use to compensate for lack of intuitive social interaction. The child tries to “remember” how to interact, rather than the skill coming automatically in each different situation.
These exceptional reading and “adult” pedantic speech patterns may be interpreted as preciousness.
Clumsy monologues replace typical to-and-fro conversations.
Older children:
Academic problems in the later elementary years with organization, inferential reading, and written output.
Math facts better than concepts.
Typically PIQ
A life of social blunders, without ever figuring out why.
May have secondary depression or anxiety.
NVLD is determined by neuropsychological testing, whereas Asperger’s is determined by detailed history and observation. There is great overlap in these two conditions—perhaps due to co-morbidity; or perhaps, as some authors feel, they are essentially the same condition but labeled by different specialties. However, Asperger’s is most primarily notable for not appearing interested in forming human bonds. [The degree to which Asperger’s kids actually are painfully aware of their trouble making bonds is debated in the literature. Nevertheless, they typically appear uninterested.] NVLD kids, though, do typically appear interested in human bonds--even though they may be clueless how to actually achieve them successfully. Additionally, children with Asperger’s more typically have diminished “symbolic play” than in NVLD. For example, the toy school bus is a box that rolls, rather than something that little plastic figures climb into.
So, how about this for a gross oversimplification? NVLD kids recognize that you exist while they miss the subtext of what you are saying. Asperger’s kids appear behind a plane of glass as they miss the subtext of what you are saying.
References: Sue Thompson’s article NVLD at http://www.nldontheweb.org/thompson-1.htm
David Dinklage, in the Spring 2001 issue of the AANE (Asperger's Association of New England). Article can be found at http://www.nldontheweb.org/Dinklage_1.htm.
Semantic-Pragmatic Communication Disorder
From “Semantic and Pragmatic Difficulties” by Caroline Bowen at
http://members.tripod.com/Caroline_Bowen/spld.htm.
See also an excellent site on SPLD at http://www.geocities.com/DeniseV2/
and www.hyperlexia.org/sp1.html on SPLD by Margo Sharp.
“Semantics” refers to the ability to use and understand words, phrases and sentences, including abstract concepts and idioms. “Pragmatics” refers to the practical ability to use language in a social setting, such as knowing what is appropriate to say, where and when to say it, the give and take nature of a conversation, and the ability to know what the other person does or does not already know. (See above for further discussion.)
Thus, semantic-pragmatic communication disorder kids have the root problem in:
Difficulty understanding the literal meaning of words and sentences. (semantics)
Difficulty with abstract words, words about emotions, idioms, and words about status such as “expert.” (semantics)
Difficulty extracting the central idea. (pragmatics)
Trouble with the appropriate rules of conversation (monologues, talking “at” you). (pragmatics)
This inability to understand verbal language and the purpose of language leads to the typical secondary problems we have discussed before:
An almost obsessive need for sameness and routine, since new situations are hard to understand.
Too much stimulus is overwhelming, leading to avoidance.
Things are more predictable than people, perhaps one reason why these children may be more drawn to objects than interpersonal relationships.
Trouble attending to correct task
Impulsive “butting in” on conversations.
Take everything literally, leading to confusion, anxiety, and social rejection.
Life of a child with SPLD through the years:
Often, very easy infants.
Delayed development of speech with few words even by two years old.
Trouble with creative or symbolic play.
Simple speech improves with therapy, but in school child is “odd.”
Good rote skills in math and computers, perhaps, but poor writing and socialization skills.
Parrot back more than they understand, leading to an aura of intellectual maturity out of synch with their social skills.
Trouble understanding what others are really thinking or feeling, i.e. trouble with theory of mind.
Many have fine motor problems; some have gross motor difficulties as well.
They may have trouble knowing what is socially acceptable, but are not usually conduct disorder teens.
May be “eccentric” adults.
Differentiation of SPLD from other Autistic Spectrum Disorders
SPLD kids tend to have somewhat better socialization skills than Asperger's.
SPLD kids tend to have more early delays in speech than Asperger's.
The appropriate label may change over time as the child matures.
Hyperlexia
The following description comes largely from: Phyllis Kupperman, et al. “Hyperlexia” at the American Hyperlexia Association website at http://www.hyperlexia.org/hyperlexia.html.
Hyperlexia is a condition almost always in boys where Austistic Spectrum symptoms are accompanied by a striking capacity for rote reading. By 18-24 months of age, these kids have taught themselves the ability to name letters and numbers. By three years old, they may read printed words, exceeding even their ability to talk. By five years old, all have a fascination with the printed word. Some of the children seemed to have a mild regression at 18—24 months (less severe than as in Autism).
In addition to this unusual reading skill, there are the other typical common Autistic Spectrum Disorder symptoms we have seen, such as:
Language problems
Good rote or echoed language.
Trouble translating words into larger gestalt ideas.
Repetitive, idiosyncratic speech.
Pragmatic language problems.
Unusual prosody (rhythm) of speech.
Socialization problems
See “Secondary Problems from Failure to Understand.”
Stereotyped, ritualistic behaviors.
Anxiety.
Trouble making friends.
?ADHD
ADHDers typically have trouble with “Executive Functions,” with subsequent difficulties in their relationship with others. Usually, though, they have adequate capacity for empathy—but may have trouble inhibiting their behavior long enough to show it. Conversely, many children with Autistic Spectrum may appear to have a short attention span, but just aren’t able to stay focused on situations they don’t understand.
It is probably best to consider ADHD as sometimes sharing the following symptoms with—but not part of—the Autistic Disorders Spectrum:
· Poor reading of social clues (“Johnny, you’re such a social klutz. Can’t you see that the other children think that’s weird.”)
· Poor ability to utilize “self-talk” to work through a problem (“Johnny, what were you thinking?! Did you ever think this through?”)
· Poor sense of self awareness (Johnny’s true answer to the above question is probably “I don’t have a clue. I guess I wasn’t actually thinking.”)
· Do better with predictable routine.
· Poor generalization of rules (“Johnny, I told you to shake hands with your teachers. Why didn’t you shake hands with the principal?)
Conclusion (Finally!)
The classification of the Autistic Spectrum Disorders is in a state of flux. The problems can overlap, cause each other, occur simultaneously in different combinations and severities, change over time, and don’t even have one “official” group attempting the classification of the whole spectrum. (Hence, this paper.)
However, unless we know all of the possible syndromes, we will continue to squeeze everyone into the same category or two. Most importantly, unless we know the full range of the Autistic Spectrum Disorders, we will not identify all of the individual symptoms which require treatment.
With trepidation, I offer the following gross oversimplifications. I am reminded of my professor’s comment on the first day of medical school: “One third of what I am going to tell you this year is wrong. Unfortunately, I don’t know which third.”
Autistic Spectrum disorders are marked by their difficulty in communication/socialization in areas other than the literal meaning of words.
Once a child has trouble with getting the big picture of communication and socialization, there will often be secondary symptoms such as: anxiety, holding back from peers, a rigid adherence to sameness, a relative preference for things (which are predictable) rather than people, and an appearance of “oddness.”
Asperger’s and Autism share primarily the difficulty of recognizing the existence of others—trouble with theory of mind. Asperger’s can talk; autism usually has limited speech.
Asperger’s children appear less interested in forming bonds and have more trouble with “theory of mind” than NVLD and Sematic-Pragmatic Disorder.
NVLDs are marked by integration problems of pragmatic language gestalt; spatial orientation; and motoric coordination.
Hyperlexia is marked by fascination with the printed word starting at an early age.
“High Functioning Autism” is used by different authors to mean either Autistic Disorder with relatively spared speech and cognition; Aspergers’s Syndrome; or PDD-NOS.
