Which symptoms of deficits in social communication and interactions did Sam exhibit? Be specific (refer to the diagnostic criteria in your notes for a list of possible symptoms.
Please read the case study and fill out the worksheet, either by typing into the document or by typing the answers into a separate document
Requirements: complete
308 Case Studies in Abnormal Psychology environmental factors were important in Bill’s life? In what we know about the case, was there any evidence for his father having antisocial traits? 2. Which symptoms of antisocial personality disorder did Bill have? 3. Research suggests that the most effective treatment for antisocial personality disorder is to prevent cases in the first place by focusing on children and adolescents at risk for the disorder. What are the obstacles to doing this? 4. The difficulty in treating people with antisocial personality disorder poses great challenges for our society, given their higher rates of violence and criminal behavior. Some have advocated keeping such people incarcerated until they are older in an attempt to prevent their future crimes. What do you think about this? What are the pros and cons of such an approach? CHAPTER 21 Autistic Disorder Sam Williams was the second child of John and Carol Williams. The couple had been married for 5 years when Sam was born; John was a lawyer and Carol a homemaker. Sam weighed 7 pounds, II ounces at birth, which had followed an uncomplicated, full-term pregnancy. Delivered by Caesarean section, he came home after 6 days in the hospital. His parents reported that Sam’s early development seemed quite normal. He was not colicky, and he slept and ate well. During his first 2 years, there were no childhood illnesses except some mild colds. By Sam’s second birthday, however, his parents began to have concerns. He had been somewhat slower than his older sister in achieving some developmental milestones (such as sitting up alone and crawling). Furthermore, his motor development seemed uneven. He would crawl normally for a few days and then not crawl at all for a while. Although he made babbling sounds, he had not developed any speech and did not even seem to understand anything his parents said to him. Simple requests such as, “Come” or, “Do you want a cookie?” elicited no response. Initially, his parents thought that Sam might be deaf. Later they vacillated between this belief and the idea that Sam was being stubborn. They reported many frustrating experiences in which they tried to force him to obey a command or say “Mama” or “Dada.” Sometimes Sam would go into a tantrum during one of these situations, yelling, screaming, and throwing himself to the floor. That same year, their pediatrician told them that Sam might be mentally retarded. As he neared his third birthday, Sam’s parents noticed him engaging in more and more strange and puzzling behavior. Most obvious were his repetitive hand movements. Many times each day, he would suddenly flap his hands rapidly for several minutes (activities like this are called self-stimulatory behaviors). Other times he rolled his eyes around in their sockets. He still did not speak, but he made smacking sounds and sometimes he would burst out laughing for no apparent reason. He was walking now and often walked on his toes. Sam had not been toilet trained, although his parents had tried. Sam’s social development was also worrying his parents. Although he would let them hug and touch him, he would not look at them and generally seemed
310 Case Studies in Abnormal Psychology indifferent to their attention. He also did not play at all with his older sister, seeming to prefer being left alone. Even his solitary play was strange. He did not engage in make-believe play with his toys-for example, pretending to drive a toy car into a gas station. Instead, he was more likely just to manipulate a toy, such as a car, holding it and repetitively spinning its wheels. The only thing that really seemed to interest him was a ceiling fan in the den. He was content to sit there for as long as permitted, watching intently as the fan spun around and around. He would often have temper tantrums when the fan was turned off. At the age of 3, the family’s pediatrician recommended a complete physical and neurological examination. Sam was found to be in good physical health, and the neurological examination revealed nothing remarkable. A psychiatric evaluation was perrormed several months later. Sam was brought to a treatment facility specializing in behavior disturbances of childhood and was observed for a day. During that time the psychiatrist was able to see firsthand most of the behaviors that Sam’s parents had described-hand flapping, toe walking, smacking sounds, and preference for being left alone. When the psychiatrist evaluated Sam, she observed that a loud slapping noise did not elicit a startle response as it does in most children. The only vocalization she could elicit that approximated speech was a repetitive “nah, nah.” Sam did, however, obey some simple commands such as “Come” and “Go get a potato chip.” She diagnosed Sam as having autistic disorder and recommended placement in a day-treatment setting. Conceptualization and Treatment Sam was 4 years old by the time there was an opening for him at the treatment center. He attended the special schoolS days a week, spending the remainder of his time at home with his parents and sister. The school provided a comprehensive educational program conducted by specially trained teachers. The program was organized mainly along operant conditioning principles. In addition, Sam’s parents attended classes once a week to learn operant conditioning so they could continue the school program at home. The school’s personnel conducted another evaluation of Sam, observing him in the school and later at home. Interviews with the parents established that they were both well adjusted and that their marriage was stable. Both parents were, however, experiencing considerable stress from having to cope with Sam on a day-to-day basis and from their fears that his condition might have been caused by something they had done. One of the first targets of the training program was Sam’s eye contact. When working with Sam, his teacher provided small food rewards when Sam spontaneously looked at him. The teacher also began requesting eye contact and again rewarded Sam when he complied. Along with this training, the teacher worked on having Sam obey other simple commands. The teacher would wait for a time when Sam seemed attentive and would then, establishing eye contact, say the command and model the desired behavior by demonstrating it. For example, the Chapter 21 Autistic Disorder 311 teacher would say, “Sam, stretch your arms up like this,” lifting Sam’s arms up and rewarding him with praise and a small amount of food, such as a grape. This procedure was repeated several times. Once Sam began to become more skilled at following the command, the teacher stopped raising Sam’s anns for him and had him do it himself. These training trials were conducted daily. As Sam’s response to a particular command became well established, the teacher would expand his learning to following commands in other situations and by other people. Sam’s progress was slow. It often took weeks of training to establish his response to a simple command. After his first year in the school, he responded reliably to several simple requests such as “Come,” “Give it to me,” and “Put on your coat.” At the same time that Sam was learning to respond to commands, other aspects of the training program were also being implemented. While Sam was in the classroom, his teacher worked with him on trying to develop skills that would be important in learning, for example, sitting in his seat, maintaining eye contact, and listening and working for longer periods of time. His teacher used the same reward strategy to teach Sam each activity. As these skills became better established, the teacher also began working on expanding Sam’s vocabulary by teaching him the words for pictures of commOn objects. A picture of one object, such as an orange, was placed on a table in front of Sam. Once Sam had looked at the object, the teacher said, “This is an orange. Point to the orange.” When Sam pointed to the orange, he was rewarded. If necessary, the teacher would move his hand for him at first. Next another picture, such as a cat, was selected and the same procedure followed. Then the two pictures were placed in front of Sam and the teacher asked him to point to one of them: “Point to the orange.” If Sam pointed correctly, he was rewarded. If he did not, the teacher moved his hand to the correct object: After Sam had correctly pointed to the orange several times in a row, the teacher asked him to point to the cat. With that response established, the teacher switched the position of the pictures and repeated the process. When Sam had begun to point correctly to the orange and the cat, a third picture was introduced and the training procedure was started anew. During I year of training, Sam learned the names of 38 common objects with this procedure. Sam’s speech therapist, whom he saw daily, was also working with him on language skills. Initially, they worked on getting Sam to imitate simple sounds. Sitting across a table from Sam and waiting until Sam was looking (or prompting him to look by holding a piece of food near his mouth), the teacher would say, “Say this, ah,” taking care to accentuate the movements required for this sound. At first, Sam was rewarded for making any sound. Subsequently, rewards were given when Sam approximated more and more closely the required sound. As sounds were mastered, Sam was trained to say simple words in a similar fashion. Over the COurse of a year, Sam learned a few words-“bye-bye,” “no more,” and “mine,” but overall, his verbal imitation remained poor. Teaching Sam to dress and undress himself was another target during the first year. Initially, his teacher helped him through the entire sequence, describing
312 Case Stud.ies in Abnormal Psychology each step as they did it. Next, they would go through the sequence again, but now Sam had to do the last step himself (taking off his shoes, putting on his shoes). More difficult steps (tying shoes) were worked on individually to give Sam more practice on them. Once some progress was being made, this aspect of the treatment was carried out by the parents. They first observed the teacher working with Sam and then discussed the procedure and were shown how to make a chart to record Sam’s progress. Over a period of weeks, the number of steps that Sam had to complete by himself was gradually increased, moving from the last toward the first. Sam was rewarded each time he dressed or undressed, usually with a special treat, such as a favorite breakfast food. In this case, the training was quite successful. By midyear, Sam had mastered dressing and undressing. Toilet training was another area that Sam’s parents and teachers tackled. At home and at school, Sam was rewarded for using the toilet. He was checked every hour to see if his pants were dry. If they were, he was praised and reminded that when he went to the toilet he would get a reward. Shortly thereafter, Sam would be taken to the toilet, where he would remove his pants and sit. If he urinated or defecated, he was given a large reward. If not, he was given a small reward just for sitting. As this training was progressing, Sam was also taught to associate the word “potty” with going to the toilet. Progress was slow at first, and there were many “accidents,” which both teachers and parents were instructed to ignore. But Sam soon caught on and began urinating or defecating more and more often when he was taken to the bathroom. Then the parents and teachers began working on having him tell them when he had to go. When they checked to see if his pants were dry, they would tell him to say “potty” when he had to go to the toilet. Although there were many ups and downs in Sam’s progress, by the end of the year he was having an average of fewer than two accidents per week. Sam’s temper tantrums slowed his progress during his first year in the special school. They occurred sometimes when he was given a command or when a teacher interrupted something he was doing. Not getting a reward during a training session also led to tantrums. Sam would scream loudly, throw himself to the ground, and flail away with his arms and legs. Several interventions were tried. Sam’s tantrums usually led to getting his own way, particularly at home. For example, a tantrum had often resulted in getting his parents to keep the ceiling fan on, even when they wanted to tum it off. Ignoring the tantmm was the first approach. Sam’s teachers and parents simply let the tantmm play itself out, acting as if it had not happened. This did not reduce the number of tantrums, so “time-out” was tried. Every time a tantrum started, Sam was picked up, carried to a special room, and left there for 10 minutes or until the screaming stopped. This procedure also failed to have much of an effect on the tantrums and screaming, even with several modifications such as lengthening the time-out period. During Sam’s second year of treatment, many of the first year’s programs were continued. Sam, now 6 years old, was responding to more commands, and his ability to recognize and point to simple objects increased. In speech therapy, Chapter 21 Autistic Disorder 313 he learned to imitate more sounds and some new words (“hello,” “cookie,” and “book”), but his progress was slow and uneven. He would seem to master some sound or word and then somehow lose it. He was still dressing and undressing himself and using the toilet reliably. Feeding skills were one of the first targets for the second-year program. Although his parents had tried to get him to use a knife, fork, and spoon, Sam resisted and ate with his fingers or by licking the food from his plate. Drinking from a cup was also a problem. He still used a baby cup with only a small opening at the top. The feeding skills program was implemented by both Sam’s teachers and parents and involved a combination of modeling and operant conditioning. Training sessions conducted at mealtime first involved getting Sam to use a spoon. Sam was shown how to hold the spoon; then the teacher picked up the spoon, saying, “Watch me. You push the spoon in like this and then lift it up to your mouth.” Sam did not initially imitate, so the teacher had to guide him through the necessary steps: moving his hand and spoon to pick up food, raising his arm until the spoon was at his mouth, telling him to open his mouth, and guiding the spoon in. Praise was provided as each step in the chain was completed. After many repetitions, he was required to do the last step by himself. Gradually, more and more of the steps were done by Sam himself. Successes were followed by praise and failures by saying “no” or removing his meal for a short time. When eating with a spoon was well established, the training was expanded to using a fork and drinking from a cup. In several months, Sam was eating and drinking well. Sam’s failure to play with other children was also a major focus during the second year. The first step was to get him to play near other children. Most of his playtime was spent alone, even when other children were in the playroom with him. His teacher watched Sam carefully and rewarded him with small bits of food whenever he was near another child with autistic disorder. A procedure was also used to force Sam to interact with another child. Sam and another child would be seated next to each other and given the task of stacking some blocks. Each child was, in turn, given a block and prompted to place it on the stack. In addition to praising them individually as they stacked each block, both children were rewarded with praise and food when they had completed their block tower. After repeating this process several times, the program was expanded to include the cooperative completion of simple puzzles. “Sam, put the dog in here. Okay now, Hannah, put the cat here.” Gradually the prompts were faded out, and the children were simply rewarded for their cooperative play. Although this aspect of therapy progressed well, transferring these skills to the natural play environment proved difficult. Attempts were made to have Sam and another child play together with toys such as a farm set or a small train. The teacher encouraged them to move the objects around, talking to them about what they were doing and rewarding them for following simple commands. Although Sam would usually follow these commands, his play remained solitary, with little eye contact or cooperation with the other child.
314 Case Studies in Abnormal Psychology Sam’s self-stimulatory behavior was a final target of the second year. Sam’s hand flapping and eye rolling had already decreased somewhat over the past year, perhaps because more of his day was being filled with constructive activities. Now a specific intervention, to be used by Sam’s teachers and his parents, was planned. Whenever Sam began hand flapping, he was stopped and told to hold his hands still, except when told to move them, for 5 minutes. During the 5-minute period, he was told to hold his hands in several different positions for periods of 30 seconds. If he did not follow the command, the teacher or parent moved his hands into the desired position; if he did not maintain the position for 30 seconds, the teacher or parent held his hands still. Food rewards were provided for successful completion of each 30-second period. Gradually, the teachers and parents were able to get Sam to comply without moving his hands for him or holding him. Then they turned to the eye rolling and implemented a similar program, having Sam fix his gaze on certain objects around his environment whenever he began to roll his eyes. Over a period of several months of training, Sam’s self-stimulatory behavior decreased by about 50 percent. At the beginning of his third year in school, Sam, now 7 years old, was given an intelligence test and achieved an IQ of 30, a score reflecting severe mental retardation. The language and speech training continued, as did the anempts to reduce the frequency of his self-stimulatory behavior. His tantrums, which had not responded to previous interventions, were becoming worse. In addition to screaming and throwing himself on the floor, he now became violent at times. On several occasions, he had either punched, bitten, or kicked his sister. His parents reported that during these tantrums he became so out of control that they feared he might seriously injure someone. Similar episodes occurred in school, usually when an ongoing activity was interrupted or he failed at some task. Trouble had also emerged on the school bus. All children were required to wear seat belts, but Sam would not do so and was often out of his seat. Twice in one week, the bus driver stopped the bus and tried to get Sam buckled back into his seat. He bit the bus driver once the first time and twice the second. The bus company acted quickly and suspended service for Sam. In an initial attempt to resolve the problem, Sam was put on haloperidol (Haldol), a drug widely used in the treatment of schizophrenia in adults. But after a month of the drug and no apparent effect, it was stopped. In the meantime, Sam’s mother had to drive him to and from school. He was beginning to miss days or be late when his mother had schedule conflicts. The seriousness of the tantrum problem and the fact that other treatments had not worked led to the implementation of a punishment system. Because Sam’s tantrums and violent outbursts were almost always preceded by loud screaming, it was decided to try to break up the usual behavior sequence and punish the screaming. Whenever Sam began to scream, a mixture of water and Tabasco sauce was squirted into his mouth. The effect of this procedure, which was used by both his teachers and parents, was dramatic. The first day of the treatment, Sam began screaming and was squirted six times. His response to Chapter 21 Autistic Disorder 31: the Tabasco mixture was one of shock and some crying, which stopped quickly after he was allowed to rinse out his mouth. The next day, he was squirted with the Tabasco twice. The third and fourth days, he did not scream at all. The fifth day, he had one screaming episode; thereafter, he neither screamed nor had a severe temper tantrum again for the rest of the year. Sam’s progress in other areas was not so dramatic. His vocabulary slowly expanded, as he learned to say more words and recognize more and more objects. But his performance was highly variable from day to day. His self-stimulatory behavior continued, although at a level below that which had been present earlier. He remained isolated, preferring to be alone rather than with other children. Discussion Autistic disorder was first described in 1943 by a Harvard psychiatrist, Leo Kanner, who noticed a group of disturbed children that behaved differently than children with mental retardation or with schizophrenia. He named the syndrome early infantile autism because they had an extreme autistic aloneness that shut out anything from the outside. Kanner considered autistic aloneness the most fundamental symptom, but he also found that these children had been unable from the beginning of life to relate to other people, were severely limited in language, and had an obsessive desire that everything about them remain exactly the same. Despite its early description by Kanner and others, the disorder was not accepted into official diagnostic nomenclature until the publication of DSM-lll in 1980 (APA). In DSM-IV-TR (APA, 2000) autistic disorder is classified as one of the Pervasive Developmental Disorders. A major feature of autistic disorder is abnormality in social development (Volkmar, Chawarska, & Klin, 2005). Children with autistic disorder have a lack of interest in or difficulty relating to people, which is found from the very beginning of life. Infants with autistic disorder are often reported to be “good babies” because they do not place any demands on their parents. They do not fret or demand attention, but nor do they reach out or smile or look at their mothers when being fed. When they are picked up or cuddled, they often arch their bodies away from their caretakers instead of molding themselves against the adult as other babies do. They are content to sit quietly in their playpens for hours, never paying attention to other people. After infancy, they do not form attachments with people but may become extremely attached to mechanical objects such as refrigerators or vacuum cleaners. As children, they often do not initiate interactions with others, use facial expressions to communicate with others, share enjoyment with others, or offer empathy to others (Bishop, Ganahan, & Lord, 2007). They rapidly fall behind their peers in development. Clearly, this feature was very characteristic of Sam. Although he did not actively avoid human contact or develop an attachment with a mechanical object, he was almost totally asocial.
316 Case Studies in Abnormal Psychology Communication deficits are a second major feature of autism. Even before the period when spoken words are usually acquired, infants with autistic disorder show deficits in communication. Babbling, an early stage of language development when infants repeat sounds such as ba-ba-ba, is less frequent in those with autistic disorder and conveys less information than it does with other children (Ricks, 1972). Older children with autistic disorder also have difficulties with language. Mutism-complete absence of speech-is prevalent, as was true with Sam. About SO percent of all children with autistic disorder never learn to speak (Paul, 1987). When they do speak, peculiarities are often found, including echolalia, where children echo, usually with remarkable fidelity, what they have heard another person say. In delayed echolalia, the child may not repeat the sentence or phrase until hours or weeks after hearing it. Another abnormality common in the speech of children with autistic disorder is pronoun reversal. They refer to themselves as “he,” “you,” or by their own proper names; they seldom use the pronouns “I” or “me” and then only when referring to others. The ability or inability to speak is often an effective means of predicting the later adjustment of children with autistic disorder, an additional indication of the central role of language. Billstedt, Gillberg, and Gillberg (2007) followed up a community sample of 105 people with autistic disorder from early childhood until young adulthood. They found that those who had developed some spoken language by age 5 had a better outcome as adults than those who had not. In fact, language development by age 5 was the best predictor of adult outcome among these individuals with autistic disorders. Based on these findings, we would predict a relatively poor outcome for Sam. A third major feature of autistic disorder is restricted or stereotyped interests (Volkmar et aI., 2005), including compulsive and ritualistic activity, such as a fascination with spinning objects, as shown by Sam. Furthermore, children with autistic disorder often become extremely upset over changes in daily routine and their surroundings. An offer of milk in a different drinking cup or a rearrangement of furniture may make them cry or bring on a temper tantrum. Even common greetings must not vary. In play, they may continually line up toys or construct intricate patterns out of household objects. They engage in much less symbolic or make-believe play than either normal or mentally retarded children of the same mental age (Sigman, Ungerer, Mundy, & Sherman, 1987). They may become preoccupied with train schedules, subway routes, or number sequences. Clearly, Sam displayed many of these behaviors. In addition to these three major signs, many children with autistic disorder have problems in eating, often refusing food or eating only one or a few kinds of food. This hyperresponsiveness, an aversion to new stimuli, is also seen in oversensitivity to new sounds or tactile experiences. Hyperresponsiveness was once thought to be unique to children with autistic disorder, but is actually strongly linked to mental age; it is observed among children who are mentally retarded as well (Baranek, Boyd, Poe, David, & Watson, 2007). They may also have difficulty walking but be quite proficient at twirling and spinning Chapter 21 Autistic Disorder 317 objects and in performing ritualistic hand movements. Other rhythmic movements, such as endless body rocking, seem to please them. They may also become preoccupied with manipulating a mechanical object and be very upset when interrupted. Often the children have sensory problems. Like Sam, some children with autistic disorder are first thought to be deaf because they never respond to any sound; some even seem to be insensitive to sound or light. Development is usually delayed, with frequent difficulty in becoming toilet trained; head banging and other self-injurious behaviors are common (Bishop et aI., 2007). Children with autistic disorder whose intelligence score is in the normal range are able to describe their simple emotional experiences such as anger or happiness, but when describing complex emotions such as embarrassment or pride, their accounts are very simplified, even impoverished, and do not fit the context in which they were described as having occurred (Losh & Capps, 2006). Autistic disorder is being diagnosed more frequently (Barbaresi, Katusic, Colligan, Weaver & Jacobsen, 2005). From 1980 to 1983, the incidence was 5.5 per 100,000 children, but for 1995 to 1997, it was 44.9 per 100,000, an 8.2-fold increase. The increase was most noticeable after the publication of the DSM-llI-R in 1988 (APA), which broadened the diagnostic criteria and increased awareness of autism. It is probable that the increase in cases is at least in part due to these changes rather than to an actual increase in the disorder. In addition, the fact that autistic disorder is now being diagnosed at a younger age increases the prevalence rate (Wazana, Bresnahan, & Kline, 2007). It is likely that many real cases of autistic disorder used to go undetected, and it is still not clear whether autistic disorder is becoming more common or just being better identified. Boys have rates of autistic disorder that are three to four times higher than girls (Volkmar et al., 2005). There is a high comorbidity with seizure disorders. There has been a growing interest in autism spectrum disorders, particularly in Asperger syndrome. There is controversy about whether the spectrum disorders are really separate disorders, and the diagnostic criteria are not well defined (Volkmar, Lord, Bailey, Schultz, & Klin, 2004). Without clearly defined criteria, such disorders, especially Asperger syndrome, are likely to be overdiagnosed. Clinicians must be cautious about doing this because labeling a child who may just have poor social skills as having an autistic disorder could have negative implications for the child and family. About 75 to 80 percent of people with autistic disorder are mentally retarded (Kabot, Masi, & Segal, 2003). A very small number of individuals with autistic disorder have the rare savant syndrome, a discrete area of outstanding ability such as calendar calculation or art, music, or memory skills in some very specific area (Heaton & Wallace, 2004). Savant syndrome is associated with autistic disorder but is not understood. What happens to such severely disturbed children when they reach adulthood? Kanner (1973) reported the adult status of some of the children whom he had described in his original paper. Two developed epileptic seizures; by 1966, one of them had died and the other was in a state mental hospital. Four others
318 Case Studies in Abnormal Psychology had spent most of their lives in institutions. One had remained mute, but was working on a farm and as an orderly in a nursing home. The last two made at least somewhat satisfactory recoveries. Although both still lived with their parents and had little social life, they were gainfully employed and had some recreational interests. From his review of early follow-up studies, Loner (1978) concluded that only 5 to l7 percent of autistic children had a relatively good outcome in adulthood. Most of the remaining children had a poor outcome, and 50 percent were institutionalized. Recent studies have reached similar conclusions (Nordin & Gillberg, 1998). Etiological Considerations Investigators believe that neurobiological factors are the cause of autistic disorder (Volkmar et aI., 2005). A number of neurological abnormalities have been documented. Toddlers with autistic disorder have heads that are 10 percent larger in volume than those without autistic disorder (Volkmar et aI., 2004). This difference is not present at birth, and the overgrowth during toddlerhood and childhood tends to level off so that differences are not so marked during adulthood. The reason for these differences is not yet understood. Abnormalities are also found in the amygdala, hippocampus, and cerebellum; the nature and causes of these abnormalities are being investigated. Furthermore, the prevalence of autism in children whose mothers had rubella during the prenatal period is approximately lO times higher than in the general population of children. Genetic factors in the etiology of autistic disorder are well established. Siblings of children with autistic disorder have a 2 percent chance of also having the disorder (McBride, Anderson, & Shapiro, 1996). Although this is a small percentage, it represents a 50-fold increase in risk as compared to the morbidity risk in the general population. Further evidence of the importance of genetic factors in autistic disorder is provided by twin studies. Monozygotic twins have concordance rates of over 60 percent, whereas dizygotic twins have concordance rates of 0 percent (Muhle, Trentacoste, & Rapin, 2004). At least three to four but maybe as many as ten different genes are believed to interact to result in the phenotype of autistic disorder (Volkmar et aI., 2004). Some argue that there is not a single cause of autistic disorder, and that separate genes may be responsible for each of its three core features, social abnormalities, communication deficits, and restricted or stereotyped interests (Happe, Ronald, & Plomin, 2006). Family studies reveal delayed language acquisition and social deficits in some nonautistic relatives of index cases with autistic disorder (Piren, Palmer, Jacobi, Childress, & Arndt, 1997). Taken together, the evidence from family and twin studies supports a genetiC basis for autistic disorder. In Sam’s case, there was no evidence of any neurological abnormality, nor was there any family history of autism. However, his older sister did have a learning disability. Genetic factors alone may not be the only etiological contributor to autistic disorder. It is possible that genes create a susceptibility to environmental factors, Chapter 21 Autistic Disorder 319 such as toxins (Lawler, Croen, Grether, & Van de Water, 2004). There is no definitive evidence at this time that any specific toxin or teratogen is related, but there is some evidence implicating prenatal exposure to valproic acid, a drug used to treat seizures and bipolar disorder, and thalidomide, a drug that has been used in the past to treat morning sickness during pregnancy (Newschaffer et a!., 2007). In addition, links to neurotoxins in air pollution, pesticides in food, and insecticides are being researched further. Others have found that prenatal problems, such as maternal viral infections and vaginal bleeding during pregnancy, and birth complications, such as emergency cesarean section, prolonged labor, and multiple births (twins or triplets) are more likely among those with autistic disorder (Brimacombe, Ming, & Lamendola, 2007). There has been tremendous focus in the media on vaccines, specifically on thimerosal, a preservative used in vaccines, as playing a role in autistic disorder, following a research report published in 1998 that speculated about such a link. However, that report was retracted because it was based on insufficient evidence and because one of the authors had a financial incentive in a lawsuit against the vaccine manufacturers (Fleck, 2004). A fturry of research on vaccines followed, and no link with autistic disorder has been found (Parker, Schwartz, Todd, & Pickering, 2004). Unfortunately, many parents have withheld vaccines for their children out of fear due to the media reports, and as a result, many children are now at risk for those infectious diseases. There are also cognitive explanations for autistic disorder. One conceptualizes autistic disorder as stemming from a deficit in social cognition, such as not having a theory of mind, and the other frames it in terms of broader difficulties with information processing, such as problems with executive brain function (Happe et a!., 2006). Theory of mind is the ability to understand the mental states of others, including their perspective, feelings, and goals. Autistic individuals have deficits in theory of mind and also in broader social cognition and communicative abilities, such as empathy and imitation (Tager-Flusberg, 2007). Recent research suggests that the mechanism underlying this deficit may lie in problems with the mirror neuron system. The mirror neuron system consists of networks of neurons in the brain that acti vate in similar patterns whether one is performing an activity or watching someone perform that activity, like grasping an object (Oberman & Ramachandran, 2007). This mirror neuron system is thought to underlie many cognitive tasks, including motor, perceptual, and verbal functions, and may allow people to run internal simulations of the experiences of others and use these simulations to make predictions about them. Research has shown that people with autistic disorder do not have mirror neuron systems that function like those of others, and problems in this system could explain many different symptoms of autistic disorder, such as pronoun reversal, lack of imitative behavior, and a tendency to respond to the emotions of others in odd ways. These cognitive and neurological theories of the etiology of autistic disorder are not independent from other theories of etiology and may emerge from genetic or environmental sources.
320 Case Studies in Abnormal Psychology Treatment Numerous medications have been tried with autistic disorder, most commonly antipsychotics (e.g., haloperidol) and selective serotonin reuptake inhibitors (Palermo & Curatolo, 2004). Some improvement is found with these medications in reducing stereotyped motor behavior, social withdrawal, and aggression. However, positive effects are not found for language impairment and social deficits (McBride et aI., 1996). There has also been some interest in two other drugs-fenfiuramine, an amphetamine derivative, and naltrexone, a drug that blocks the brain’s opioid receptors. Both may lead to some improvement, although neither appears to alter the core symptoms of the disorder (Kolmen, Feldman, Handen, & Janosky, 1995; Rapin, 1997). The major psychological treatment for autism is behavior therapy. As we saw in Sam’s case, it requires a great expenditure of time and effort. Furthermore, autistic children have several problems that make teaching them particularly difficult. They have difficulty adjusting to changes in routine, such as substitute teachers. Their self-stimulatory behavior interferes with effective teaching, and finding reinforcers that motivate autistic children can be challenging. Whereas children without autism are often motivated by praise, this is not the case for many children with autism. In general, behavior therapists focus on reliably assessed, observable behav-iors and manipulate the consequences these behaviors elicit from the environment. As in Sam’s case, desirable behaviors (e.g., speech, playing with other children) are rewarded, and undesirable ones (e.g., hand flapping, screaming) are either ignored or punished. The desired behaviors are broken down into smaller elements that are learned first and then assembled into a whole. A good example of this procedure was seen in the procedures used to try to get Sam to speak. Modeling is a frequent adjunct in these operant behavior therapy programs. Intensive behavioral intervention programs have shown significant improvements in preschool children’s cognitive abilities, self-care skills, language, and positive social behavior (Remington et aI., 2007). Ivar Lovaas developed the intensive behavior therapy program with very young (under 4 years) children with autistic disorder (Lovaas, 1987). Therapy encompassed all aspects of the children’s lives for more than 40 hours a week for more than 2 years. Parents were trained extensively so that treatment could continue during almost all waking hours of the children’s lives. Nineteen children receiving this intensive treatment were compared to 40 control children who received a similar treatment for less than 10 hours per week. All children were rewarded for being less aggressive, more compliant, and more socially appropriate, including talking and playing with other children. The results were quite dramatic and encouraging for the intensive therapy group. Their measured IQs averaged 83 in first grade (after about 2 years in the intensive therapy) compared to about 55 for the controls; 12 of the 19 reached the normal range as compared to only 2 (of 40) in the control group. Furthermore, Chapter 21 Autistic Disorder 321 9 out of the 19 intensives were promoted to second grade in a normal public school, whereas only one of the much larger control group achieved this level of normal functioning. A 4-year follow-up showed that they had maintained their gains (McEachin, Smith, & Lovaas, 1993). A recent randomized control trial of this treatment approach confirmed that it was more effective than a parent training control group, although the gains were not as impressive as those reported originally above (Volkmar et aI., 2004). Moreover, other types of treatment have been shown to be effective as well. This ambitious study confirms the need for heavy involvement of both professionals and parents in dealing with the extreme challenge of autistic disorder. Such intensive treatment is expensive and time consuming, costing on average about $40,000 a year for each child (Shattuck & Grosse, 2007). However, the long-term dependence and loss of productive work in less intensively treated children with autistic disorder may represent a greater cost to society than a treatment that enables some of these children to achieve a normal level of functioning. Even with intensive early intervention, though, most children will not recover or have normal functioning, but will continue to have significant symptoms and impairment (Shea, 2004). Discussion Questions 1. To intervene in Sam’s tantrums and violent outbursts, the therapy involved squirting Tabasco sauce into his mouth when he started a tantrum by screaming. Do you think this form of intervention is ethical? What are the pros and cons of using such a treatment? 2. Had you heard before about the vaccine controversy related to autistic disorder? Despite repeated investigations that have exonerated vaccines, many parents are still refusing to vaccinate their children. What should researchers, physicians, and the media do about this? 3. Why are there increases in the number of diagnosed cases of autistic disorder? 4. The most effective treatment for autistic disorder is early intensive behavior therapy, which is very costly. What ethical dilemmas does this pose for our society? How should we balance the need for autism treatment with the need for preventative health care for other children with our limited health-care dollars?
Case Study #5 (Oltmanns et al.) – Active Learning Worksheet
Drawing on the case example, please answer each of the following questions below. You can use bullet points or sentences – but make sure to provide evidence and examples from the case to back up your points. Be as thorough as you can – often there are multiple examples for a question.
1. Which symptoms of deficits in social communication and interactions did Sam exhibit? Be specific (refer to the diagnostic criteria in your notes for a list of possible symptoms.
2. Which symptoms of deficits in restricted, repetitive patterns of behavior, interests, or activities did Sam exhibit? Be specific (refer to the diagnostic criteria in your notes for a list of possible symptoms.
3. What was the developmental progression of Sam’s disorder? What were the early warning signs vs. current manifestation of his disorder? What has gotten worse and what has improved?
4. Consider how Sam’s behavior meets the definition of abnormality according to the following dimensions. Give specific examples:
Distress
Disability
Deviation
Dysfunction
5. Identify the possible etiology of Sam’s disorder according to:
The biological perspective
Any other potential risk factors or factors in the environment that contributed to Sam’s disorder?
6. Evaluate Sam’s treatment, using evidence from the case study. Specifically:
What treatments did Sam receive? Why do these particular treatments make sense for this disorder and Sam’s presentation of it?
What were any issues (e.g., side effects, obstacles to adherence) with the treatment Sam received?
What do you think Sam’s prognosis is (i.e., how successful will be at treating his disorder and functioning well in his life)? What are the risk and protective factors in his case that will make him more or less likely to succeed?
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