The use of the ADI-R as a diagnostic tool in the differential diagnosis of children with infantile autism and children with a receptive language disorder

Children with infantile autism and children with a specific receptive language disorder often show similar behavioural problems, making the differentiation between these two diagnostic categories difficult. The purpose of this study is to evaluate the usefulness of parental information in the differential diagnosis of the two types of disorders mentioned above. Sixteen children with a receptive language disorder and 11 children with infantile autism participated in the study. All children had normal non-verbal IQs. The ADI-R (Autism Diagnostic Interview-Revised) was performed with all children. The results showed that the ADI-R items reflecting behavioural features at pre-school age (age range 4–5 years) were better suited to differentiate the groups than the items reflecting behavioural features at the time of the investigation (mean age: 9 years). The items on the dimension “Reciprocal social interaction” and “Communication and language” discriminated the groups better than the items of the dimension “Restricted interests”. According to the ICD-10 algorithm of the ADI-R one child with autism and one child with a receptive language disorder were falsely classified. These false classifications were mainly due to a distorted parental perception of the child's behaviour. The ADI-R is a useful tool in the differential diagnosis of developmental disorders. Accepted: 27 April 2001     

Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder

Several studies have described problems in motor functions in children with autism and children with a specific speech and language disorder. The purpose of this study was to identify neuromotor deficits in these neurodevelopmentally impaired children. A standardised neurological examination was performed in 11 children with childhood autism, 11 children with an expressive language disorder, 11 children with a receptive language disorder and 11 control children. The children were matched for age and non-verbal IQ, not for gender. All children had a non-verbal IQ above 85. The neurological examination procedure allowed for a qualitative and quantitative assessment of five specific neurological subsystems: fine and gross motor functions, balance, coordination and oral motor functions. The high-functioning children with autism and the children with a specific language disorder (expressive or receptive) had more motor problems than the control children on most neurological subsystems. There were few statistically significant differences between the three groups of developmentally impaired children. The frequent co-occurrence of verbal and non-verbal, in particular neuromotor, deficits in developmentally impaired children put an additional burden on the development of these children and should be diagnosed as early as possible. Accepted: 8 May 2002 The research was funded by grant AM 63/4–2 of the Deutsche Forschungsgemeinschaft. Correspondence to Dr. M. Noterdaeme     

Repetitive behaviors in autistic disorder

Introduction: Repetitive behaviors are common in autistic disorder, as in other developmental disabilities. Behaviors as diverse as stereotypies, cognitive inflexibility, and a need for sameness are grouped together under DSM IV classification, even though they are diverse in phenomenology, underlying neural circuitry, and possible clinical significance. In order to better define repetitive behaviors, we studied the relationship between such behaviors and chronological age, developmental level, estimated IQ, presumed mood state, severity of illness, as well as behavior reactivity to environmental stimuli, in a group of 121 consecutive autistic children, aged 2–4 and 7–11 years. Results: Younger autistic children displayed more motor and sensory repetitive behaviors. Older children had more complex behaviors. Children with higher IQ scores, likewise, demonstrated more complex repetitive behaviors. Most motor behaviors and self injury showed features of reactivity. Conclusions: Certain “repetitive” activities may not represent core features of autistic disorder and may be equivalent to normal motor and cognitive behaviors, as seen during typical development. Accepted: 28 August 2002 Correspondence to Mark T. Palermo, MD     

Evaluation of emotional and behavioral problems in language impaired children using the Child Behavior Checklist

Speech and language impaired children are at special risk for developing psychiatric disorders. Attention deficit, aggressive behaviour as well as overanxiety and excessive shyness have been reported in speech and language impaired children. The purpose of this study was to determine how the Child Behavior Checklist (CBCL) could be used as a screening instrument in language impaired children. In a sample of 83 language impaired children, emotional and behavioural problems were evaluated using the CBCL. Independent of this assessment, DSM-IV diagnoses were established for all children. Sixty-six of the 83 children had a psychiatric diagnosis. The use of the Total Behavior Problem score (TBP) as a global measure of behavioural disturbance showed that children with a psychiatric diagnosis had significantly higher scores on the TBP score than children without a psychiatric diagnosis. The specificity of the TBP was 88.2%, the sensitivity 75.8%, and the false classification rate 21.6%. The most frequently reported behavioural disturbances were problems on scale VI (“Attention Problems”-39 children) and on scale I (“Withdrawn”-32 children). A small group of children with a receptive language disorder and pronounced compulsive behavioural problems had elevated scores on scale V (“Thought Problems”). Accepted: 10 August 1998     

DSM-IV Conduct Disorder symptoms in adolescents as markers of registered criminality

A nationwide sample of 1,079 Norwegian adolescent psychiatric in-patients, 581 males and 498 females, were followed up after 11–33 (mean 23.2) years. On the basis of detailed records from index hospitalisation they were re-diagnosed and retrospectively scored on 14 of the 15 behaviour items listed as diagnostic criteria for conduct disorder in DSM-IV. The patient list was linked to the national criminal registry, and 48 % were found to have a criminal record. The ability of the 14 behaviour items to identify overall and specific kinds of registered criminality was investigated. In males, “stealing” was the strongest marker for overall and violent crime. “Having forced someone into sexual activity” was a strong marker for later sex offences. In females, “running away from home” was strongly associated with overall and violent registered criminality. ROC curves were constructed to test the sensitivity and specificity of the sum of conduct disorder behaviour items fulfilled in the identification of individuals with registered criminality. The area under the curve was 0.81 (95 % c. i. = 0.78–0.85) in males and 0.75 (95 % c. i. = 0.71–0.80) in females. A cut-off at 3 criteria fulfilled seemed optimal in males and somewhat high in females. Accepted: 17 May 2001     

Early childhood autism and the question of egocentrism

An individual's social competence is often considered in terms of his role-taking abilities. In the light of studies by Piaget, it has been supposed that a child's developing capacity to appreciate the viewpoints of others in a social context is reflected in his ability to recognize points of view in a visuospatial setting. If this is valid, then visuospatial role-taking tasks may afford a measure of some relatively “cognitive” component of the capacity to engage in social behavior. Tasks in which subjects were required to make judgments about different and yet related views of a three-dimensional scene or object, together with tests of operational thinking, were presented to normal children and to subjects with the diagnosis of infantile autism. The results indicate that autistic children are no more impaired in their recognition of visuospatial perspectives than are normal children of comparable intellectual level in tests of operational thinking. A further, more limited study yielded suggestive evidence that over this series of tasks, autistic children perform as well as subjects with Down's syndrome who have a similar verbal mental age. These findings render it improbable that autistic children are especially “egocentric” in their appreciation of visuospatial perspectives. The present research was undertaken in partial fulfillment of a Ph.D. degree at the Institute of Psychiatry, University of London. Some of the tasks were originally devised in collaboration with David Mant in the course of undergraduate work at Cambridge University. I am indebted to the subjects who took part in the study and to the teaching staff who helped me, particularly Mrs. Wendy Brown, Mrs. Elizabeth Kelleher, and the staff at the Helen Alisson School for Autistic Children, Gravesend. I am grateful to Dr. Beate Hermelin, Professor Michael Rutter, and Dr. Peter Clark for their encouragement and advice, and to Ms. Maria Callias and Dr. Richard Cromer for their helpful criticisms.     

Growth of Head Circumference in Autistic Infants During the First Year of Life

This study analyzed the increase in head circumference (HC) of 85 autistic infants (64 boys and 21 girls) during their first year of life. The data were collected from their “mother-and-baby” notebooks. This notebook is a medical record of the baby’s growth and development delivered to the parents of all babies born in Japan. This is a retrospective study which gathered the data from the notebooks after the diagnosis of autism. However, none of the babies were known to have autism at the time the records were made. The head circumference at birth of these autistic children was similar to that of the average found in a Japanese Government Study of 14,115 children. However, it showed a marked increase at 1 month after birth. The discrepancy reached a peak at 6 months, while the difference became smaller at 12 months. Body length (BL) and body weight (BW) began to increase at 3 months, although at a rate smaller than the head circumference increase.     

Evaluation of attention problems in children with autism and children with a specific language disorder

Children with autism and children with a specific language disorder show additional attention deficits. The literature on the neuropsychological investigation of attention in both groups of children suggests that the nature of their attention problems might be different. The purpose of this study is to examine the attention test profiles in these two groups of children with developmental disorders. Nineteen children and adolescents with autism, 17 subjects with a specific language disorder and 19 control subjects participated in the study. Non-verbal intelligence was normal for all subjects. The “Testbatterie zur Aufmerksamkeitsprüfung” was administered to all subjects. This instrument provides the possibility to examine a wide range of attention functions and executive functions. The results showed that the autistic individuals had deficits in executive functions, whereas the language impaired children had deficits in auditory sustained attention, in auditory selective attention, and in the domain of executive functions. It is concluded that although both groups of developmentally impaired subjects showed attention problems, the deficits are not the same in both groups. The different neuropsychological profiles probably reflect different mechanisms in the pathogenesis of the attention deficits in both types of developmental disorders. Accepted: 1 September 2000     

Gilles de la Tourette Syndrome in a child with congenital deafness

We present the case of a 10-year-old boy, Sam, with congenital deafness and Gilles de la Tourette Syndrome (GTS). GTS is characterised by multiple motor tics and one or more vocal tics that wax and wane. Due to his deafness Sam never developed vocal language but instead used sign language from the age of four. His tic disorder rapidly accelerated from the age of seven over a six-month period and soon sign language was incorporated into tics as complex “vocal” tics. Bursting out “words”in sign language would also occur in front of people unfamiliar with sign language and often with an obscene content although this was not evident to someone not trained in sign language. To our knowledge this is the first reported case of a congenital deaf child with GTS. The case presented here supports previously published work that the intentional share of the tics in GTS is very small. This case also questions former theories on which regions and circuits of the brain are involved in GTS. Accepted: 16 May 2001     

The opinion of caregivers on aspects of schizophrenia and major affective disorders in a Nigerian setting

Background In Nigeria the burden of caring for persons with severe mental disorders rests largely on families whose attitudes to these conditions have not been explored. Objectives To assess the opinion of relatives of 75 schizophrenics and 20 major affective disorder cases on aspects of the disease and compare with the responses of relatives of cancer, infertility and sickle cell disease (SCD) cases. Method Caregivers were assessed using a burden questionnaire that contained items on etiological beliefs and attitudes to illness. Results The responses of relatives of the two psychiatric illness groups were similar. The single most important etiological factors were that “it is Satan's work” (35.8 %) and “it is a natural illness“ (23.2 %). Other factors were “genetic” (9.5 %), “witchcraft” (10.5 %) and “curse by enemies” (10.5 %). This was similar to the opinion of cancer and infertility caregivers; but different from SCD where the most important causative factors were “genetic” (41.5 %) and “natural” (21.5 %). Psychiatric caregivers had higher frequency of anger and stigma. Over two-thirds of psychiatric caregivers felt glad caring for the patient and would not like the patient institutionalized. Most families were thought to be supportive and there was an impression that caring had made family emotional ties closer. Conclusions These families were tolerant and would cooperate with health authorities. Causative models are influenced by available knowledge and practices in the culture. To actualize the potential of families to play useful community psychosocial roles, there is a need for public mental health literacy and welfare support. Accepted: 10 July 2001     

Adult attachment style. I: Its relationship to clinical depression

Background Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002). Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into “Angry-dismissive” and “Withdrawn”. The degree to which attitudes and behaviour within such styles were dysfunctional (“non-standard”) was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder. Results The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the “non-standard” levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder. Conclusion The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance. Accepted: 21 September 2001     

Social use of language in children with reactive attachment disorder and autism spectrum disorders

Children with a diagnosis of reactive attachment disorder (RAD) appear to show difficulties in social understanding. We aimed to compare the pragmatic language functioning of children with (RAD) and autism spectrum disorder (ASD). Assessments were made in three groups of children aged 5–8 years, with verbal IQ estimates in the normal range: 35 with a RAD diagnosis, 52 with an ASD diagnosis and 39 with typical development. The Children’s Communication Checklist (CCC) was used to compare their pragmatic language skills, and ADI-R algorithms were used to compare autistic symptomatology, according to parent report. According to the CCC, the RAD group demonstrated significant problems in their use of context, rapport and social relationships with a degree of severity equivalent to children in the ASD comparison group. More than 60% of the group with RAD met ADI-R clinical criteria on the Use of Language and Other Social Communication Skills subscale, 46% on the Reciprocal Social Interaction subscale, and 20% had significant repetitive and stereotyped behaviours. Children with RAD appear to be at least as impaired as children with ASD in certain domains of social relatedness, particularly in their pragmatic language skills.     

Non-specific markers of neurodevelopmental disorder/delay in selective mutism

Selective mutism (SM) in children is frequently associated with language disorder/delay suggesting that neurobiological factors may be involved in the development of SM. Motor co-ordination problems, reduced optimality pre- and perinatally and minor physical anomalies represent other markers for neurodevelopmental disorder/delay. The present study explores these markers in referred children with SM (n=54), non-referred matched controls (n =108) and in SM subgroups with and without a communication disorder (CoD). Children with SM differed significantly from controls in parent-reported motor developmental delay, and they obtained a higher pre- and perinatal “reduced optimality score”. They scored significantly lower on a motor performance test and showed a higher frequency of minor physical anomalies compared with controls. There were no differences in these respects between SM and CoD compared with SM without CoD. The results confirm that neurobiological factors may be involved in the development of SM. Accordingly, the clinical assessment of referred children with SM should include a thorough history of motor development and an evaluation of present motor skills. The interplay of shyness/social anxiety and motor function problems has to be addressed to reduce misunderstandings of the child's behaviour and to adjust demands for motor skills to the actual level of the child. Accepted: 12 October 2001     

Autism in Northern Finland

 Resent research reports show that autistic spectrum disorders may actually be more common than previously believed. General awareness and clinical knowledge of these disorders have increased, and the criteria in the ICD-10 and the DSM-IV are also now more detailed. The diagnostic criteria and the methods of ascertainment influence the prevalence. The age specific incidence obtained in this study showed the cumulative incidence to be lowest, 6.1 per 10 000, in the oldest age group of 15- to 18-year-old children, and highest, 20.7 per 10 000, in the age group of 5–7 year-olds, when the criteria of the ICD-10 and the DSM-IV were used. In this study, almost 50% of the autistic cases had a tested IQ above 70. The degree of autism, as assessed by the Childhood Autism Rating Scale (CARS), varied from mild autistic features in 8.5% through moderate in 58.5% to severe in 33.0%. Accepted: 15 November 1999     

Reliability and validity of a child-specific cross-cultural instrument for assessing posttraumatic stress disorder

 The Posttraumatic Stress Symptoms in Children (PTSS-C) was developed as a cross-cultural semi-structured interview to diagnose posttraumatic stress disorder (PTSD) and to identify PTSD-non-related posttraumatic stress symptoms in children after various traumatic experiences. The psychometric properties were studied in two different child populations in Iraqi Kurdistan (the survivors of the military operation “Anfal”, and the orphans), in a sample of Kurdistanian refugee children in Sweden, and in a comparison sample of Swedish children. The instrument yielded satisfactory internal consistency, high interrater agreement, and excellent validity on cross-validation with the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI) and the Diagnostic Interview for Children and Adolescents (DICA) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Accepted: 14 March 2000     

Comparison of psychotic and autistic children using behavioral observation

The purpose of this study was to assess the relationship between autism and childhood psychosis. Fifteen children with psychotic symptoms were compared to 15 children with autism, using two observational measures, the Ritvo-Freeman Real Life Rating Scale (RLRS) and the Childhood Autism Rating Scale (CARS), which rate subjects on behaviors pathognomic to autism. In comparison to autistic persons, psychotic individuals were judged to have better language and social skills. In addition, autistic persons were also rated as having more difficulty adapting to new situations and appeared more autistic-like. Overall scores on the CARS and RLRS were significantly different between the two groups, indicating that these two assessment instruments may be useful in differential diagnosis. However, 20% of the psychotic subjects received pervasive developmental disorder diagnoses, indicating that there may be a relationship between those two disorders.     

Infantile autism and developmental receptive dysphasia: A comparative follow-up into middle childhood

An interim follow-up study of a group of higher functioning boys with infantile autism and control group of boys with severe (receptive) developmental language disorder (or dysphasia) is reported. The boys were compared both initially and at follow-up for overall functioning in the areas of language, peer relationships, stereotyped behaviors, and disruptive public behaviors, as well as for the presence of a number of specific symptoms. In some respects, the behaviors that differentiated the groups initially did so also at follow-up, although there were important differences. Very few of the autistic boys had good language skills at follow-up, whereas nearly half of the dysphasic group were communicating well, a difference that is striking in view of the initial general similarity between the groups in terms of poor language functioning. However, some of the dysphasic children had developed greater difficulties in peer relationships. The implications for concepts of the nature of the deficit in severe receptive developmental language disorders are considered.     

Randomized Controlled Trial for Early Intervention for Autism: A Pilot Study of the Autism 1-2-3 Project

We piloted a 2-week “Autism-1-2-3” early intervention for children with autism and their parents immediately after diagnosis that targeted at (1) eye contact, (2) gesture and (3) vocalization/words. Seventeen children were randomized into the Intervention (n = 9) and Control (n = 8) groups. Outcome measures included the Autism Diagnostic Observation Schedule, Ritvo-Freeman Real Life Rating Scale, Symbolic Play Test, and Parenting Stress Index. Children with autism improved in language/communication, reciprocal social interaction, and symbolic play. Parents perceived significant improvement in their children’s language, social interaction, and their own stress level. This intervention can serve as short-term training on communication and social interaction for children with autism, and reduce the stress of their parents during the long waiting time for public health services.     

Brief Report: No Increase in Criminal Convictions in Hans Asperger’s Original Cohort

Hans Asperger originally used the term “autistic psychopathy” to describe his patients on the autism spectrum, leading to a possible confusion with psychopathic disorder and delinquent behaviour. We conducted a penal register search for 177 former patients of Asperger’s clinic with a childhood diagnosis of “autistic psychopathy” or features of the disorder in Austria. The mean percentage of registered convictions was similar to that in the general male population of Austria over the studied time period. A qualitative assessment of offence types in Asperger’s former patients suggests that the nature of offences does not differ from that in the general population. In this original cohort of Asperger’s patients, convictions were no more common than in the general male population.     

Is social anxiety disorder in childhood associated with developmental deficit/delay?

Children with social anxiety disorder (SAD) have been reported to display reduced social skills. Less attention has been paid to whether neurodevelopmental deficits/delays (NDD’s) in language and motor function may contribute to their impaired social skills. The present study aimed to assess the extent of language and motor impairment in children with SAD. A population-based screened sample consisting of 150 children (11–12 years) was assessed with a diagnostic interview (Kiddie-SADS), the Wechsler Abbreviated Scale of Intelligence (WASI) and the Motor Assessment Battery for Children (MABC). Test results were compared across five diagnostic groups: SAD (n = 29); ADHD (n = 23); SAD and ADHD (n = 6); “other disorder” (n = 44) and “no disorder” (n = 48). Delays in language and motor development as reported by mother were also investigated. Verbal IQ and motor skills were reduced and maternally reported delay was more frequent in the SAD group compared to the “other disorder” and “no disorder” group.