The Triad of Impairments Past, Present and Future

1
The Triad of ImpairmentsPast, Present and Future

• Dr Judith Gould
• Director
• The NAS Lorna Wing Centre for Autism

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Development of the Concept of the Autism Spectrum

• Lotter (1960) in his Middlesex prevalence study,
  used Kanners criteria very strictly applied in a
  total population of children of all levels of
  ability.
• Wing and Gould (1979), in their Camberwell study,
  looked for any kind of strange behaviour in a
  total population of children identified as having
  any kind of special need. This group was
  selected because virtually all the children
  Lotter identified were known to have special
  needs.
• A group fitting Kanners criteria were
  identified, with the same prevalence as found by
  Lotter.
• A few children fitting Aspergers criteria were
  also identified. This group was very small
  because the mainstream children in the area were
  not screened.
• (continued)

3
Continued

• There were many more children who did not fit
  Kanners or Aspergers criteria but who had all
  kinds of mixtures of features of these
  syndromes.
• It was found that impairments of social
  interaction, communication and imagination could
  occur in a very wide range of manifestations.
  But, however they were manifested, there was a
  strong tendency for them to cluster together and
  to be associated with a narrow, repetitive
  pattern of activities. It was very difficult to
  draw neat boundaries between the named
  syndromes and those with the triad of
  impairments who did not fit into a syndrome.
• The concept of a spectrum of autistic disorders
  fitted the findings better than the categorical
  approach. This does not imply a smooth continuum
  from the most to the least severe. All kinds of
  combinations of features are possible.

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WING AND GOULD (1979)Camberwell study

• Group fitting Kanners criteria 4.9 in 10,000
• Group fitting Aspergers criteria 1.7 in 10,000
• (mainstream children in the area were not
  screened)
• Group with mixtures of features 15.4 in 10,000
• (The groups overlapped with each other.
  Clinical pictures on the borderlines could be
  classified differently by different workers)

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WING AND GOULD (1979)Camberwell study

• What held all these groups together was a triad
  of impairments of
• social interaction
• communication and
• imagination.
• There was a strong tendency for these
  impairments
• a) to cluster together
• b) to be associated with a narrow, repetitive
  pattern of activities.

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• The triad and the repetitive activities
• could be shown in a wide range
• of different ways

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Social Impairment

• Different manifestations

Aloof, indifferent Passive Active but odd, bizarre Over-formal, stilted Sociable with 1 person problems with groups ( Kanner Asperger
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Social Communication Impairment(verbal and
non-verbal)

• Different manifestations

No communication Communicates own needs Repetitive, one sided Formal, long-winded, literal ( Kanner Asperger)
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Imagination Impairment

• Different manifestations

Handles objects for simple sensations Handles objects for practical uses Copies pretend play of others Limited pretend play repetitive, isolated Invents own imaginary world but rigid, stereotyped ( Kanner Asperger
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Repetitive Activities

• Different manifestations

Bodily movements Fascination with sensory stimuli Simple, object directed Routines involving objects Routines in space or time Verbal routines Routines related to special skills Intellectual interests ( Kanner Asperger
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Other Features Often Present With The Triad

• Untypical patterns of
• Language comprehension / use
• Responses to sensory stimuli
• Movement and posture
• Attention / level of activity
• Eating / drinking / sleeping
• Mood
• Behaviour

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Factors Affecting the Clinical Picture

• The way the triad is manifested
• Associated features
• Associated disabilities developmental, physical,
  psychiatric
• The overall level of ability
• Age
• Gender
• Personality and temperament
• Environment
• Education

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Evidence For A Spectrum

• Many people show mixtures of features of
  different sub-groups
• One person can show different features in
  different environments
• One person can show different features at
  different ages
• Members of the same family can show different
  features
• Identical twins or triplets can show different
  features
• The same basic principles underlie methods of
  education and care for whole spectrum

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Conditions That May Be Associated With The
Spectrum

• Attention deficit/hyperactive disorder
• Tourettes syndrome
• Developmental receptive language disorder
• Dyspraxia
• Dyslexia
• DAMP syndrome
• Generalised learning disability
• Epilepsy
• Tuberous sclerosis
• Fragile X
• Phenylketonuria (untreated)
• Retts syndrome
• Williams syndrome

• Sotos syndrome
• Cornelia de Lange syndrome
• Turners syndrome
• Kleinfelters syndrome
• Neurofibromatosis
• Downs syndrome
• Obsessive-compulsive disorder
• Catatonia / Parkinsonism
• Psychotic states in response to stress
• Anxiety
• Affective disorders
• Schizophrenia rare
• Any other developmental, physical or psychiatric
  condition

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The Importance of the Social Impairment

• Leo Kanner 1943
• Present from birth
• Genetic-
• We must assume that the children have come into
  the world with innate inability to form the
  usual, biologically provided affective contact
  with people

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Social Withdrawal

• Lorna Wing 1964
• Social withdrawal is an important characteristic
  of autistic children which perhaps is related to
  the inability to communicate in speech. A mother
  often senses this in her child almost from birth.
  Later the mother notices that the child does not
  attract her attention to things going on around
  indeed her child appears oblivious of them
• This is now referred to as lack of
  joint-referencing.

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The Social Impairment is the Key to Diagnosis

• In children and adults with severe or profound
  learning disabilities the level of development
  may be too low for communication and imagination.
  
• But, interest in other humans is present
  virtually from the beginning of life.

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The Social Impairment is the Key to Diagnosis

• Children and adults with extremely high levels of
  cognitive ability may be verbally articulate with
  good imagination but have learned social skills
  through their intellect rather than by social
  intuition.

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Revision of the Triad of Impairments

• Social Interaction
• Social Communication
• Social Imagination
• The Triad is usually associated with repetitive
  patterns of activities

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• The reason for selecting social impairment as the
  only defining feature of autism spectrum
  disorders is purely practical and not related to
  any causal theory.

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Research

• Neuropathology underlying social impairment
• Biology of the social instinct
• Causes
• Genetic, pre-natal environment, post-natal
  environment
• Neurological relationships to other conditions
• Physical Phenylketonuria, Tuberose Sclerosis
• Developmental ADHD, Tourettes, Dyspraxia
• Psychiatric Anxiety, Depression, OCD
• Effective methods of helping and support

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Change in Thinking

• Attempts to define sub-groups among autism
  spectrum disorders by behavioural features and
  arbitrary age-based cut-off points related to
  current International Diagnostic Systems.
• Apart from the lack of the social instinct
  untypical behaviours are found to varying degrees
  in all diagnostic sub-groups, in all
  developmental disorders and to some extent in
  typical development.

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Dimensions Versus Categories

• In clinical practice, it is extremely difficult
  to define the boundaries between different
  diagnostic categories, whatever the criteria
  used.
• The clinical pictures found in those with
  autistic spectrum disorders fit better with the
  concept of multiple dimensions than with the
  concept of separate, definable categories.
• Individual needs are more accurately assessed
  from the profile of levels on different
  dimensions than from assigning a categorical
  diagnosis.

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Key Similarities and Methods of Supporting all
People within the Autism Spectrum

• What can a person with severe learning
  disability and typical autism have in common with
  someone brilliant in a chosen field and whose
  behaviour fits Aspergers descriptions?
• Everyone with an autism spectrum disorder has a
  number of specific problems in coping with
  everyday life
• All have difficulties following subtle, unwritten
  rules that govern social life
• All need other people to communicate with them in
  clear and easily understandable terms
• All are helped if complex, shifting ideas are
  explained in concrete terms eg with visual
  illustrations
• All have difficulty comprehending the passage of
  time

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Continued

• All have, to varying degrees difficulty working
  out the consequences of their own and other
  peoples actions
• All need more time than most other people to
  process information
• All need to be informed clearly in advance with
  careful explanations if plans are changed
• Difficulties caused by over sensitivity to
  various kinds of sensory input are very common