The Triad of Impairments Past, Present and Future Dr Judith Gould Director The NAS Lorna Wing Centre for Autism

Development of the Concept of the Autism Spectrum Lotter (1960) in his Middlesex prevalence study, used Kanner’s 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 Kanner’s criteria were identified, with the same prevalence as found by Lotter. A few children fitting Asperger’s criteria were also identified. This group was very small because the mainstream children in the area were not screened. (continued)

Continued There were many more children who did not fit Kanner’s or Asperger’s 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.

WING AND GOULD (1979) Camberwell study Group fitting Kanner’s criteria – 4.9 in 10,000 Group fitting Asperger’s 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)

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.

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

Social Impairment Different manifestations: * # Aloof, indifferent Passive Active but odd, bizarre Over-formal, stilted Sociable with 1 person – problems with groups (* Kanner # Asperger

Social Communication Impairment (verbal and non-verbal) Different manifestations: * # No communication Communicates own needs Repetitive, one sided Formal, long-winded, literal (* Kanner # Asperger)

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

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

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

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

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

Conditions That May Be Associated With The Spectrum Attention deficit/hyperactive disorder Tourette’s syndrome Developmental receptive language disorder Dyspraxia Dyslexia DAMP syndrome Generalised learning disability Epilepsy Tuberous sclerosis Fragile X Phenylketonuria (untreated) Rett’s syndrome Williams’ syndrome Sotos’ syndrome Cornelia de Lange syndrome Turner’s syndrome Kleinfelter’s syndrome Neurofibromatosis Down’s syndrome Obsessive-compulsive disorder Catatonia / Parkinsonism “Psychotic” states in response to stress Anxiety Affective disorders Schizophrenia – rare Any other developmental, physical or psychiatric condition

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”

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.

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.

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.

Revision of the Triad of Impairments Social Interaction Social Communication Social Imagination The Triad is usually associated with repetitive patterns of activities

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.

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, Tourette’s, Dyspraxia Psychiatric – Anxiety, Depression, OCD Effective methods of helping and support

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.

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.

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 Asperger’s 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

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