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

2. 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)

3. 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.

4. 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)

5. 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.

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

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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”

16. 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.

17. 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.

18. 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.

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

20. 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.

21. 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

22. 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.

23. 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.

24. 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

25. 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