In the past, no distinction was made between schizophrenia and pervasive disorders, such as autism. Nowadays we do differentiate between them. Schizophrenia is rare among children, often develops in adolescence and increases in adulthood. Autism and Asperger's syndrome are non-psychotic disorders that arise at a young age.
The DSM-V contains the Pervasive Developmental Disorders (PDD) category. This category includes:
Rett's disorder is now viewed differently and will not be further discussed for this reason. Criticism, such as whether Autistic Disorder and Asperger's syndrome would not be a single disorder, was common. In the DSM-V, the above-mentioned disorders are no longer considered separate. They now coincide in the Autism Spectrum Disorder (ASD). Two domains with primary symptoms can be distinguished in ASD: Firstly, persistent limitations in social communication and interaction, and secondly, restrictive, repetitive behavioural patterns.
What is Autistic disorder (autism)?
Kanner described autism as a disorder characterized by communication problems, atypical cognitive skills and behavioural problems such as obsessiveness, repetitive behaviour and unimaginative play. However, Kanner saw social inability as the biggest problem.
Primary characteristics
Social interaction
Already before the age of 1, autistic children show subtle differences from normally developing babies. They respond less to visual stimuli, respond less when someone calls their name and often don't like to be touched. They do not follow people with their eyes, avoid eye contact, appear to have an ‘empty’ or unseeing eye and respond little to others with emotional expression and positive emotions. Particularly striking is that autistic children exhibit deficits in joint attention, where the child and parent or caregiver focus attention on the same object or situation, thereby sharing an experience. Joint attention is facilitated by certain gestures, such as pointing, and eye contact. Another component of an atypical social interaction is abnormal processing of social stimuli, particularly the face. Children with autism have difficulty recognizing and remembering faces (and associated expressions of emotion). They also process faces in other ways than normal developing children. All in all, delayed or atypical social behaviours seem to occur at a young age in at least five areas of social behaviour: attention to social stimuli, joint attention, emotion, imitation and facial processing. Although the symptoms may change over time, many social deviations are persistent.
Communication
Children with autism have problems with non-verbal communication, such as gestures and facial expressions. In addition, 30% of the children do not learn to talk. Children who do acquire language show a delayed and abnormal language development. Echolalia and the reversal of pronouns are common among children with autism. Of echolalia occurs when an autistic child always repeats what another has just said. This also occurs for example with language disorders, schizophrenia and blindness. When reversing pronouns (pronoun reversal) for example, the child says 'I' or 'me' to others (instead of 'you') and calls himself 'he', 'she' or 'you'. Autistic children have difficulty with syntax, understanding and other structural forms of language. Particularly striking are the problems with pragmatics: the social use of language. Children with autism randomly jump from one topic to the other, do not communicate back and forth (or cannot start a conversation at all) and provide irrelevant details about topics. However, it should be noted that some children can function at a higher level and are more socially skilled.
Restrictive, repetitive and stereotyped behaviour and interests
A distinction can be made between two categories of restrictive, repetitive and stereotyped behaviour:
It is not clear why autistic children exhibit restrictive, repetitive and stereotyped behaviour. Possibly excessive arousal or anxiety plays a role, or such behaviour serves as self-stimulation. Research has shown that restrictive, repetitive and stereotyped behaviour can change over time.
Secondary characteristics
Sensory or perceptual limitations
Children with autism also have other problems and deficits. The senses are intact, but there are abnormal responses to stimuli. Both hyposensitivity and hypersensitivity to sensory stimuli are more common in children with autism. If a child is hypersensitive, he or she does not like stimuli, he or she is afraid of it or he or she avoids stimuli. However, hyposensitivity is more common. Here, for example, the child does not respond to sounds or runs into things.
Also, selectivity is common in autism: a child focuses on a select part of a stimulus, while other parts of it are ignored. This interferes with normal development and functioning. For example, ignoring specific aspects of a learning task can have a negative impact on task performance. Over selectivity can also have negative consequences in the social field. For example, an autistic child can pay a lot of attention to a toy that another child is holding, but not to the child's message (for example, "Shall we play together?" Versus "Go away, this is my toy").
Intelligence
Although children with autism can vary widely in intelligence, intellectual disabilities are common. Its prevalence is between 40% and 55%. Based on intelligence, a distinction is made between individuals who function at a higher and lower level. An IQ of 70 is used as the limit. A higher IQ is often accompanied by less severe symptoms and a greater chance of normal functioning.
Children with autism often exhibit an unbalanced cognitive development. They exhibit deficiencies in abstract thinking, language and social insight. On the other hand, they are relatively strong in memorizing things and visual-spatial skills. The non-verbal IQ is often higher than the verbal IQ.
A small proportion of autistic children have splinter skills : skills that are much better than would be expected based on their intelligence. Some children also have savant abilities: skills that are considerably better than those of normally developing children. For example, they can quickly calculate difficult sums in their heads or make very detailed drawings of something that they have only seen once. Although savant abilities are often associated with a higher IQ, they also occur in autistic children with an IQ of 55.
Adaptive behaviour
Autism is characterized by various problems in daily life. The self-help and daily living skills mainly depend on intelligence. Children with autism, however, have significant deficits in communication and social skills. These restrictions increase with age.
Social cognition: Theory of Mind
Research has shown that children with autism have a limitation in the theory of mind (ToM). The ToM is the ability to understand mental states with others and with themselves. It refers to the insight that people have mental states (such as intentions, beliefs, feelings and wishes) and that these mental states are related to their actions. ToM determines the interaction with others. Normally developing children have first-order capabilities around the age of 4: they understand the mental states of others somewhat. Around the age of 6 they acquire second-order capabilities: they can think about other people's thoughts about the thoughts of a third person. Because ToM is considered crucial for understanding the social world, it is claimed that the deficits of children with autism in ToM are at the root of many of the social and communication problems they have.
Aspects of ToM are measured with various tests. The Sally-Anne test measures whether a child understands that another person may have a false belief. The child is told during this test that Sally put a marble in a basket and then left the room. Anne then went inside, and she moved the marble to a box. The child is asked where Sally will look for the marble. To prove a ToM, the child must understand that Sally thinks the marble is still in the basket.
This first-order test can also be adapted to test the second-order power. In this case, Sally leaves the room, but peeks through a window and sees Anne move the marble to the box. The child then has to answer the following question: "Where does Anne think Sally will look for the marble?" The majority of children with autism fail both first and second order tests. It is still unclear what this explains.
For older children, or children who do well on the second-order test, more difficult tests have been developed, such as the faux pas test. The researcher reads a story in which person A makes a faux pas (accidentally saying something that may have a negative influence on person B). The child is asked to identify the faux pas. To be able to do this test correctly, the child must understand that person A and person B both have different knowledge and that the comment from person A influences the emotions of person B. Children with autism find this more difficult than other children.
Cognition: Central coherence
Normally developing children tend to use the context to link pieces of information together to form a whole. This is also called central coherence . Autistic people show shortages in this: they focus primarily on parts of stimuli and not on integrating information into a whole. Simply put, they see trees instead of a forest. Children with autism tend to process information in a more analytical, less global and integrative way than normally developing youngsters. This can lead to exceptionally good performance on one task and poor performance on the other task.
Cognition: Executive functions
Children with autism have deficits in executive functions. These deficits develop secondary, because autistic children of pre-school age do not yet differ from their peers. Kanner states that there is a lack of intersubjectivity in children with autism : an innate awareness that people have of each other, so that they are motivated to communicate with each other.
Physical characteristics
Autism is associated with minor physical anomalies (MPA) , such as a large forehead and low ears. This indicates genetic processes and disturbed prenatal development. Some autistic people have poor balance and limitations in gross motor skills. In addition, some exhibit unusual eating preferences and sleeping problems. Young people with autism sometimes exhibit maladaptive behaviour, such as aggression, withdrawn behaviour and auto-mutilation.
Comorbidity
Determining comorbidity in people with autism can be difficult due to communication problems. In addition, it is difficult to distinguish between some primary characteristics of autism and psychiatric disorders. Social phobia and OCD are examples of disorders that can resemble aspects of autism. The symptoms and disorders that are often associated with autism are anxiety, depression, hyperactivity and oppositional behaviour. The comorbidity of autism and anxiety may be the result of a hypersensitivity to stimuli. A social phobia could also arise if a child with autism is aware of his or her social deficits.
The pattern of comorbidity can depend on intelligence. For example, lower intelligence is related to irritability and hyperactivity, while higher intelligence is primarily associated with depression.
Epidemiology
The number of children with autism appears to have risen sharply in recent decades. There are a number of possible explanations for this increase:
Boys are more likely to suffer from autism than girls. An intellectual disability and more serious symptoms, on the other hand, are more common among girls. The gender difference may be partly explained by the fact that boys have a higher risk of genetic disorders associated with autism. In addition, it is claimed that there is a tendency for autism to systematize the world: a tendency that is more characteristic of the male brain.
No evidence was found for a connection between social class and autism. There is, however, some evidence that autism occurs more frequently among white children in the US and that prevalence increases faster for African American and Latin-American children.
Development process
Parents of children with autism often notice the first symptoms around the age of 2, but the diagnosis is often made a few years later, when there is a delay in language development and social problems. There are three patterns of onset of autism:
Research has shown that the development of autism can proceed in different ways. A study has identified six common pathways. With regard to social and communicative behaviour, children often improve over time. Children with the least severe symptoms often improve faster. Many people with autism show a decrease in the primary symptoms of autism and associated maladaptive behaviour. In general, people with intellectual disabilities and a lower family income improve less.
Despite some improvement, the symptoms persist in most people with autism until adulthood. About 15% of autistic children eventually become independent, have a good job and have a social life. The long-term outcomes are particularly poor if there is limited intelligence and limited communication skills at a young age.
Neurobiological abnormalities
The temporal-limbic system, the frontal lobes and the cerebellum belong to the "social brain" and are associated with autism. Research has shown that 5-10% of autistic children have a relatively large brain. They are born with a small to normal brain, but soon after birth there is an atypical growth spurt.
Evidence has also been found for abnormalities in brain volume. In the cerebrum there is an excessive amount of grey and white matter and in the cerebellum a lot of white matter. There are also deviations in the cell structure and organization of the temporal limbic system, the frontal lobes and the cerebellum, such as a reduced number of cells, fewer large cells, a high cell density, few dendritic branches and abnormal cell migration. In addition, research shows that there is less activity in different brain regions, particularly in the frontal lobes and the limbic system (especially the amygdala). The research findings regarding the role of neurotransmitters, such as serotonin and dopamine, are inconsistent.
Aetiology
Genetic influences
There is evidence for a genetic influence on autism. In addition, there appears to be a genetic predisposition to autism. Research has shown that identical twins have a 60% chance of having both autism, while this is only 4.5% for fraternal-twins. In 2-7% of the cases, brothers or sisters of an autistic child also have autism. In addition, other pervasive developmental disorders are more common in families with autistic individuals. Social, communicative and motor problems also occur in 20-30% of family members, who are not serious enough to meet the diagnostic criteria of an ASD. There may also be family members who exhibit other non-diagnosed symptoms of ASD, such as an increased serotonin level and neuroanatomical abnormalities. Fragile X syndrome and tuberculosis are genetic disorders that are associated with autism.
Prenatal and perinatal risk factors
There are several prenatal and perinatal factors associated with autism, such as an older age of the parents, medication use by the mother, bleeding of the mother, and troubles with the delivery.
Medical conditions and vaccines
In addition to fragile X syndrome and tuberculosis, there are other medical conditions that are associated with autism, such as hearing impairments, epilepsy and meningitis. The idea that autism is associated with vaccines is controversial but not proven.
Environment and social interaction
In many studies, the role of environmental and psychosocial factors in autism has been ignored. Dawson and Faja have developed a model that contains three components. This model states that genetic and environmental factors lead to brain abnormalities, which influence the interactions between the child and the environment. These interactions disrupt the input that is crucial for further brain development, leading to additional brain abnormalities and autism.
Asperger's syndrome is characterized by problems in social interaction and restrictive, repetitive and stereotyped behaviours. According to the DSM, children with Asperger's syndrome, on the other hand, have no delay in language development, cognitive development, adaptive behaviour (except in the social field) and curiosity about the environment.
Children with Asperger's syndrome have difficulty making friends. They show deficiencies in the use of non-verbal behaviour and are not very empathetic. They seem interested in others but are often lonely. In addition, they sometimes have obsessive and limited interests, for example in kitchen appliances or historical events. Young people with autism often have secondary problems, such as motor or behavioural problems.
Children are less likely to be diagnosed with Asperger's syndrome than with autism and the diagnosis is on average much later in life than with autism. Boys suffer from this syndrome more often than girls. The outcomes are fairly good, but the social problems are likely to persist over time.
It is doubtful that Asperger's syndrome is a qualitatively different disorder than autism. Research has shown that there are not very many significant differences between Asperger's syndrome and high-functioning autism, so that Asperger's syndrome can be considered as a variation on the autism spectrum. On the other hand, Asperger's syndrome differs qualitatively from autism in certain respects. For instance, Asperger's syndrome develops later in life than autism does. Children with Asperger's syndrome also have a higher verbal than performance IQ (instead of the other way around), they have more limited interests and they exhibit fewer motor symptoms than children with autism.
A person is not otherwise specified with pervasive disorder (PDD-NOS) if he or she exhibits symptoms that resemble the symptoms associated with autism and other pervasive developmental disorders but do not meet the diagnostic criteria of these disorders. The diagnostic criteria of PDD-NOS state that there must be a disrupted reciprocal social interaction. In addition, there must be a disturbed communication or stereotyped behaviour and interests. The prevalence of PDD-NOS is higher than that of other autism spectrum disorders. However, the diagnosis is less stable, which may be explained by the vagueness of the diagnostic criteria or a tendency of clinicians to use the diagnosis due to uncertainty.
What is Childhood Disintegrative Disorder?
The childhood disintegrative disorder (CDD) is diagnosed when a child develops normally until the age of 2, but then loses much of the acquired skills. The symptoms must be present before the age of 10. Autism also sometimes shows a decline in development, but the loss of skills occurs at a later age with CDD than with autism. The CDD diagnostic criteria state that there must be a significant loss of skills in at least two of the following areas: language, social skills, toilet training, game behaviour and motor skills. In addition, there must be abnormal behaviour in two of the following areas: social interaction, communication or restrictive, repetitive and stereotyped behaviour.
CDD often develops (gradually or abruptly) around the age of 3 or 4. The limitations are fairly stable over time. CDD is more common among boys than among girls. Compared with children with autism, mutism is more common among children with CDD. They also have fewer self-help skills and more often have an IQ below 40. These youngsters are among the lowest-functioning youngsters of children with pervasive developmental disorders.
Assessment
Because autism spectrum disorders (ASD) are characterized by problems in different areas, the assessment must be comprehensive. It is important to involve the parents in the assessment. It is also important to obtain a clear picture of the (medical) history of the child. Psychological and behavioural evaluations often include interviews, observations of the child and psychological tests. Tests are often used to assess intelligence, adaptive behaviour and language development. In addition, there are instruments for assessing autistic behaviour based on observation.
Evaluate autism-related behaviours and prevention
The universal prevention of autism includes good prenatal care and the improvement of environmental factors. However, early identification and treatment in particular are important for the prevention of autism. Identification could be through discussion with parents, observation and the use of 'screening tools'. Prevention programs for young children are often implemented at home or at school and use behavioural techniques. Programs often focus on language, social skills and imitation. This is conducive to the intelligence, language development and general development of children and can lead to a decrease in autistic symptoms.
Intervention
Pharmacological treatment
If children with ASD are prescribed medication, this is usually to reduce problem behaviour, such as aggression and auto mutilation. Antipsychotic medication that focuses on dopamine can be effective but has side effects such as motor problems. For this reason, atypical antipsychotic medication is used nowadays, which focuses on both dopamine and serotonin. These drugs have fewer side effects. Stimulants reduce the disruptive behaviour of children, but also have many side effects. Although many children receive ASD medication, it is unclear what the effects are (in the long term).
Behavioural intervention
A distinction can be made between two types of behavioural treatment:
Lovaas was the first to try to teach autistic children verbal communication. To achieve this goal, operant behavioural techniques such as modelling, and empowerment were used. Initially, the children benefited from the treatment, but failed to generalize the skills learned to other situations.
Functional analyses of maladaptive behaviour and Functional Communication Training are used to teach adaptive behaviour, among other things by learning the skills in a natural environment. This increases the chance of generalization.
The Central Response Treatment assumes that reinforcing central behaviour will have a positive influence on other behaviours. The general purpose of the intervention is to promote the independence of the child. The intervention takes place in natural settings. Motivation is considered as a key component in this treatment. It is assumed that improved motivation and behaviour have a positive influence on other behaviour. There is evidence for the effectiveness of the Central Response Treatment.
The Young Autism Project is an example of an intensive and long-term treatment method. Children of preschool age receive 40 hours a week (and three years of) skills taught by psychologists. Initially, it is often necessary to reduce maladaptive behaviour, to learn imitation and obedience, and to learn basic skills such as dressing oneself. Next attention is paid to the development of language and communication skills, interaction with peers and interactive play. In the final year the emphasis is on advanced communication and adaptation to school. Parents play an important role in the intervention. The research results show that the Young Autism Project is effective for some, but not all, children. For example, the treatment has positive effects on intelligence, language skills, social behaviour and adaptive functioning.
All in all, it can be concluded that intensive, early treatments can be very effective. Effective behavioural treatments are associated with carefully controlled learning situations. Use should also be made of techniques that promote the generalization and retention of the skills learned, such as educating parents as primary caregivers. The effects of different treatments differ per child.
Education
Treatment and Education of Autistic and related Communication Handicapped Children (TEACH) is a service research and training program for people with autistic spectrum disorders. The emphasis is on change at home, education and adapting to the community. TEACH works with individual programs and is applied in America and Europe.
The 'Individuals with Disabilities Education Act' (IDEA) also applies to children with ASD. The principles of least restrictive placement and inclusion have led to declining institutionalization and increasing educational opportunities for children with autism. The advantage of inclusion is that inclusion is that peers can model socially competent behaviour. There is evidence that some autistic children benefit from inclusion. On the other hand, it has been shown that children with autism have relatively fewer reciprocal friendships that are of poorer quality.
Primary symptoms
According to the DSM, the primary symptoms of schizophrenia are:
The first four characteristics are called positive symptoms . To be diagnosed with schizophrenia, someone must experience at least two of the above symptoms for a significant portion of the period being looked at (one month). These symptoms must last for at least six months. If the disorder develops in childhood or adolescence, the expected level of interpersonal, academic, or professional development should not be achieved.
Secondary symptoms
Schizophrenia is associated with various secondary characteristics, such as motor abnormalities (such as poor coordination), minor physical anomalies, limited communication skills, social problems (such as withdrawn behaviour) and emotional problems (such as anxiety). Many children with schizophrenia also score lower than average on intelligence tests. They have difficulty with tasks that require attention, memory and executive functions. There may also be social issues such as shyness, reclusive behaviour and isolation, and emotional issues such as depression, anxiety and a moody mood.
Epidemiology
Approximately 1% of the entire population suffers from schizophrenia. Schizophrenia develops more often at the end of adolescence rather than childhood. Few cases of schizophrenia diagnoses are known before the age of ten. Schizophrenia is most common in boys in childhood. However, this difference in sex has almost disappeared in adolescence. Among adults, the prevalence of schizophrenia is higher in lower socio-emotional classes.
Development process
Schizophrenia often develops gradually in childhood (insidious). Initially there are only non-psychotic symptoms, such as a delay in language skills and in cognitive, sensory and motor functions. There are also problems with peers, problems at school and socially withdrawn behaviour. Later the psychotic symptoms arise. Early hallucinations and delusions are simple and often deal with animals, toys and monsters. The content of delusions and hallucinations changes with the developmental level of the child.
When the disorder develops in adolescence, it is much less gradual. However, many children who are diagnosed with this disorder in adolescence have in the past suffered from attention problems, motor-perceptual problems and neurodevelopmental problems such as shyness, anxiety and aggression. This image is very similar to schizophrenia that develops in adulthood, where there is a lot of variation in the timing, severity and nature of early traits. The psychotic symptoms also resemble those of adults with schizophrenia. Hallucinations and delusions, for example, are more complex.
There is a lot of variation in the developmental course of schizophrenia. Some adolescents and adults with schizophrenia continue to experience difficulties throughout their lives, while others heal completely. Risk factors for poor outcomes are poor adaptation to living conditions before being diagnosed, a gradual and early onset, a long psychotic episode and severe symptoms.
Neurobiological abnormalities
The motor problems, coordination problems and minor physical anomalies of people with schizophrenia indicate neurobiological abnormalities. With regard to the brain structure, research shows that schizophrenia is associated with abnormal neurons, which are sometimes located at abnormal locations. Neurons have a high density and there are fewer synaptic processes and connections. The lateral ventricles are also larger in children, adolescents and adults with schizophrenia. The frontal and temporal limbic areas, on the other hand, are smaller than in normally developing individuals. In addition, it appears that the white matter in the frontal, parietal and occipital areas, especially in the right hemisphere, grows slower. This indicates poorer connections between brain regions.
With regard to brain activity, it appears that people with schizophrenia suffer from underactivity and overactivity in different areas of the brain when performing various tasks. Research has shown that the neurotransmitters dopamine, serotonin, GABA and glutamate are involved in schizophrenia.
Aetiology
Genetic factors
There is evidence for the influence of genetic factors on schizophrenia. There is approximately a 12% chance that children with a schizophrenic parent will also get schizophrenia themselves. There is a 59% chance that identical twins will both develop schizophrenia, while that is 14% for fraternal twins. Genetic vulnerability in families is also reflected in disorders similar to but less severe than schizophrenia and in cognitive processing deficits associated with schizophrenia. So it seems that a general vulnerability is inherited. It is probably a combination of several genes that together increase the risk of schizophrenia.
Prenatal and perinatal factors
Examples of prenatal risk factors for schizophrenia are poor nutrition, infections and problems during pregnancy. An emergency caesarean section can also be a risk factor for the development of schizophrenia. However, it is unclear what the direction of such relationships are. Perinatal problems may be due to genetic or prenatal factors.
Psychosocial factors
Psychosocial stress can also contribute to schizophrenia in young people. In adults, an increase in stress often precedes the first symptoms of schizophrenia. Stress can also contribute to the worsening of symptoms. Family characteristics are also related to the onset of schizophrenia.
Neuro-development model
The vulnerability stress model states that schizophrenia has various causes. According to the model, genetic (or prenatal) factors interact with environmental stress. Some people reach their limit and develop schizophrenia, while others show mild or no symptoms.
The neuro-development model of schizophrenia states that early brain development is what goes wrong. Early development is characterized by problems such as language problems, motor problems and problems in cognitive, social and psychological functioning. In most cases, the symptoms of schizophrenia are related to brain development in adolescence or young adulthood. All kinds of hormonal changes then take place, which make it possible to express the disorder. It is also possible that an excessive pruning process, whereby unnecessary connections between neurons are removed, is related to the development of symptoms. Biological factors lead to the development of schizophrenia in interaction with environmental factors.
Assessment
The following aspects are important in the assessment of a child or adolescent who is probably schizophrenic:
It is difficult to identify schizophrenia at a young age because the early non-psychotic symptoms are also characteristic of other disorders. Moreover, it is difficult to disassemble strange ideas and psychoses in young children. In addition, identifying a mental disorder can be difficult because the assessment is influenced by the child's language skills. Moreover, the classification of thinking patterns varies as abnormal with the level of development.
Prevention
Proper prenatal care, particularly for high-risk children, is important in the prevention of schizophrenia. In addition, early identification and treatment are associated with a better outcome. That is why it is very important to pay attention to early cognitive deficits, social problems and behavioural problems.
Intervention
Pharmacological treatment
In the pharmacological treatment of schizophrenia, antipsychotic or second-generation antipsychotic drugs are often used. These can reduce hallucinations, delusions, thinking problems and other symptoms, but are not effective for everyone. Second-generation antipsychotic drugs are used more often because they have less side effects. These side effects may have more impact on young people than on adults.
Psychosocial intervention
While pharmacological treatment focuses on reducing psychotic symptoms, psychosocial therapy focuses on broader goals. The most promising forms of treatment are:
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