Autism Spectrum Disorders: A Research Review for Practitioners

Autism was once thought to be a rare disorder. Knowledge of this condition—its diagnosis, management, causes, course, and outcome—was not considered necessary for most mental health practitioners. It was only minimally covered and discussed in child psychiatry fellowships or residencies. When I began my child psychiatry training at the children’s psychiatric hospital at the University of Michigan Medical Center, I was assigned five autistic children to treat. I read whatever I could about the management and treatment of such children. In 1960, we routinely blamed parents for their autistic children, and we had little available in our therapeutic armamentarium to treat these children and help their families. As a resident/fellow, I was advised to help families work through their grief and disappointment at having an autistic child and help them recognize that, in all probability, their child would be hospitalized and/or institutionalized for the rest of his or her life.

One of the children who were assigned to me at the beginning of my residency was later transferred to the state hospital system, and I was her treating therapist there as well. She had a brief period of time in the community, and I was involved in a treatment plan that placed her in a special education program. When I left the state hospital to practice in the community, she was still a patient in that same state hospital, having returned when community placement was unsuccessful and the school indicated it could no longer tolerate her unusual behavior. The plan was then for her to be raised in the hospital.

Today, the number of children identified with autism spectrum disorders has skyrocketed, and fortunately the range of treatment options available is wide. Although there is no cure for autism, treatments are available that can reduce symptoms, and hope can be offered to patients and their parents.

This book synthesizes the most recent research on the etiology, assessment, and treatment of autism spectrum disorders. It is written for the general psychiatrist, and it contains reviews of the latest scientific literature. It is full of practical suggestions for clinical care in this era of evidence-based medicine and provides empirically supported guidelines for evaluation and treatment. It is a valuable resource for clinicians, patients, and their families.

The authors emphasize that there are five specific autism spectrum diagnoses, or pervasive developmental disorders (the term used by DSM-IV-TR that is synonymous with autism spectrum disorders). These are autistic disorder, Asperger’s disorder, Rett’s disorder, childhood disintegrative disorder, and pervasive development disorder not otherwise specified. All of these disorders share certain features, such as deficits in reciprocal social interaction, deficits in communication, and restricted repetitive behaviors, interests, or activities. However, each of these disorders is different in some way. Children with Asperger’s syndrome have well-developed language and cognitive abilities. Rett’s disorder, in its classic and best-recognized form, is a rare behavioral syndrome found only in girls; female infants appear fine at birth and developmentally normal for at least 5 months or longer, but, within 6 months to a year, these girls lose use of their hands and lose interest in others and in social interaction. Childhood disintegrative disorder is a very rare condition that also involves a period of normal development of at least 2 years, followed by a loss of skills, resulting in severe impairments in cognitive, self-help, and other abilities. Although childhood disintegrative disorder can occur in either boys or girls, it is much more common in boys.

Part 1 of this book deals with scientific advances that have shaped clinical practice since Leo Kanner first advanced the diagnosis. Part 2 details important interdisciplinary approaches to assessment, describing the contributions of psychiatry, psychology, pediatrics, and neurology. The psychiatrist has many roles, including clarifying the diagnoses, assessing for pharmacologic intervention, and working with the family. The psychiatrist is urged to work in concert with other professionals and take active responsibility for encouraging the team process. The psychologist, too, has many roles, including assessment of language, adaptive behavior, neuropsychological function, and academic ability. The pediatrician is urged to conduct a complete medical examination and to help in the decision regarding which laboratory tests are valuable. In particular, the pediatrician can suggest relevant genetic studies, including time-resolution cytogenetic testing, and relevant blood and urine testing. The neurologist is encouraged to approach an autistic child with an open mind and to select from a battery of diagnostic tests those which might be relevant if the child has seizures.

Part 3 deals with treatment options. Nonmedical interventions for autism spectrum disorders and pharmacotherapy are carefully reviewed. One particularly important chapter deals with alternative theories. In my experience, parents with autistic children have been led to believe that there are some special environmental factors—food allergies, secretin, immune and infectious diseases, and toxic exposure (i.e., mercury, lead, and ethanol)—leading to the serious illnesses of their children, many of which have been discredited. The authors note that many families try specialized approaches, whether their medical caregivers agree with their decisions or not, and comment that practitioners have a responsibility to be aware of, and conversant in, alternative approaches.

The final section of this book is devoted to professional-parent collaboration; the model for such collaboration is the M.I.N.D. Institute (http://www.ucdmc.ucdavis.edu/mindinstitute/). Parents of an autistic child organized and energized the local parent community and professional community to develop a collaborative effort to research and treat this serious childhood illness. At the time this book was written, the parent/academic/community partnership had solicited enough funds to plan and begin building a research treatment center on the campus of the University of California, Davis.

The contributors to this book are leaders in the fields of pediatrics, psychology, psychiatry, neurology, genetics, education, and early childhood development. The chapters have been well edited and well integrated. This book has been a pleasure to read, and one that I expect to keep and to share with child fellows and parents of children with autistic spectrum disorders.