The Triad of ImpairmentsPast, 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 movementsFascination with sensory stimuliSimple, object directedRoutines involving objectsRoutines in space or timeVerbal routinesRoutines related to special skillsIntellectual 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