Unusual brain growth patterns in early life in patients with autistic disorder: an MRI study.

OBJECTIVE: To quantify developmental abnormalities in cerebral and cerebellar volume in autism. METHODS: The authors studied 60 autistic and 52 normal boys (age, 2 to 16 years) using MRI. Thirty autistic boys were diagnosed and scanned when 5 years or older. The other 30 were scanned when 2 through 4 years of age and then diagnosed with autism at least 2.5 years later, at an age when the diagnosis of autism is more reliable. RESULTS: Neonatal head circumferences from clinical records were available for 14 of 15 autistic 2- to 5-year-olds and, on average, were normal (35.1 +/- 1.3 cm versus clinical norms: 34.6 +/- 1.6 cm), indicative of normal overall brain volume at birth; one measure was above the 95th percentile. By ages 2 to 4 years, 90% of autistic boys had a brain volume larger than normal average, and 37% met criteria for developmental macrencephaly. Autistic 2- to 3-year-olds had more cerebral (18%) and cerebellar (39%) white matter, and more cerebral cortical gray matter (12%) than normal, whereas older autistic children and adolescents did not have such enlarged gray and white matter volumes. In the cerebellum, autistic boys had less gray matter, smaller ratio of gray to white matter, and smaller vermis lobules VI-VII than normal controls. CONCLUSIONS: Abnormal regulation of brain growth in autism results in early overgrowth followed by abnormally slowed growth. Hyperplasia was present in cerebral gray matter and cerebral and cerebellar white matter in early life in patients with autism.

Enhancing conversation skills in children with autism via video technology. Which is better, "self" or "other" as a model?

The present study was designed to compare the efficacy of "self" versus "other" video-modeling interventions. Five children with autism ranging in age from 4 to 11 were taught to answer a series of conversation questions in both self and other video-modeled conditions. Results were evaluated using a combination of a multiple baseline and alternating treatments design. Three out of the five participants performed at levels of 100% accuracy at posttreatment. Results indicated no overall difference in rate of task acquisition between the two conditions, implying that children who were successful at learning from video in general, learned equally as well via both treatment approaches. Anecdotal evidence suggested that participants who were successful with video treatment had higher visual learning skills than children who were unsuccessful with this approach. Results are discussed in terms of a visual learning model for children with autism.

Intensive behavioral/psychoeducational treatments for autism: research needs and future directions.

It is widely acknowledged that, to date, the forms of treatment enjoying the broadest empirical validation for effectiveness with individuals with autism are those treatments based upon a behavioral model and that such treatments are best implemented intensively and early in the child's development. This paper describes several features important in the success of this model and presents remaining issues to be addressed for improving treatment effectiveness. While it is appreciated that there is no "one size fits all" treatment for children with autism, there is as yet no established protocol for relating specific child, family, target behavior, and treatment variables to individualized treatment regimens. Future research needs to include well-conceived and methodologically rigorous investigations allowing for the determination of these important variables.

Social perception in children with autism: an attentional deficit?

Research suggests that the attentional deficits found in children with autism may be related to impairments in social functioning (e.g., Courchesne et al., 1994a, 1994b; Lewy & Dawson, 1992; Schreibman & Lovaas, 1973). In the present investigation, 14 children with autism, 14 mentally handicapped, and 14 typically functioning children participated in a study designed to investigate the effects of number of social cues on the ability to interpret social situations. Participants were shown videotaped vignettes of child-child interactions in which the number of cues leading to the correct interpretation of the story varied from one to four (i.e., tone, content, nonverbal, or nonverbal with object). Subjects were then asked a series of questions which varied in degree of complexity. Overall, results indicated that children with autism performed as well as both groups of comparison subjects on general attention questions (i.e., identification of number and gender of interactants) and social perception questions relating to stories containing one cue. However, children with autism performed more poorly than both comparison groups on social perception questions relating to stories containing multiple cues. Results are discussed in terms of an attentional dysfunction hypothesis of autism.

Multiple peer use of pivotal response training to increase social behaviors of classmates with autism: results from trained and untrained peers.

Two children with autism and 8 typical peers participated in a study designed to replicate an earlier finding of successful social-skills intervention for children with autism using peer-implemented pivotal response training (PRT) and to assess the effects of using multiple peer trainers on generalization of treatment effects. During training, peers were taught PRT strategies using didactic instruction, modeling, role playing, and feedback. After treatment, children with autism engaged in increased levels of social behavior.

Deficits, delays, and distractions: an evaluation of symbolic play and memory in children with autism.

Two experiments were conducted to evaluate symbolic-deficit and memory-deficit hypotheses to account for the cognitive problems seen in children with autism. Experiment 1 tested imitation, in immediate and deferred conditions, of familiar actions with different sets of objects representing the developmental progression from functional to symbolic play. The results showed that the autism group and both their receptive language and nonverbal IQ-matched controls imitated familiar actions with realistic objects (evidence for functional play) and placeholder objects (evidence for symbolic play) after delays ranging from 24 hr to 3 weeks. Experiment 2 tested familiar three-step event sequences in which a placeholder object was substituted for the second step in half the events. The results showed that the autism group remembered as many of the actions with the placeholder objects as their language-matched controls and as many correctly ordered sequences, a finding that supports a symbolic-delay (rather than deficit) hypothesis. These results were obtained in highly structured test situations and sharply contrast with the impairments seen in children with autism who are observed in naturalistic settings. Two interpretations of these findings are offered. First, structured test settings minimize distractions that typically occur in naturalistic settings that may interfere or disrupt symbolic play in children with autism. Second, the results are consistent with an executive function deficit in that the autistic group demonstrated more knowledge in the test settings than they demonstrate spontaneously in naturalistic ones.

Collateral effects of parent training on family interactions.

Recent research suggests that using naturalistic teaching paradigms leads to therapeutic gains in clinic settings for children with autism and related disorders. More recent studies are demonstrating that implementing these strategies within a parent training format may produce collateral effects in other areas of family life. The present experiment assessed collateral effects of two very different parent training paradigms during unstructured dinnertime interactions in the family setting. One paradigm focused on teaching individual target behaviors (ITB) serially, and the other focused on a recently developed naturalistic paradigm that teaches the pivotal responses (PRT) of motivation and responsivity to multiple cues. Two groups of families were randomly assigned to each of the parent training conditions. Pretraining and post-parent-training videotapes of dinnertime interactions were scored in a random order across four interactional scales (level of happiness, interest, stress, and style of communication). Results obtained for the four interactional scales showed that the families in both conditions initially scored in the neutral range, and the ITB training paradigm produced no significant influence on the interactions from pretraining to posttraining. In contrast, however the PRT parent training paradigm resulted in the families showing positive interactions on all four scales, with the parent-child interactions rated as happier, the parents more interested in the interaction, the interaction less stressful, and the communication style as more positive.

Neurologic abnormalities in infantile autism.

Neuroanatomic, pathologic, and neurobehavioral studies point to a cerebellar and parietal abnormality in autism. We used a standardized protocol to examine neurologic function in 28 pediatric autistic subjects and 24 pediatric normal healthy volunteer controls. As a group, the autistic subjects had quantitative measures from magnetic resonance imaging suggesting hypoplasia or hyperplasia of the cerebellar vermis, as well as measurements of posterior corpus callosum suggesting abnormalities of posterior cortex. In groups of tests that reflect cerebellar and parietal function, the neurologic abnormalities detectable by clinical examination were significantly greater for autistic subjects than for normal controls. These studies confirm that the structural and behavioral deficit in autism does lead to abnormalities that can be detected on the clinical neurologic examination.

Effects of sociodramatic play training on children with autism.

We assessed the effects of teaching sociodramatic play to three children with autism. The training was conducted using a variation of Pivotal Response Training (PRT), a program traditionally used to teach language to children with autism. Measures of play skills, social behavior, and language skills were obtained before treatment, after treatment, and at a follow-up period. The correlation between language and pretend play was explored, as was the relationship between sociodramatic play and social competence. Positive changes were observed in play, language, and social skills. These changes generalized across toys and settings, although little generalization to other play partners occurred. Effects of play training with children with autism and maintenance of behavior change is discussed.

Cross-sectional area of the posterior hippocampus in autistic patients with cerebellar and corpus callosum abnormalities.

Using MRI methods previously shown to optimize visualization of cytoarchitectonic details in the body of the hippocampal formation caudal to the pes hippocampi, we imaged and quantified the hippocampus proper including the subiculum and the dentate gyrus in 33 autistic patients between the ages of 6 and 42 years and in 23 age-matched normal healthy volunteers. Measures of these structures in autistic patients and normal healthy volunteers differed nonsignificantly, by less than 1.4%, regardless of whether or not the autistic patients were retarded or had a history of seizure episodes. By contrast, measures of vermian lobules VI and VII and the posterior portion of the corpus callosum in these same autistic and normal volunteers differed significantly, by more than 9.9%. The lack of a significant difference in the cross-sectional size of the posterior hippocampal formation between autistic and normal 6- to 42-year-olds is discrepant with predictions based on some, but not all, autopsy studies. This suggests that there is a need for additional quantitative autopsy study of the hippocampal formation and quantitative MRI study of rostral hippocampal regions that we did not explore in the present report. Also, quantitative autopsy and MRI studies have yet to examine hippocampal development in autistic patients younger than 6 years of age; whether early stages of growth are normal or not is unknown.

Increasing complex social behaviors in children with autism: effects of peer-implemented pivotal response training.

Two children with autism were taught to engage in a variety of complex social behaviors using peer-implemented pivotal response training (PRT), a set of procedures designed to increase motivation and promote generalization. Typical peers were taught to implement PRT strategies by modeling, role playing, and didactic instruction. After training, peers implemented the procedures in the absence of direct supervision in a classroom environment. After the intervention, both children with autism maintained prolonged interactions with the peer, initiated play and conversations, and increased engagement in language and joint attention behaviors. In addition, teachers reported positive changes in social behavior, with the largest increases in peer-preferred social behavior. Further, these effects showed generality and maintenance. Implications of these findings are discussed.

Impairment in shifting attention in autistic and cerebellar patients.

MRI and autopsy evidence of early maldevelopment of cerebellar vermis and hemispheres in autism raise the question of how cerebellar maldevelopment contributes to the cognitive and social deficits characteristic of autism. Compared with normal controls, autistic patients and patients with acquired cerebellar lesions were similarly impaired in a task requiring rapid and accurate shifts of attention between auditory and visual stimuli. Neurophysiologic and behavioral evidence rules out motor dysfunction as the cause of this deficit. These findings are consistent with the proposal that in autism cerebellar maldevelopment may contribute to an inability to execute rapid attention shifts, which in turn undermines social and cognitive development, and also with the proposal that the human cerebellum is involved in the coordination of rapid attention shifts in a fashion analogous to its role in the coordination of movement.

Teaching daily living skills to children with autism in unsupervised settings through pictorial self-management.

We investigated the efficacy of pictorial self-management to teach daily living skills to 3 low-functioning children with autism. Stimulus and response generalization, stimulus control of self-management materials, and maintenance of behavior change were also assessed. Results showed that children with autism could successfully use pictures to manage their behavior in the absence of a treatment provider, generalize their behavior across settings and tasks, and maintain behaviors at follow-up. In addition, when compared to baseline, all children showed a substantial decrease in stereotypic behaviors. When picture order was manipulated in stimulus control probes, the children followed the new picture sequence, suggesting that the pictures were controlling their behavior. Further, a savings effect was demonstrated, in that 2 subjects reached criterion on second and third behaviors within less than 25% of original training time.

Abnormality of cerebellar vermian lobules VI and VII in patients with infantile autism: identification of hypoplastic and hyperplastic subgroups with MR imaging.

OBJECTIVE: Infantile autism is a neurobehavioral disorder that is widely believed to have etiologically distinct subtypes, including subtypes with a genetic basis, but no neuroanatomic evidence firmly supports this belief. To date, only one type of cerebellar abnormality has been identified in patients with autism: hypoplasia of the vermis and hemispheres. By using a large sample of autistic patients and healthy volunteers along with precise MR imaging and quantitative procedures, we sought to replicate previous reports of cerebellar vermian hypoplasia in autism and to identify additional subtypes of cerebellar abnormality. MATERIALS AND METHODS: Using MR technology, we imaged and measured posterior and anterior vermian regions in 50 autistic patients (2-40 years old) and 53 healthy control subjects (3-37 years old). The autistic patients had social, language, cognitive, behavioral, and medical history characteristics that were typical of the general autistic population. By using precise procedures for positioning and aligning MR slices, we obtained comparable MR images within and across subject groups. RESULTS: Statistical analyses showed two subgroups of autistic patients, one (86% of the patients) with findings consistent with vermian hypoplasia and another (12% of the patients) with evidence of vermian hyperplasia. The hypoplasia subgroup included 43 patients whose mean midsagittal area for vermian lobules VI and VII was 237 +/- 38 mm2, and the hyperplasia subgroup included six patients whose mean area was 377 +/- 12 mm2. Thus, the area of lobules VI and VII in the hypoplasia subgroup was 16% smaller than the mean area in the control subjects (282 +/- 42 mm2) (p < .0001), whereas that in the hyperplasia subgroup was 34% larger (p < .0001). Analyses showed that these two subtypes of vermian abnormalities were present across all ages of autistic patients studied. CONCLUSION: Two different subtypes of autistic patients can be identified on the basis of the presence of vermian hypoplasia or hyperplasia as seen on MR images. Possible origins for vermian hypoplasia include environmental trauma and genetic factors.

Stress profiles for mothers and fathers of children with autism.

Stress profiles in 18 mothers vs 12 fathers of children with autism were compared on three measures, the Questionnaire on Resources and Stress, the Coping Health Inventory for Parents, and the Beck Depression Inventory. Mothers showed significantly more stress than fathers on each inventory, with a pattern suggesting stress may be related to the differing responsibility assigned to child rearing for each parent.

Consistent stress profiles in mothers of children with autism.

The present study extends the area of research on stress in parents of autistic children. In this study we used the Questionnaire on Resources and Stress (Holroyd, 1987) to compare the stress profiles across mothers (a) who lived in different cultural and geographic environments; (b) who had children of different ages; and (c) who had children with different functioning levels. Results showed a characteristic profile that was highly consistent across each of these subgroups. Major differences from the normative data occurred on scales measuring stress associated with dependency and management, cognitive impairment, limits on family opportunity, and life-span care. Results suggest the importance of developing treatment programs aimed at reducing stress in specific areas in families with autistic children.

Teaching children with autism appropriate play in unsupervised environments using a self-management treatment package.

The present study used a self-management treatment package to teach 3 children with autism, who exhibited inappropriate play behaviors, to play appropriately in the absence of a treatment provider. After self-management training, generalization and maintenance of the behavior change were assessed. Because of the detrimental effects of self-stimulation (arm flapping, spinning toys, twirling, etc.) on learning, the relationship between self-stimulatory behaviors and appropriate play was measured. Results indicated that the children learned to exhibit appropriate play skills in unsupervised settings, appropriate play skills generalized to new settings, and 2 of the children maintained their gains at 1-month follow-up. In addition, self-stimulatory behaviors decreased as appropriate play increased. Treatment implications of these findings are discussed.

Training social initiations to a high-functioning autistic child: assessment of collateral behavior change and generalization in a case study.

The present case study used a multiple treatment design to assess the effects of two interventions--peer social initiations and target child initiations--on the social and disruptive behavior of a high-functioning autistic child. Intervention included initiation training and videotaped feedback highlighting successful and unsuccessful initiations. During Interventions 1 and 2, nonhandicapped peers were trained to initiate social interaction with the autistic child, resulting in an increase in social interaction which dramatically decreased in a reversal phase. Social interaction quickly increased again in Intervention 3 when the autistic child was trained to initiate interaction using the same procedures. During Interventions 1 and 2 no decrease in the autistic child's disruptive behaviors was observed; however during Intervention 3 these behaviors decreased to a low rate. Social validation, generalization, and maintenance of these behavior changes are discussed.