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Home Books CURRENT Diagnosis & Treatment: Psychiatry, 2e

Chapter 34. Autism and the Pervasive Developmental Disorders

Fred R. Volkmar, MD

Autism and the related pervasive developmental disorders are disorders of early onset in which abnormalities in the development of social interaction and communication are associated with problems in behavior and unusual sensitivity to the inanimate environment. Autism is the best known of these conditions. DSM-IV-TR criteria for it are listed in Table 34–1. In autism a marked and sustained impairment in social interaction is associated with delayed and deviant communication and restricted, stereotyped patterns of interest and behavior. The condition was first described by Leo Kanner in 1943. Kanner emphasized two key features: autism (social disinterest) and restricted interests and trouble with change. His report underscored the importance of the lack of social interest for other aspects of development and social factors are consistently identified as central to the diagnosis of the condition. In the first decades after its description, autism was often incorrectly assumed to be a form of schizophrenia. Only in 1980 was it officially recognized as a diagnostic category (Volkmar & Klin, 2005).

Table 34–1. Differential Diagnostic Features: Autism and Related Disorders
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Table 34–1. Differential Diagnostic Features: Autism and Related Disorders
FeatureAutismAspergerRettCDDPDD-NOS
Social DisturbanceSevereModerate–severeVariableSevereVariable
Language/Communication ImpairmentMarkedGood verbal ability, poor communicationVery markedMarked (previously normal)Variable
Restricted interestsMarked, mannerisms, trouble with change, occasionally savant abilityUsually highly circumscribed interests (interfering with normal functioning)Significant psychomotor retardationMarked, as in autismVariable—often troubled by change, Mannerisms may be less prominent
Motor issuesOften preserved early but poor later when imitation is requiredOften clumsy, with fine and gross motor difficultiesSignificant loss of motor abilities, hand-washing stereotypiesOften preserved but lose some self-care skillsVariable
OnsetAlways before age 3 yr, often before age 1 yr. A minority regress after normal developmentProblems often recognized in preschool. Motor delays may have been notedBefore age 5 yr (typically, onset with loss of skills)By definition, child normal until age 2 yr; then major loss of skills and dramatic “autistic-like” pictureVariable

DSM-IV-TR Criteria for Autistic Disorder

  1. A total of at least six items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

    1. Qualitative impairment in social interaction, as manifested by at least two of the following:

      1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

      1. Failure to develop peer relationships appropriate to developmental level

      1. A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)

      1. Lack of social or emotional reciprocity

    1. Qualitative impairments in communication as manifested by at least one of the following:

      1. Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to ...

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