BOOK Volkmar 2013 Encyclopedia of Autism Spectrum Disorders

Encyclopedia of Autism
Spectrum Disorders
Fred R. Volkmar
Editor
Encyclopedia of Autism
Spectrum Disorders
With 100 Figures and 131 Tables

Editor
Fred R. Volkmar
Director, Child Study Center
Irving B. Harris Professor of Child Psychiatry, Pediatrics and Psychology
Yale University School of Medicine
Chief, Child Psychiatry Children’s Hospital at Yale-New Haven
Child Study Center
New Haven, CT, USA
ISBN 978-1-4419-1697-6 ISBN 978-1-4419-1698-3 (eBook)

ISBN 978-1-4419-1699-0 (print and electronic bundle)
DOI 10.1007/978-1-4419-1698-3
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2012949356
# Springer Science+Business Media New York 2013

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To individuals with autism, their families, teachers, and all the
professionals who work with them
Preface
Why an encyclopedia of autism? There are several answers to this question.

They include the need to provide a comprehensive and current guide to the
diverse knowledge now available. There has been a significant upsurge in
research in autism during the past two decades. Several hundred papers
were published in 1991 compared to more than 2,000 articles during 2011.
The quantity of research (not even counting non-peer-reviewed publications)
has increased so dramatically that it is difficult, if not impossible, for
researchers and clinicians to keep up. Access to a reference work that pro-
vides an introduction to relevant information is clearly needed.
Although several excellent handbooks and textbooks have been published
in recent years, these are, almost intrinsically, fated to become increasingly
out of date more and more quickly. Fortunately, many of the same techno-
logical advances that have been adapted for use with individuals with autism
have uses for those of us who support them. The ability to produce both a print
reference work as well as an online version with additional content was
a major attraction for us in undertaking this project. It also can be updated
easily and will have additional content. The electronic format also provides
for an extensive cross-referencing system, which is designed to facilitate
rapid searching and information retrieval.
With contributions on a range of topics from leaders in the field, this
reference work breaks new ground as a resource. The Encyclopedia contains
several thousand entries relevant to autism and related conditions, including
new research findings; entries on development and behavior; assessment
methods and instruments; treatments and educational interventions; biogra-
phies of leaders in the field; and information relevant to epidemiology, social
policy, and treatment planning.
Both I and the associate editors of this work hope that you will benefit from
using the encyclopedia and welcome your feedback. By the time the print
publication of this work appears, the online edition will already have had
entries added reflecting new knowledge in various areas. We hope that this
resource enhances the work of clinicians and researchers alike.
New Haven, Connecticut Fred R. Volkmar MD

USA Editor
September 2012
vii
Acknowledgments
A work of this complexity and scope is the product of considerable work by

a tremendous number of people. Our thanks go to the individual contributors
and to the field editors who helped us in countless ways including adding to
our topic lists, soliciting authors for entries, and coordinating with authors on
their entries.
At Springer, Judy Jones was the person who inspired the project in the first
place. Springer staff, including Tina Shelton, Madhumati Deshpande, and
Michaela Bilic, all were extremely supportive throughout the process. At the
Yale Child Study Center Emily Hau, Lori Klein, and Rosemary Serra were
profoundly helpful. To all of these individuals our deep and sincere thanks.
Fred R. Volkmar, M.D. – Editor

Kevin Pelphrey, Ph.D. – Associate Editor
Rhea Paul, Ph.D. – Associate Editor
Michael Powers, Psy.D. – Associate Editor
ix
About the Editors
Fred R. Volkmar, M.D., is Irving B. Harris Professor of Child Psychiatry,

Pediatrics, and Psychology and Director of the Yale University Child Study
Center, Yale University School of Medicine. He is also the Chief of Child
Psychiatry at Yale-New Haven Hospital, New Haven, CT. A graduate of the
University of Illinois where he received an undergraduate degree in psychology
in 1972 and of Stanford University where he received his M.D. and a master’s
degree in psychology in 1976, Dr. Volkmar was the primary author of the
American Psychiatric Association’s DSM-IV autism and pervasive develop-
mental disorders section. He is the author of several hundred scientific papers
and chapters as well as a number of books, including Asperger’s Syndrome
(Guilford Press), Health Care for Children on the Autism Spectrum (Woodbine
Publishing), and the Handbook of Autism (Wiley Publishing), with three books
forthcoming. He has served as an Associate Editor of the Journal of Autism and
Developmental Disabilities, the Journal of Child Psychology and Psychiatry,
and the American Journal of Psychiatry and now serves as Editor in Chief of the
Journal of Autism and Developmental Disabilities. He has served as co-
chairperson of the autism/intellectual disabilities committee of the American
Academy of Child and Adolescent Psychiatry. In addition to having directed the
internationally known autism clinic, he also served as director of autism
research at Yale before becoming chairperson of the Department. Dr. Volkmar
has been the principal investigator of three program project grants, including
a CPEA (Collaborative Program of Excellent in Autism) grant from the
National Institute of Child Health and Human Development and a STAART
(Studies to Advance Autism Research and Treatment) Autism Center Grant
from the National Institute of Mental Health.
xi
Associate Editors
Rhea Paul Yale Child Study Center, New Haven, CT, USA
Kevin Pelphrey Yale Child Study Center, New Haven, CT, USA
Michael D. Powers The Center For Children With Special Needs,
Glastonbury, CT, USA
xiii
Section Editors
Nirit Bauminger School of Education, Bar - Illan University, Ramat-Gan,

Israel
Susan Y. Bookheimer UCLA School of Medicine, Department of Psychi-
atry and Biobehavioral Sciences, Los Angeles, CA, USA
Alice Carter Department of Psychology, University of Massachusetts,
Boston, Boston, MA, USA
Tony Charman Centre for Research in Autism and Education, Department
of Psychology and Human, Institute of Education, University of London,
London, UK
Katarzyna Chawarska Yale Child Study Center, New Haven, CT, USA
Joshua Diehl Dept. of Psychology, University of Notre Dame, Notre Dame,
IN, USA
Peter Doehring Foundations Behavioral Health, Doylestown, PA, USA
Andrew L. Egel Department of Special Education, University of Maryland,
College Park, MD, USA
Susan Ellis-Weismer Department of Communicative Disorders/Waisman
Center, University of Wisconsin-Madison, Madison, WI, USA
Ruth Eren Southern Connecticut State University, New Haven, CT, USA
Adam Feinstein Looking Up, London, UK
Eric Fombonne Department of Psychiatry, McGill University, Montreal,
Quebec, Canada
Joaquin Fuentes Servicio de Psiquiatria Infantil y Adolescente, Policlinica
Gipuzkao, Donostia-20014, San Sebastian, Spain
Howard Goldstein Schoenbaum Family Center The Ohio State University,
Human Development and Family Science, Columbus, OH, USA
Francesca Happe MRC Social, Genetic and Developmental Psychiatry
Centre at the Institute of Psyc, London, UK
Patricia Howlin Institute of Psychiatry, King’s College, London, UK
xv
xvi Section Editors
Susan Hyman University of Rochester, Golisano Children’s Hospital,

Rochester, NY, USA
Connie Kasari Graduate School of Education and Information Studies and
the Semel Institute for, University of California, Los Angeles, Los Angeles,
CA, USA
Robert L. Koegel University of California, Santa Barbara, Gevirtz Graduate
School of Education, Santa Barbara, CA, USA
Ann S. Le-Couteur Sir James Spence Institute, Royal Victoria Infirmary,
University of Newcastle, Newcastle upon Tyne, UK
Luc Lecavalier Ohio State University and Nisonger Cente, Columbus,
OH, USA
Pat Levitt Zilkha Neurogenetic Institute, Keck School of Medicine at USC,
Los Angeles, CA, USA
James W. Loomis Glastonbury, CT, USA
Catherine Lord Institute for Brain Development, New York-Presbyterian
Hospital/Westchester Division, White Plains, NY, USA
Lee Marcus University of North Carolina Division TEACCH, CB#7180,
Chapel Hill, NC, USA
Christopher McDougle Indiana University School of Medicine, Indianap-
olis, IN, USA
James McPartland Yale Child Study Center, New Haven, CT, USA
Nancy J. Minshew University of Pittsburgh, Pittsburgh, PA, USA
Paul A. Offit Chief, Division of Infectious Diseases, Department of Pediat-
rics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Rhea Paul Yale Child Study Center, New Haven, CT, USA
Kevin A. Pelphrey Yale Child Study Center, New Haven, CT, USA
Kristen M. Powers Center for Children with Special Needs, Glastonbury,
CT, USA
Michael D. Powers The Center For Children With Special Needs, Glaston-
bury, CT, USA
Patricia Prelock University of Vermont, Communication Sciences, Bur-
lington, VT, USA
Brian Reichow Yale Child Study Center, New Haven, CT, USA
Sally Rogers Department of Psychiatry and Behavioral Sciences, UC Davis
M.I.N.D. Institute, Sacramento, CA, USA
Lawrence David Scahill Yale School of Nursing, Rm A284, New Haven,
CT, USA
Section Editors xvii
Tristram H. Smith Department Pediatrics, SCDD, University of Rochester

Medical Center, Rochester, NY, USA
Matthew W. State Department of Psychiatry, Yale Child Study Center,
Yale University School of Medicine, New Haven, CT, USA
Wendy Stone UW Autism Center, University of Washington, Seattle,
WA, USA
Helen Tager-Flusberg Lab of Developmental Cognitive Neuroscience,
Boston University, Boston, MA, USA
John W. Thomas Quinnipiac University School of Law, Hamden, CT, USA
Geralyn Timler Speech Pathology & Audiology, Miami University,
Oxford, OH, USA
Rutger Jan Van der Gaag University Medical Centre St. Radboud,
Karakter University Centre Child & Adoles, Utrecht, Netherlands
Ernst VanBergeijk Vocational Independence Program, New York Institute
of Techonolgy, Central Islip, New York, USA
Giacomo Vivanti Olga Tennison Research Centre, School of Psychological
Science, La Trobe University, Melbourne, Victoria, Australia
Sara Jane Webb University of Washington, Seattle, WA, USA
Deborah Weiss Department of Communication Disor, Southern Connecti-
cut State University, New Haven, CT, USA
Mary Jane Weiss Douglass Developmental Disabilities Center, Rutgers
University, New Brunswick, NJ, USA
Virginia C. N. Wong Division of Child Neurology/Developmental
Pediatrics/Neurohabilitation, Departme, The University of Hong Kong,
Hong Kong, China
Jeffrey J. Wood UCLA Departments of Psychiatry and Education, UCLA
Center for Autism Research an, Los Angeles, CA, USA
Marc Woodbury-Smith McMaster University, Hamilton, ON, Canada
Contributors
Karen Aalst University Utrecht, Utrecht, The Netherlands

Benjamin Aaronson Psychiatry and Behavioral Sciences, UW Autism
Center, University of Washington, Seattle, WA, USA
Pasquale Accardo Virginia Commonwealth University, Richmond, VA,
USA
Thomas Achenbach Department of Psychiatry, University of Vermont,
Burlington, VT, USA
Silvia Adaes Quinnipiac University School of Law, Hamden, CT, USA
Gail Fox Adams Department of Applied Linguistics, University of Califor-
nia, Los Angeles, Los Angeles, CA, USA
Catherine Adams Human Communication and Deafness/School of Psycho-
logical Sciences, University of Manchester, Manchester, UK
Ralph Adolphs Division of the Humanities and Social Sciences, California
Institute of Technology, Pasadena, CA, USA
Rodrı́guez Adriana Department of Psychology, Virginia Commonwealth
University, Richmond, VA, USA
Bill Ahearn The New England Center for Children, Southborough,
MA, USA
Kimberly Aldinger Department of Cell and Neurobiology, Keck School of
Medicine, University of Southern California, Los Angeles, CA, USA
Elizabeth Allen Test Development, PROED, Inc., Austin, TX, USA
Melissa L. Allen Department of Psychology, Lancaster University Fylde
College, Lancaster, UK
Michael G. Aman Nisonger Center, UCEDD, The Ohio State University,
Columbus, OH, USA
Evdokia Anagnostou Department of Peadiatrics, University of Toronto
Clinician Scientist, Bloorview Research Institute, Toronto, ON, Canada
George M. Anderson Laboratory of Developmental Neurochemistry,
Yale Child Study Center, Yale University, New Haven, CT, USA
xix
xx Contributors
Elizabeth Archer Department of Psychology, Virginia Commonwealth

Jennifer Arnold Department of Psychology, University of North Carolina,
Miya Asato Pediatrics and Psychiatry, University of Pittsburgh School of
Medicine Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
Kristen Ashbaugh Koegel Autism Center, University of California, Santa
Barbara, CA, USA
Karla K. Ausderau Department of Kinesiology, Occupational Therapy
Program, University of Wisconsin-Madison, Madison, WI, USA
Sarita Austin Laboratory of Developmental Communication Disorders,
Yale Child Study Center, New Haven, CT, USA
Bonnie Auyeung Autism Research Centre, University of Cambridge,
Cambridge, UK
Mitrah E. Avini Yale Child Study Center, New Haven, CT, USA
Alvi Azad Yale Child Study Center, The Edward Zigler Center in Child
Development and Social Policy, Yale University, New Haven, CT, USA
Marina Azimova The Center for Children with Special Needs, Glastonbury,
CT, USA
Michelle Sondra Ballan Columbia University School of Social Work, New
York, NY, USA
Claudio Banzato Psychiatry, University of Campinas – Unicamp, Campi-
nas, São Paulo, Brazil
Grace T. Baranek Department of Allied Health Sciences, Division of
Occupational Science, University of North Carolina at Chapel Hill, Chapel
Hill, NC, USA
Aurélie Baranger Autism-Europe, Bruxelles, Belgium
Ramon Barinaga GAUTENA, Donostia Gipuzkoa, Spain
Gregory Barnes Department of Neurology, School of Medicine, Vanderbilt
University, Nashville, TN, USA
Simon Baron-Cohen Autism Research Centre, University of Cambridge,
Cambridge, UK
Anjali Barretto Department of Special Education, Gonzaga University,
Spokane, WA, USA
Kevin Barry Quinnipiac University School of Law, Hamden, CT, USA
Christine Barthold Center for Disabilities Studies, University of Delaware,
Newark, DE, USA
Contributors xxi
Erin E. Barton University of Colorado Denver, Denver, CO, USA

Marianne Barton Department of Psychology, University of Connecticut,
Storrs, CT, USA
Nirit Bauminger-Zviely School of Education, Bar - Illan University,
Ramat-Gan, Israel
Allison Bean Speech and Hearing Science, The Ohio State University,
Columbus, OH, USA
Daniel F. Becker Department of Psychiatry, University of California,
San Francisco, San Francisco, USA
Cynthia Beesley Benhaven, Inc, North Haven, CT, USA
Sander Begeer Developmental Psychology, VU University Amsterdam,
Amsterdam, The Netherlands
Autism Research Amsterdam, Amsterdam, The Netherlands
School of Psychology, University of Sydney, Australia
Marlene Behrman Department of Psychology, Carnegie Mellon University
Center for the Neual Basis of Cognition, Pittsburgh, PA, USA
Jennifer S. Beighley Department of Psychology, Louisiana State Univer-
sity, Baton Rouge, LA, USA
Stephanie Bendiske The Center For Children With Special Needs, Glaston-
bury, CT, USA
Terry Bennett Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Hamilton, ON, Canada
Randi Bennett Child Neuroscience Laboratory, Yale Child Study Center,
New Haven, CT, USA
Loisa Bennetto Department of Clinical and Social Sciences in Psychology,
University of Rochester, Rochester, NY, USA
Betsey A. Benson Nisonger Center, UCEDD The Ohio State University,
Columbus, OH, USA
Michael Berger Department of Psychology, Royal Holloway University of
London, Egham, Surrey, UK
Thomas P. Berney Newcastle University, Sir James Spence Institute, Royal
Victoria Infirmary, Newcastle upon Tyne, UK
Raphael Bernier Psychiatry and Behavioral Sciences, University of
Washington, Seattle, WA, USA
Armando Bertone McGill University, Montreal, Canada
Frank Besag Child & Adolescent Mental Health Services, SEPT. (South
Essex Partnership University NHS Foundation Trust), Bedford, Bedfordshire,
UK
xxii Contributors
Linas Bieliauskas Departments of Psychology and Psychiatry, University

of Michigan Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
Dorothy Bishop Department of Experimental Psychology, University of

Oxford, Oxford, UK
Somer Bishop Cincinnati Children’s Hospital Medical Center, Cincinnati,

OH, USA
Vicki Bitsika Faculty of Humanities and Social Sciences, Bond University,

Robina, QLD, Australia
Amanda Blackwell School of Behavioral and Brain Sciences, Callier Cen-

ter for Communication Disorders, University of Texas-Dallas, Dallas, TX,
USA
Michael Bloch Yale OCD Research Clinic, New Haven, CT, USA
Danielle Bolling Yale Child Study Center, New Haven, CT, USA
Laura Bonazinga Vermont Speech Language Pathology Private Practice

Services, South Burlington, VT, USA
Alex Bonnin Keck School of Medicine, University of Southern California,

Susan Y. Bookheimer Department of Psychiatry and Biobehavioral

Sciences, UCLA School of Medicine, Los Angeles, CA, USA
Susan Boorin School of Nursing Yale University, New Haven, CT, USA
Hilary Boorstein Children’s Mercy Hospital, Kansas,
Jill Boucher Developmental Psychology, Autism Research Group,

City University, London, London, UK
Linda Bowers LinguiSystems, Inc, East Moline, IL, USA
Dermot Bowler Autism Research Group, City University London, London,

UK
Jessica Bradshaw Clinical Psychology, UCSB Koegel Autism Center,

University of California, Santa Barbara, USA
John Bradshaw Faculty of Medicine, Nursing and Health Sciences,

Monash University, Victoria, Australia
Jennifer Brielmaier Laboratory of Behavioral Neuroscience, National

Institute of Mental Health, NIH, Bethesda, MD, USA
Nicolette Bainbridge Brigham Vanderbilt Kennedy Center, Treatment and

Research Institute for Autism Spectrum Disorders (TRIAD) Vanderbilt
University, Nashville, TN, USA
Erik Bromberg University of California, Santa Barbara, USA

Contributors xxiii
Rechele Brooks Psychiatry and Behavioral Sciences, University of

Institute for Learning & Brain Sciences (I–LABS), University of Washing-
ton, Seattle, WA, USA
Whitney T. Brooks Nisonger Center, UCEDD The Ohio State University,
Columbus, OH, USA
Jeffrey P. Brosco Department of Pediatrics, Miller School of Medicine,
University of Miami, Mailman Center for Child Development, Miami, FL,
USA
Ted Brown Department of Occupational Therapy, Monash University –
Peninsula Campus, Frankston, Victoria, Australia
Lauren Turner Brown Department of Psychiatry, Carolina Institute for
Developmental Disabilities, CB #3367 University of North Carolina at
Chapel Hill, Chapel Hill, NC, USA
Pamela Brucker Special Education and Reading, Southern Connecticut
State University, New Haven, CT, USA
Crystal I. Bryce School of Social & Family Dynamics, Arizona State
University, Tempe, AZ, USA
Karen Burner Department of Psychology, University of Washington,
Seattle, WA, USA
Courtney Burnette Center for Development & Disability, University of
New Mexico, Albuquerque, NM, USA
Sarah Butler Center for Autism and the Developing Brain, New York-
Presbyterian Hospital/Westchester Division, White Plains, NY, USA
Claudia Califano Yale-New Haven Hospital, New Haven, CT, USA
Daniel Campbell Yale Child Study Center, Yale University, New Haven,
CT, USA
Ricardo Canal Clinical Psychology Department, University Institute on
Community Integration Universidad de Salamanca, Salamanca, Spain
Allison R. Canfield Department of Pediatrics, University of Rochester
School of Medicine and Dentistry, Rochester, NY, USA
Lindsey Capece Quinnipiac University, Hamden, CT, USA
Matthew R. Capriotti Department of Psychology, University of Wiscon-
sin-Milwaukee, Milwaukee, WI, USA
Laurie Cardona Yale Child Study Center, Yale University, New Haven,
CT, USA
L. Lee Carlisle Division of Child and Adolescent Psychiatry, Department of
Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA,
USA
xxiv Contributors
Christi Carnahan University of Cincinnati, Cincinnati, OH, USA

Staci Carr UniqueKids Inc, Moseley, VA, USA
Themba Carr University of Michigan Center for Human Growth and
Development, Ann Arbor, MI, USA
Alice S. Carter Department of Psychology, University of Massachusetts,
Manuel Casanova Department of Psychiatry, University of Louisville,
Louisville, KY, USA
Jane Case-Smith Division of Occupational Therapy, School of Health and
Rehabilitation Sciences, Columbus, OH, USA
Arlette Cassidy Psychologist, The Gengras Center, University of Saint
Joseph, West Hartford, CT, USA
Lisa Castagnola Child Study Center, The Edward Zigler Center in Child
Development & Social Policy, Yale University School of Medicine, New
Haven, CT, USA
A. Charles Catania Department of Psychology, UMBC (University of
Maryland, Baltimore County), Baltimore, MD, USA
Paul Cavanagh New York Institute of Technology, Central Islip, NY, USA
S. Michael Chapman TEACCH Autism Program, University of North
Carolina Chapel Hill, Chapel Hill, NC, USA
Marjorie H. Charlop Department of Psychology, Claremont McKenna
College, Claremont, CA, USA
Tony Charman Centre for Research in Autism and Education, Department
of Psychology and Human Institute of Education, University of London,
London, UK
Karen Chenausky Boston University, Boston, MA, USA
Tessa Chesher Tulane University, New Orleans, LA, USA
Coralie Chevallier SGDP Centre, Institute of Psychiatry, King’s College,
London, UK
Center for Autism Research, Children’s Hospital of Philadelphia, Philadel-
phia, PA, UK
Rob Christian Department of Psychiatry, The Carolina Institute for Devel-
opmental Disabilities, University of North Carolina School of Medicine,
Lillian Christon Department of Psychology, Virginia Commonwealth Uni-
versity, Richmond, VA, USA
Domenic V. Cicchetti Departments of Psychiatry and Biometry, Yale Child
Study Center, Yale University, New Haven, CT, USA
Contributors xxv
Keith A. Coffman Department of Pediatrics, School of Medicine, Pitts-

burgh, PA, USA
John N. Constantino Department of Psychiatry, Washington University
School of Medicine, St. Louis, MO, USA
Barbara Cook Center of Excellence on Autism Spectrum Disorders,
Department of Special Education, Southern Connecticut State University,
Middlebury, CT, USA
Elaine Coonrod Department of Psychiatry, School of Medicine, TEACCH
The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Judith Cooper NIDCD (National Institute on Deafness and Other Commu-
nication Disorders), National Institute of Health EPS – Executive Plaza
South, 400C, Rockville, MD, USA
Eugenia Corbett Franklin County Home Health, St. Albans, VT, USA
Cara Cordeaux Child Neuroscience Lab, Yale Child Study Center,
New Haven, CT, USA
Lauren Cornew Radiology Department, Children’s Hospital of Philadel-
phia, Philadelphia, PA, USA
Christoph U. Correll Psychiatry Research, The Zucker Hillside Hospital,
Glen Oaks, NY, USA
Christina Corsello Department of Psychiatry, Child & Adolescent Services
Research Center, University of San Diego, San Diego, CA, USA
Laura Crane Department of Psychology, Goldsmiths, University of
London, New Cross, London, UK
Jacqueline N. Crawley Laboratory of Behavioral Neuroscience, National
Institute of Mental Health, NIH, Bethesda, MD, USA
Lisa Croen Autism Research Program, Kaiser Permanente Division of
Research, Oakland, CA, USA
Michael J. Crowley Developmental Electrophysiology Laboratory,
Tamara C. Daley Westat, Durham, NC, USA
Paulo Dalgalarrondo University of Campinas Cidade Universitária
“Zeferino Vaz”, São Paulo, Brazil
Jeffrey Danforth Department of Psychology, Eastern Connecticut State
University, Willimantic, CT, USA
John T. Danial Psychological Studies in Education, University of California,
Los Angeles, Los Angeles, CA, USA
Clarissa Dantas Department of Psychiatry, Faculty of Medical Sciences,
University of Campinas (Unicamp), Campinas, São Paulo, Brazil
xxvi Contributors
Catherine Davies Indiana Resource Center for Autism Indiana University,

Bloomington, IN, USA
Naomi Davis 3-C Institute for Social Development, Cary, NC, USA
Cheryl Davis 7 Dimensions Consulting, Southborough, MA, USA
Geraldine Dawson Department of Psychiatry, University of North
Carolina, NC, USA
Michelle Dawson Centre d’excellence en troubles envahissants du
développement de l’université de Montréal, Hôpital Rivière-des-Prairies,
Montréal, QC, Canada
Annelies de Bildt Child and Adolescent Psychiatry, Accare, Accare,
Groningen, The Netherlands
Rebecca DeAquair The Center for Children with Special Needs,
W. Thornton N. Deegan Yale Child Study Center, New Haven, CT, USA
Lara Delmolino Douglass Developmental Disabilities Center, Rutgers,
The State University of New Jersey, New Brunswick, NJ, USA
Kristen D’Eramo The Center for Children with Special Needs, Glaston-
bury, CT, USA
K. Mark Derby Department of Special Education, Gonzaga University,
Spokane, WA, USA
Mieke Dereu Experimental Clinical and Health Psychology, Ghent Univer-
sity, Ghent, Belgium
Whitney J. Detar Gevirtz Graduate School of Education, The University of
California Center for Special Education, Disabilities, & Devel, Santa
Barbara, CA, USA
Joshua Diehl Department of Psychology, University of Notre Dame, Notre
Dame, IN, USA
Nicholas M. DiLullo Child Study Center, Yale University School of
Medicine, New Haven, CT, USA
Ilan Dinstein Psychology Department, Carnegie Mellon University,
Pittsburgh, PA, USA
Amiris Dipuglia Pennsylvania Training and Technical Assistance Network,
Harrisburg, PA, USA
Cheryl Dissanayake Olga Tennison Autism Research Centre, School of
Psychological Science La Trobe University, Melbourne, VIC, Australia
Peter Doehring Foundations Behavioral Health, Doylestown, PA, USA
Rebecca Doggett Koegel Autism Center, Gevirtz Graduate School of Edu-
cation, University of California, Santa Barbara, Santa Barbara, CA, USA
Contributors xxvii
Elizabeth Howell Dohrmann Vanderbilt Kennedy Center, Treatment and

Research Institute for Autism Spectrum Disorders (TRIAD), Nashville, TN,
USA
Amy Donaldson Speech & Hearing Sciences Department, Portland State
University, Portland, OR, USA
Constance Doss Department of Psychology, University of Alabama-Bir-
mingham, Birmingham, AL, USA
Carolyn A. Doyle Indiana University School of Medicine, Indianapolis, IN,
USA
Ed Duncan SPL, La Trobe University Children’s Centre, Melbourne,
Australia
Debra Dunn The Center for Autism Research, The Children’s Hospital of
Philadelphia, Philadelphia, PA, USA
Kathleen Dyer River Street Autism Program at Coltsville, Capitol Region
Education Council/Elms College, Hartford, CT, USA
Marilyn Van Dyke Psychological Studies, UCLA’s Graduate School of
Education and Information Systems, University of California, Los Angeles,
Shaun M. Eack School of Social Work, University of Pittsburgh 2117
Cathedral of Learning, Pittsburgh, PA, USA
Maureen Early Christian Sarkine Autism Treatment Center, Indianapolis,
IN, USA
Lisa Edelson Department of Psychology, Boston University, Boston, MA,
USA
Elizabeth R. Eernisse Department of Language and Literacy, Cardinal
Stritch University, Milwaukee, WI, USA
Shaunessy Egan The Center for Children with Special Needs, Glastonbury,
CT, USA
Inge-Marie Eigsti Department of Psychology, University of Connecticut,
Storrs, CT, USA
Haskins Laboratories, New Haven, CT, USA
Svein Eikeseth Department of Behavioral Science, Oslo and Akershus
University College, Lillestrom, Norway
Annemarie van Elburg Child and Adolescent Psychiatry, Rintveld center
for Eating Disorders, Altrecht Mental Health Institute, University Medical
Center Utrecht, Utrecht, The Netherlands
Paul El-Fishawy State Laboratory, Child Study Center, Yale University,
New Haven, CT, USA
xxviii Contributors
Stephen N. Elliott Learning Sciences Institute, Arizona State University,

Tempe, AZ, USA
Eric Emerson Centre for Disability Research, Lancaster University, Lan-
caster, LA, UK
Centre for Disability Research and Policy, University of Sydney, Lidcombe,
NSW, Australia
Peter Enticott Faculty of Medicine, Nursing and Health Sciences, Monash
University, Victoria, Australia
Ruth Eren Southern Connecticut State University, New Haven, CT, USA
Craig Erickson Christian Sarkine Autism Treatment Center, Indianapolis,
IN, USA
Department of Psychiatry, Indiana University School of Medicine, Indianap-
olis, IN, USA
Gianluca Esposito Kuroda Research Unit, RIKEN Brain Science Institute
(Saitama, Japan), Wako-shi, Saitama, Japan
Joshua Ewen Kennedy Krieger Institute, Baltimore, MD, USA
Susan Faja Department of Psychiatry and Behavioral Sciences, University
of Washington, Seattle, WA, USA
Megan Farley Psychiatry, University of Utah School of Medicine, Univer-
sity Neuropsychiatric Institute, Salt Lake City, UT, USA
Cristan Farmer Nisonger Center Psychology, Ohio State University,
Columbus, OH, USA
Janet Farmer Thompson Center for Autism and Neurodevelopmental
Disorders University of Missouri, Columbia, MO, USA
Miranda Farmer Yale Child Study Center, New Haven, CT, USA
Deborah Fein Department of Psychology, University of Connecticut,
Storrs, CT, USA
Adam Feinstein Autism Cymru and Looking Up, London, UK
Eunice Feng Koegel Autism Center, Eli and Edythe L. Broad Center for
Asperger Research, University of California, Santa Barbara, CA, USA
Thomas Fernandez Yale Child Study Center, Yale University School of
Summer Ferreri Department of Counseling, Educational Psychology and
Special Education, College of Education Michigan State University, East
Lansing, MI, USA
Sean Field The School at Springbrook, Oneonta, NY, USA
Michael B. First Department of Psychiatry, Columbia University,
New York State Psychiatric Institute, New York, NY, USA
Contributors xxix
Paul El Fishawy State Lab, Yale University Child Study Center,

New Haven, CT, USA
Faye van der Fluit Department of Psychology, University of Wisconsin,

Milwaukee, Milwaukee, WI, USA
Renee Folsom Semel Institute for Neuroscience and Human Behavior,

University of California Los Angeles (UCLA) The Help Group/UCLA
Neuropsychology Program, Los Angeles, CA, USA
Joy Fopiano Department of Elementary Education, Southern Connecticut

Danielle Forbes Psychology, University of Massachusetts Boston, Boston,

MA, USA
Solandy Forte The Center for Children with Special Needs, Glastonbury,
CT, USA
Thomas Frazier Research Center for Autism, The Cleveland Clinic, Cleve-
land, OH, USA
Stephanny Freeman Center for Autism Research and Treatment (CART),

University of California, Los Angeles, Los Angeles, CA, USA
Cori Fujii Division of Psychological Studies in Education, University of

California, Los Angeles, Los Angeles, CA, USA
Maria Fusaro Department of Psychiatry and Behavioral Sciences, UC

Davis M.I.N.D. Institute, Sacramento, CA, USA
Jan Van der Rutger Gaag University Medical Centre St. Radboud,
Karakter Child & Adolescent Psychiatry University Centre, Nijmegen,
Utrecht, Netherlands
Cheryl Smith Gabig Department of Speech-Language-Hearing Sciences,

Lehman College/The City University of New York, Bronx, NY, USA
Sebastian Gaigg Autism Research Group, City University London, London,

UK
Beth Garrison Hartford Hospital Pain Treatment Center, Bristol, CT, USA
Grace Gengoux Child and Adolescent Psychiatry, Stanford University

School of Medicine, Lucile Packard Children’s Hospital, Stanford, CA, USA
Danielle Geno The College of Arts and Sciences, The University of

Vermont, Burlington, VT, USA
Sima Gerber Department of Linguistics & Communication Disorders,

Queens College, Flushing, NY, USA
Jennifer Varley Gerdts Department of Psychology, University of Wash-

ington, Seattle, WA, USA
xxx Contributors
Ahmad Ghanizadeh Shiraz University of Medical Sciences, School of

Medicine, Research Center for Psychiatry and Behavioral Sciences, Shiraz,
Iran
Mohammad Ghaziuddin University of Michigan, Ann Arbor, MI, USA
Tobi Gilbert Quinnipiac University School of Law, Hamden, CT, USA
Christopher Gillberg Department of Child and Adolescent Psychiatry,

Gillberg Neuropsychiatry Centre, University of Gothenburg, Gothenburg,
Sweden
Walter Gilliam Child Study Center, Yale University School of Medicine,

New Haven, CT, USA
Regina Gilroy Quinnipiac University School of Law, Hamden, CT, USA
Tara J. Glennon Occupational Therapy, Quinnipiac University – Hamden,

CT Center for Pediatric Therapy, Fairfield & Wallingford, CT, Hamden, CT,
USA
Jeffrey Glennon Department of Cognitive Neuroscience, Radboud Univer-

sity Nijmegen Medical Centre, Nijmegen, The Netherlands
Dorie Glover Psychiatry and Biobehavioral Sciences, University of

California at Los Angeles, Los Angeles, CA, USA
Nitin Gogtay Division of Child and Adolescent Psychiatry, National Insti-

tutes of Mental Health, Bethesda, MD, USA
Melissa C. Goldberg Kennedy Krieger Institute, Baltimore, MD, USA
Tina R. Goldsmith Center for Development and Disability, University of

New Mexico, Albuquerque, NM, USA
Howard Goldstein Human Development and Family Science, The Ohio

State University, Columbus, OH, USA
Gerald Goldstein VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
Peyman Golshani David Geffen School of Medicine at UCLA, Los

Angeles, CA, USA
Amanda E. Gordon Quinnipiac University School of Law, Hamden, CT,

USA
Ilanit Gordon Child Study Center, Yale University, New Haven, CT, USA
Judith Gould NAS Lorna Wing Centre for Autism, Bromley, Kent, United
Kingdom
Michele Goyette-Ewing Yale Child Study Center, New Haven, CT, USA
Richard B. Graff The New England Center for Children, Inc,

Southborough, MA, USA
Contributors xxxi
Temple Grandin Department of Animal Sciences, Colorado State Univer-

sity, Colorado, USA
Sarah A. O. Gray Department of Psychology, University of Massachusetts,

Kylie M. Gray Centre for Developmental Psychiatry and Psychology,

School of Psychology and Psychology Monash University, ELMHS, Monash
Medical Centre, Clayton, VIC, Australia
Shulamite A. Green Department of Psychology, University of California,

Evelynne Green The University of Vermont, Burlington, VT, USA
Alissa L. Greenberg Claremont Graduate University, Claremont, CA, USA
Alyse Greer Quinnipiac University School of Law, Hamden, CT, USA
Frank M. Gresham Department of Psychology, Louisiana State University,

Baton Rouge, LA, USA
Elena L. Grigorenko Yale Child Study Center, Psychology, and Epidemi-

ology and Public Health, Yale University, New Haven, CT, USA
Jemma Grindstaff Chapel Hill TEACCH Center, Carrboro, NC, USA
Roy Grinker Anthropology, The George Washington University, N.W.

Washington, DC, USA
Mark Groskreutz Special Education and Reading Department, The Center

of Excellence on Autism Spectrum Disorders, Southern Connecticut State
University, New Haven, CT, USA
Matthew Grover Nisonger Center - UCEDD, The Ohio State University,

Columbus, OH, USA
Amanda C. Gulsrud UCLA Semel Institute for Neuroscience and Human

Behavior, Los Angeles, CA, USA
Abha R. Gupta Developmental-Behavioral Pediatrics, Child Study Center,

Yale University, New Haven, CT, USA
Nouchine Hadjikhani Harvard Medical School, Charlestown, MA, USA
Eileen Haebig Dept. of Communication Sciences and Disorders, University

of Wisconsin-Madison, Madison, WI, USA
Deborah Hales Division of Education, American Psychiatric Association,

Arlington, VA, USA
Jane Hamilton Quinnipiac University School of Law, Hamden, CT, USA
Robin Hansen Pediatrics, Center for Excellence in Developmental Disabil-

ities, M.I.N.D. Institute/UCDavis, Sacramento, CA, USA
xxxii Contributors
Francesca Happé MRC Social, Genetic and Developmental Psychiatry

Centre at the Institute of Psychiatry, King’s College London, London, UK
Antonio Hardan Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, CA, USA
Sarah Hardy Department of Psychology, University of Rhode Island,
Kingston, RI, USA
Sandra Harris Douglass Developmental Disabilities Center, Rutgers,
The State University of New Jersey, New Brunswick, NJ, USA
Devon Hartford Carolina Institute for Developmental Disabilities, Univer-
sity of North Carolina School of Medicine, Chapel Hill, NC, USA
Catharina Hartman Department of Psychiatry, University of Groningen,
University Medical Center Groningen, Accare, Groningen, The Netherlands
Tyler A. Hassenfeldt Virginia Polytechnic Institute & State University,
Blacksburg, VA, USA
Susan M. Havercamp Nisonger Center, UCEDD, The Ohio State Univer-
sity, Columbus, OH, USA
Pamela Heaton Department of Psychology, University of London, London,
UK
Amy Heberle Clinical Psychology, University of Massachusetts, Boston,
MA, USA
Heather A. Henderson Department of Psychology, University of Miami,
Coral Gables, FL, USA
Dawn Hendricks Department of Special Education and Disability Policy,
VCU Autism Center for Excellence, Virginia Commonwealth University,
Richmond, VA, USA
Susan Hepburn Department of Psychiatry & Pediatrics, JFK Partners,
University of Colorado at Denver, Aurora, CO, USA
Amaia Hervas Child and Adolescent Mental Health Unit, University
Hospital Mutua of Terrassa, Barcelona, Spain
David Hessl Department of Psychaitry and Behavioral Sciences, University
of California, Davis Medical Center, M.I.N.D. Institute, Sacramento, CA,
USA
Ashley Durkee Hester Carolina Institute for Developmental Disabilities,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Manon H. J. Hillegers Department of Psychiatry, University Medical Cen-
ter Utrecht, Rudolph Magnus Institute of Neuroscience, Utrecht, Netherlands
R. Peter Hobson Tavistock Clinic and Institute of Child Health, University
College, London, UK
Contributors xxxiii
Sandra Hodgetts Pediatrics, University of Alberta, Edmonton, Canada

Kristin Hodgson UNC TEACCH Autism Program-Charlotte, Charlotte,
NC, USA
Ellen J. Hoffman Albert J. Solnit Integrated Training Program, Yale Child
Study Center, New Haven, CT, USA
Thomas P. Hogan Department of Psychology, University of Scranton,
Scranton, PA, USA
Kerry Hogan Wilmington Psych, Wilmington, NC, USA
Katherine C. Holman Department of Special Education, Towson Univer-
sity, Towson, MD, USA
Anne Holmes Eden Autism Services, Princeton, NJ, USA
David L. Holmes Lifespan Services, Princeton, NJ, USA
Stephen R. Hooper Department of Psychiatry, The Carolina Institute for
Developmental Disabilities, School of Medicine, University of North
Carolina, Chapel Hill, NC, USA
Ernst Horwitz Department of Psychiatry, Groningen University Medical
Center, Groningen, The Netherlands
Patricia Howlin Institute of Psychiatry, King’s College of London, London,
UK
Kristelle Hudry Olga Tennison Autism Research Centre, School of
Psychological Science, La Trobe University, Bundoora, VIC, Australia
Marisela Huerta Center for Autism and the Developing Brain, Weill
Cornell Medical College, NewYork Presbyterian Hospital, White Plains,
NY, USA
Samantha Huestis Yale Child Study Center, New Haven, CT, USA
Rosemary Huisingh LinguiSystems, Inc, East Moline, IL, USA
Kara Hume University of North Carolina, Chapel Hill, NC, USA
Hillary Hurst Department of Psychology, University of Massachusett
Vanessa Hus Department of Psychology, University of Michigan, Ann
Arbor, MI, USA
Tiffany Hutchins Department of Communication Sciences and Disorders,
The University of Vermont 407 Pomeroy Hall, Burlington, VT, USA
Ted Hutman Department of Psychiatry & Biobehavioral Science, David
Geffen School of Medicine, UCLA, Los Angeles, CA, USA
Soonjo Hwang Psychiatry, Massachusetts General Hospital, Boston, MA,
USA
xxxiv Contributors
Wei-Chin Hwang Department of Psychology, Claremont McKenna Col-

lege, Claremont, CA, USA
Susan Hyman Division of Neurodevelopmental and Behavioral Pediatrics,
University of Rochester Golisano Children’s Hospital, Rochester, NY, USA
Marco Iacoboni Semel Institute for Neuroscience and Human Behavior,
David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Sheree Incorvaia Vocational Independence Program, New York Institute of
Technology, Central Islip, NY, USA
Brooke Ingersoll Department of Psychology, Michigan State University,
East Lansing, MI, USA
Irma Isasa Polyclinic Gipuzkoa Paseo Miramón, 174, Donostia, Spain
Andrew Iskandar Division TEACCH, CB 7180, UNC-CH, TEACCH
Early Intervention Program, Chapel Hill, NC, USA
Laudan B. Jahromi School of Social & Family Dynamics, Arizona State
Sara Jelinek Department of Psychology, Michigan State University, East
Lansing, MI, USA
Cynthia R. Johnson Pediatrics, Psychiatry, & Education, University of
Pittsburgh, Pittsburgh, PA, USA
Kristin Johnson Yale University, New Haven, CT, USA
Kimberly Johnson Neurodevelopmental and Behavioral Pediatrics,
Children’s Hospital Colorado, Aurora, CO, USA
Ellen Johnson Section of Social Work, Mayo Clinic, Rochester, MN, USA
Catherine R. G. Jones Department of Psychology, University of Essex,
Colchester, UK
Emily Jones Department of Psychiatry and Behavioral Sciences, University
Maretha de Jonge Department of Psychiatry, University Medical Center,
Utrecht, Netherlands
Rita Jordan School of Education, The University of Birmingham, Birming-
ham, UK
Roger J. Jou Child Study Center, Yale University School of Medicine, New
Haven, CT, USA
Martha Bates Jura Department of Psychiatry, UCLA/Geffen School of
Medicine. Private Practice, West Los Angeles, Los Angeles, CA, USA
Aaron Kaat Nisonger Center, Ohio State University, Columbus, OH, USA
Allison Kahl New York University School of Law, New York, NY, USA
Contributors xxxv
Martha D. Kaiser Child Neuroscience Laboratory, Yale Child Study

Center, New Haven, CT, USA
Rajesh Kana Department of Psychology, University of Alabama-Birming-
ham, Birmingham, AL, USA
Steve Kanne Department of Health Psychology, School of Health Profes-
sions Thompson Center for Autism and Neurodevelopmental Disorders,
University of Missouri, Columbia, MO, USA
Sara Kaplan-Levy Clinical Psychology, University of Massachusetts, Bos-
ton, Boston, MA, USA
Annette Karmiloff-Smith Birkbeck College, London, UK
Christie P. Karpiak Department of Psychology, University of Scranton,
Scranton, PA, USA
Connie Kasari Graduate School of Education and Information Studies and
the Semel Institute, University of California, Los Angeles, Los Angeles, CA,
USA
Juli Katon Department of Special Education, University of Maryland,
Alice Kau Intellectual and Developmental Disabilities (IDD) Branch,
Eunice Kennedy Shriver National Institute of Child Health and Human
Development, Bethesda, MD, USA
Alan S. Kaufman Yale University School of Medicine, San Diego, CA,
USA
Jacqueline Kelleher Education, Sacred Heart University Isabelle
Farrington School of Education, Southern Connecticut State University,
Fairfield, CT, USA
Daniel P. Kennedy Division of the Humanities and Social Sciences,
California Institute of Technology, Pasadena, CA, USA
Lindsey Kent Medical and Biological Sciences Building, University of
St Andrews, St Andrews, Fife, UK
Danielle Geno Kent The College of Arts and Sciences, The University of
Meena Khowaja Georgia State University, Atlanta, GA, USA
Emily Kilroy Mayes Lab, Yale Child Study Center, New Haven, CT, USA
Young-Shin Kim Psychiatry, Yale Child Study Center, New Haven, CT,
USA
So Hyun (Sophy) Kim Department of Psychology, University of Michigan,
Ann Arbor, MI, USA
Mina Kim College of Education Temple University, Philadelphia, PA, USA
xxxvi Contributors
Sunny Kim Koegel Autism Center, University of California, Santa Barbara,

CA, USA
Jinah Kim Department of Arts Therapy, College of Alternative Medicine,
Jeonju University, Jeonju, South Korea
Yael Kimhi School of Education, Bar-Ilan University, Ramat-Gan, Israel
Bryan King Department of Psychiatry and Behavioral Sciences and Seattle
Children’s Hospital, University of Washington, Seattle, WA, USA
Usha Kini Consultant Clinical Geneticist, Oxford Radcliffe Hospitals NHS
Trust University of Oxford, Oxford, UK
Bonnie Klein-Tasman Department of Psychology, University of Wiscon-
sin, Milwaukee, Milwaukee, WI, USA
Harvey J. Kliman Reproductive and Placental Research Unit, Department
of Obstetrics, Gynecology and Reproductive Sciences, Yale University
School of Medicine, New Haven, CT, USA
Vicki Madaus Knapp Summit Educational Resources, Summit Academy,
Getzville, NY, USA
Rebecca Knickmeyer Department of Psychiatry, University of North
Carolina, Chapel Hill, NC, USA
Brittany L. Koegel University of California, Santa Barbara, CA, USA
Lynn Koegel Koegel Autism Center, Eli and Edythe L. Broad Center for
Asperger Research, University of California, Santa Barbara, CA, USA
Robert L. Koegel Koegel Autism Center/Clinical Psychology, Gevirtz Grad-
uate School of Education, University of California, Santa Barbara, CA, USA
Frances L. Kohl Department of Special Education, University of Maryland,
Koorosh Kooros Pediatric Gastroenterology and Nutrition, Children’s
Medical Center, The University of Texas Southwestern Medical Center at
Dallas, Dallas, TX, USA
David J. Krainski Vocational Independence Program, New York Institute
of Technology, Central Islip, NY, USA
Cate Kraper Clinical Psychology, University of Massachusetts Boston,
Boston, MA, USA
Anna M. Krasno The Gevirtz School, UC Santa Barbara Koegel Autism
Center, Santa Barbara, CA, USA
Kimberly Kroeger-Geoppinger Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH, USA
Steven E. Kroupa Department of Psychiatry, The University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA
Contributors xxxvii
Lydia Kruse Human Development and Family Science, The Ohio State
University 202 Schoenbaum Family Center, Columbus, OH, USA
Megan Kuhn-McKearin Counseling, Higher Education, and Special Edu-
cation, University of Maryland, College Park, MD, USA
Sarah Kuriakose Department of Counseling, Clinical, and School Psychol-
ogy (CCSP), University of California, Santa Barbara, CA, USA
Emily S. Kuschner Center for Autism Spectrum Disorders, Division of
Neuropsychology, Children’s National Medical Center, Washington, DC,
USA
Jennifer M. Kwon Department of Neurology & Pediatrics (SMD), Univer-
sity of Rochester, School of Medicine and Dentistry, Rochester, NY, USA
Kristen Lam UNC Neurodevelopmental Disorders Research Center,
Rebecca Landa Director Center for Autism and Related Disorders,
Kennedy Krieger Institute, Baltimore, MD, USA
Traci Lanner The School at Springbrook, Oneonta, NY, USA
Kyle Lanning Quinnipiac University School of Law, Hamden, CT, USA
Robert LaRue Douglass Developmental Disabilities Center, Rutgers, The
State University of New Jersey, New Brunswick, NJ, USA
Susan Latham Department of Communication Disorders, St. Mary’s
College (IN), Notre Dame, IN, USA
Kathy Lawton Special Education & Nisonger Center, The Ohio State
University, Columbus, OH, USA
Eli R. Lebowitz Yale School of Medicine, Child Study Center, Yale
Luc Lecavalier Nisonger Center, Ohio State University, Columbus, OH,
USA
Ann S. Le Couteur Institute of Health & Society, Newcastle University, Sir
James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, UK
Su Mei Lee Child Neuroscience Lab, Yale Child Study Center, New Haven,
CT, USA
Evon Batey Lee Pediatrics, Kennedy Center/Vanderbilt University,
Nashville, TN, USA
Susan Leekam School of Psychology Cardiff University, Cardiff, UK
Michelle Lestrud The Gengras Center, University of Saint Joseph, West
Hartford, CT, USA
Bennett Leventhal Psychiatry, Nathan Kline Institute for Psychiatric
Research (NKI), Orangeburg, NY, USA
xxxviii Contributors
Philip Levin The Help Group – UCLA Neuropsychology Program,

Harriet Levin University of Connecticut, Storrs, CT
Michael Levine Quinnipiac University School of Law, , Hamden, CT, USA
Mark Lewis College of Medicine, University of Florida, Gainesville, FL, USA
Moira Lewis Speech-Language Pathologist, Marcus Autism Center
Children’s Healthcare of Atlanta, Atlanta, GA, USA
Diane M. Lickenbrock Human Development and Family Studies,
The Pennsylvania State University, University Park, PA, USA
Joan Lieber Department of Special Education, University of Maryland,
C. Enjey Lin Departments of Education and Psychiatry, University of
California, Los Angeles, Los Angeles, CA, USA
Karen M. Lionello-Denolf Shriver Center, University of Massachusetts
Medical School, Shrewsbury, MA, USA
Andrew Lolli Quinnipiac University School of Law, Hamden, CT, USA
Michael Lombardo Autism Research Centre, University of Cambridge,
Cambridge, UK
Steven Long Speech Pathology & Audiology, Marquette University,
Milwaukee, WI, USA
James W. Loomis Center for Children with Special Needs, Glastonbury,
CT, USA
Catherine Lord Center for Autism and the Developing Brain, New York-
Presbyterian Hospital/Westchester Division, White Plains, NY, USA
Erin Loring Yale Department of Genetics, New Haven, CT, USA
Susan Luger Susan Luger Associates, New York, NY, USA
James Luiselli May Institute, Randolph, MA, USA
Joyce Lum UNC TEACCH Autism Program-Charlotte, Charlotte, NC,
USA
Stanley E. Lunde Psychology, UCLA-MRRC Laboratories, Lanterman
Developmental Center, Pomona, CA, USA
Rhiannon Luyster Department of Communication Sciences and Disorders,
Emerson College, Boston, MA, USA
Megan Lyons Laboratory of Developmental Communication Disorders,
Suzanne Macari Yale Child Study Center, New Haven, CT, USA
Contributors xxxix
Tim MacLaughlin Department of Special Education, Gonzaga University,

Spokane, WA, USA
Kailey MacNeill Communication Sciences and Disorders, The University

of Vermont, Burlington, VT, USA
Kelly Macy Department of Communication Sciences, The University of

Brenna Burns Maddox Psychology Department, Virginia Tech, Blacks-

burg, VA, USA
James S. Magnuson Department of Psychology, University of Connecticut

Haskins Laboratories, New Haven, CT, Storrs, CT, USA
Caroline I. Magyar Department of Pediatrics, University of Rochester

Zoe Mailloux Private Practice, Redondo Beach, CA, USA
Mark Malady Florida Institute of Technology, Melbourne, FL, USA
David Mandell Center for Autism Research, The Children’s Hospital of

Melissa Manjarrés Speech Pathology & Audiology, Marquette University,

Milwaukee, WI, USA
Deepali Mankad Holland Bloorview Kids Rehabilitation Hospital,

Toronto, ON, Canada
Lee Marcus TEACCH Autism Program, University of North Carolina,

Itxaso Marti Neupediatrics, Hospital Universitario Donostia, San

Sebastian, Spain
Andres Martin Yale Child Study Center, New Haven, CT, USA
Susan A. Mason Services for Students with Autism Spectrum Disorders,

Montgomery County Public Schools, Silver Spring, MD, USA
Natasa Mateljevic Yale University, New Haven, CT, USA
Johnny L. Matson Department of Psychology, Louisiana State University,

Baton Rouge, LA, USA
Melissa Maye Clinical Psychology, University of Massachusetts, Boston,

Boston, MA, USA
Carla Mazefsky Department of Psychiatry, School of Medicine, University

of Pittsburgh, Pittsburgh, PA, USA
David McAdam Department of Pediatrics, University of Rochester Medical

Center, Rochester, NY, USA
xl Contributors
Bonnie McBride Intervention Services for Autism, University of Oklahoma

College of Medicine, Oklahoma, OK, USA
Iain McClure The Royal Hospital for Sick Children, Edinburgh, UK
Jennifer McCullagh Department of Communication Disorders, Southern

Connecticut State University, New Haven, CT, USA
Christopher J. McDougle Lurie Center for Autism/Harvard Medical

School, Lexington, MA, USA
Andrea McDuffie M.I.N.D. Institute, Sacramento, CA, USA
Kate McFadden Department of Pathology, University of Pittsburgh School

of Medicine Room A506 PUH, Pittsburgh, PA, USA
Jenny McGinley Physiotherapy, Centre for Movement Disorders and Gait

Research, Southern Health, The University of Melbourne, Parkville, VIC,
Australia
Heather McKay Quinnipiac University School of Law, Hamden, CT, USA
Bryce D. McLeod Department of Psychology, Virginia Commonwealth

William McMahon Department of Psychiatry, University of Utah, Salt

Lake City, UT, USA
Edward McNulty Quinnipiac University School of Law, Hamden, CT,

USA
James C. McPartland Yale Child Study Center, Yale University,

New Haven, CT, USA
Shantel E. Meek School of Social & Family Dynamics, Arizona State

Karen Meers Center of Excellence on Autism Spectrum Disorders, South-

ern Connecticut State University, New Haven, CT, USA
Smita Shukla Mehta Department of Educational Psychology, University of

North Texas, Denton, TX, USA
Lisa J. Meier Department of Psychology, George Mason University, Falls

Church, VA, USA
Sarah Melchior School Psychologist, Services for Students with Autism

Spectrum Disorders Montgomery County Public Schools, Silver Spring, MD,
USA
Alicia Melis Department of Developmental and Comparative Psychology,

Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
Michael Miklos Pennsylvania Training and Technical Assistance Network,

Harrisburg, PA, USA
Contributors xli
Judith H. Miles Pediatrics, Medical Genetics & Pathology, The Thompson

Center for Autism & Neurodevelopmental Disorders, Columbia, MO, USA
Margaret Millea Department of Psychology, University of Notre Dame,

Indiana, USA
Lucy Miller Sensory Processing Disorder Foundation, Greenwood Village,

CO, USA
Trube Miller Department of Educational Studies, Hardin-Simmons Univer-

sity, Abilene, TX, USA
Catherine A. Miltenberger Claremont Graduate University, Claremont,

CA, USA
Ruud Minderaa Department of Psychiatry, University of Groningen, Uni-

versity Medical Center Groningen, Accare, Groningen, The Netherlands
Nancy J. Minshew Departments of Psychiatry and Neurology, University of

Pittsburgh, Pittsburgh, PA, USA
Pat Mirenda Department of Educational & Counseling Psychology and

Special Education, Centre for Interdisciplinary Research and Collaboration
in Autism, The University of British Columbia, Vancouver, BC, Canada
Ralph-Axel M€ uller SDSU Department of Psychology, San Diego State

University, San Diego, CA, USA
John Molteni Institute for Autism and Behavioral Studies, University of

Saint Joseph, West Hartford, CT, USA
Guillermo Montes St. John Fisher College, Rochester, NY, USA
Marcel Moran Indiana University School of Medicine, Indianapolis, IN,

USA
Hope Morris Communication Sciences and Disorders, The University of

Philippa Moss Psychology, Institute of Psychiatry King’s College London,

London, UK
Stewart Mostofsky Kennedy Krieger Institute, Baltimore, MD, USA
Laurent Mottron Center of Excellence in Pervasive Developmental Disor-

ders of University of Montreal, QC, Canada
Department of Psychiatry, Riviere-des-Prairies Hospital, University of Mon-
treal, Montreal, QC, Canada
Svend Erik Mouridsen Child and Adolescent Psychiatry Centre,

Bispebjerg University Hospital, Copenhagen, Denmark
Maura Moyle Speech Pathology & Audiology, Marquette University,

Milwaukee, WI, USA
xlii Contributors
Dennis Mozingo Department of Pediatrics, University of Rochester Medical

Center,
Daniel Mruzek Department of Pediatrics (SMD), University of Rochester,

Vannesa T. Mueller Speech-Language Pathology Program, University of

Texas at El Paso College of Health Science, El Paso, TX, USA
Cora Mukerji Yale Child Study Center, New Haven, CT, USA
James Anton Mulick Child Development Center Columbus Children’s

Hospital, Columbus, OH, USA
Rebecca Munday The Center for Children with Special Needs, Glaston-
bury, CT, USA
Peter Mundy Psychiatry and School of Education, UC Davis, Davis, CA,

USA
John D. Murdoch Child Study Center, Yale University School of Medicine,

New Haven, CT, USA
Donna S. Murray Division of Developmental & Behavioral Pediatrics,

Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Michelle Myers The School at Springbrook, Oneonta, NY, USA
Josh Nadeau Department of Educational Psychology, University of South

Florida, Tampa, FL, USA
Aparna Nadig School of Communication Sciences and Disorders, McGill

University, Montreal, QC, Canada
Jo Anne Nakagawa Tuberous Sclerosis Alliance, Silver Spring, MD, USA
Adam Naples Yale Child Study Center, Yale University, New Haven, CT,
USA
Anahita Navab Department of Psychology, University of California, Los

Angeles, CA, USA
Maureen Nevers Augmentative Communication Consultant, Center on Dis-

ability & Community Inclusion, Burlington, VT, USA
Rose E. A. Nevill Nisonger Center, UCEDD, The Ohio State University,

Columbus, OH, USA
Diana B. Newman Communication Disorders Department, Southern Con-

necticut State University, New Haven, CT, USA
Tina Newman The Center for Children with Special Needs, Glastonbury,
CT, USA
Brandon Nichols The School at Springbrook, Oneonta, NY, USA

Contributors xliii
Jacqueline A. Noonan Department of Pediatrics, University of Kentucky,

College of Medicine, Lexington, KY, USA
Courtenay Norbury Psychology Department, Royal Holloway, University

of London, Egham, Surrey, UK
Leona Oakes Graduate Student, Department of Clinical & Social Sciences

in Psychology, University of Rochester, Rochester, NY, USA
Marisa O’Boyle Clinical Psychology, University of Massachusetts, Boston,

Boston, MA, USA
Samuel L. Odom FPG Child Development, University of North Carolina at

Chapel Hill, Chapel Hill, NC, USA
Paul A. Offit Division of Infectious Diseases, Department of Pediatrics, The

Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Kirsten O’Hearn Laboratory of Neurocognitive Development, Department

of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA,
USA
Kim E. Ono Department of Psychology, University of Miami, Coral Gables,

FL, USA
Alyssa Orinstein Department of Psychology, University of Connecticut,

Storrs, CT, USA
Felice Orlich Autism Psychology Services, Seattle Children’s Hopsital

CAC – Autism Center, Seattle, WA, USA
Jessica Palilla Departments of Psychology and Neuroscience, Brigham

Young University, Provo, UT, USA
Shannon Palmer Central Michigan University, Mount Pleasant, MI, USA
Mark Palmieri Feeding Clinic, Center for Children with Special Needs,
Vincent Pandolfi Psychology Department, Rochester Institute of Technol-

ogy, Rochester, NY, USA
Mi Na Park Department of Counseling, Clinical, and School Psychology,

University of California, Santa Barbara, CA, USA
Jeremy Parr Institute of Health & Society, Newcastle University, Royal

Victoria Infirmary, Newcastle Upon Tyne, UK
Rizwan Parvez Yale Child Study Center, New Haven, CT, USA
Rhea Paul Department of Speech-Language Pathology, College of Health

Professions, Sacred Heart University, Fairfield, CT, USA
Diane R. Paul Clinical Issues in Speech-Language Pathology, American

Speech-Language-Hearing Association, Rockville, MD, USA
xliv Contributors
Deborah A. Pearson Department of Psychiatry and Behavioral Sciences,

University of Texas Medical School at Houston, Houston, TX, USA
Liz Pellicano Centre for Research in Autism and Education (CRAE),
Department of Psychology and Human Development, Institute of Education,
University of London, London, UK
Kevin A. Pelphrey Child Study Center, Yale University School of Medi-
cine, New Haven, CT, USA
Sue Peppé High Appin, Tynron, Thornhill, UK
Kate S. Perri Christian Sarkine Autism Treatment Center, Riley Hospital
for Children, Indianapolis, IN, USA
Danielle Perszyk Yale Child Study Center, New Haven, CT, USA
Andrew Pickles School of Epidemiology and Health Science, University of
Manchester, Manchester, UK
Madison Pilato Neurodevelopmental and Behavioral Pediatrics, University
of Rochester Medical Center, Rochester, NY, USA
Ozgur Pirgon Department of Pediatrics, Division of Pediatric Endocrinol-
ogy, S. Demirel University, Isparta, Turkey
Bertram O. Ploog Department of Psychology, College of Staten Island and
Graduate Center, CUNY, Staten Island, NY, USA
Claire Plowgian Speech Pathology & Audiology, Marquette University,
Milwaukee, WI, USA
Sue Porr Carolina Institute for Developmental Disabilities, University of
North Carolina at Chapel Hill, Chapel Hill, NC, USA
Kristen M. Powers Coordinator of Rehabilitative Services, Center for
Children with Special Needs, Glastonbury, CT, USA
Michael D. Powers The Center For Children With Special Needs, Glaston-
bury, CT, USA
Shirley Poyau Clinical Psychology, University of Massachusetts, Boston,
Boston, MA, USA
Cathy Pratt Indiana Resource Center for Autism, Indiana University,
Bloomington, IN, USA
Patricia Prelock Communication Sciences & Disorders, Dean’s Office,
College of Nursing & Health Sciences, University of Vermont, Burlington,
VT, USA
Rebecca Edmondson Pretzel Carolina Institute for Developmental Disabil-
ities, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Josh Pritchard Applied Behavior Analysis, Florida Institute of Technol-
ogy, Orlando, FL, USA
Contributors xlv
Colleen Quinn TEACCH-Fayetteville Center, Fayetteville, NC, USA

Ana Figueroa Quintana Child and Adolescent Psychiatry Unit, Hospital
Perpetuo Socorro, Las Palmas, Spain
Isabelle Rapin Neurology and Pediatrics (Neurology), Albert Einstein
College of Medicine, Bronx, NY, USA
Kristin Ratliff Research & Development, Western Psychological Services,
Torrance, CA, USA
Corey Ray-Subramanian Waisman Center, University of Wisconsin-
Madison, Madison, WI, USA
Brian Reichow Child Study Center, Associate Research Scientist, Yale
University School of Medicine, New Haven, CT, USA
Beau Reilly Psychiatry and Behavioral Sciences, University of Washington,
Seattle, WA, USA
Patricia Renno Department of Education, University of California,
Los Angeles, Los Angeles, CA, USA
Leslie Rescorla Bryn Mawr College, Bryn Mawr, PA, USA
Ann Reynolds Pediatrics, Child Development Unit, B-140, Aurora, CO,
USA
Catherine E. Rice National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
J. Don Richardson Department of Psychiatry, University of Western
Ontario, London, ON, Canada
Raili Riikonen Department of Child Neurology, University of Kuopio,
Kuopio, Finland
Nicole Rinehart Faculty of Medicine, Nursing and Health Sciences,
Monash University, Melbourne, VIC, Australia
Alexandra Ristow Yale Child Study Center, New Haven, CT, USA
Edward Ritvo UCLA School of Medicine, Los Angeles, CA, USA
Ariella Riva Ritvo Clinical Faculty, The Child Study Center, Yale Univer-
sity School of Medicine, Los Angeles, CA, USA
Timothy P. L. Roberts Radiology Department, Children’s Hospital of
Diana Robins Georgia State University, Atlanta, GA, USA
Janine Robinson CLASS, Cambridgeshire & Peterborough NHS Founda-
tion Trust, Cambridge, UK
Adriano Rodrigues Health Sciences Center, Federal University of Piaui –
UFPI, Teresina, Brazil
xlvi Contributors
Jessica L. Roesser Department of Pediatrics (SMD), University of Roches-

ter, School of Medicine and Dentistry, Rochester, NY, USA
Bernadette Rogé Clinical Psychopathology, Health Psychology and Neu-

roscience, Université de Toulouse Le Mirail, Toulouse, France
Sally J. Rogers Department of Psychiatry and Behavioral Sciences, UC

Jessica Rohrer The Center for Children with Special Needs, Glastonbury,
CT, USA
Johannes Rojahn Department of Psychology, George Mason University,

Fairfax, VA, USA
Raymond G. Romanczyk Institute for Child Development, State Univer-

sity of New York, Binghamton, NY, USA
Michael Rosanoff Autism Speaks, New York, NY, USA
Sara D. Rosenblum-Fishman Psychology, University of Massachusetts

April Rosenkrantz Quinnipiac University School of Law, Hamden, CT,

USA
Allyson Ross Florida Institute of Technology, Melbourne, FL, USA
Erin Rotheram-Fuller School Psychology, Department of Psychological

Studies in Education, College of Education Temple University, Philadelphia,
PA, USA
Justin Rowberry Developmental and Behavioral Pediatrics, New Haven,

CT, USA
Lisa Ruble Educational School & Counseling Psychology, University of

Kentucky, Levington, KY, USA
Hanna C. Rue The May Center for Children, Randolph, MA, USA
Kristin Ruedel Department of Special Education, University of Maryland

Washington State University, Richland, WA, USA
Mustafa Sahin Department of Neurology, Children’s Hospital Boston, Har-

vard Medical School, Boston, MA, USA
Stephan Sanders Child Study Center, Yale University, New Haven, CT,
USA
Geeta Sarphare Department of Child & Adolescent Psychiatry, Kennedy

Krieger Institute, Johns Hopkins University School of Medicine, Baltimore,
MD, USA
Celine A. Saulnier Department of Pediatrics, Emory University School of

Medicine, Atlanta, GA, USA
Contributors xlvii
Sarah Savage Institute of Psychiatry, King’s College of London, London,

UK
Lawrence David Scahill Nursing & Child Psychiatry, Yale University
School of Nursing, Yale Child Study Center, New Haven, CT, USA
Lauren Schmitt Psychiatry, UT Southwestern Medical Center, Dallas, TX,
USA
Naomi Schneider College of Education and Human Ecology, The Ohio
Andrea Schneider Department of Pediatrics, University of California,
Davis Medical Center, M.I.N.D. Institute, Sacramento, CA, USA
Elizabeth Schoen Simmons Laboratory for Developmental Communica-
tion Disorders, Yale Child Study Center, New Haven, CT, USA
Sarah Schoen Sensory Processing Disorder Foundation, Rocky Mountain
University of Health Professions, Provo Utah, Denver, CO, USA
Winifred Schultz-Krohn Department of Occupational Therapy, San José
State University, San José, CA, USA
Cyndi Schumann UC Davis M.I.N.D. Institute, Sacramento, CA, USA
Caley B. Schwartz Department of Psychology, University of Miami, Coral
Gables, FL, USA
Ilene Sharon Schwartz Haring Center for Applied Research and Training in
Education, University of Washington, Seattle, WA, USA
Haleigh Scott Ohio State University Nisonger Center, Columbus, OH, USA
Ifat Seidman Department of Psychology, The Hebrew University of
Jerusalem, Jerusalem, Israel
Marsha Mailick Seltzer Waisman Center, University of Wisconsin-
Madison, Madison, WI, USA
Atsushi Senju Centre for Brain and Cognitive Development, Birkbeck,
University of London, London, UK
Amitta Shah Leading Edge Psychology Clinical Psychology Consultancy
Centre, Purley, Surrey, UK
Aditya Sharma Academic Child and Adolescent Mental Health, Sir James
Spence Institute Newcastle University, Newcastle upon Tyne, UK
Paul Shattuck George Warren Brown School of Social Work, Washington
University, St. Louis, MO, USA
Katie Shattuck School of Nursing, University of North Carolina-Chapel
Hill, University of North Carolina School of Medicine, Chapel Hill, NC, USA
Victoria Shea Department of Psychiatry, TEACCH Autism Program,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
xlviii Contributors
Mark Sherry Department of Sociology and Anthropology, University of

Toledo, Toledo, OH, USA
Frederick Shic School of Medicine, Yale Child Study Center, Yale Univer-
sity, New Haven, CT, USA
Carolyn M. Shivers Department of Psychology, Vanderbilt University,
Nashville, TN, USA
Timothy Shriver Special Olympics, Inc, Washington, DC, USA
Oren Shtayermman New York Institute of Technology Mental Health
Counseling, Old Westbury, NY, USA
Lisa Shull Division of Neurodevelopmental and Behavioral Pediatrics,
Golisano Children’s Hospital, University of Rochester School of Medicine,
Jamaica, NY, USA
Clinical Psychology, Long Island University, Brooklyn, NY, USA
Cory Shulman The Paul Baerwald School of Social Work, The Hebrew
University of Jerusalem, Jerusalem, Israel
Sarah Shultz Department of Psychology, Yale University, New Haven, CT,
USA
Reet Sidhu Department of Pediatric Neurology, Columbia University,
New York, NY, USA
Bryna Siegel Autism Clinic, Department of Child & Adolescent Psychiatry,
University of California, San Francisco, San Francisco, CA, USA
Laura B. Silverman Department of Pediatrics, University of Rochester
Linda Simonson Benhaven, Inc, North Haven, CT, USA
Alison Singer Autism Science Foundation, NY, USA
Anjileen Singh Counseling, Clinical, and School Psychology, UC Santa
Barbara, Santa Barbara, CA, USA
Bram Sizoo Psychiatry, Center for Developmental Disorders, Deventer,
Netherlands
Nicole Slade Department of Psychology, University of Massachusetts-
Jonathan Sliva Quinnipiac University School of Law, Hamden, CT, USA
Martyna Smielewska Quinnipiac University School of Law, Hamden, CT,
USA
Tristram Smith Department of Pediatics, University of Rochester Medical
Center, Rochester, NY, USA
Wanda L. Smith Department of Psychiatry and Behavioural Neurosci-
ences, McMaster University, Hamilton, ON, Canada
Contributors xlix
Jonathan Smith Chief Resident in Neurology, University of Rochester

Elizabeth G. Smith Department of Psychology, University of Rochester
(NY), Rochester, NY, USA
Anne Snow Child Study Center, Autism Program, Yale University,
New Haven, CT, USA
Margaret Snowling Department of Psychology, Centre for Reading and
Language, University of York, Heslington, York, UK
Kate Snyder University of Cincinnati, Cincinnati, OH, USA
Martine Solages Child Study Center, Yale University, New Haven, CT,
USA
Marjorie Solomon Department of Psychiatry and Behavioral Sciences, UC
Youeun Song Child Study Center, Yale University School of Medicine,
New Haven, CT, USA
Timothy Soto Clinical Psychology, University of Massachusetts Boston,
Boston, MA, USA
Isabelle Soulières Centre d’excellence en troubles envahissants du
développement de l’université de Montréal, Hôpital Rivière-des-Prairies,
Montréal, QC, Canada
Department of Psychology, Université du Québec à Montréal, Montréal, QC,
Canada
Michael A. Southam-Gerow Department of Psychology, Virginia
Commonwealth University, Richmond, VA, USA
Mikle South Departments of Psychology and Neuroscience, Brigham
Young University, Provo, UT, USA
César Soutullo Child & Adolescent Psuychiatry Unit, Department of Psy-
chiatry and Medical Psychology, University of Navarra Clinic, Pamplona,
Spain
Louise Spear-Swerling Southern Connecticut State University, New
Haven, CT, USA
Sarah Spence Department of Neurology, Children’s Hospital Boston
Harvard Medical School, Boston, MA, USA
Elizabeth Spencer College of Education and Human Ecology, The Ohio
Trina D. Spencer Institute for Human Development, Northern Arizona
University, Flagstaff, AZ, USA
Beth Springate Department of Psychology, University of Connecticut,
Storrs, CT, USA
l Contributors
Dorrey Sproatt Psychological Studies in Education, University of Califor-

nia, Los Angeles, CA, USA
Margaret St. John Quinnipiac University School of Law, Hamden, CT,
USA
Wouter Staal Neuroscience, Radboud University Nijmegen Medical Centre
Karakter, Nijmegen, The Netherlands
Aaron Stabel The M.I.N.D. Institute, University of California Davis Med-
ical Center, Sacramento, CA, USA
Lawrence H. Staib Department of Diagnostic Radiology, Yale University
School of Medicine, New Haven, CT, USA
Amanda Steiner Yale Child Study Center, New Haven, CT, USA
Lindsey Sterling Department of Psychiatry, Jane & Terry Semel Institute
for Neuroscience & Human Behavior UCLA, Los Angeles, CA, USA
Arianne Stevens Psychiatry and Behavioral Sciences, University of
Kimberly Stigler Christian Sarkine Autism Treatment Center, James
Whitcomb Riley Hospital for Children, Indianapolis, IN, USA
Wendy L. Stone Psychology, UW Autism Center, University of Washing-
ton, Seattle, WA, USA
Eric Storch Departments of Pediatrics and Psychiatry, University of South
Florida, St. Petersburg, FL, USA
Susan M. Strahosky School of Medicine and Dentistry, University of
Rochester, Rochester, NY, USA
William Strein Counseling, Higher Education, and Special Education,
University of Maryland, College Park, MD, USA
Dorothy Stubbe Yale University School of Medicine Child Study Center,
New Haven, CT, USA
Stephen Sulkes Division of Neurodevelopmental and Behavioral Pediatrics,
Golisano Children’s Hospital, University of Rochester, Rochester, NY, USA
Hanna Swaab Social and Behavioural Sciences, Leiden University, Leiden,
The Netherlands
Peter Szatmari Department of Psychiatry and Behavioural Neurosciences,
McMaster University Hamilton Health Sciences Corporation, Hamilton, ON,
Canada
Christen Szymanski Department of Pediatrics (SMD), University of Roch-
ester, School of Medicine and Dentistry, Rochester, NY, USA
Nicole Takahashi Thompson Center for Autism & Neurodevelopmental
Disorders, Columbia, MO, USA
Contributors li
Yoshihiro Takeuchi Department of Pediatrics, Shiga University of Medical

Science, Otsu, Shiga, Japan
Karen Tang Department of Psychology, University of Notre Dame, Notre

Dame, IN, USA
Digby Tantam School of Health and Related Research, University of

Sheffield, Sheffield, UK
Pamela Targett Virginia Commonwealth University, Richmond, VA, USA
Marc J. Tassé Nisonger Center – UCEDD, Departments of Psychology and

Psychiatry, The Ohio State University, Columbus, OH, USA
Marc B. Taub Southern College of Optometry, Memphis, TN
Julie Lounds Taylor Vanderbilt Kennedy Center and Department of Pedi-

atrics, Vanderbilt University, Nashville, TN, USA
Johanna Patricia Taylor Pediatrics & Education, University of Pittsburgh,

Pittsburgh, PA, USA
Ito Tetsuya Department of Neonatology and Pediatrics, Graduate School of

Medical Sciences, Nagoya City University, Aichi, Japan
Linda Thibodeau Callier Advanced Hearing Research Center, Dallas, TX,

USA
Kathy Thiemann-Bourque Schiefelbusch Institute for Life Span Studies

Juniper Gardens Children’s Project, University of Kansas, Lawrence, KS,
USA
Brynn Thomas The Neurodevelopmental Disabilities Laboratory, Labora-

tory for Understanding Neurodevelopment, Northwestern University, and the
University of Notre Dame, Chicago, IL, USA
Kenneth Thomas School of Law, Quinnipiac University, Hamden, CT,

USA
John Thomas Independent Educational Consultant, Durham, NC, USA
John W. Thomas Quinnipiac University School of Law, Hamden, CT, USA
John Thorne Department of Speech and Hearing Sciences, University of

Washington Fetal Alcohol Syndrome Diagnostic and Prevention Network,
Seattle, WA, USA
Elaine Tierney Department of Psychiatry, Kennedy Krieger Institute, Johns

Hopkins University School of Medicine, Baltimore, MD, USA
Geralyn Timler Speech Pathology & Audiology, Miami University,

Oxford, OH, USA
James Todd Professor of Psychology, Eastern Michigan University,

Ypsilanti, MI, USA
lii Contributors
Karen Toth Department of Psychiatry and Behavioral Sciences, University

Joshua Trachtenberg David Geffen School of Medicine at UCLA,
Darold A. Treffert St. Agnes Hospital, Fond du Lac, WI, USA
Eva Troyb Department of Psychology, University of Connecticut, Storrs,
CT, USA
Katherine Tsatsanis Yale Child Study Center, New Haven, CT, USA
Roberto Tuchman Department of Neurology, Miami Children’s Hospital,
Weston, FL, USA
Katherine Tyson Department of Psychology, University of Connecticut,
Storrs, CT, USA
Joanne Valdespino Test Development, PRO-ED, Inc., Austin, TX, USA
Megan Van Ness Department of Psychology, University of Notre Dame,
Notre Dame, IN, USA
Ernst VanBergeijk Vocational Independence Program, New York Institute
of Technology, Central Islip, NY, USA
Brent Vander Wyk Yale Child study center, New Haven, CT, USA
Pamela Ventola Yale Child Study Center, New Haven, CT, USA
Ty Vernon Yale Child Study Center, New Haven, CT, USA
Michaela Viktorinova Yale Child Study Center Temple Medical Center,
New Haven, CT, USA
Michele Villalobos The Edward Zigler Center in Child Development and
Social Policy, Yale Child Study Center, New Haven, CT, USA
Oana De Vinck Department of Pediatrics, Yale University School of
Micaela Violette Yale Child Study Center, New Haven, CT, USA
Benedetto Vitiello Child & Adolescent Treatment & Preventive Interven-
tion Research Branch, NIMH, NIH, Bethesda, MD, USA
Giacomo Vivanti Olga Tennison Autism Research Centre, School of Psy-
chological Science, La Trobe University, Melbourne, Victoria, Australia
Dawn Vogler-Elias Communication Sciences and Disorders, Nazareth
College, Rochester, NY, USA
Fred R. Volkmar Director – Child Study Center, Irving B. Harris Professor
of Child Psychiatry, Pediatrics and Psychology, School of Medicine, Yale
Contributors liii
Lucy Volkmar Achievement First East New York Elementary School,

Brooklyn, NY, USA
Guus van Voorst Clinical Psychology, Center for Autistic Disorders, GGZ
Centraal, Amersfoort, Amersfoort, Netherlands
Avery Voos Yale Child Study Center, New Haven, CT, USA
Allison Wainer Department of Psychology, Michigan State University,

Michael F. Walker Child Study Center, Yale University School of

Katherine S. Wallace Department of Psychiatry and Behavioral Sciences,

UC Davis M.I.N.D. Institute, Sacramento, CA, USA
Gregory L. Wallace Psychiatry and Behavioral Sciences and Pediatrics,

The George Washington University, School of Medicine and Health
Sciences, Washington, DC, USA
Pat Walsh Centre of Medical Law and Ethics, Dickson Poon School of Law,
Somerset House East Wing, Kings College London, London, UK
Katherine Walton Department of Psychology, Michigan State University,

Kai Wang Dept of Psychiatry and Dept of Preventive Medicine, The Zilkha
Neurogenetic Institute, Keck School of Medicine, University of Southern
California, Los Angeles, CA, USA
Tracey Ward Simons Autism Family Collaboration University of

Washington, Autism Research Center, Seattle, WA, USA
Felix Warneken Department of Psychology, Harvard University,

Cambridge, MA, USA
Zachary Warren Vanderbilt Kennedy Center, Treatment and Research

Institute for Autism Spectrum Disorders (TRIAD), Nashville, TN, USA
Renee Watling Division of Occupational Therapy, Department of Rehabil-

itation Medicine, University of Washington, Seattle, WA, USA
Sara Jane Webb Psychiatry and Behavioral Sciences and UW Autism,

University of Washington, Seattle, WA, USA
Paul Wehman Department of Physical Medicine and Rehabilitation,

Virginia Commonwealth University, Richmond, VA, USA
Mary Jane Weiss Institute for Behavioral Studies, Endicott College,

Beverly, MA, USA
Deborah Weiss Department of Communication Disorders, Southern

Connecticut State University, New Haven, CT, USA
liv Contributors
Therese R. Welch University of Rochester School of Medicine and

Dentistry, Rochester, NY, USA
Aurelie Welterlin Chapel Hill TEACCH Center, Carrboro, NC, USA
Julia Wenegrat Psychiatry, University of Washington, Seattle, WA, USA
Femke Wessels Stumass, Arnhem, Netherlands
Alexander Westphal Yale Child Study Center, New Haven, CT, USA
Susan White Psychology Department, Virginia Tech, Blacksburg, VA,
USA
Andrew Whitehouse Research Section (Psychology), University of
Western Australia, Crawley, WA, Australia
Siena Whitham Psychological Studies in Education, University of Califor-
nia, Los Angeles, Los Angeles, CA, USA
Jennifer Wick Community Consultation Program, Division of Neurodeve-
lopmental and Behavioral Pediatrics, University of Rochester School of
Medicine and Dentistry, Rochester, NY, USA
Serena Wieder Profectum Foundation, New York, NY, USA
Kristin Wier Department of Psychology, University of Notre Dame, Notre
Dame, IN, USA
Sonya Ansari Center for Autism, LOGAN Center, South Bend, IN, USA
Lisa Wiesner Pediatrics and Adolescent Medicine, Orange, CT, USA
Susan Wilczynski National Autism Center, Randolph, MA, USA
A. Jeremy Willsey Department of Genetics, Yale University School of
Dawn Wimpory School of Psychology, University of Wales Bangor,
Gwynedd, UK
Gayle C. Windham Division of Environmental and Occupational Disease
Control, CA Department of Public Health, Richmond, CA, USA
Lorna Wing Centre for Social and Communication Disorders, Bromley,
Kent, UK
Logan Wink Christian Sarkine Autism Treatment Center, Indianapolis,
IN, USA
Department of Psychiatry, Indiana University School of Medicine, Indianap-
olis, IN, USA
Vince Winterling Delaware Autism Program, Newark, DE, USA
Julie M. Wolf Yale Child Study Center, New Haven, CT, USA
Connie Wong FPG Child Development Institute, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA
Contributors lv
Jeffrey J. Wood Departments of Psychiatry and Education, University of

California, Los Angeles, CA, USA
Marc Woodbury-Smith Department of Psychiatry and Behavioural
Neuroscience, McMaster University, Hamilton, ON, Canada
Douglas W. Woods Department of Psychology, University of Wisconsin-
Milwaukee, Milwaukee, WI, USA
Julie Worley Department of Psychology, Louisiana State University, Baton
Rouge, LA, USA
Maya Yaari Department of Psychology, The Hebrew University of Jerusa-
lem, Jerusalem, Israel
Brett Yamane Department of Psychiatry and Behavioral Sciences, Univer-
sity of Washington, Seattle, WA, USA
Nurit Yirmiya Department of Psychology, The Hebrew University of
Jerusalem, Jerusalem, Israel
Casey Zampella Department of Clinical and Social Sciences in Psychology,
University of Rochester, Rochester, NY, USA
Thomas Zane The Institute for Behavioral Studies, Endicott College,
Beverly, MA, USA
Charles H. Zeanah Department of Neurology and the Department of
Psychiatry and Behavioral Sciences, Tulane University, School of Medicine,
New Orleans, LA, USA
Cynthia Zierhut Department of Psychiatry and Behavioral Sciences,
UC Davis M.I.N.D. Institute, Sacramento, CA, USA
0–9
1-[1-[4,4-bis(p-fluorophenyl)butyl]- multiple times. 16p11.2 CNVs are found in

4-piperidyl]-2-benzimidazolinone about 1% of individuals with autism, compared
with less than 0.1% of the population. CNVs in
▶ Pimozide this region have also been associated with intel-
lectual disability, developmental delay, schizo-
phrenia (duplications only), and obesity
(deletions only) (http://www.ncbi.nlm.nih.gov/
16p11.2 books/NBK11167/).
CNVs involving this interval are among the
Stephan Sanders most well-established risk factors for ASD.
Child Study Center, Yale University, They also highlight the complexity of the genetic
New Haven, CT, USA contribution to these syndromes: the CNVs are
neither necessary (ASD can occur without
16p11.2 CNVs) nor sufficient (ASD is not always
Definition present with the CNV) to cause ASD. Both dele-
tions and duplications can contribute to risk, and
16p11.2 refers to a particular region on the these variations may either be de novo or transmit-
short (p) arm of chromosome 16 that corre- ted within families. Moreover, in some families in
sponds to an approximately 500 kilobase copy which one affected child carries a 16p11.2, there
number variation (CNV) that is strongly asso- may be other affected family members who do not.
ciated with the risk for ASD. The region The region contains multiple biologically
contains 28 genes and is flanked by segmental plausible gene candidates for ASD (see list
duplications (stretches of near-identical DNA). below). At this time, it is not known whether
These are known to increase the likelihood of a single gene is responsible for the ASD pheno-
a process known as nonhomologous allelic type or if a combination of genes within the
recombination, which can lead to gains or region accounts for the risk.
losses of the chromosomal segment flanked by The genes in the 16p11.2 region are ALDOA,
these repeats. ASPHD1, C16orf53, C16orf54, CDIPT, CORO1A,
The importance of deletions and duplications DOC2A, FAM57B, FLJ25404, GDPD3, HIRIP3,
at 16p11.2 in ASD was recognized simulta- INO80E, KCTD13, LOC100271831, LOC440356,
neously by three research groups (Kumar et al., MAPK3, MAZ, MVP, PPP4C, PRRT2, QPRT,
2008; Marshall et al., 2008; Weiss et al., 2008). SEZ6L2, SLC7A5P1, SPN, TAOK2, TBX6,
These findings have since been replicated TMEM219, and YPEL3.
F.R. Volkmar (ed.), Encyclopedia of Autism Spectrum Disorders,

DOI 10.1007/978-1-4419-1698-3, # Springer Science+Business Media New York 2013
0–9 2 3-(2-chloro-10 H-phenothiazin-10-yl)-N,N-dimethylpropan-1-amine Hydrochloride
See Also
504 Plan
▶ Candidate Genes in Autism
▶ Chromosomal Abnormalities Kate Snyder1, Kara Hume2 and
▶ Common Disease-Rare Variant Hypothesis Christi Carnahan1
▶ Copy Number Variation 1
University of Cincinnati, Cincinnati, OH, USA
▶ DNA 2
University of North Carolina, Chapel Hill,
▶ Genetics NC, USA
References and Readings Definition
Kumar, R. A., KaraMohamed, S., Sudi, J., Conrad, D. F., Section 504 is a regulation of the Rehabilitation
Brune, C., Badner, J. A., et al. (2008). Recurrent
Act of 1973 that extends civil rights to individ-
16p.112 microdeletions in autism. Human Molecular
Genetics, 17(4), 628–638. uals with disabilities. Enforced by the Office of
Marshall, C. R., Noor, A., Vincent, J. B., Lionel, A. C., Civil Rights (OCR) within the US Department
Feuk, L., Skaug, J., et al. (2008). Structural variation of of Health and Human Services, Section 504
chromosomes in autism spectrum disorder. American
states that “No otherwise qualified individual
Journal of Human Genetics, 82(2), 477–488.
Weiss, L. A., Shen, Y., Korn, J. M., Arking, D. E., with a disability in the United States . . . shall,
Miller, D. T., Fossdal, R., et al. (2008). Association solely by reason of her or his disability, be
between microdeletion and microduplication at excluded from the participation in, be denied
16p.112 and autism. The New England Journal of
the benefits of, or be subjected to discrimination
Medicine, 358(7), 667–675.
under any program or activity receiving Federal
financial assistance. . .” (29 U.S.C. } 794(a)).
Section 504 applies to any organization
receiving federal funding; thus, it has important
3-(2-chloro-10 H-phenothiazin-10- implications for individuals with autism
yl)-N,N-dimethylpropan-1-amine spectrum disorders (ASD) and their participa-
Hydrochloride tion in various educational, recreational,
community, and employment settings.
▶ Chlorpromazine
Historical Background
3-Chloro-5-[3-(dimethylamino) The Civil Rights Act of 1964 and its prohibition

propyl]-10,11-dihydro-5H-dibenz of discrimination based on race, color, or national
[b,f]azepine Monohydrochloride origin was a catalyst for the development of
Section 504 of the 1973 Rehabilitation Act. Sen-
▶ Clomipramine ator Hubert Humphrey (D., Minnesota) led the
work to add an amendment to the Rehabilitation
Act of 1973 that would address the discrimination
of individuals with disabilities who had not been
included under the Civil Rights Act. Section 504
3-Day Measles was the first piece of legislation that specifically
addressed the civil rights of individuals with
▶ Rubella disabilities.
504 Plan 3 0–9
Implementation of Section 504 was wrought physiological disorder or condition, cosmetic
with challenges. Initial responsibility for writing disfigurement, or anatomical loss . . .or any mental
0–9
implementation regulations was left to the US or psychological disorder.” Major life activities, as
Department of Health, Education, and Welfare defined by the Section 504 regulations at 34 C.F.R.
(HEW). Though drafts of the regulations were 104.3(j)(2)(ii), include functions such as caring for
written as early as 1975 (Pfeiffer, 2002), by one’s self, performing manual tasks, walking,
1977, the regulations had yet to be signed and seeing, hearing, speaking, breathing, learning, and
implementation of Section 504 had stalled. In working. It is important to note that this list is also
response, on April 5, 1977, the American Coali- not considered exhaustive, and thus other activities
tion of Citizens with Disabilities (ACCD) led or functions not explicitly stated may be considered
demonstrations in HEW regional offices across “major life activities” under Section 504.
the country. These demonstrations and other lob- Since autism is a brain-based disorder
bying efforts led to the signing of the regulations (Wass, 2011), individuals with a diagnosis of
on April 28, 1977. Delays in the creation of ASD would “have record” of a “mental
government-wide implementation slowed the impairment” that could potentially qualify them
process of issuing regulations within individual for protection under Section 504. Qualification is
federal agencies (National Council on Disability, determined based upon the influence of an
2003). Each department within the executive individual’s autism on his or her ability to perform
branch of the federal government now has its a “major life activity.” The characteristics of autism
own regulations for implementing the provisions manifest in social interactions, communicative
of Section 504 (Yell, 2006). exchanges, and through restricted or stereotyped
As the first civil rights legislation for individuals patterns of behavior, interests, or activities
with disabilities, Section 504 of the 1973 Rehabil- (American Psychiatric Association, 2000). Though
itation Act paved the way for future legislation for to qualify for Section 504 each person on the autism
individuals with disabilities, including the 1990 spectrum must be evaluated on an individual basis,
adoption of the Americans with Disabilities Act the disorder could potentially influence many
(ADA) and the Individuals with Disabilities “major life activities.”
Education Act (IDEA). Together, Section 504,
ADA, and IDEA protect the rights and equal Application of Section 504 in Education
participation of individuals with disabilities in (From Preschool Through Postsecondary)
employment, in education, and in the community. The provisions of Section 504 extend civil rights to
individuals with disabilities to ensure access to
activities and programs for which they “otherwise
Current Knowledge qualify” (29 U.S.C. } 794(a)). In other words, an
individual meets program or employment criteria
Qualification Under Section 504 despite his or her disability. Applied to public
Section 504 specifically states that to be protected education, this means that the individual with
under the law, an individual must be determined to a disability is of public school age. Schools pro-
(1) have a physical or mental impairment that sub- viding a public education must ensure that students
stantially limits one or more major life activities, with disabilities have equal opportunity to benefit
(2) have a record of such an impairment, or (3) be from educational programs and facilities under
regarded as having such an impairment. Though no Section 504 (Yell, 2006).
exhaustive list of specific “mental or physical A central component of Section 504 as it
impairments” covered by Section 504 exists, regu- applies to public schools is the provision of
latory provision 34 C.F.R. 104.3(j)(2)(i) defines a free appropriate public education (FAPE).
a physical or mental impairment as “any FAPE, as defined by Section 504, requires that
0–9 4 504 Plan
a student with a disability be provided with reg- comparable (i.e., in terms of space, location, size) to
ular or special education and related aids and the district’s other facilities. Thus, Section 504 pro-
services that are designed to meet his or her tects students with disabilities from the historical
individual educational needs. These provisions practice of establishing special education class-
must meet the individual’s needs as adequately rooms in areas not conducive to learning, such as
as the needs of students without disabilities are storage rooms or partitioned areas (Yell, 2006).
met. Examples relevant to learners with ASD
include using visuals to supplement verbal Eligibility Determination
instruction, providing tape recorders, modifying Since Section 504 and IDEA both protect the
textbooks, using behavior support techniques rights of individuals with disabilities in public
such as reinforcement, adjusting class schedules, education settings (through age 21), there is
and increasing classroom organization/structure. often confusion about eligibility requirements. It
Section 504 also requires that all educational is important to note that not all students with
programs be accessible to all learners. This does disabilities who qualify for an individualized
not mean that schools are required to make every plan under Section 504 will meet the require-
room or program accessible to all students but that ments for special education under IDEA. How-
all learners have equal access to programming. For ever, all students protected by IDEA also qualify
example, a school may offer multiple sections of for protections under Section 504. One reason for
a biology lab in three different classrooms. If one of this distinction is that under IDEA, a disability
the lab classrooms is accessible and two are not, the must have an adverse impact on a student’s learn-
school still meets the expectation of Section 504 ing that requires special education and related
because the educational program is accessible to all services. If a student does not require specialized
students. It is not permissible, however, to create instruction as a result of their disability, then he
a scenario where a disproportionate number of or she would not meet the requirements of IDEA.
students with disabilities are assigned to the same While IDEA explicitly requires the involvement
program or activity because of accessibility issues. of special education programming, implementa-
Returning to the example of the biology lab, it tion of Section 504 is general education respon-
would not be acceptable for the school to create sibility (Yell, 2006). Essentially, Section 504
one section of the lab in which students with provides access to an education (“to and through
disabilities were overrepresented. the schoolhouse door,” Wright & Wright, 2008);
This issue of disproportionality, or overrepre- however, Section 504 includes no guarantee that
sentation, is related to the FAPE provision within the individual will receive educational benefit, as
Section 504 that students with disabilities and specified in IDEA.
students without disabilities should be placed in In order to determine a student’s eligibility
the same setting, to the maximum extent appro- under Section 504, schools are required to follow
priate to meet the needs of the students with certain procedural safeguards related to the iden-
disabilities. In addition, students with disabilities tification, evaluation, or educational placement
may not be excluded from participating in any of students with a disability (U.S. Department of
school activities, including extracurricular pro- Education, Office for Civil Rights, 2010). An
grams such as recreational sports or special inter- evaluation must occur if a parent or teacher has
est clubs, in which students without disabilities referred a student, if a student has a medical
would participate (US Department of Education, diagnosis, or if a student has missed an excessive
Office of Civil Rights, 2010). number of school days due to illness. Schools
Section 504 also requires that students with dis- must use an evaluation procedure to determine
abilities access programs and services in “compa- whether a student’s disability (or perceived dis-
rable facilities.” In the event that a student with ability) limits his or her ability to perform a major
a disability is educated in a separate facility from life activity, but there is no standardized protocol
their peers, a district must ensure that the facility is for how this evaluation should take place.
504 Plan 5 0–9
504 Plan, Table 1 Overview of major differences between Section 504 and IDEA
0–9
Section 504 IDEA
Eligibility Individuals must qualify under the broad Students (aged 3–21) must qualify under one of
definition: (1) have a physical or mental the fourteen disability categories; students must
impairment that substantially limits one or demonstrate need for special education services
more major life activities, (2) have a record of
such an impairment, or (3) be regarded as
having such an impairment. Need for
special education is not a requirement
Major provisions No otherwise qualified individual with disability Procedural safeguards and the right to free
shall solely by reason of his or her disability be: appropriate public education in the least
• Excluded from participation in restrictive environment as defined by IDEA
• Denied the benefits of
• Be subjected to discrimination under any
program or activity receiving federal financial
assistance
Funding No funding provided for Section 504 Both state and federal funding
Overall Local education agency (LEA); general education State education agency (SEA); special
responsibility education
The FAPE provision requires that once stu- level are those individuals with a disability who
dents have been evaluated and determined to also meet the academic or technical standards
meet the criteria for Section 504, school teams that are required for admission by the institution.
must develop an individualized plan that outlines Individuals must also meet the participation
how services and accommodations will be pro- requirements for the institution’s activity or pro-
vided. Many students who meet the criteria of gram. FAPE does not apply to postsecondary
Section 504 are also protected under IDEA. educational settings; instead, institutions are
These students will therefore have an individual- required to provide “appropriate academic
ized education program (IEP) that will also con- adjustments and auxiliary aids and services that
stitute their written plan. If a student’s are necessary to afford an individual with a
educational needs can be met with accommoda- disability an equal opportunity to participate in
tions and related services that do not include a school’s program” (US Department of
specialized instruction, they do not typically Education, Office of Civil Rights, 2011). The
qualify for special education. These students accommodations and services provided by
have only a Section 504 plan that reflects their a postsecondary institution should not alter the
needs. Finally, a number of rights and safeguards individual’s program in a fundamental way nor
provided by IDEA are not similarly provided to should they create an “undue burden” on the
individuals under Section 504, including prior institution.
written notice, rights to independent educational Individuals with autism who meet the require-
evaluations, and protections from permanent ments for Section 504 while in elementary or
expulsion. Table 1 provides an overview of the secondary education should recognize that they
supports and services provided under Section 504 might not receive the same services or accommo-
and under IDEA. dations at the postsecondary level. For example,
some individuals with autism may be provided
Application in Postsecondary Education support from an educational assistant while in
Any postsecondary institution that receives fed- high school. Postsecondary institutions are not
eral funding is required to apply the regulations required to provide the same service because it
of Section 504 for qualifying individuals. Quali- may result in an undue financial burden to the
fying individuals at the postsecondary education institution (US Department of Education, Office
0–9 6 504 Plan
of Civil Rights, 2007). Another difference in pro- Future Directions

visions at the postsecondary level is the shift in
responsibility. At the elementary and secondary Increased Prevalence
school level, school districts are required to iden- A recent prevalence study estimated that 2–3%
tify, evaluate, and ensure services for an individ- (1:38) of the total school-age population have an
ual with a disability under Section 504. At the autism spectrum disorder (Kim et al., 2011). Many
postsecondary level, individuals must disclose of these students are served in the general education
their disability to the university and follow the setting (i.e., two-thirds of the sample in the Kim
institution’s procedures for requesting academic et al. study, 2011) and may not qualify for services
adjustments. Individuals with ASD must be pre- under IDEA. This increases the likelihood that
pared to discuss their individual needs when individuals with ASD will receive protections
transitioning to the postsecondary education set- under Section 504, which has vast implications for
ting (Adreon & Durocher, 2007). school staff. This resurgence in 504 cases will
require that school staff is adept in identifying and
Application in Employment Settings implementing appropriate accommodations and
Any employer who receives federal funding must modifications for students with ASD – likely
also fulfill the mandates of Section 504 that protect requiring additional staff training and expertise. In
qualified individuals with a disability. The disabil- addition, an increase in litigation around 504 pro-
ity criterion for protection under Section 504 in an tections is expected as families and schools struggle
employment setting is the same as in educational to identify what accommodations and auxiliary aids
settings; however, the definition of “qualified” is are required. For example, Section 504 does not
changed. For the purposes of employment, in order mandate specific education programs or models nor
to be “qualified” an individual with a disability does it require that students with ASD receive
must be able to perform the essential function individualized instruction in specialized settings
of the job with reasonable accommodation (Katsiyannis & Reid, 1999). As this population
(US Department of Health and Human Services, ages, the demand for Section 504 protections at
Office of Civil Rights, 2006). An employer is postsecondary settings, including universities,
required to take steps to accommodate an community colleges, and trade schools, will likely
employee’s disability unless doing so would cause also increase. The resources required to implement
an undue burden to the employer. these plans, both human resources and financial
Workplace accommodations for individuals resources, may create new challenges for these
with disabilities are somewhat intuitive in certain institutions. Finally, employers will likely face
situations (i.e., providing a sign language inter- similar challenges in supporting employees on the
preter for an individual who is deaf or an access autism spectrum protected by Section 504.
ramp for an individual with a physical disability).
Workplace accommodations can sometimes be Technology
less obvious in the case of an individual with The use of personal and portable technology with
ASD but are no less important in ensuring the individuals with ASD is on the rise (e.g., iPad, iPod,
individual’s success in the workplace. Accom- personal digital assistants, communication devices)
modations for individuals with autism in the (Mechling, Gast, & Seid, 2009). These tools are
workplace could include minor modifications to often used to support processing, communication,
work materials or physical changes in the work- self-management, self-care, independent function-
place that make the position more accessible. For ing, and other “major life activities” (e.g., learning
example, an employer could make the reasonable and working, per Section 504). It is not clear, how-
accommodation of providing a quieter workspace ever, whether provisions in Section 504 provide for
that reduces distractions if such a change would the procurement/use of these devices, and this
be an appropriate accommodation for the individ- ambiguity is likely to be discussed and debated in
ual with autism. upcoming years. Though Section 504 requires that
5-Hydroxytryptamine 7 0–9
auxiliary aids such as technology are provided to References and Readings
individuals with specific disabilities (i.e., hearing or
0–9
vision impairments) at no additional cost, there is Adreon, D., & Durocher, J. S. (2007). Evaluating the
college transition needs of individuals with
no mention of such supports for individuals with
high-functioning autism spectrum disorders. Interven-
broader developmental delays such as ASD or com- tion in School and Clinic, 42, 271–279.
munication impairments as result of such delays. Bellini, S., Peters, J., Benner, L., & Hopf, A. (2007).
The fact that no funding is allocated to school A meta-analysis of school-based social skills interven-
tions for children with autism spectrum disorders.
districts, postsecondary institutions, or workplaces
Remedial & Special Education, 28, 153–162.
in association with Section 504 may further com- Katsiyannis, A., & Reid, R. (1999). Autism and Section 504:
plicate the issue of providing technological sup- Rights and responsibilities. Focus on Autism and Other
ports for individuals with ASD. Developmental Disabilities, 14, 66–72.
Kim, Y. S., Leventhal, B., Koh, Y. J., Fombonne, E.,
Laska, E., et al. (2011). Prevalence of autism spectrum
Social Skills Instruction disorders in a total population sample. AJP in Advance.
Similar questions are likely to arise around the issue doi:10.1176/appi.ajp. 2011.10101532.
of social skills instruction. Because socializing and/ Mechling, L., Gast, D., & Seid, N. (2009). Using a Personal
Digital Assistant to increase independent task comple-
or social functioning is described as one of the
tion by students with autism spectrum disorder. Journal
major life activities under Section 504, accommo- of Autism & Developmental Disorders, 39, 1420–1434.
dations and modifications in this area are Rehabilitation Act of 1973. Section 504 (34 C.F.R. Part 104),
recommended for individuals with ASD (Bellini 93rd Congress, H. R. 8070.
Turnbull, R., Wilcox, B., & Stowe, M. (2002). A brief
et al., 2007). These may include peer-mediated overview of special education law with focus on
strategies, direct social skills instruction, behavioral autism. Journal of Autism & Developmental Disor-
modification, self-management, and/or other ders, 32, 479–494.
evidence-based social skill strategies. Currently, U.S. Department of Education, Office for Civil Rights.
(2010). Free Appropriate Public Education for Students
however, the state of social skills instruction for With Disabilities: Requirements Under Section 504 of
individuals with ASD who do qualify under IDEA the Rehabilitation Act of 1973. Washington, D.C: U.S.
is bleak (Bellini et al.), and little is known about the Department of Education, Office for Civil Rights.
status of this type of instruction for those who are U.S. Department of Health & Human Services. (June 2006).
Your rights under the Section 504 and the Americans
protected under Section 504. It is safe to assume
with Disabilities Act. In Office for Civil Rights Fact
that services for this population would not exceed Sheet. Retrieved May 3, 2011, from http://www.hhs.
that of those who qualify under IDEA and likely gov/ocr/civilrights/resources/factsheets/504.pdf.
also safe to assume that social skills services for the Wass, S. (2011). Distortions and disconnections: Disrupted
brain connectivity in autism. Brain & Cognition, 75,
504 protected group are close to nonexistent. As 18–28.
discussed above, as this population continues to Wright, P. & Wright, P. (March 2, 2008). Key differences
increase, particularly a higher functioning group between Section 504, the ADA, and the IDEA. In
of students who may not receive services under Wrightslaw.com. Retrieved May 3, 2011, from http://
wrightslaw.com/.
IDEA, an increased focus on this type of instruction Yell, M. L. (2006). The Law and Special Education
will fall to those implementing Section 504 plans. (2nd ed.). Upper Saddle River: Pearson, NJ.
See Also
5-HT
▶ Academic Supports
▶ Americans with Disabilities Act ▶ Serotonin
▶ Employment
▶ Individual Education Plan
▶ Individuals with Disabilities Education Act 5-Hydroxytryptamine
(IDEA)
▶ Toilet Training ▶ Serotonin
0–9 8 7-[4-[4-(2,3-Dichlorophenyl)-1-piperazinyl]butoxy]-3,4-dihydro-2(1H)-quinolinone
Reciprocal deletions at 7q11.23 cause

7-[4-[4-(2,3-Dichlorophenyl)-1- Williams-Beuren syndrome characterized by dis-
piperazinyl]butoxy]-3,4-dihydro-2 tinctive facial features, supravalvular aortic
(1H)-quinolinone stenosis, and intellectual disability (http://
www.omim.org/entry/194050?search¼7q11.23&
▶ Aripiprazole highlight¼7q1123). Of note, these individuals
also are known for highly sociable personalities.
The distinctive phenotypes resulting from oppo-
site changes in the number of copies of this region
7-Dehydrocholesterol Reductase raise the intriguing possibility that the level of
Deficiency expression of a gene, or genes, within the
7q11.23 region plays a key role in the develop-
▶ Smith-Lemli-Opitz Syndrome
ment and/or functioning of the social brain.
The genes in the 7q11.23 region are ABHD11,
BAZ1B, BCL7B, CLDN3, CLDN4, CLIP2,
7q11.23 Duplications DNAJC30, EIF4H, ELN, FKBP6, FZD9,
GTF2I, GTF2IRD1, LAT2, LIMK1, MLXIPL,
Stephan Sanders NSUN5, RFC2, STX1A, TBL2, TRIM50,
Child Study Center, Yale University, VPS37D, WBSCR22, WBSCR26, WBSCR27,
New Haven, CT, USA and WBSCR28.
Synonyms See Also
Williams-Beuren region duplication ▶ Candidate Genes in Autism

▶ Chromosomal Abnormalities
▶ Common Disease-Rare Variant Hypothesis
Definition ▶ Copy Number Variation
▶ DNA
7q11.23 duplications are copy number variations ▶ Genetics
(CNVs) in which an extra copy of 1,400 kb of DNA
from the long arm of chromosome 7 is present.
Duplications in this region are associated with References and Readings
“non-syndromic” ASD (Sanders et al. 2011). The
region contains 26 genes, listed below, and is Sanders, S. J., Ercan-Sencicek, A. G., Hus, V., Luo, R.,
Murtha, M. T., Moreno-De-Luca, D., et al. (2011).
flanked by two segmental duplications (stretches Multiple recurrent de novo CNVs, including duplica-
of near-identical DNA). These are known to tions of the 7q11.23 Williams syndrome region, are
increase the likelihood of a process known as strongly associated with autism. Neuron, 70(5),
nonhomologous allelic recombination, which can 863–885.
lead to gains or losses of the chromosomal segment
flanked by these repeats and account for the com-
mon breakpoints seen in the vast majority of indi-
viduals carrying duplications in this region. 7q11.23
duplications have also been seen in combination 8-Chloro-1-methyl-6-phenyl-4H-s-
with intellectual disability, speech delay, and car- triazolo [4,3-a] [1,4] Benzodiazepine
diac malformations (http://www.omim.org/entry/
609757?search¼7q11.23&highlight¼7q1123). ▶ Alprazolam
A
Aarskog Syndrome “centile.” Puberty is often delayed, but these

patients do display a growth spurt in the late
Marc B. Taub teens resulting in adult height in the low-to-
Southern College of Optometry, Memphis, TN normal range. Final height is around the 10th
“centile.” Serum growth hormone levels are
reported as normal and treatment with growth
Synonyms hormone is ineffective. Spina bifida occulta, cer-
vical spine abnormalities, and scoliosis have been
Aarskog-Scott syndrome; Faciogenital dysplasia documented (Taub & Stanton, 2008).
The nose is often described as short and stubby,
with a broad nasal bridge and anteversion of the
Definition nostrils. The ears are low set and protuberant. They
are fleshy superiorly and referred to as “jug-handle
Aarskog syndrome was first reported in 1970 by ears.” Maxillary hypoplasia and dental malocclu-
Aarskog in a seven-patient case series. The syn- sion has been reported as well as a transverse
drome is characterized by short stature with crease below the lower lip (Taub & Stanton,
peculiar facies, “shawl” scrotum (the scrotal 2008). Associated ophthalmic conditions include
folds encircle the penis ventrally), cryptorchi- hypertelorism, telecanthus, blepharoptosis, and
dism (the testis fails to descend into its normal antimongoloid (downward) obliquity of the palpe-
position in the scrotum), and abnormalities of bral fissures. Ophthalmoplegia, strabismus, hyper-
the hands and feet (Aarskog, 1970). Aarskog opic astigmatism, retinal vessel tortuosity,
syndrome can be inherited as an X-linked disor- nystagmus, and Brown’s syndrome have also
der caused by FGD1 mutations or possibly in an been reported.
autosomal dominant or recessive pattern (Xu The hands and feet are affected by this condi-
et al., 2010). tion in several ways. The hands are often short
Intelligence ranges from normal to mild men- and broad with mild syndactyly (interdigital
tal retardation. A normal IQ distribution has been webbing) and/or brachydactyly (shortness in
found (Pilozzi-Edwards et al., 2011). Mild learn- comparison to the other bones and body parts).
ing difficulties and attention deficit hyperactivity Hyperextensible joints with concomitant flexion
disorder have been reported (Pilozzi-Edmonds of the distal joints (a hallmark sign), single
et al.). Comorbidity has been documented with palmer creases, and short medially incurved
autism (Schwartz et al., 2000). fifth fingers are also found. The feet are broad
Birth size is often normal. Until puberty, most and flat with metatarsus versus and short, splayed
patients are short with height at or below the third bulbous toes (Taub & Stanton, 2008).

A 10 Aarskog-Scott Syndrome
Genital anomalies include a “shawl” scrotum,

bilateral or unilateral cryptorchidism, and ABAS, Second Edition
macroorchidism (abnormally large testes). Ingui-
nal hernia (a condition in which part of the intes- ▶ Adaptive Behavior Assessment System,
tine bulges through a weak area in muscles in the Second Edition
abdomen, specifically the groin) has been found
in association with the syndrome. No character-
istic anomaly has been documented in females
(Taub & Stanton, 2008). ABAS-II
▶ Adaptive Behavior Assessment System,

See Also Second Edition
▶ Genetics
▶ Strabismus
ABC
References and Readings ▶ Autism Behavior Checklist
▶ Aberrant Behavior Checklist
Aarskog, D. (1970). A Familial syndrome of short stature
associated with facial dysplasia and genital anomalies.
The Journal of Pediatrics, 77, 856–861.
Pilozzi-Edwards, L., Maher, T. A., Basran, R. K.,
Milunsky, A., Al-Thihli, K., Braverman, N. E., et al.
(2011). Fraternal twins with Aarskog-Scott syndrome ABC-C
due to maternal germline mosaicism. American Jour-
nal of Medical Genetics Part A, 155, 1987–1990. ▶ Aberrant Behavior Checklist
Schwartz, C. E., Gillessen-Kaesbach, G., May, M., Cappa,
M., Gorski, J., Steindl, K., et al. (2000). Two novel
mutations confirm FGD1 is responsible for the
Aarskog syndrome. European Journal of Human
Genetics, 8, 869–874.
Taub, M. B., & Stanton, A. (2008). Aarskog syndrome:
ABC-R
A case report and literature review. Optometry, 79,
371–377. ▶ Aberrant Behavior Checklist
Xu, M., Qi, M., Zhou, H., Qui, H., et al. (2010). Familial
syndrome resembling Aarskog syndrome. American
Journal of Medical Genetics. Part A, 152A,
2017–2022.
Aberrant Behavior Checklist
Michael G. Aman
Aarskog-Scott Syndrome Nisonger Center, UCEDD, The Ohio State
University, Columbus, OH, USA
▶ Aarskog Syndrome
Synonyms
ABA ABC; ABC-C; ABC-R; Aberrant behavior

checklist – community; Aberrant behavior check-
▶ Didactic Approaches list – residential
Aberrant Behavior Checklist 11 A
Abbreviations than or equal to 1 are warranted. The instructions
also encourage informants to consider observa-
ASD Autism spectrum disorder tions and reports of other responsible adults who A
DD Developmental disability know the client well when making their ratings.
Finally, the instructions indicate that behaviors
which interfere with the client’s development,
Description functioning, and/or social relationships should
be rated as a problem, even if these behaviors
The Aberrant Behavior Checklist (ABC) is an do not interfere with other people around the
informant rating instrument that was empirically client. The 58 behavior items consume about
derived by principal component analysis (Aman, 1½ pages of the form.
Singh, Stewart, & Field, 1985a). It contains 58 Initially, the ABC was developed primarily as
items that resolve onto five subscales. The sub- a measure of treatment effects, especially as an
scales and the respective number of items are as outcome measure for pharmacological interven-
follows: (a) irritability (15 items), (b) lethargy/ tion. With time, the use of the ABC has expanded,
social withdrawal (16 items), (c) stereotypic and it has been employed, fairly frequently, for
behavior (7 items), (d) hyperactivity/ the following applications: (a) to examine psy-
noncompliance (16 items), and (e) inappropriate chometric characteristics of other instruments
speech (4 items). The ABC was designed to be and/or the ABC itself, (b) to study the behavioral
completed by any adult who knows the client phenotypes of individuals with genetic and met-
well. This could be a parent, teacher, workshop abolic conditions, (c) to examine the effects of
supervisor, case worker, and possibly informants different environmental variables (e.g., size of
in other roles as well. Depending upon reading housing arrangements) on behavior, (d) to char-
ability, completion time varies, but most raters acterize the composition of subjects within stud-
can complete the ABC in 10–15 min the first time ies and/or programs, (e) to assess the effects of
they fill it in. Thereafter, rating times usually sleep disruption on client behavior, (f) to charac-
decline. terize individuals with different types of psychi-
The face page asks for the client’s gender, date atric disorders, and (g) to evaluate quality of life.
of birth, rater’s relationship to the client, type of The ABC has become fairly popular for research
classroom (if relevant), ethnicity, presence of and clinical applications. There are at least 26 lan-
sensory or physical impairments, and a listing of guages into which it has been translated, including
any medicine being used by the client. In the the following: Afrikaans, Chinese, Czech, Danish,
context of treatment studies, this information Dutch, Finnish, French (Canadian and European),
(other than the subject’s name and date) is often German, Hebrew, Hungarian, Italian, Japanese,
not collected. Pages 2 and 3 contain instructions Korean, Lithuanian, Norwegian, Persian (Farsi),
for completing the ABC and its 58 items. The Portuguese, Romanian, Russian, Slovak, Spanish,
period over which informants rate the client Turkish, Slovenian, Telugu (regional language of
defaults to 4 weeks. However, depending on the Andhra Pradesh, India), and Vietnamese.
clinical or research needs, this period can be Currently, there are two manuals available for
increased or decreased accordingly. The instruc- the ABC, and they complement one another. The
tions ask the informant to rate the client on original Aberrant Behavior Checklist Manual
a scale ranging from 0 (not at all a problem) to 3 (Aman & Singh, 1986) gives the history of the
(the problem is severe in degree). Further, the ABC’s development and elaborates upon the
instructions ask raters to take relative frequency meanings of all 58 items. Average subscale
into account, such that if a given behavior occurs scores and standard deviations are provided for
more than the client’s reference group (e.g., other males and females residing in both United States
children of the same age and sex), scores greater (N ¼ 508) and New Zealand (N ¼ 854)
A 12 Aberrant Behavior Checklist
developmental centers. Data are also presented treatment effects in people with DD (e.g., Singh
on internal consistency, interrater reliability, & Aman, 1981). Development of the ABC was
test-retest reliability, criterion group validity, con- closely modeled on the Behavior Problem Check-
current and discriminant validity, and correspon- list of Quay and Peterson (Quay, 1977) and the
dence of ratings with direct observation scores. enormously popular Conners’ Parent and
The Aberrant Behavior Checklist – Community, Teacher Rating Scales (Conners, 1969, 1970).
Supplementary Manual (Aman & Singh, 1994) We began the process by inspecting case records
presents data on the community version of the for candidate problem behaviors in a 400-bed
ABC (ABC-C). The community version was residential center, by adopting items from popu-
developed by eliminating certain institutional lar instruments in the intellectual disability and
terms and replacing them with more appropriate child psychopathology fields, and by consulting
language for community use. Subsequent factor direct care staff about additional items and the
analysis indicated that the item assignment of the wording of items. The first forerunner of the ABC
ABC-C remains unchanged from the original contained 125 items; these were rated by care-
ABC. The supplementary manual (Aman & givers of 418 adolescents and adults with DDs.
Singh, 1994) contains normative data for children Items endorsed for fewer than 10% of subjects
and adolescents in special educational classes for were dropped, and a principal factoring method
young people with developmental disabilities was conducted with oblique rotation, leaving 76
(DDs) and for adults in group homes in the United items. The intermediate 76-item scale was then
States Midwest. Normative data are provided for used to rate a new group of 509 adolescents and
teacher ratings of young people in the following adults.
formats: (a) T-scores and percentiles by gender The data from both samples were analyzed
and age, (b) T-scores with all ages and genders independently by a principal factoring method
combined, and (c) means and standard deviations followed by oblique rotation. A five-factor solu-
broken out by age and gender, as well as col- tion seemed most interpretable in both analyses.
lapsed across all ages. The group home norms The five-factor solution produced a reasonably
are presented in the following ways: (a) T-scores fine-grained breakdown of behavior, whereas
and percentiles by age (10-year groupings) and solutions with more factors merely splintered
functional levels (mild, moderate, severe, and previously meaningful dimensions into more
profound intellectual disability); (b) T-scores domains that were redundant. Items that failed
and percentiles collapsed across functional to load on the same respective factors across
level, summarized for age alone and for gender analyses were deleted, leaving 58 items in the
alone; (c) means and standard deviations broken ultimate ABC.
out by combinations of functional level and age, Two important subsequent changes took place
and summarized by gender alone. Unfortunately, more or less simultaneously. First, the original
the Supplemental Manual does not provide norms ABC contained some language that was distinctly
for parent ratings of children and adolescents. institutional in flavor (e.g., “excessively active on
However, these norms can be found in the ward”). This language was modified in the
a publication by Brown, Aman, and Havercamp early 1990s (e.g., “excessively active at home,
(2002) in which the means and standard devia- school, work, or elsewhere”) to form what was
tions are summarized for various combinations of then called the ABC-community. At about the
age, gender, and type of classroom. same time, investigators assessed the ABC in
child samples and found that the original factor
structure was maintained for children and adoles-
Historical Background cents (e.g., Marshburn & Aman, 1992; Brown
et al., 2002). The earlier version of the ABC
The development of the ABC grew out of was dubbed the ABC-residential to distinguish
a practical need for an instrument to assess it from the newer ABC-community. Thus, at
this stage, there were residential and community below, the ABC has been used for a multitude of
versions available, and the community version’s pharmacological and nonpharmacological pur-
structure was validated for children, adolescents, poses over the last 25 years. A
and adults.
With time, the ABC came to be used more and
more in pharmacological research involving peo- Psychometric Data
ple with intellectual disability and/or autism
spectrum disorders (ASDs). Other uses are There is a wealth of psychometric data on the
described under Clinical Uses, below. Almost ABC.
all published research with the ABC can be Construct Validity. There have been several
accessed through the Annotated Bibliography independent factor analyses with the ABC which
on the ABC (Aman, 2012; available at http:// have supported its construct validity (a) across
psychmed.osu.edu/resources.htm). One impor- versions of the ABC, (b) across settings (large
tant development was the adoption of the residential vs. small, within the community), and
ABC’s irritability subscale as the primary out- (c) across age groups. All of these studies have
come measure by the Research Units on Pediatric been referenced and summarized in the Anno-
Psychopharmacology (RUPP et al., 2005, 2002), tated Bibliography on the ABC (Aman, 2011;
a network of experienced psychopharmacology available at http:/psychmed.osu.edu/resources.
laboratories funded by the US National Institute htm), and they are summarized in Table 1.
of Mental Health. In two studies, the RUPP net- Please note that we make frequent reference to
work showed that risperidone (Risperdal) was the Annotated Bibliography on the ABC here, as it
highly effective in reducing agitated and irritable references almost all research work conducted
behavior for children and adolescents with autis- with the ABC. It provides references to over
tic disorder chosen for high initial scores on the 330 studies and contains summaries of many of
irritability subscale. Using data from these piv- these. Interested readers are welcome to consult
otal investigations and from another clinical trial, the Bibliography and to make copies of it, at no
Johnson & Johnson Pharmaceuticals was able to cost, if they wish.
obtain a clinical indication from the United States As shown in Table 1, all studies of construct
Food and Drug Administration for the use of validity found essentially the same factor struc-
risperidone in children and adolescents with tures as reported in the original report (Aman
autism and significant agitation and irritability. et al., 1985a). Two of 11 studies failed to find
At this point, this was the only medication the inappropriate speech factor in children, pos-
approved by the FDA for treating patients with sibly because of a lack of participants with ASDs.
autism. Subsequently, Bristol-Myers Squibb One study (Brinkley et al., 2007) found signifi-
Company launched two pivotal clinical trials of cant changes to the irritability factor when sub-
aripiprazole (Abilify) in children and adolescents jects with high rates of self-injury (SIB) were
with autism and agitated/irritable behavior, again included, but the factor structure was confirma-
with the ABC irritability subscale as the primary tory when these subjects were excluded. All of
outcome measure. Bristol-Myers Squibb was also the remaining studies essentially verified the
able to obtain a clinical indication for its product. ABC’s construct validity.
These developments have made the ABC Other Forms of Validity. When the ABC was
a popular choice as an outcome measure for the introduced, we presented several validity compar-
pharmaceutical industry when targeting behavior isons as follows (Aman, Singh, Stewart, & Field,
problems in patients with developmental disabil- 1985b). First, ratings on the ABC were found to
ities. However, it is important to realize that correlate with ratings on other standardized scales
individual academic investigators were using to establish its concurrent validity. For instance,
the ABC long before it was adopted as an out- the following ABC subscales were shown to cor-
come by industry. As noted under Clinical Uses, relate positively with analogous domains on the
Aberrant Behavior Checklist, Table 1 Studies of the construct validity of the ABC
Residential/ % of items on same
community children/ Number of same factor (mean factor Coefficient of
Authors adults factors loading) congruence (mdn)
Aman, Singh, and Res, Adultsa 5 (Same)b 86% (.58) .88–.96 (.94)
Turbott (1987)
Netwon and Res, Adults 5 (Same) 78% and 81%c NRd
Sturmey (1988)
Bihm and Res, Adults 5 (Same) NR NR
Poindexter (1991)
Freund and Reiss Comm, Childra 5 (Same)e 91% .88–.82 (.86)
(1991)
Comm, Childr 5 (Same)f 80% .65–.91 (.81)
Rojahn and Res, Childr 5 (Same) NR .80–.89 (.82)
Helsel (1991))
Marshburn and Aman Comm, Childr 4 (1–4 Same) 84% (.65) .87–.96 (.90)
(1992)
Aman, Burrow, and Comm, Adults 5 (Same) 95% (.59) .84–.97 (.90)
Wolford, (1995)
Ono (1996) Res, Childr/Adults 5 (Same) 83% NR
Siegfrid (2000) Comm,g Adults 5 (Same) 84% (.69) NR
Brown et al. (2002) Comm, Childr 4 (1–4 Same) 71% (.51) .62–.91 (.85)
Brinkley et al. (2007) Comm, Childr 5 (Same for low SIB 78% NRh
subjects)
4 (Subscales 2–5 same 60% NRi
for high SIB subjects)
a
Res residential facility, Comm community Setting, Childr children
b
Same same factor composition
c
using ordinal and dichotomous dichotomous coding (absent/present), respectively
d
NR not reported
e
parent ratings
f
teacher ratings
g
hostels (relatively small group residential settings), activity centers, workshops
h
RMSEA ¼ 0.088, borderline fit
i
RMSEA 0.12, poor fit; (mdn) = median value
AAMD Adaptive Behavior Scale, respectively: (a) units. The direct observation categories were
irritability and self-abusive behavior (rs ¼ .59), (b) “crying/irritability,” “self-injury,” “withdrawal/
irritability and psychosocial disturbances (rs ¼ apathy,” “stereotypy,” “noncompliance,” “gross
.39), (c) lethargy/social withdrawal and with- body movements,” “off-task behavior,” and
drawal (rs ¼ .69), (d) stereotypic behavior and “repetitive speech.” With the exception of the
stereotypic behavior (rs ¼ .42), and (e) inappro- first category, all observation categories strongly
priate speech and unacceptable vocal habits (rs ¼ validated their respective ABC subscales.
.42). Criterion groups were found to differ in “Crying/irritability” was nominally confirmatory
predictable ways (e.g., those attending formal as well, but rates of these behaviors were much
training activities had substantially lower too low to show statistical significance. Subjects
subscale scores than those not receiving training; taking psychotropic drugs were compared with
the same was found for subjects with Down syn- those taking none, and in general, those who were
drome vs. those without). medicated received substantially and signifi-
Subjects with high and low ABC scores were cantly higher ABC scores on all except the repet-
observed with direct observations on their living itive speech subscale.
Aberrant Behavior Checklist, Table 2 Summary of interrater reliability studies with the ABC
Authors Sample size Ages of subjects Correlation range Median correlation
Aman et al. (1985b) (a) 35 Adults .54–.67 .59 A
(b) 40 Adults .51–.88 .71
Aman et al. (1987) (a) 28 Adults .52–.74 .60
(b) 28 Adults .40–.66 .59
Freund and Reiss (1991)a 94? Children .39–.49b .45b
Rojahn and Helsel (1991) 130 Children/Adolescents .39–.61 .49
Ono (1996) 33 Children/Adults .58–.78b .68
Schroeder, Rojahn, and Reese, 1997 30 Adults .12–.53 .45
)
Siegfrid (2000)c 90 Adults 1..76–.90d
2..61–.75 .73
3..68–.88
Miller, Fee, and Netterville (2004) 22 Children .72–.80 NRe
All references can be found in Annotated Bibliography on the ABC (Aman, 2012). Unless indicated otherwise, all
correlations were Pearson correlation coefficients. Unless coded otherwise, raters had the same roles
a
Parent-teacher agreement
b
Spearman correlation coefficients
c
Intraclass correlation coefficients
d
Three different settings
e
NR not reported
There have been numerous other examples of Test-Retest Reliability. Several studies that
validity demonstrated through the developmental examined test-retest reliability are summarized
disabilities literature. Examples of this include in Table 3. Median reliability ranged from the
concurrent validity between the ABC and other mid-.60s to highs in the .90s. In general, test-
formal instruments, including (a) the Psychopa- retest reliably was quite high, falling within
thology Instrument for Mentally Retarded ranges characterized by Cicchetti and Sparrow
Adults, (b) the Nisonger Child Behavior Rating (1981) as good to excellent.
Form, (c) Conners’ Teacher Rating Scale, (d)
Diagnostic Assessment for the Severely
Handicapped-II, (e) Reiss Screen for Maladap- Clinical Uses
tive Behavior, (f) Stereotyped Behavior Scale, (g)
Teacher Report Form, and (h) The ADD-H Com- As noted, the ABC was developed as an outcome
prehensive Teacher’s Rating Scale. measure for pharmacological trials in people with
Reliability Assessments. Many researchers, developmental disabilities, and it has been
especially those who conducted factor analysis heavily used for this purpose (see Annotated
with the ABC, reported alpha coefficients – Bibliography, Aman, 2012). It is a “broadband”
a measure of internal consistency. Generally, coef- instrument that provides fairly good coverage of
ficient alpha ranged from the low .80s to the behaviors suggested by its subscale names (irri-
middle .90s, indicating a high level of consistency. tability, social withdrawal, etc.). Its early use was
Interrater Reliability. Many of the studies that primarily among individuals with intellectual dis-
examined cross-informant reliability are summa- abilities alone, but in recent years it has been used
rized in Table 2. These generally fell into the a great deal to assess treatment outcomes in indi-
low .50s to high .60s range, which is quite ade- viduals with ASDs as well. Although several sub-
quate for both research and clinical practice. scales assess features of ASDs (e.g., lethargy/
Using criteria established by Cicchetti and social withdrawal, stereotypic behavior, inappro-
Sparrow (1981), these reliabilities fall into the priate speech), the ABC was not intended to be
fair to good ranges. a measure of autism symptom severity. Recently,
Aberrant Behavior Checklist, Table 3 Summary of test-retest reliability studies with the ABC
Authors Lag Sample size Age group Correlation range Median correlation
Aman et al. (1987) 4 week 28 Adults .55–.83 .72 (mean)
Freund and Reiss (1991) 1 month 30a Children .80–.95 .88
1 month 25b Children .50–.67 .61
Ono (1996) 4 weeks 43 Children, Adults .84–.90 .85
Schroeder et al. (1997) 30 days 30 Adults .52–.76 .59
)
Siegfrid (2000)c 4 week 20 Adults 1..84–.92d
2..89–.96 .94
3..88–.98
Miller et al. (2004) 2 weeks 48 Children .68–.85 b NRe
.74–1.00 f NR
Berry-Kravis et al. (2006) 5 week; 2 week 49 Adults .60–.90g .90
All references can be found in the Annotated Bibliography on the ABC (Aman, 2012). Unless indicated otherwise, all
were Pearson correlation coefficients
a
Parent ratings
b
Teacher ratings
c
Intraclass correlation coefficients
d
Three different settings
e
NR not reported
f
Teaching assistants
g
Intraclass correlation coefficient
pharmaceutical companies have become inter- The ABC has primarily been used to assess
ested in possible treatments of patients with frag- school-aged children, adolescents, and adults
ile X syndrome, and the ABC is being employed through late middle age. Although there have
to monitor outcome in several of these trials. been a few studies among preschoolers/toddlers
Although much of the discussion thus far has and elderly people, its utility in preschoolers and
been in the context of clinical research, it should elders has yet to be properly and thoroughly
be apparent that the ABC can be helpful to mon- established.
itor the effects of routine clinical care, both in
people with intellectual disabilities and in those
with ASDs. References and Readings
Periodically, the ABC had been used to assess
the effects of behavior intervention, both in for- Aman, M.G.(2012, April). Annotated bibliography on the
Aberrant Behavior Checklist (ABC). Unpublished
mal research (Aman et al., 2009) and in everyday manuscript, The Nisonger Center UAP, Ohio State
care. Obviously, it is important to document the University, Colombus, OH.
efficacy of such treatment. The ABC has been Aman, M. G., Burrow, W., & Wolford, P. L. (1995). The
used to select participants for various forms of Aberrant Behavior Checklist Community: Factor
validity and effect of subject variables for adults in
research intervention, especially pharmacologi- group homes. American Journal on Mental Retarda-
cal investigations. It may serve a similar role in tion, 100, 283–292.
routine clinical care to identify individuals who Aman, M. G., McDougle, C. J., Scahill, L., Handen, B.,
warrant preventive care and/or active interven- Arnold, L. E., Johnson, C., Stigler, K. A., Bearss, K.,
Butter, E., Swiezy, N. B., Sukhodolsky, D. D., Rama-
tion. As noted earlier, the ABC has been used to dan, Y., Pozdol, S. L., Nikolov, R., Lecavalier, L.,
monitor behavior in those experiencing transi- Kohn, A. E., Koenig, K., Hollway, J. A., Korzekwa,
tion, such as moving from one living environ- P., Gavaletz, A., Mulick, J. A., Hall, K. L., Dziura, J.,
ment to another. It has also been used to assess Ritz, L., Trollinger, S., Yu, S., Vitiello, B., Wagner, A.
(Research Units on Pediatric Psychopharmacology).
co-occurring behavioral issues in people with (2009). Medication and parent training in children
genetic or metabolic syndromes, and this is with pervasive developmental disorders and serious
another likely area of clinical application. behavior problems: Results from a randomized clinical
Aberrant Behavior Checklist – Community 17 A
trial. Journal of the American Academy of Child and (Eds.), Behavior modification for persons with devel-
Adolescent Psychiatry, 48, 1143–1154. opmental disabilities: Treatments and supports (Vol. I,
Aman, M. G., Novotny, S., Samango-Sprouse, C., pp. 160–189). Kingston, NY: NADD.
Lecavalier, L., Leonard, E., Gadow, K., et al. (2004). Marshburn, E. C., & Aman, M. G. (1992). Factor validity A
Outcome measures for clinical drug trials in autism. and norms for the Aberrant Behavior Checklist in
CNS Spectrums, 9, 36–47. a community sample of children with mental retarda-
Aman, M. G., & Singh, N. N. (1986). Aberrant Behavior tion. Journal of Autism and Developmental Disorders,
Checklist manual. East Aurora, NY: Slosson Educa- 22, 357–373.
tional Publications. Miller, M. L., Fee, V. E., & Netterville, A. K. (2004).
Aman, M. G., & Singh, N. N. (1994). Aberrant Behavior Psychometric properties of ADHD rating scales
Checklist – community. Supplementary manual. East among children with mental retardation I: Reliability.
Aurora, NY: Slosson Educational Publications. Research in Developmental Disabilities, 25, 459–476.
Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. Newton, J. T., & Sturmey, P. (1988). The Aberrant
(1985a). The Aberrant Behavior Checklist: A behavior Behaviour (sic) Checklist: A British replication and
rating scale for the assessment of treatment effects. extension of its psychometric properties. Journal of
American Journal of Mental Deficiency, 89, 485–491. Mental Deficiency Research, 32, 87–92.
Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. Ono, Y. (1996). Factor validity and reliability for the
(1985b). Psychometric characteristics of the Aberrant Aberrant Behavior Checklist-community in
Behavior Checklist. American Journal of Mental a Japanese population with mental retardation.
Deficiency, 89, 492–502. Research in Developmental Disabilities, 17, 303–309.
Aman, M. G., Singh, N. N., & Turbott, S. H. (1987). Quay, H. C. (1977). Measuring dimensions of deviant
Reliability of the Aberrant Behavior Checklist and behavior: The behavior problem checklist. Journal of
the effect of variations in instructions. American Abnormal Child Psychology, 5, 277–287.
Journal of Mental Deficiency, 92, 237–240. Rojahn, J., & Helsel, W. J. (1991). The Aberrant Behavior
Berry-Kravis, E., Krause, S., Block, S., Guter, S., Wuu, J., Checklist with children and adolescents with dual
Leurgans, S., et al. (2006). Effect of CX516, an AMPA- diagnosis. Journal of Autism and Developmental
modulating compound, on cognition and behavior in Disorders, 21, 17–28.
fragile X syndrome: A controlled trial. Journal of Child RUPP, Aman, M. G., Arnold, L. E., Lindsay, R., Nash, P.,
and Adolescent Psychopharmacology, 16, 525–540. Hollway, J., et al. (2005). Risperidone treatment of
Bihm, E. M., & Poindexter, A. R. (1991). Cross-validation autistic disorder: Longer term benefits and blinded
of the factor structure of the Aberrant Behavior Check- discontinuation after six months. American Journal
list for persons with mental retardation. American of Psychiatry, 162, 1361–1369.
Journal on Mental Retardation, 96, 209–211. RUPP, McCracken, J. T., McGough, J., Shah, B., Cronin, P.,
Brinkley, J., Nations, L., Abramson, R. K., Hall, A., Hong, D., et al. (2002). A double-blind, placebo-
Wright, H. H., Gabriels, R. et al. (2007). Factor controlled trial of risperidone in children with autistic
analysis of the Aberrant Behavior Checklist in individ- disorder. The New England Journal of Medicine, 347,
uals with autism spectrum disorders. Journal of Autism 314–321.
and Developmental Disorders, 37(10), 1949–1959. Schroeder, S. R., Rojahn, J., & Reese, R. M. (1997).
Brown, E. C., Aman, M. G., & Havercamp, S. M. (2002). Reliability and validity of instruments for assessing
Factor analysis and norms on parent ratings with the psychotropic medication effects on self injurious
Aberrant Behavior Checklist community for young behavior in mental retardation. Journal of Autism and
people in special education. Research in Developmen- Developmental Disorders, 27, 89–102.
tal Disabilities, 23, 45–60. Siegfrid, L. W. K. (2000). A study of the reliability and
Cicchetti, D. V., & Sparrow, S. A. (1981). Developing validity of the Chinese version Aberrant Behavior
criteria for establishing interrater reliability of specific Checklist. M. Sc. Thesis done at the Hong Kong
items: Applications to assessment of adaptive behavior. Polytechnic University, Hong Kong.
American Journal of Mental Deficiency, 86, 127–137. Singh, N. N., & Aman, M. G. (1981). Effects of
Conners, C. K. (1969). A teacher rating scale for use in thioridazine dosage on the behavior of severely
drug studies with children. American Journal of Psy- mentally retarded persons. American Journal of
chiatry, 126, 884–888. Mental Deficiency, 85, 580–587.
Conners, C. K. (1970). Symptom patterns in hyperkinetic,
neurotic, and normal children. Child Development,
141, 667–682.
Freund, L. S., & Reiss, A. L. (1991). Rating problem
behaviors in outpatients with mental retardation: Use Aberrant Behavior Checklist –
of the Aberrant Behavior Checklist. Research in
Developmental Disabilities, 12, 435–451.
Community
Lecavalier, L., & Aman, M. G. (2005). Rating instru-
ments. In J. L. Matson, R. B. Laud, & M. L. Matson ▶ Aberrant Behavior Checklist
A 18 Aberrant Behavior Checklist – Residential
effects. The scale was developed by the Psycho-

Aberrant Behavior Checklist – pharmacology Research Branch in 1975 and is
Residential currently in the public domain.
▶ Aberrant Behavior Checklist

See Also
▶ Atypical Antipsychotics
Abilify ▶ Tardive Dyskinesia
▶ Aripiprazole
References and Readings
Boyd, M. A. (2008). Appendix D. In Psychiatric nursing:

Contemporary practice (pp. 891–892). Philadelphia,
ABLLS-R PA: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
▶ Assessment of Basic Language and Learning Branch, P. R. (1975). Abnormal involuntary movement
scale (AIMS). Early Clinical Drug Evaluation Unit
Skills (ABLLS)
Intercom, 4, 3–6.
Martinez, M., Marangell, L. B., & Martinez, J. M. (2011).
Psychopharmacology. In R. E. Hales, S. C. Yudofsky,
& G. O. Gabbard (Eds.), Essentials of psychiatry
Abnormal Involuntary Movement (3rd ed., pp. 455–524). Washington, DC: American
Psychiatric Publishing.
Scale Sadock, B. J., & Sadock, V. A. (2003). Biological thera-
pies. In Synopsis of psychiatry: behavioral sciences/
Maureen Early1, Logan Wink1,2, clinical psychiatry (pp. 974–1150). Philadelphia, PA:
Lippincott Williams & Wilkins.
Craig Erickson1,2 and Christopher J. McDougle3
1 Wyatt, R. J. (1998). Instructions for using the abnormal
Christian Sarkine Autism Treatment Center, involuntary movement scale (AIMS) and AIMS-
Indianapolis, IN, USA modified (AIMS-M3D). In Practical psychiatric
2 practice: Forms and protocols for clinical use: Second
Department of Psychiatry, Indiana University
edition (pp. 77–82). Washington, DC: American
School of Medicine, Indianapolis, IN, USA
3 Psychiatric Press.
Lurie Center for Autism/Harvard Medical
Abnormality
Synonyms
▶ Exceptionality
AIMS
Definition Absence Seizures
A scale used by physicians for evaluating and ▶ Petit Mal Seizure

monitoring abnormal movements such as those
associated with tardive dyskinesia which rates the
severity of abnormal movements from 0 to 4. The
scale is used every 3–6 months to monitor Academic Disability
patients taking antipsychotic medications for
the development of movement-related side ▶ Developmental Disabilities
Academic Skills 19 A
of any kind. If there was treatment, it was of
Academic Skills a clinical and/or therapeutic kind. It was left to
a few pioneering schools (in the UK and A
Rita Jordan Denmark) to demonstrate that these children
School of Education, The University of were able to learn and benefit from education,
Birmingham, Birmingham, UK although even then, the specialist curricula of
such schools were largely concerned with teach-
ing adaptive behaviors and practical occupation
Definition skills; academic skills were still regarded as
largely inappropriate.
Academic skills have the same meaning within Two things changed this picture. Wing (1988)
the field of autism as without; they refer to skills introduced the notion of an autism spectrum that
in subject areas that form the academic curricu- included children and young people with average
lum, available to all children in that country. or above average intellectual ability and good
Increasingly, children and young people within structural language skills (introducing the term
the autism spectrum are entitled to the skills, “Asperger’s syndrome” to describe such
knowledge, and understanding available to others children). It became clear that many of these
as a matter of human rights, although there may children (albeit often undiagnosed or
be problems in exercising these rights where misdiagnosed) were already in mainstream
there are additional inherent problems (such as schools. Secondly, there grew a worldwide
language or intellectual difficulties) or behavioral movement for the social inclusion of all children
difficulties. There are also common comorbid in education with the same entitlement to
conditions that may occur with autism (such as the culturally valued skills knowledge and under-
specific learning difficulties: dyslexia, dyspraxia) standing available to other children and young
that may cause particular academic difficulties. people in that culture. Inclusion is not about inte-
However, there are no reasons why individuals gration alone, where a child may be “allowed”
with autism should be excluded from any aca- access but depending on special measures to be
demic area as a result of their autism alone. There applied to that child, but to the designing of cur-
may be difficulties in accessing certain subjects ricula and educational systems that take account of
because of the way they are taught or the physical all children, in all their diversity and needs, from
or social context in which they are taught. As with design to implementation. This is an ideal that is
others, success in acquiring academic skills in still a “work in progress” in most countries, but it
autism depends on intellectual level, particular did open the door to the realization that many
talents, and interests, as well as an autism- children on the autism spectrum could and should
friendly teaching approach. benefit from access to the full academic curricu-
lum. The goal was to identify barriers to this
process and to seek ways of overcoming them.
Historical Background The effects of these developments were that
children with autism in many countries began to
Although Kanner (1943) had recognized the biobe included in special needs legislation that rec-
logical base of autism, he was later influenced by ognized their entitlement to a broad and relevant
current psychological theories, which saw autism curriculum, including academic skills. This did
as a form of childhood schizophrenia with treat- not always mean mainstream education since
ment confined to therapy for the child, or the many children had learning and behavioral diffi-
family, depending on the theory of causation culties that made full integration problematic,
adopted. Thus, for two decades following the and staffs in mainstream schools were then
identification of autism, most children with largely unaware of the special needs of those
autism were excluded from academic education with autism, and lacked strategies to meet those
A 20 Academic Skills
needs or help the pupils overcome their many learning for many (Murray & Aspinall, 2006)
barriers to learning. However, special schools and its increasing role in the academic curriculum
often (although not universally) adapted their of many schools has aided participation by those
curricula to include access to academic skills with autism.
that enabled all their pupils to participate in the The end result has been that many more stu-
National Curriculum of their country, albeit often dents with autism are succeeding academically,
adapted to individual needs. At the same time as gaining qualifications at school and entering fur-
more children with autism were learning to be ther and higher education. Although most people
included in the general educational system avail- with autism will continue to need understanding
able to others, a contrary movement developed and some support even in Universities, greater
from a clinical perspective, which claimed that numbers are able to qualify. Sadly, social diffi-
education for those with autism should focus on culties and levels of anxiety remain high and may
the remedial aspects alone, training the child in interfere with future job prospects and quality of
basic adaptive functioning as a precursor to any life. Yet the chance to pursue areas of interest
other form of learning. This was introduced with through academic study does of itself improve
preschool children and made the claim that such life for those with autism. Some do attempt to
programs would be so successful in remediating stay within academia, gaining more and more
core difficulties that no special measures to qualifications. Sometimes this is a positive out-
access the academic curriculum would be come but for some it reflects fear and anxiety
needed. Some children appear to have benefited about moving on from university to the wider
significantly from such intensive behavioral world. Those who do succeed provide role
intervention at an early age, although there is no models for younger students but also help rein-
follow-up showing the later effects on learning force the value of academic skills to people with
academic skills (except of the most basic skills of autism. For those with additional learning diffi-
reading and writing). However, research shows culties high academic achievement may be out of
that not all children benefit equally and that for reach, but academic skills still have relevance in
some children (especially those of higher ability) their education. Daily living skills may have
it is not relevant to their academic learning. The a higher priority but interest and development
emphasis on developmental, as opposed to aca- are fostered by participation in academic tasks
demic, skills however, has influenced some edu- and basic academic skills are needed to live
cational practice, especially in special schools. a life of dignity and some independence.
The growth of autobiographies of those with
autism has also had a profound effect on the
understanding of what might be appropriate cur- Current Knowledge
ricular content for those with autism. Many “suc-
cessful” individuals with autism demonstrate that A study by the Council of Europe a few years ago
success (especially in terms of vocational success (Jordan, 2009) showed that almost all countries
and being able to achieve financial indepen- across Europe “included” children and young
dence) depends on building skills and expertise people with autism within their education sys-
in particular academic subjects at least as much as tems, although the definition of “education” was
overcoming supposed “deficits” in functioning. varied. For some countries, especially where
The influence of special interests in guiding and children with autism had additional learning dif-
developing academic skills has been shown to be ficulties, “education” was very like what other
even more important in autism than with other countries might describe as “clinical” practice.
learners and “interest-led” curricula are being This was true of some countries that had devel-
developed. Information Technology (IT) is not oped treatment services for people with autism
a universal interest of those with autism but it for many decades and where standards of indi-
has been shown to be a valuable medium for vidualized treatment were very high. It is almost
as if successful “treatment” is seen as an alterna- may be strengths but those who are not visual
tive to inclusive education for some of these thinkers (and visual thinking is not universal
children. Even in countries where official policy across the spectrum) this may be a particular dif- A
is for full inclusion for all children with autism ficulty rather than a strength. For the larger group
(including those with additional difficulties) there of visual thinkers, algebra rather than geometry
remain considerable barriers to its full and suc- may be a problem. Algebra represents a problem
cessful implementation (Jordan, 2008), mostly because to understand algebra, one has to under-
related to insufficient understanding of autism in stand reversibility of operations, which, in turn,
mainstream schools. Many developed countries requires explicit working memory ability – often
have made significant efforts to increase under- a problem in autism. A recent development is
standing of autism across the education service a computer program that makes these internal
with online in-service training of staff and the operations visible (the child can see what opera-
growth of accredited programs in autism studies. tion has been performed and so needs to be
Even where inclusive practice is well devel- reversed) but this awaits evaluation with children
oped, there are usually ways of excluding some with autism.
children from some aspects of the academic cur- Even computation skills may be compromised
riculum, where these are not considered relevant by context and time constraints. When a numeracy
to the individual pupil. There will always be some program was introduced as a core part of the
children and young people for whom it is more National Curriculum in the UK, it was expected
advantageous to concentrate on a narrower band that this would pose no particular problems for
of academic subjects than is generally taught as those with autism. But the key skill emphasized
part of the National Curriculum. This might be in this program was mental arithmetic, conducted
because of specific difficulties with subjects that at speed in a class context. This proved disastrous
are not considered vital for that individual’s for many with autism who could neither concen-
development and future quality of life or it may trate fully in such a group context nor be able to
be because dropping some subjects will allow access their answers at speed. It became clear that
concentration on other subjects that are more implicit knowledge of the answer might be there
interesting and/or relevant to the individual. The (and could be accessed given time) but there were
problem is that not all such decisions are evi- problems in making the answer explicit and only
dence based. Ultimately, each decision should responding when directed to (inhibiting responses
be an individual one and there is no good scien- if the teacher did not direct the question specifi-
tific research that can decide which academic cally at them). As a result many children with
subjects will be of benefit to those with autism autism began to fail at a subject they had previ-
and which will not. In fact, it is unlikely that such ously felt confident in, with disastrous effects on
generalized statements will apply across such their morale and general learning ability.
a heterogeneous population. Too often, such One aspect of mathematics, however, has
decisions are made based on assumptions that largely unrealized potential in autism: statistics.
have not been tested. It is well established that people with autism
struggle with uncertainty and that many behav-
Academic Subjects in Relation to Autism ioral issues arise when expected circumstances
Mathematics: It is often assumed that mathemat- change or when people find it hard to give definite
ics will be strength in autism but this is too broad decisions and keep to them. Being told that some-
an assumption. The early stages of mathematics thing “may” happen or that we “will see” if an
(computation and rule-governed stages) are often event unfolds will generally result in much dis-
areas of strength in autism However, later stages tress in individuals with autism and even result in
may produce problems and the aspects that cause challenging behavior. Yet clearly not all of life’s
problems will vary according to learning style. events can be predicted with certainty and people
For visual learners, geometry and graphical work with autism need to be prepared for situations that
change. As long as the individual is intellectually this reason, reversing the typical progression of
able enough to understand, this can be solved by being able to tell a story by arranging pictures in
introducing the notion of probability and statis- sequence before learning to read. It is not the
tics. In reality, saying that an event has a 90% sequencing that is a difficulty but the “making
chance of occurring tomorrow and a 10% chance sense” of the underlying narrative. It has been
of not occurring, may have little basis in fact but suggested, with some research support, that peo-
the numbers seem to make it more acceptable to ple with autism struggle with many aspects of
the person with autism than if one just said it narrative: understanding the basic narrative struc-
might or might not happen. Degrees of certainty ture of events (steady state, event, restoration of
can be refined as the child is taught the variables the state marked by a coda); telling the gist of an
on which the occurrence depends and the degrees event rather than verbatim details; understanding
of confidence in that statement. Using such num- different roles within an event; keeping track of
bers to replace indecisive language not only helps protagonists within a story by appropriate pro-
reduce distress and consequent challenging noun use; understanding emotional responses of
behavior, but also it gives an acceptable language protagonists; understanding agents and inten-
of numbers for describing and predicting the tional acts. Reading in autism often emerges
world. In some cases it can lead to a life-long through reading instructions in computer games
interest in statistics and even an occupation using or on videos. However, this ability to read short
statistics. phrases or to memorize large chunks of text is
On a less positive note, a special ability to very different from the ability to make sense of
calculate at speed may seem like an expression longer connected texts such as fictional stories or
of a high level of mathematical ability, that could novels. This is especially true if, as is often the
be utilized in a work situation or be useful for case, there is associated dyslexia in autism. It is
increasing academic ability. But high-speed cal- paradoxical that individuals with autism may also
culators may have no insight into how answers be hyperlexic, in that they can “read” large
are reached, that is, no ability to reflect or monitor chunks of text but in a rote manner, without
their own learning. This can be a great drawback being able to perceive meaning in the text.
when it comes to examinations, where it is impor- Less commonly, some people with autism are
tant to show working to demonstrate understand- verbal thinkers and have good verbal ability. For
ing: the actual correct answer carrying less these individuals their verbal ability may help
weight than this working out. It can also prevent with their understanding of the world. For exam-
effective vocational uses of this computational ple, linguistic structure can help distinguish
ability. People with autism can sometimes have actual from reported, or imagined, events and
the capacity to add up a shopping list mentally, this has been shown to be a factor in some able
for example, but cannot follow the sequential people with autism learning to develop an under-
process of recording each item of shopping on standing of mental states (Theory of Mind).
a till. The sad fact is that no shopper will trust the Inasmuch as literature does involve some of the
mental calculations of someone who does not key difficulties in autism, teaching literature can
record them on a till, so an apparent strength also be seen as an opportunity to address some of
ends up having little value. these difficulties: understanding motivations,
Literature: Just as mathematics may be intentional actions, and their consequences. In
assumed to be universally strong in autism, so written form, these ideas can be addressed at the
literature may be seen as a universal problem, child’s own pace, rather than trying to be grasped
but that is equally untrue. Written language is in real-life situations which may pass too quickly
often easier than speech for people with autism, and which may be harder to interpret in terms of
because it does not vary so much between people key events and characters. Literature can provide
and situations. Some children with autism come a structure with which to interpret events and
to develop speech through written language for some approaches use written scripts to help the
person with autism understand, prepare for, and typical intuitive empathetic understanding but
carry out social actions. research shows that a cognitive approach
When it comes to writing, there may be supported with many examples in practice can A
dyspraxic or other motor or sensory problems provide the best approach for people with autism
that hinder the development of handwriting to develop some understanding of others; the
skills. It is useful to learn some basic handwriting explicit discussion of motivation and effects of
skills, where possible, and teachers need to take actions in history may provide this.
advice from occupational therapists to look at Science: Science (and engineering) is usually
supports (e.g., in posture, in pencil grips) to considered to be one of the most accessible aca-
make this happen. Since typing or touch screen demic subjects for individuals with autism.
technology means that “writing” (or at least com- People with autism are often, mistakenly thought
municating in a visual form) is more accessible to to have problems with abstract concepts, which
children even with the most severe motor prob- would make the abstract concepts of science dif-
lems, difficulties in handwriting should not be ficult to master. However, it is not “abstract” as
allowed to hinder the expression of ideas. Such a description of a concept that causes problems in
technological solutions have enabled some autism; rather it is the process of abstraction
people with autism to demonstrate their ability through which everyday “fuzzy” concepts are
to think and to express themselves, when it would normally acquired that causes the problems.
otherwise have been assumed they were incapa- People with autism, therefore have problems
ble of doing so. Using writing (or an equivalent with everyday concepts but scientific concepts
form), children can also be taught skills such as do not rely on this process of abstraction; they
making a précis of a text, which helps them are defined explicitly by criterial features and so
understand how to extract meaning from a text fit the learning style of those with autism. It is the
in a very tangible way. specificity and explicitness of science that makes
History: Whether or not history presents it an attractive choice for those with autism.
a problem for people with autism depends on However, there can be some difficulties with the
the nature of the curriculum and how it is taught. scientific process. People with autism find it dif-
If it is presented as a list of facts that can be ficult to tolerate uncertainty so the scientific
memorized, then most people with autism (unless method of hypothesis testing can be a problem
they have severe learning difficulties) will man- for them. Once again, however, the process of
age this without difficulty. However, unless there scientific enquiry can help by specifying the con-
are clear rules, it can be more difficult to try to ditions under which facts are established and by
assess possible causes for certain events or, even being rule governed. Statistics can also help with
more problematically, try to imagine alternative this understanding and the acceptance of
outcomes. The most difficulties for those with uncertainty.
autism, however, are caused by history teaching Foreign Languages: There is a common view
that requires the pupils to imagine, for example, in education that, if there is pressure on the cur-
what it might feel like to have been a Roman riculum for those with autism because of the need
soldier on Hadrian’s Wall, or a pilgrim arriving to provide education in social and life skills, then
in North America. As with literature, the very fact learning a foreign language can be dropped to
that history may present some difficulties for provide that curricular space. The argument is
pupils with autism can also be seen as an oppor- often made that the person with autism has strug-
tunity for teaching. It can be a chance to make gled to master his/her first language so it would
explicit some of the things that might affect how be a waste of time to attempt to teach them
someone might feel. This allows pupils with a second language. There may well be individual
autism to learn more about emotions and to cases where this is the correct decision, and cer-
develop a cognitive frame for developing empa- tainly curriculum subjects need to be prioritized.
thy (or at least, sympathy). This does not lead to But such decisions should always be on an
individual basis – not on an assumption that all people with autism as well as being a useful tool
pupils with autism will struggle with a foreign for accessing other parts of the academic curric-
language. Some may indeed have struggled to ulum. Computers can provide a patient, control-
acquire their first language and may still have lable and, above all, nonsocial environment for
problems with receptive language and with the learning and thus provide access to a large part of
pragmatic uses of language. A foreign language, the academic curriculum. Information technol-
however, is not generally taught in the way that ogy can be a rigorous academic subject in its
a first language is acquired. Everything is made own right also and offer a potential vocational
more explicit, so that the processes and structures opportunity for many individuals with autism.
of the language are much more apparent to the Psychology: A minority of schools offer psy-
pupils with autism than the implicit understand- chology as an academic subject. Although few
ings that characterize first language acquisition. It people with autism will be suited to a career in
may be the first time that students with autism psychology (in spite of the fact that some have
have understood these aspects of language and done so), it can be a valuable subject to study as
not only will this make the foreign language an academic subject. Knowledge of self and
easier to acquire but may also help with the others is typically acquired through natural intu-
understanding of their first language. itive routes but difficulties in such routes of
In addition, learning a foreign language in acquisition are at the heart of autism. People
a mainstream school is often the only opportunity with autism, therefore, have to learn about them-
given to the pupil to be taught everyday social selves and others in an academic way, so the
skills such as greetings, social rules and different opportunity to engage in this systematically
language styles, adjusting language to context through psychology can be very beneficial. Nat-
and useful skills like waiting in restaurants, ural understanding will always be superior (faster
gaining attention, expressing regret, asking direc- and able to happen without effort and alongside
tions, and so on. The fact that these vital social other cognitive tasks), but academic psychologi-
skills are being taught in a foreign language is cal skills may be the best route to increased
a minor problem compared with the general fail- understanding in people with autism. There may
ure in mainstream schools to address these impor- still need to be support in applying these aca-
tant areas of learning at all. Once again, many demic skills to real-life understanding of self
individuals with autism become very interested and others, but it is better than having no way to
in, and skilled at, foreign languages and some are understand.
able to obtain employment through acquiring this
academic skill.
Few schools remain that teach classical subjects Future Directions
such as Ancient Latin and Greek, but such “dead”
languages are also often highly appealing to people Technological aids have enabled more individuals
with autism. These dead languages do not have the with autism gain and demonstrate their potential.
pragmatic learning opportunities of modern for- This is likely to continue. Technology itself is
eign languages but they do offer “pure” academic likely to grow as an academic subject and there
skills. Because these languages are no longer live, will be more vocational opportunities to develop
they do not vary according to deictic factors like and apply such technological academic skills. The
time, place, and person. Thus, they can be learnt as fact that typical children now also use more tech-
a system, almost divorced from social meaning, nologically driven and explicit ways of learning
and one that remains unaltered over time. means that learning styles of students with autism
Information Technology: This relatively new will begin to merge with those of the typical
academic subject is not universally attractive or majority of learners. This should aid the develop-
accessible to all individuals with autism, but it ment of inclusive practices in education. People
has made academic study accessible to many with autism may always remain at a disadvantage
Academic Supports 25 A
when it comes to understanding and operating in Jordan, R. (2009). Education and social integration of
the social world, but they may be at an advantage children and youth with autism spectrum disorders:
Definition, prevalence, rights, needs, provision and
when it comes to understanding and operating in examples of good practice. Strasbourg: Council of A
the technological world. As technology takes over Europe.
many low-level cognitive skills (storing and Kanner, L. (1943). Autistic disturbance of affective con-
manipulating data, for example), there will be tact. Nervous Child, 2, 217–250.
Murray, D., & Aspinall, A. (2006). Getting IT: Using
increased need for the exercise of higher-level information technology to empower people with com-
academic skills – making sense of the data, prob- munication difficulties. London: Jessica Kingsley.
lem-solving, and interrogating data in meaningful Wing, L. (1988). The continuum of autistic characteris-
ways. These are high-level skills but they are tics. In E. Schopler & G. B. Mesibov (Eds.), Diagnosis
& assessment in autism. New York: Plenum Press.
teachable and experience shows that what is
clearly (and explicitly) taught can be learnt by
people with autism, as long as there is not signif-
icant learning or other difficulties.
Already it is seen that some academic skills Academic Supports
(such as handwriting) have lost some value as
other ways of expressing oneself have developed. Kara Hume
There may be other academic skills that become University of North Carolina, Chapel Hill,
redundant, but it is doubtful if humans can flour- NC, USA
ish and grow without the exercise of some aca-
demic skills. It may be that everyone does not
need to learn how to be a historian, say, but Definition
everyone needs to understand about how to find
sources, how to make sense of them, and to Academic supports provide students with addi-
understand notions of trust and reliability. There tional help in specific skill areas or subject areas,
will be different ways of teaching such skills, but such as reading, math, or writing. These may
they will be at least as valuable to children with include a small group tutoring session, a test-
autism as they will be to all. taking skill program, or other adjustments to the
length and difficulty of an assignment, all
intended to assist students to reach proficiency
See Also in an academic area. Though the term academic
supports is not used specifically in special educa-
▶ Academic Supports tion law, it is similar to the term “specially
▶ Computer-Based Intervention Assistive designed instruction,” which is defined in IDEA
Technology (Individuals with Disabilities Education Act of
▶ Education 2004) as:
▶ Homework/Assignments, Modifying Adapting, as appropriate to the needs of an eligible
▶ Inclusion child. . .the content, methodology, or delivery of
▶ Narrative Assessment instruction-
▶ Reading i. To address the unique needs of the child that
▶ School-Aged Children results from the child’s disability; and
ii. To ensure access of the child the general cur-
riculum, so that the child can meet the educa-
tional standards within the jurisdiction of the
public agency that applies to all children.
References and Readings [300.39 (b)(3)]
Jordan, R. (2008). Autism spectrum disorders:

Academic supports can also include accommo-
A challenge and a model for inclusion in education. dations and modifications to a student’s schedul-
British Journal of Special Education, 35(1), 11–15. ing, setting, materials, instruction, and/or student
A 26 Academic Supports
response. Modifications change the content that is with ASD in the academic domain has been slow.
being taught and/or what is expected of the stu- The academic profile of individuals with ASD is
dent, such as providing a text at a different reading complex, and academic skills are often difficult
level or offering shorter assignments. Accommo- for individuals with ASD to fully demonstrate
dations change only how the information is during assessments and classroom instruction.
received or how the student responds, without Historically, most individuals with ASD, as
altering the content difficulty or student expecta- many as 75 %, were thought to also have a diag-
tions. Accommodations may include providing nosis of mental retardation (Ghaziuddin, 2000).
audiotaped books, allowing answers to be given Due to better instrumentation and understanding
orally, and using a computer to complete written of the learning profiles of individuals with ASD,
work. Finally, supplementary aids are an addi- more recent research indicates that approxi-
tional source of academic support available for mately 16–30 % of the population with ASD
students with disabilities, as described in IDEA. has a comorbid condition of mental retardation
These include assistive technology, such as word (now termed “intellectual disability” in the
processors or communication systems; adapted United States) (de Bildt, Systema, Kraijer, &
materials, including audio books or highlighted Minderaa, 2004).
notes; and peer tutors. Accurately identifying intellectual disabilities
in individuals with ASD has been challenging, as
has accurately indentifying their academic
Historical Background strengths and needs. Individuals with ASD often
present an uneven profile of skills, as they may be
Prior to 1975, most individuals with autism spec- reading at a very young age (i.e., hyperlexia) but
trum disorders (ASD) in the United States were may not be able to describe what they have read
denied academic instruction in the public schools. or respond verbally to comprehension questions.
These individuals were either not educated or Similarly, individuals with ASD may have other
were served in private institutions that focused splinter skills (i.e., a talent or ability in a specific
less on academics and more on the reduction of area such as music or calendar knowledge) that
challenging behavior and/or on the development may not translate to other areas such as math or
of life skills (e.g., cooking, cleaning). The passage reading. Without an accurate understanding of an
of the Education for All Handicapped Children individual’s present level of performance in aca-
Act in 1975 (reauthorized as IDEA in 1990 and demic domains, practitioners have had difficulty
including students with autism specifically for the in developing and implementing appropriate aca-
first time) guaranteed for the first time that indi- demic supports for students on the autism
viduals with ASD and other disabilities could spectrum.
access a free and public education (FAPE). This
law also requires that schools and families
develop an Individualized Education Program Current Knowledge
(IEP) which clearly outlines the academic sup-
ports (e.g., accommodations, modifications, and Research in the last decade focused on the cog-
supplementary aids) to be provided to the student nitive profile of individuals with ASD has
with ASD. Finally, the law mandates that students informed the field around important and often
with ASD have access to the least restrictive envi- essential academic supports designed to benefit
ronment (LRE), essentially ensuring that to the students with ASD. Following is a brief summary
maximum extent possible, students with ASD are of the processing style of many on the spectrum
educated in the general education setting with as well as the state of academic supports currently
their nondisabled peers. in use by individuals with ASD. Lastly, a brief
Though the law has now been in place for over description of a number of currently used aca-
30 years, progress in the education of individuals demic supports will be described.
The Cognitive Profile of Many Individuals The State of the Use of Academic Supports
with ASD Little is known about what types of academic
Auditory and Visual Processing: Research indi- supports are actually in use by students with A
cates that individuals with ASD may process ASD, as few researchers have investigated this
auditory or linguistic information at a slower issue. One source of data, however, has provided
rate than their typically developing peers (Cashin the field with a snapshot of the accommodations
& Barker, 2009). This auditory processing lag and modifications used by secondary students
can cause great difficulty during traditional class- with ASD. The National Longitudinal Transition
room instruction. In addition, research indicates Study 2 (NLTS2) provides data on approximately
that processing verbal and visual stimuli simulta- 1,000 students with ASD ages 14–18 enrolled in
neously may also be difficult. Visual processing, secondary education settings. The data indicates
however, appears to be intact and in fact, can be that 91 % of students with ASD receive some
a strength for individuals on the spectrum. type of academic support or modification in
Weak Central Coherence: Individuals with their academic settings (Newman, 2007). The
ASD may have difficulty processing incoming types of supports and the percentage of students
information in context, and instead, the specific with ASD who access those supports are listed in
details of an event or concept are remembered Table 1.
instead of the “big picture.” This piecemeal Additional learning supports are provided to
processing makes understanding abstract concepts 81 % of the sample (Newman, 2007), and those
more difficult, as information is stored in chunks supports are listed below in Table 2.
without being unified by past experiences or Finally, 57 % of the population used some sort
understandings of the world. For example, when of technology aid to support their academic
recalling a story, individuals with autism are more instruction. See Table 3.
likely to remember only specific details of the
story, perhaps names and locations, rather than Description of Commonly Used Academic
the main idea of the story and how it may relate Supports with Students with ASD
to other stories or past experiences (Hill, 2004). As practitioners gain a better understanding of the
Executive Function: “Executive function” is cognitive profile of the individuals with ASD that
a term used to describe brain functions such as they serve, they are more likely to select mean-
planning, working memory, and flexibility. These ingful and successful academic supports. Below
functions are often impaired in individuals with are some of the most commonly used supports
ASD, specifically the ability to plan multistep designed to match the academic content and
sequences of events (e.g., steps required to com- expectations to the strengths and needs of indi-
plete a homework project) and to demonstrate viduals with ASD.
mental flexibility (e.g., shift quickly from one Additional Time: Providing extra time for stu-
idea or plan to another). dents with ASD to complete assignments or tests
Attention and Inhibition: Individuals with is a common academic support and is recommend
ASD may have difficulty orienting, sustaining, for students who have auditory processing lags as
and shifting attention to relevant targets (e.g., described above, as well as for students who may
the teacher or appropriate topic during instruc- have anxiety, a common co-occurring condition.
tion) (Patten & Watson, 2011). Students with The time constraints posed by testing protocols
ASD may focus on details that are not relevant, may prompt higher levels of anxiety, thus reduc-
such as a pattern of light created by the blinds or ing academic success.
the color of the teacher’s shirt, and miss the most Visual Supports: Visuals are a common aca-
meaningful information or content presented. In demic support used by individuals with ASD.
addition, individuals with ASD may have diffi- Visual supports include any concrete cue that
culty in managing their impulsive behavior supports verbal explanations and directions pro-
(Mesibov, Shea, & Schopler, 2005). vided by teachers. These include diagrams,
A 28 Academic Supports
Academic Supports, Table 1 Accommodations and Academic Supports, Table 3 Technology aids pro-
modifications provided to students with autism vided to students with autism
Additional time to complete assignments 52 % A calculator for activities not allowed other 28 %
More time in taking tests 52 % students
Alternative tests or assessments 49 % Computer software designed for students with 23 %
Slower-paced instruction 41 % disabilities
Shorter or different assignments 38 % A computer for activities not allowed other students 16 %
Modified tests 33 % Communication aids 16 %
Modified grading standards 30 % Computer hardware adapted for special needs 8%
Tests read to student 25 % Books on tape 8%
Modifications to physical aspects of the classroom 16 %
well organized and free of distracters to assist in

Academic Supports, Table 2 Learning supports pro- maintaining the attention of the students with
vided to students with autism ASD. Establishing a color-coded folder or filing
Monitoring of progress by special education 57 % system for the student’s desk or locker may also
teacher assist the student in competing and turning in
A teacher’s aide or instructional assistant 55 % academic assignments.
More frequent feedback 32 % Computer-Assisted Instruction: Using com-
Learning strategies/study skills assistance 22 % puters to present academic materials to students
A peer tutor 14 % with ASD may be beneficial for several reasons,
Self-advocacy training 13 % including the increased predictability, frequent
Tutoring by an adult 9% feedback and reinforcement, and the limited
A reader or interpreter 6%
need for social interaction; another deficit are
for students with ASD. Computer-based teaching
has been proven to promote achievement in math,
pictures, objects to hold, graphic organizers, con- spelling, literacy, and problem-solving.
cept maps, outlines, flowcharts, checklists, and Assistive Technology: Technology can be used
schedules. Descriptions of abstract concepts as an academic support in a number of other ways
should include a hands-on and realistic explana- including an organizational tool (e.g., using
tion and application, including a visual represen- a personal digital assistant to serve as
tation. Students with ASD may benefit from a reminder or provide a to-do list), a teaching
audio recording class lectures and then later tran- tool (e.g., using video to teach a specific aca-
scribing them or using a peer/peer tutor to assist demic behavior or skill), a supplement to instruc-
with note-taking. Highlighting text is also tion (e.g., student listens to a book on tape while
a helpful visual support, as students can then the class reads it aloud), a communication tool
clearly “see” what concepts are important. Class- (e.g., a nonverbal student can indicate the correct
room rules and expectations should also be answer using a communication device), or a basic
presented to students with ASD visually to ensure support (e.g., a calculator).
their understanding. Strategy Instruction: Learning strategy
Organizational Supports: Both the instruction instruction provides step-by-step processes for
and environment should be organized for stu- students to follow in classroom settings and situ-
dents with ASD. Assignments should be broken ations. For example, individuals with ASD may
down into clear smaller steps (i.e., task analysis), be taught specific strategies around test-taking,
and those steps may be written or visually such as how to read instructions, how to respond
represented clearly on a “to-do” list. Feedback appropriately (e.g., filling in “bubbles”), and how
and redirection from teachers should be frequent to reduce anxiety during test-taking. Strategy
to ensure task completion. Classrooms should be instruction can also be used to help students
with ASD take notes during a lecture, complete challenges in developing ideas. Academic
large projects such as a term paper, and write an supports include the use of graphic organizers,
essay. These strategies have been used with stu- planning charts, writing prompts, a word bank, A
dents with learning disabilities with great success and/or a story grammar map.
and have recently been applied to students with Reading: A number of academic supports have
ASD (Songlee, Miller, Tincani, Sileo, & Perkins, been identified to assist in the development of
2008). literacy skills. These include several discussed
Attention and Motivation Supports: Several previously, including graphic organizers, mul-
supports can contribute to an increased ability to timedia programs, strategy instruction, and
attend to and successfully complete academic highly structured direct instruction (Chiang
tasks. A self-monitoring procedure teaches indi- & Lin, 2007). In addition, cooperative groups,
viduals with ASD to observe their own attending one-to-one instruction, interactive books,
behavior, compare it with predetermined models peer/class-wide tutoring, and flash cards have
of behavior (i.e., attending to task), and record if proven to be effective academic supports in
their behavior matches the desired example. enhancing literacy skills. Reading comprehen-
Allowing students to choose the sequence in sion can prove especially difficult for students
which activities are completed as well as the on the spectrum, as broad themes, story mean-
stimulus used in activities (e.g., choose what ing, and character motivation may be missed,
color marker to use) is also a proven academic though recall of specific details and facts may
support for students with ASD. Building aca- be intact.
demic activities around the special interest of Math: Computational skills have generally been
a student with ASD can be helpful to increase a strength for students with ASD; however,
motivation, as can allowing access to highly pre- difficulty often arises in applying these skills
ferred materials after the completion of academic to real tasks or problem-solving (Aspy &
work. Finally, pairing nonpreferred academic Grossman, 2007). Academic supports to assist
tasks with preferred academic tasks has been in skill development in this area include the
shown to increase task completion as well. use of practical examples with pictures or dia-
Academic Subject-Specific Supports: The aca- grams to clarify concepts, the use of visual and
demic supports described above can be applied tactile cues such as TouchMath, use of graph
across academic subjects. Below are supports paper during computation activities to help
designed specifically for the following subject students organize their problems, increased
areas: time to complete math tasks, use of calculators
Writing: Writing is often difficult for individuals and computer programs, and peer tutoring.
on the spectrum, likely due to visual-motor
and coordination challenges. These may be
reduced or alleviated through the use of sev- Future Directions
eral supplementary aids such as word proces-
sors, voice recognition software, special Additional research is needed in the area of aca-
pencils or grips, or slant boards (Heflin & demic supports, including a better understanding
Alaimo, 2007). Teachers may offer reduced of what supports are currently in place for ele-
writing assignments or allow students to pro- mentary-aged students and how effective the sup-
duce outlines rather than lengthier written ports are in increasing student engagement and
assignments. Students may also use a note- academic success. Matching a support with the
taker or scribe to assist in reducing the writing cognitive strengths and needs of individual stu-
load. Beyond the physical difficulties of writ- dents would be most effective, but additional
ing, the production of written text can be dif- study is required to determine how to accurately
ficult for students with ASD for other reasons, assess the academic skills of students with ASD.
including organizational difficulties and This is important work, though challenging, as
A 30 Academic Testing
our understanding of the cognitive profile of stu- Cashin, A., & Barker, P. (2009). The triad of impairment
dents with ASD is changing and evolving as more in autism revisited. Journal of Child and Adolescent
Psychiatric Nursing, 22, 189–193.
sophisticated brain research is conducted, includ- Chiang, H., & Lin, Y. (2007). Reading comprehension
ing the use of functional MRIs. Additionally, the instruction for students with autism spectrum disor-
prevalence of students with ASD appears to be ders: A review of the literature. Focus on Autism and
increasing (Kim et al., 2011), which increases the Other Developmental Disorders, 22, 259–267.
de Bildt, S., Systema, D., Kraijer, A., & Minderaa, R. (2004).
likelihood that all teachers, both special and gen- Prevalence of pervasive developmental disorders in chil-
eral education, will be serving students with dren and adolescents with mental retardation. Journal of
ASD, thus implementing a number of academic Child Psychology and Psychiatry, 46, 275–286.
supports. This requires additional staff training, Ghaziuddin, M. (2000). Autism in mental retardation.
Current Opinion in Psychiatry, 13, 481–484.
both for in-service and preservice teachers, as Heflin, J., & Alaimo, D. (2007). Students with autism
staff must appropriately implement supports spectrum disorders. Pearson, NJ: Upper Saddle River.
determined by the IEP team. Finally, the use of Hill, E. (2004). Executive dysfunction in autism. TRENDS
personal and portable technology with individ- in Cognitive Sciences, 8, 26–32.
Kim, Y. S., Leventhal, B., Koh, Y. J., Fombonne, E.,
uals with ASD is on the rise (e.g., iPad, iPod, Laska, E., et al. (2011). Prevalence of autism spectrum
personal digital assistants, communication disorders in a total population sample. AJP in Advance.
devices). It is likely that these devices will serve doi:10.1176/appi.ajp. 2011.10101532.
as academic supports for individuals with ASD, Mesibov, G., Shea, V., & Schopler, E. (2005). The
TEACCH approach to autism spectrum disorders.
as they can provide visual supports (e.g., graphic New York: Plenum Press.
organizers, video clips), organizational supports Newman, L. (April 2007). Facts from NLTS2: Secondary
(e.g., to-do lists), strategy instruction (e.g., pro- school experiences of students with autism. Menlo
vide step-by-step cues or directions), and motiva- Park, CA: SRI International. Available at www.nlts2.
org/fact_sheets/nlts2_fact_sheet_2007_04.pdf.
tional supports (e.g., students with ASD are often Patten, E., & Watson, L. (2011). Interventions targeting
attracted to the use of technology). Further attention in young children with autism. American
research on the efficacy of personal technology Journal of Speech-Language Pathology, 20, 60–69.
as an academic support is warranted. Songlee, D., Miller, S., Tincani, M., Sileo, N., & Perkins,
P. (2008). Effects of a test-taking strategy instruction
on high functioning adolescents with ASD. Focus on
Autism and Other Developmental Disorders, 23,
See Also 217–228.
▶ Academic Skills
▶ Computer-Based Intervention Assistive
Technology Academic Testing
▶ Individuals with Disabilities Education Act ▶ Educational Testing
(IDEA)
▶ Modified Testing
▶ Self-management Interventions
▶ Visual Supports Acallosal Syndrome
▶ Agenesis of Corpus Callosum

Aspy, R., & Grossman, B. (2007). The ziggurat model:

A framework for designing interventions for individ-
uals with high functioning autism and Asperger syn-
ACC
drome. Shawnee Mission, KS: Autism Asperger
Publishing. ▶ Anterior Cingulate
Achenbach System of Empirically Based Assessment 31 A
Description
Accommodations
The Achenbach System of Empirically Based A
▶ Modified Testing Assessment (ASEBA) comprises instruments
▶ Special Needs for assessing behavioral, emotional, social, and
thought problems and adaptive functioning.
Developmentally appropriate instruments are
available for ages from 1½ to over 90 years.
This entry focuses on ages 1½–5 and
Accommodations in Testing 6–18 years, but ASEBA instruments for ages
18–59 are also useful for assessing parents of
▶ Modified Testing children with autism spectrum disorders (ASD)
for both clinical and research purposes. Most
ASEBA instruments can be self-administered
online or on paper and can also be administered
by lay interviewers.
Accuracy of Treatment
Implementation Ages 1½–5 Years
The Child Behavior Checklist for Ages
▶ Treatment Fidelity 1½–5-Language Development Survey (CBCL/
1½–5-LDS; Achenbach & Rescorla, 2000) is
completed by parents and other adults who see
children in home-like contexts. The Caregiver-
Teacher Report Form (C-TRF) is completed by
Achenbach System of Empirically daycare providers, preschool teachers, and other
Based Assessment adults who see children in groups. Completed in
about 10 min, the CBCL/1½–5 and C-TRF each
Thomas Achenbach1 and Leslie Rescorla2 comprise 99 items describing behavioral, emo-
1
Department of Psychiatry, University of tional, and social problems that are rated 0 ¼ not
Vermont, Burlington, VT, USA true (as far as you know), 1 ¼ somewhat or
2
Bryn Mawr College, Bryn Mawr, PA, USA sometimes true, and 2 ¼ very true or often true,
based on the child’s functioning over a 2-month
period. The CBCL/1½–5 and C-TRF differ with
Synonyms respect to 17 items that are tailored either to
family contexts (e.g., CBCL/1½–5 item 28.
CBCL/1½–5; CBCL/6–18; Child behavior Does not want to go out of home) or to group
checklist for ages 1½–5; Child behavior checklist contexts (e.g., C-TRF item 28. Disturbs other
for ages 6–18 children). Both forms also have open-ended
items for rating additional problems described
by the informant, for reporting illnesses and dis-
Abbreviations abilities, for describing the informant’s concerns
about the child, and for describing the best things
BPM Brief problem monitor about the child.
C-TRF Caregiver-Teacher Report Form To assess language development, the CBCL/
LDS Language Development Survey 1½–5 includes the LDS, a 310-word vocabulary
TRF Teacher’s Report Form checklist on which a parent indicates those words
YSR Youth Self-Report that the child says spontaneously, plus additional
A 32 Achenbach System of Empirically Based Assessment
words that the child uses. The LDS also requests Achenbach, 2009). The Semistructured Clinical
informants to report on the child’s multi-word Interview for Children and Adolescents (SCICA)
phrases (if the child is combining words), and includes an interview protocol and instruments
requests information about risk factors for lan- for rating self-reports and behaviors during clin-
guage delays (e.g., short gestation, low birth ical interviews (McConaughy & Achenbach,
weight, ear infections, and family members who 2001). The Test Observation Form (TOF) com-
were late talkers). To enable users to evaluate the prises standardized ratings of functioning during
child’s language development, norms are pro- the administration of individual ability and
vided for the number of vocabulary words spoken achievement tests (McConaughy & Achenbach,
by 18–35-month-olds and the mean length of 2004).
multi-word phrases for 24–35-month-olds. The
norms can also be used to determine whether Scales for Scoring ASEBA Instruments
the speech of language-delayed older children ASEBA problem items are scored on syndrome
corresponds to particular levels within the scales that were derived from statistical analyses
18–35-month range. of ratings of thousands of children in order to
identify actual patterns of co-occurring problems.
Ages 6–18 Years Analyses of associations among the syndrome
Analogous to the instruments for ages 1½–5, the scales have yielded broad scales comprising sub-
instruments for ages 6–18 include the Child sets of the syndromes. The broad scales are des-
Behavior Checklist for Ages 6–18 (CBCL/ ignated as Internalizing (anxiety, depression,
6–18), which is completed by parent figures, social withdrawal, and somatic complaints with-
and the Teacher’s Report Form (TRF), which is out apparent physical cause) and Externalizing
completed by teachers and other school staff (aggressive and rule-breaking behavior). Each
(Achenbach & Rescorla, 2001). The Youth Self- ASEBA instrument is additionally scored on
Report (YSR) is completed by 11–18-year-olds a Total Problems scale computed by summing
to describe their own functioning. The CBCL/ the ratings of all the problem items on the
6–18, TRF, and YSR have 93 problem items in instrument.
common, plus additional problem items tailored ASEBA problem items are also scored on
to each kind of informant. Each item is rated on DSM-oriented scales that consist of items
the same 0-1-2 scale as the CBCL/1½–5 and selected by experts from many cultures as being
C-TRF, but the CBCL/6–18 and YSR specify very consistent with DSM diagnostic categories.
6-month rather than 2-month rating periods. In Additional scales comprise ASEBA problem
addition to the problem items and open-ended items found to be good measures of particular
items for describing illnesses and disabilities, clinical constructs. Table 1 lists the scales scored
what concerns the informant about the child, from the CBCL/1½–5-LDS, C-TRF, CBCL/6–
and the best things about the child, the school- 18, TRF, and YSR, which are the instruments
age instruments assess various kinds of social that assess children’s functioning in everyday
competence and adaptive functioning. Moreover, environments, as reported by lay informants.
the Brief Problem Monitor (BPM) includes par-
ent, teacher, and self-report versions designed to Cross-Informant Comparisons
be completed over periods of days, weeks, or Many studies have reported low to moderate
months to assess responses to interventions levels of agreement between reports of children’s
(RTIs) and other short-term changes in function- problems by mothers, fathers, caregivers,
ing (Achenbach, McConaughy, Ivanova, & teachers, and children themselves. Consequently,
Rescorla, 2011). professionals who work with children recognize
The Direct Observation Form (DOF) assesses that no one informant is apt to provide the same
functioning in group settings, as rated by picture of a child as all other relevant informants.
nonparticipant observers (McConaughy & Professionals also understand that discrepancies
Achenbach System of Empirically Based Assessment, Table 1 Scales scored from rating forms completed by lay
respondents for ages 1½–18 years
Instruments Syndromes DSM-oriented scales Other scales
A
Ages 1½–5
CBCL/1½–5-LDS Emotionally reactive Affective problems Stress problems
C-TRF Anxious/Depressed Anxiety problems Internalizing
Somatic complaints Pervasive developmental problems Externalizing
Withdrawn Attention deficit/Hyperactivity problems Total problems
a a
Sleep problems Oppositional defiant problems Length of phrases
a
Attention problems Vocabulary
Aggressive behavior
Ages 6–18
b
CBCL/6–18 Anxious/Depressed Affective problems Activities
b
TRF Withdrawn/Depressed Anxiety problems Social
b
YSR Somatic complaints Somatic problems School
b
Social problems Attention deficit/Hyperactivity problems Total competence
c
Thought problems Oppositional defiant problems Academic performance
c
Attention problems Conduct problems Adaptive functioning
Rule-breaking behavior Obsessive-compulsive
problems
Aggressive behavior Posttraumatic stress problems
d
Sluggish cognitive tempo
e
Positive qualities
Internalizing
Externalizing
Total problems
Note: CBCL/1½–5-LDS Child Behavior Checklist for ages 1½–5-Language Development Survey, C-TRF Caregiver-
Teacher Report Form, CBCL/6–18 Child Behavior Checklist for ages 6–18, TRF Teacher’s Report Form, YSR Youth
Self-Report (Copyright T.M. Achenbach. Used with permission)
a
Scales that are only on the CBCL/1½–5-LDS
b
Scales that are only on the CBCL/6–18 and YSR
c
Scales that are only on the TRF
d
Scale that is only on the CBCL/6–18 and TRF
e
Scale that is only on the YSR
between different informants do not mean that for the child’s age and gender, the type of infor-
one informant is right while other informants mant (parent, caregiver, teacher, youth), and
are wrong. Instead, each informant may provide user-selected multicultural norms (explained
valuable information based on what they observe, later). Users can thus compare profiles of scale
remember, and consider to be worth reporting. scores to identify similarities and discrepancies
Discrepancies between different informants’ between profile patterns and elevations based on
reports may therefore reflect both differences in the different informants’ ratings. To provide
how a child behaves in the presence of different more rigorous cross-informant comparisons, the
informants and differences in how each infor- software also displays side-by-side listings of the
mant thinks of the child’s functioning. 0-1-2 ratings of each problem item, plus bar
To facilitate use of multiple informants’ graphs of scale scores from up to eight infor-
views, data from ASEBA forms are entered into mants. These displays enable users to quickly
software that produces profiles of scales scored identify similarities and discrepancies between
from each informant’s ratings in relation to norms reports by different informants.
Translations and Multicultural Norms and differences associated with Taiwan and
ASEBA instruments have been translated into Mainland China parent ratings and with US care-
over 85 languages, and reports of their use have giver-teacher ratings.
been published from 80 societies and cultural At this writing, translations are available for
groups (Bérubé & Achenbach, 2012). ASEBA one or more ASEBA instruments in the languages
software provides multicultural norms for com- listed in Table 2. Users can obtain updated infor-
paring a child’s problem scale scores with scores mation about translations and the societies for
for children from the society where the child which normative data are available for each
resides and also from other relevant societies, instrument at www.ASEBA.org.
such as those from which parents have emigrated.
The multicultural norms were constructed from
ASEBA ratings of children living in many socie- Historical Background
ties, as rated by parents, teachers, caregivers, and
11–18-year-old youths (Achenbach & Rescorla, The first ASEBA publication (Achenbach, 1966)
2012). Using the computer-scoring module for reported research that tested whether more syn-
the CBCL/1½–5 and C-TRF or the module for dromes of child psychopathology could be empir-
the CBCL/6–18, TRF, and YSR, users can select ically identified than were implied by the two
norms for societies appropriate for each ASEBA child diagnostic categories of the then-prevailing
instrument completed for a child. American Psychiatric Association’s (1952) Diag-
As an example, if 3-year-old Chiang’s (not his nostic and Statistical Manual (DSM-I). Statisti-
real name) mother came from Taiwan, scales cal analyses of problems reported in child
scored from her CBCL/1½–5 could be displayed psychiatric case records indeed identified many
on profiles and cross-informant bar graphs in rela- syndromes other than the two DSM-I diagnostic
tion to norms appropriate for Taiwan parent rat- categories.
ings. If Chiang’s father came from Mainland Subsequent research produced instruments for
China, scales scored from his CBCL/1½–5 could obtaining assessment data directly from parents,
be displayed in relation to norms appropriate for teachers, and children themselves and provided
Mainland China parent ratings, which are in practical tools for scoring and displaying the data
a different norm group than Taiwan parent ratings. in relation to norms. Thereafter, cross-informant
If Chiang attended a daycare, Head Start, or pre- syndromes having clear counterparts in parent,
school program in the USA, scales scored from teacher, and self-ratings, plus rigorous cross-
C-TRFs could be displayed in relation to US norms. informant comparisons of item and scale scores,
When displayed on cross-informant bar graphs, the were developed to integrate data from multiple
bar for each scale scored from each informant’s informants in the assessment of individual chil-
ratings would be standardized for the type of infor- dren (Achenbach, 1991).
mant (parent versus caregiver-teacher) and for the In order to mesh the ASEBA’s empirically
norms appropriate for that informant. based approach with diagnostically based assess-
Figure 1 illustrates the cross-informant bar ment, DSM-oriented scales were then developed
graph for the DSM-oriented scales scored from (Achenbach & Rescorla, 2000, 2001). The
the CBCL/1½–5 completed by Chiang’s mother DSM-oriented scales for ages 1½–5 include the
in relation to norms for Taiwan, the CBCL/1½–5 Pervasive Developmental Problems scale, which
completed by Chiang’s father in relation to norms comprises items selected by experts from many
for Mainland China, and C-TRFs completed by cultures as being very consistent with the DSM-
two teachers in relation to US norms. The height IV-TR (American Psychiatric Association, 2000)
of each bar shows the magnitude of Chiang’s category of Pervasive Developmental Disorders.
scale score for each DSM-oriented scale, after The DSM-oriented scales will be revised on the
controlling for differences associated with the basis of DSM-5 diagnostic categories, which are
kind of informant (parent vs. caregiver-teacher) expected to include Autistic Spectrum Disorders.
Affective Problems Anxiety Problems Pervasive Developmental Problems
100
90
A
T SCORE
80
70
60
50
70-C 56 61 61 57 54 67-B 67-B 86-C 79-C 89-C 81-C
C151C152 T153 T154 C151C152 T153 T154 C151C152 T153 T154
Attention Deficit/ Hyperactivity Problems Oppositional Defiant Problems

100
90
B = Borderline clinical range;

T SCORE
80
C = Clinical range
70
Broken lines = borderline clinical
range
60
50
51 54 70-C 74-C 50 51 60 58
C151 C152 T153 T154 C151 C152 T153 T154
Achenbach System of Empirically Based Assessment, Fig. 1 Cross-informant comparisons of DSM-oriented scale
scores for Chiang (Copyright T.M. Achenbach & L.A. Rescorla. Used with permission)
The multicultural norms described in the pre- and for differentiating ASD from other
ceding section were derived from data obtained conditions.
with ASEBA instruments by indigenous profes-
sionals working in 47 societies (Achenbach & Preschool Children
Rescorla, 2012). Translations in over 85 lan- Rescorla (1988) was the first to publish on the
guages and norms for many societies enable CBCL’s ability to identify children with ASD.
users to apply and coordinate the same instru- She used the CBCL to rate problems reported
ments for assessing children from many cultural for 3–5-year-old boys who were diagnosed as
groups and societies. “severe atypical,” “mild atypical,” “reactive,” or
ASEBA instruments were developed to assess undiagnosed. Prior to DSM-III (American Psy-
a broad spectrum of problems and adaptive func- chiatric Association, 1980), the term “atypical”
tioning, rather than being targeted specifically on was virtually a synonym for ASD. Rescorla found
autistic disorders. However, the Pervasive Devel- eight syndromes, including an Autistic/Bizarre
opmental Problems scale – comprising 13 CBCL/ syndrome with five items (e.g., Confused/in
1½–5 and C-TRF items selected by international a fog, Strange behavior, Withdrawn). Analysis
experts – and the broadening conception of Autis- of syndrome profiles yielded a pattern character-
tic Spectrum Disorders have led to use of ASEBA izing the boys diagnosed “severe atypical” or
instruments to assess autism. The following sec- “mild atypical,” a second characterizing the
tions summarize relevant evidence. “reactive” boys, and a third characterizing the
undiagnosed boys.
Two decades later, Sikora, Hall, Hartley,
Clinical Uses Gerrard-Morris and Cagle (2008) compared the
ability of the CBCL/1½–5 and the Gilliam
Findings from multiple societies demonstrate the Autism Rating Scale (GARS; Gilliam, 1995) to
ASEBA’s value for assessing children with ASD differentiate among preschool children with
Achenbach System of Empirically Based Assessment, Table 2 Translations of ASEBA formsa

Afaan Oromo (Ethiopia) Georgian Portuguese (Brazil)
Afrikaans German Portuguese (Portugal)
Albanian (Albania, Kosovo) Greek Portuguese Creole
American Sign Language Gujarati (India) Punjabi (India)
Amharic (Ethiopia) Haitian Creole Romanian
Arabic Hebrew Russian
Armenian Hindi Samoan
Auslan (Australian Sign Language) Hungarian Sepedi (Northern Sotho, South Africa)
Bahasa (Indonesia) Icelandic Serbian
Bahasa (Malaysia) Italian Sesotho (Southern Sotho, South Africa)
Bangla (Bangladesh) Japanese Sinhala (Sri Lanka)
Bengali Kannada (India) Slovak
Bosnian Khmer (Cambodia) Slovenian
Braille Kiembu (Kenya) Somali
British Sign Language Kiswahili (Kenya) Spanish (Castilian)
Bulgarian Korean Spanish (Latino)
Catalan (Spain) Laotian Swedish
Chinese Latvian Tagalog (Philippines)
Croatian Lithuanian Tamil (India)
Czech Macedonian Telugu (India)
Danish Malay Thai
Dutch (Netherlands, Flanders) Malayalam (India) Tibetan
Estonian Maltese Turkish
Farsi (Persian, Iran) Marathi (India) Ukrainian
Finnish Nepalese Urdu (India, Pakistan)
French (Belgian) Norwegian Vietnamese
French (Parisian) Papiamentu (Curacao) Visayan (Philippines)
French (Quebecois) Pashto (Afghanistan, Pakistan) Xhosa (South Africa)
Ga (Ghana) Polish Zulu
a
Languages into which at least one ASEBA form has been translated (From Achenbach & Rescorla, 2012)
autism, ASD, or a non-spectrum disorder, as model for preschoolers with ASD. They found
diagnosed with the Autism Diagnostic Observa- that the CBCL measures the same syndromes for
tion Schedule-Generic (ADOS-G; Lord, Rutter, both ASD and normal children. Children with
DiLavore, & Risi, 2002). The CBCL Withdrawn ASD scored higher on all the CBCL/1½–5 syn-
syndrome and the DSM-oriented Pervasive dromes (e.g., Emotionally Reactive, Withdrawn,
Developmental Problems scale provided the Attention Problems, etc.) except Anxious/
best discrimination among the groups. The Depressed.
CBCL achieved higher sensitivity and specificity Muratori et al. (2011) used the Italian CBCL/
in identifying autism and ASD than did the 1½–5 to test differences between preschoolers
GARS. High sensitivity means that the instru- with ASD, preschoolers with other psychiatric
ment correctly identified most children diagnosed disorders (OPD), and preschoolers with typical
as having autism or ASD. High specificity means development (TD). The ASD group had signifi-
that the instrument also correctly identified most cantly higher scores than the OPD group on
children diagnosed as not having autism or ASD. the Withdrawn, Attention Problems, and
Pandolfi, Magyar and Dill (2009) evaluated DSM-Pervasive Developmental Problems (PDP)
the adequacy of the CBCL/1½–5 syndrome scales. The three CBCL scales yielded high
sensitivity (85–92%) and moderate specificity Would rather be alone than with others; 46. Ner-
(60–65%) in distinguishing ASD from both vous movements or twitching; 66. Repeats certain
OPD and TD. acts over and over; compulsions; 79. Speech A
problem; 84. Strange behavior; and 111. With-
School-Age Children drawn, does not get involved with others. This
Bolte, Dickhut and Poustka (1999) tested the scale demonstrated moderate sensitivity
ability of the CBCL to identify autism by com- (68–78%) and higher specificity (73–92%) for
paring German children with autism, children discriminating children with ASD from other
with other disorders, and children not referred children.
for mental health services. Bolte et al. found
that autistic children obtained significantly higher Using the CBCL to Identify ASD in Clinical
scores on Social Problems, Thought Problems, Practice
and Attention Problems than either of the other The Autism Diagnostic Observation Scale-
groups of children. Generic (ADOS-G; Lord et al., 2002) and the
Duarte, Bordin, de Oliveira and Bird (2003) Autism Diagnostic Interview-Revised (ADI-R;
tested the ability of the CBCL to identify ASD Rutter, Le Couteur, & Lord, 2003) are often
using Brazilian children with autism, other disor- used to diagnose ASD. Extensive training is
ders, or no reported abnormalities. Using the required for authorized use of these instruments,
1991 CBCL syndromes plus Rescorla’s (1988) and they are very time-intensive. Less-
Autistic/Bizarre syndrome, Duarte et al. (2003) demanding instruments such as the ASEBA may
found significantly higher Thought Problems and be more practical for identifying children who
Autistic/Bizarre syndrome scores in the ASD may then warrant in-depth assessment.
group than in the other two groups. To screen for ASD, an instrument should be
Biederman et al. (2010) found that the CBCL quick to administer, require little professional
Withdrawn/Depressed, Social Problems, and time, yield results understood by relevant health
Thought Problems syndromes were the best pre- and educational professionals, and identify chil-
dictors for differentiating American children dren likely to be diagnosed as having ASD upon
diagnosed with ASD from children with other in-depth assessment but not at the cost of over-
psychiatric diagnoses. Biederman et al. called identifying many children. An instrument
this triad of elevated syndromes the CBCL-ASD should also be able to identify other kinds of
profile. ASD profile scores accurately identified behavioral and emotional problems, such as
children diagnosed as having ASD. ADHD, aggression, anxiety, and depression,
Finally, Ooi, Rescorla, Ang, Woo and Fung which may occur in children with or without
(2011) tested the ability of the CBCL to discrim- ASD. Furthermore, a screening instrument for
inate between Singaporean school-age children ASD should not be labeled as being for ASD, to
with ASD, children with Attention Deficit Hyper- avoid “halo effects” that may raise ASD scores
activity Disorder (ADHD), referred children who because respondents suspect a child has ASD.
did not receive diagnoses, and children from The CBCL/1½–5, CBCL/6–18, C-TRF, and
a community sample. Like Biederman et al., TRF fit these desiderata. These instruments are
Ooi et al. found that the Withdrawn/Depressed, widely used in school and health settings; they
Social Problems, and Thought Problems scales are quick to administer, score, and interpret;
discriminated well between the ASD group and norms are available for many societies; and
the other groups. Moreover, based on analyses of they can identify many kinds of problems with-
all 118 CBCL problem items, the authors out the halo effects incurred by more narrowly
constructed an ASD scale consisting of nine focused instruments.
items: 1. Acts too young for his/her age; 25. With any assessment instrument, it is impor-
Does not get along with other kids; 29. Fears tant to maximize correct identification and mini-
certain animals, situations, or places; 42. mize erroneous identification. However,
maximizing identification of true cases may incur may lead to ASD diagnoses, even though stricter
overidentification of non-cases. That is, if a cut diagnostic criteria might not yield ASD diagno-
point for a “positive screen” is set low enough to ses. Whether or not children actually receive
miss few “true” cases, it is likely that some “false ASD diagnoses, elevated scores on the CBCL/
alarms” will occur (i.e., non-cases who screen 6–18 Withdrawn/Depressed, Social Problems,
positive). In other words, there is a trade-off and Thought Problems scales and/or on the
between sensitivity and specificity such that max- ASD scale constructed by Ooi et al. (2011) indi-
imizing sensitivity tends to reduce specificity, cate needs for help with social awareness and
and vice versa. Consequently, the costs and ben- skills.
efits of different kinds of errors must be weighed
when screening for ASD. One might argue that
the “cost” of overidentifying some children as
having ASD is more than outweighed by the
“benefit” of not missing any children with ASD. Achenbach, T. M. (1966). The classification of children’s
Furthermore, children who screen positive for psychiatric symptoms: A factor-analytic study. Psy-
ASD and turn out not to receive an ASD diagno- chological Monographs 80(No. 615).
sis may have other conditions that warrant Achenbach, T. M. (1991). Integrative guide for the 1991
CBCL/4-18, YSR, and TRF profiles. Burlington, VT:
intervention. University of Vermont, Department of Psychiatry.
To illustrate how “overidentification” may Achenbach, T. M., McConaughy, S. H., Ivanova, M. Y., &
lead to beneficial interventions, consider a 2½- Rescorla, L. A. (2011). Manual for the ASEBA Brief
year-old whose mother completes the CBCL/1½– Problem Monitor (BPM). Burlington, VT: University
of Vermont, Research Center for Children, Youth, and
5 at her pediatrician’s office. The LDS indicates Families.
lags in the child’s vocabulary and use of phrases. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for
The CBCL Withdrawn and DSM-Pervasive the ASEBA preschool forms & profiles. Burlington,
Developmental Problems scores are in the clini- VT: University of Vermont, Research Center for Chil-
dren, Youth, and Families.
cal range. Problems endorsed by the mother indi- Achenbach, T. M., & Rescorla, L. A. (2001). Manual for
cate that the child is shy and withdrawn, does not the ASEBA school-age forms & profiles. Burlington,
make eye contact, does not respond when spoken VT: University of Vermont, Research Center for Chil-
to, and is somewhat inflexible when faced with dren, Youth, and Families.
Achenbach, T. M., & Rescorla, L. A. (2012). Multicul-
new situations. Although further assessment may tural guide for the ASEBA forms & profiles for ages
not yield an ASD diagnosis, the child’s social- 1½–18 (2nd ed.). Burlington, VT: University of Ver-
emotional problems may nevertheless warrant mont, Research Center for Children, Youth, &
intervention. In addition to therapy for her lan- Families.
American Psychiatric Association. (1952). Diagnostic
guage delay, the child may need help to increase and statistical manual of mental disorders (1st ed.).
social engagement, foster eye contact, promote Washington, DC: Author.
responsivity to language, and improve flexibility American Psychiatric Association. (1980). Diagnostic
in new situations. and statistical manual of mental disorders (3rd ed.).
Washington, DC: Author.
Since the addition of Asperger’s Disorder as American Psychiatric Association. (1994). Diagnostic
a subtype of PDD in the DSM-IV (American and statistical manual of mental disorders (4th ed.).
Psychiatric Association, 1994) and the greatly Washington, DC: Author.
increased prevalence of ASD diagnoses, many American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders (4th ed.
children now diagnosed as having ASD have text rev.). Washington, DC: Author.
better language and intellectual skills than chil- Bérubé, R. L., & Achenbach, T. M. (2012). Bibliography
dren previously diagnosed as having autism. In of published studies using the Achenbach System of
“high-functioning” school-age children, “ASD- Empirically Based Assessment (ASEBA). Burlington,
VT: University of Vermont, Research Center for Chil-
like” characteristics such as intense specialized dren, Youth, and Families.
interests, social awkwardness, “quirkiness,” poor Biederman, J., Petty, C. R., Fried, R., Wozniak, J., Micco,
language pragmatics, and behavioral inflexibility J. A., Henin, A., et al. (2010). Child Behavior
Achievement Testing 39 A
Checklist clinical scales discriminate referred youth
with autism spectrum disorder: A preliminary study. Achievement Testing
Journal of Developmental and Behavioral Pediatrics,
31, 485–490. doi:10.1097/DBP.0b013e3181e56ddd. A
Bolte, S., Dickhut, H., & Poustka, F. (1999). Patterns of Melissa Maye
parent-reported problems indicative in autism. Psy- Clinical Psychology, University of
chopathology, 32, 93–97. Massachusetts, Boston, Boston, MA, USA
Duarte, C. S., Bordin, I. A. S., de Oliveira, A., & Bird, H.
(2003). The CBCL and the identification of children
with autism and related conditions in Brazil: Pilot
findings. Journal of Autism and Developmental Disor- Definition
ders, 33, 703–707.
Gilliam, J. E. (1995). Gilliam autism rating scale. Austin,
TX: PRO-ED. Achievement tests are designed to assess an indi-
Lord, C., Rutter, M., DiLavore, P., & Risi, S. (2002). vidual’s competencies in relation to scholastic
Autism diagnostic observation schedule: Manual. material that she/he has been expected to be
Los Angeles: Western Psychological Services. exposed to in school, home, and community set-
McConaughy, S. H., & Achenbach, T. M. (2001). Manual
for the Semistructured Clinical Interview for Children tings (Stetson, Stetson, & Sattler, 2001).
and Adolescents (2nd ed.). Burlington, VT: University Achievement tests are different from intelligence
of Vermont, Research Center for Children, Youth, and tests. Achievement tests are designed to measure
Families. mastery of a specific subject, or subjects, such as
McConaughy, S. H., & Achenbach, T. M. (2004). Manual
for the Test Observation Form for ages 2–18. Burling- reading ability, number fluency, and scientific
ton, VT: University of Vermont, Research Center for knowledge; whereas, intelligence tests are
Children, Youth, and Families. designed to measure both novel problem-solving
McConaughy, S. H., & Achenbach, T. M. (2009). Manual abilities and stored knowledge (Stedman Medical
for the ASEBA Direct Observation Form. Burlington,
VT: University of Vermont, Research Center for Chil- Dictionary, 2006). Typically, achievement tests
dren, Youth, and Families. are administered in the school setting, as opposed
Muratori, F., Narzisi, A., Tancredi, R., Cosenza, A., to in mental health clinics (Klin, Saulnier,
Calugi, S., Saviozzi, I., et al. (2011). The CBCL 1.5- Tsatsanis, & Volkmar, 2005).
5 and the identification of preschoolers with autism in
Italy. Epidemiology and Psychiatric Sciences, 20,
329–338. doi:10.1017/S204579601100045X.
Ooi, Y. P., Rescorla, L., Ang, R. P., Woo, B., & Fung, Historical Background
D. S. S. (2011). Identification of autism spectrum
disorders using the Child Behavior Checklist in Singa-
pore. Journal of Autism and Developmental Disorders, Achievement testing has been respected as an
41, 1147–1156. doi:10.1007/s10803-010-1015-x. accurate tool of academic attainment since 1914
Pandolfi, V., Magyar, C. I., & Dill, C. A. (2009). Confir- when the Department of Superintendence of the
matory factor analysis of the Child Behavior Checklist National Education Association officially adopted
1.5-5 in a sample of children with autism spectrum
disorders. Journal of Autism and Developmental a favorable view toward educational assessment
Disorders, 39, 986–995. doi:10.1007/s10803-009- (Levine, 1976), another phrase for achievement
0716-5. testing. Achievement testing was not held in high
Rescorla, L. A. (1988). Cluster analytic identification of regard until it was identified as a political tool that
autistic preschoolers. Journal of Autism and Develop-
mental Disorders, 18, 475–492. doi:10.1007/ both sides, both educators and policymakers,
BF02211868. could use to pursue their own interests. However,
Rutter, M., Le Couteur, A., & Lord, C. (2003). ADI-R: The the origins of achievement testing date back to
Autism Diagnostic Interview-Revised. Los Angeles, 1903 when Edward Lee Thorndike and his stu-
CA: Western Psychological Services.
Sikora, D. M., Hall, T. A., Hartley, S. L., Gerrard-Morris, dents developed the Comprehension, Arithmetic,
A. E., & Cagle, S. (2008). Does parent report of behav- Vocabulary, and Direction following test, better
ior differ across ADOS-G classifications: Analysis of known as the CAVD. Thorndike believed that
scores from the CBCL and GARS. Journal of Autism these four domains were four of the most impor-
and Developmental Disorders, 38, 440–448.
doi:10.1007/s10803-007-0407-z. tant dimensions of intellect (Thorndike, 1949).
A 40 Achievement Testing
In addition to developing four distinct subtests to equitable educational experiences for children
assess intellect, Thorndike developed scales for across economic background (Levine, 1976).
the CAVD. While Thorndike was a frontrunner Early achievement test findings were also used
in the development of the achievement test he was to discriminate against other marginalized groups
primarily interested in measurement of achieve- such as racial minorities and immigrants deeming
ment as a utility to establish psychology as them incompetent (Levine, 1976).
a science (Levine, 1976). This pattern of discrimination against lower
Achievement tests have come to be critical in social classes and marginalized groups continued
the measurement of elementary, middle, and high into the late 1970s, and to some extent still affects
school students. These tests are used in all states minorities and individuals of lower socioeco-
to assess both a student’s competency and nomic status today. For example, the effects of
a school’s success. Achievement testing is espe- summer vacation reading recognition regression
cially important for high school students hoping have been found to be significant among lower-
to gain entry into college. Lastly, used clinically, class students, whereas, middle class students
achievement tests are administered on a case-by- saw improvement in this subtest following sum-
case basis to identify strengths and weaknesses mer vacations (Cooper, Nye, Charlton, Lindsay,
for academic planning. & Greathouse, 1996).
The achievement test was revolutionized dur- It has been found that schooling improves
ing the late 1940s and the early 1950s when achievement and that highly effective schooling
Henry Chauncey developed the Census of Abili- raises achievement more. Until recently, achieve-
ties. The Census of Abilities was the first test that ment testing had been thought to reflect intelli-
the Educational Testing Service published, with gence and the belief was that the influence of
Chauncey as the first president. Chauncey’s goal schooling was nonsignificant (Hansen, Heckman,
in creating the first test of achievement was to be & Mullen, 2004). This new knowledge has many
able to assess the strengths of every member of implications for all students, particularly those
society and to utilize these strengths in determin- with some degree of learning difficulty. This
ing each person’s role in society (Lemann, 2000). new research indicates that quality and fit of
While this ideology would certainly be consid- schooling could be significant in a child’s
ered problematic today, the remnants of the Cen- achievement score.
sus of Abilities still exist in the form of the
Scholastic Aptitude Test, better known as the
SAT. The SAT was one of the first standardized Current Knowledge
tests to assess individual competencies in the
subject areas of reading, writing, and math and Two types of achievement tests are generally
significantly changed the procedure in which stu- employed: screening for academic delays/deficits
dents are selected for admission to university. and comprehensive tests to characterize profiles
Psychologists have been aware of differences of academic achievement functioning. Screening
between socioeconomic status and race (which tests are brief and typically contain only one
are often confounded in the US context), since the subtest, or a set of questions, for each subject
beginning of the development of these measures. covered. Comprehensive tests utilize more than
However, when Alfred Binet determined that one subtest for each subject area and generally
significant differences in level of academic func- cover more depth, often in the service of deter-
tioning existed across different social classes, this mining appropriate intervention services. Both
information was used to legitimatize different screening and comprehensive achievement
educational experiences for different social clas- tests routinely assess reading, writing, and
ses, as opposed to calling to the need for more mathematics.
Achievement Testing 41 A
Screening tests are generally short and easier to identification, word identification, word attack,
score. This makes them a useful tool to assess word comprehension, and passage comprehen-
whether or not gaps exist within an individual’s sion. Single-subject tests may be particularly A
educational development and prompt whether or useful in the development of an individualized
not further comprehensive testing may be needed. education plan (IEP) given that they provide
The Wide Range Achievement Test-4 and the detailed information regarding an individual’s
Wechsler Individual Achievement Test-Screener strengths and weaknesses in a particular subject,
are two commonly used screening tests that have thus allowing for a more exact IEP.
one subtest each of reading, math, and spelling. Generally, achievement tests are organized
Comprehensive tests assess at least three with lower-level cognitive tasks first and increase
subject areas typically taught in schools, include the cognitive difficulty as the task progresses.
at least two different subtests from each subject Achievement tests are organized in this way
area, and assess both high and lower levels because the lower the level assessed the less
of cognitive ability within each subject area reliable one can predict performance on higher-
(Stetson et al., 2001). A commonly used level skills. Comprehensive tests have several
comprehensive test is the Wechsler Individual subtests within each subject area and therefore
Achievement Test-Comprehensive. A common allow several distinct levels of cognition to be
achievement test used with individuals with assessed, thus allowing a more accurate predic-
an Autism Spectrum Disorder (ASD) is the tion of achievement. Screener tests, in large part
Woodcock-Johnson III Tests of Achievement. due to only having one subtest per subject, test
The Woodcock-Johnson III contains 23 different lower levels of cognition and therefore do not
achievement scales or subtests. predict achievement as well as comprehensive
In addition to screening and comprehensive tests (Stetson et al., 2001).
achievement tests, there are single-subject versus A note on seasonal norms: achievement tests
multiple-subject achievement tests. Single- that include seasonal norms need to be paid close
subject tests include several subtests designed to attention to. The difference in standard score of
explore an individual’s competency within one just 1 day can be significant in some tests (Stetson
subject area and multiple-subject tests explore et al., 2001). Additionally, it has been found that
several subject areas with one or more subtest over summer vacation, achievement test scores
(e.g., reading, writing, and mathematics). tend to regress. Of the three core subjects
Educators and school psychologists often use assessed (reading, writing, and mathematics), it
multiple-subject tests more often than single- was found that math skills seemed to deteriorate
subject tests because they assess at least three the most (Cooper et al., 1996).
school subjects and provide preliminary analysis When completing achievement testing with an
of an individual’s overall level of academic individual who has an ASD, choosing the right
achievement. In general, it is recommended that achievement test should depend on the specific
multiple-subject tests be used first in order to needs of the individual. For example, some indi-
assess areas of strengths and weaknesses. viduals with an ASD struggle with maintaining
Single-subject tests should then be used to further their attention and should be administered
assess an individual’s competency in a specific a screening test to maximize concentrated perfor-
subject area (Stetson et al., 2001). mance (Koegel, Koegel, & Smith, 1997).
Single-subject tests allow an assessor to gain Whereas, other individuals with an ASD may be
a more in-depth understanding of an individual’s able to focus for long periods of time but may
competency. For example, a single-subject have considerable gaps in knowledge and a more
test, such as the Woodcock Reading Mastery comprehensive test may be the more appropriate
Tests – III, includes subtests such as letter choice (Koegel et al., 1997).
A 42 Achievement Testing
Tests that include visual stimuli and that do ▶ Wide Range Assessment of Memory and
not require long verbal responses may also be Learning (WRAML)
most appropriate for some individuals with ▶ Woodcock-Johnson Cognitive and
ASD. For example, the Peabody Individual Achievement Batteries
Achievement Test – Revised (PIAT-R) touts
a multiple choice format that is designed to be
easy to use with individuals having severe dis- References and Readings
abilities. While the simple administration and
Cooper, H., Nye, B., Charlton, K., Lindsay, J., &
multiple choice responses certainly make the
Greathouse, S. (1996). The effects of summer vacation
PIAT-R a desirable choice for testing individ- on achievement test scores: A narrative and meta-
uals with severe disability, it should be noted analytic review. Review of Educational Research,
that this test was developed with a typical pop- 66(3), 227–268. doi:10.3102/00346543066003227.
Hansen, K. T., Heckman, J. J., & Mullen, K. J. (2004). The
ulation and therefore the norms do not address
effect of schooling and ability on achievement test
the unique needs of individual special needs scores. Journal of Econmetrics, 121(1–2), 39–98.
populations. doi:10.1016/j.jeconom.2003.10.011.
Klin, A., Saulnier, C. D., Tsatsanis, K. D., &
Volkmar, F. R. (2005). Clinical evaluation in autism
spectrum disorders: Psychological assessment within
Future Directions a transdisciplinary framework. In F. R. Volkmar, R.
Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism
While considerable gains have been made in the and pervasive developmental disorders (3rd ed.).
Hoboken, NJ: John Wiley & Sons.
development of achievement tests since they
Koegel, L. K., Koegel, R. L., & Smith, A. (1997). Vari-
were first developed in the early 1900s, it is ables related to differences in standardized test
imperative that research and development of outcomes for children with autism. Journal of Autism
new tests continue to create measures that repre- and Developmental Disorders, 27(3), 233–243.
doi:0162-3257/97J0600-0233$12.50/0.
sent the abilities of all individuals. When consid-
Lemann, N. (2000). The big test. New York: Farrar, Straus
ering the development of new measures, it is and Giroux.
important to take into consideration the needs of Levine, M. (1976). The academic achievement test: Its histor-
the groups that most often use achievement tests, ical context and social functions. American Psychologist,
31(3), 228–238. doi:10.1037/0003-066X.31.3.228.
aside from those used in state and nationwide
Markwardt, F. C. (1997). Peabody individual achievement
testing. Additionally, future editions of achieve- test – Revised/normative update. Bloomington, MN:
ment tests should strive to include norms for Pearson Assessments.
different populations. It would be especially use- Stedman, T. L. (2006). Stedman’s medical dictionary
(28th ed.). Philadelphia: Lippincott Williams & Wilkins.
ful, given the number of individuals affected, if
Stetson, R., Stetson, E. G., & Sattler, J. M. (2001). Assess-
norms for the ASD population were provided. ment of academic achievement. In J. M. Sattler (Ed.),
These norms would provide helpful insight to Assessment of children (4th ed., pp. 576–609).
providers and parents regarding what is typical San Diego, CA: Jerome M. Sattler.
Thorndike, E. L. (1949). Selected writings from
and could be expected of children in this popula-
a connectionist’s psychology. New York: Appleton.
tion over the course of their development. Wechsler, D. (2009). Wechsler individual achievement test
third edition (WIAT III). San Antonio, TX: Pearson.
Wilkinson, G. S., & Robertson, G. J. (2006). Wide range
achievement test 4. Lutz, FL: Psychological Assess-
See Also ment Resources.
Woodcock, R. N. (1997). Woodcock reading mastery
▶ Educational Testing test – Revised/normative update. Circle Pines, MN:
▶ Peabody Individual Achievement Test, American Guidance Service.
Woodcock, R. W., Mather, N., & McGrew, K. S. (2007).
Revised
Woodcock-Johnson III tests of cognitive abilities,
▶ Psychological Assessment normative update (NU) complete. Rolling Meadows,
▶ Wechsler Scales of Intelligence IL: Houghton Mifflin Harcourt, Riverside.
Acquired Autism 43 A
2. Childhood disintegrative disorder –
Acquired Autism Exceptionally rare language/autistic/intellec-
tual but not motor regression of all functions A
Isabelle Rapin between ages 2 and 10 years following
Neurology and Pediatrics (Neurology), entirely normal earlier development. Its
Albert Einstein College of Medicine, Bronx, causes are unknown, its prognosis poor, with-
NY, USA out known medical treatment. It requires thor-
ough neurologic investigation.
3. Rett syndrome – Generalized developmental
Synonyms regression in girls, mostly between 6 and
18 months when they cease progressing,
Autistic regression; Disintegrative disorder; head growth stagnates, irritability, hand ste-
Language/autistic regression; Regressive autism reotypies, and a variety of other systemic and
neurologic symptoms appear. Severity varies,
prognosis is poor. Most are due to mutations of
Definition the MECP2 gene.
4. Malignant epilepsies of early life – Infantile
Autism (autism spectrum disorders – ASD) spasms with a hypsarrhythmic EEG (West syn-
typically denotes a static, behaviorally drome) in infancy and Lennox-Gastaut syn-
defined, developmental disorder of the imma- drome in toddlers with drop and other seizure
ture brain, with identifiable etiologies rare types and slow spike waves in the EEG are the
and biologically treatable causes rarer still. most prevalent harbingers of acquired autism
Acquired autism implies newly acquired/ with cognitive impairment. They and others
progressive brain dysfunction, with multiple, have a variety of genetic and acquired etiologies.
mostly undefined, potential causes, presum- Prognosis is guarded, but some are medically
ably affecting similar brain circuitry as devel- treatable; so prompt diagnosis is key.
opmental ASD. Acquired autism requires 5. Cerebellar surgery – Transitory (usually
prompt neurologic investigation and, in some weeks) postoperative mutism with autistic
cases, brain imaging, electrophysiologic, features following removal of midline cere-
genetic, or other tests to detect potentially bellar tumors, mostly medulloblastomas.
medically treatable causes or progressive 6. Psychoses, drug intoxication – Catatonia may
disease overlap with acquired autism and needs to be
Subtypes of acquired autism (discussed in diagnosed because treatable. Psychotic
more detailed entries in the encyclopedia): depression, mania, and drug intoxication
1. Language/autistic regression – Reported by must be considered in unexplained acquired
20–35% of parents, usually between 15 and social withdrawal and loss of language and
30 months. Its causes are unknown because functional skills. Immunizations are not cred-
language regression/plateau is rarely stud- ible causes of autism.
ied while in process, especially when its 7. Encephalopathies – Rarely, acute or chronic
insidious onset is glossed over. It occasion- infectious, immune, metabolic, or toxic
ally follows a nonspecific illness or emo- encephalopathies that involve limbic circuitry
tional stress. Epilepsy only exceptionally may result in an acquired autistic state.
plays a causative role. Regression rarely Diagnosing the causes of encephalopathies
overlaps acquired epileptic aphasia (Lan- is critical because some are treatable,
dau-Kleffner syndrome) of preschoolers e.g., Hashimoto encephalitis, NMDA receptor
who all have seizures or epileptiform limbic encephalitis, herpes simplex, or other
EEGs, but not autism. infectious encephalitis.
A 44 Acquired Dysgraphia
References and Readings in nonhuman primates such as chimpanzees and

apes (Byrne & Russon, 1998).
Dhossche, D. (1998). Brief report: Catatonia in autistic
disorders. Journal of Autism and Developmental Dis-
orders, 28, 329–331.
Homan, K. J., Mellon, M. W., Houlihan, D., & See Also
Katusic, M. Z. (2011). Brief report: Childhood disin-
tegrative disorder: A brief examination of eight ▶ Action on Objects
case studies. Journal of Autism and Developmental
▶ Imitation
Disorders, 41, 497–504.
Offit, P. A. (2009). Autism’s false prophets: Bad science,
risky medicine, and the search for a cure. New York:
Columbia University Press. References and Readings
Riva, D., & Giorgi, C. (2000). The cerebellum contributes
to higher functions during development: Evidence
Byrne, R., & Russon, A. (1998). Learning by imitation:
from a series of children surgically treated for posterior
A hierarchical approach. Behavioral and Brain Sci-
fossa tumours. Brain, 123(Pt 5), 1051–1061.
ences, 21(5), 667–721.
Tuchman, R., Cuccaro, M., & Alessandri, M. (2010).
Lopes, M., & Santos-Victor, J. (2004). Visual learning by
Autism and epilepsy: Historical perspective. Brain &
imitation with motor representations. IEEE Transac-
Development, 32, 709–718.
tions on Systems, Man and Cybernetics, Part B, Cyber-
netics, Special issue on learning in Computer Vision
and Patter Recognition, 35(3). Retrieved February 13,
2012, from http://ieeexplore.ieee.org/xpls/abs_all.jsp?
arnumber¼1430829
Acquired Dysgraphia Nehaniv, C., & Dautenhahn, K. (1998). Mapping between
dissimilar bodies: Affordances and the algebraic
foundations of imitation. In Proceedings of the
▶ Agraphia Seventh European Workshop on Learning Robots,
Edinburgh, UK.
Action Level Imitation

Action on Objects
Nicole Slade
Department of Psychology, University of Nicole Slade
Massachusetts-Boston, Boston, MA, USA Department of Psychology, University of
Massachusetts-Boston, Boston, MA, USA
Definition
Definition
An individual copies, or mimics (Lopes &
Santos-Victor, 2004), the actions of a model Movement of an object by another object or
(Nehaniv & Dautenhahn, 1998). It is considered person. Action on object imitation trials are
a lower form of imitation because it is not nec- often used when studying imitation in children
essary for the imitator to process the meaning of and other nonhuman primates (Tomasello,
the actions. Action level imitations can range Savage-Rumbaugh, & Kruger 1993). Some
from single actions (e.g., sticking out tongue, research has shown that adult humans use action
tapping on a table, making a bunny hop) to on objects to stimulate and engage infants in play.
a string of actions. The imitation is considered
successful when the behavior or set of behaviors
is repeated exactly as presented by the model See Also
(Nehaniv & Dautenhahn, 1998). This kind of
imitation is seen in human newborns as well as ▶ Action Level Imitation
Activities of Daily Living 45 A
References and Readings and often copied from others or DVD’s/TV.
This type of play can be misinterpreted as imag-
Bard, K., & Vauclair, J. (1984). The communicative
context of object manipulation in Ape and Human
inative play but on careful observation over time A
the quality is not representational or symbolic but
adult-infant Pairs. Journal of Human Evolution,
13(2), 181–190. is a repetitive routine. As adults, this group shows
Tomasello, M., Savage-Rumbaugh, S., & Kruger, A. a lack of social imagination. They are unable to
(1993). Imitative learning of actions on objects by foresee the consequences in social and practical
children, Chimpanzees, and enculturated Chimpan-
terms of their own and other people’s actions and
zees. Child Development, 64(6), 1688–1705.
to act appropriately on that knowledge. They find
it difficult to learn from experience so tend to
make the same mistakes repeatedly.
In his paper, Asperger described some chil-
Active-But-Odd Group dren with this pattern of social interaction (1944).
It must be emphasized that there are no clear
Judith Gould dividing lines between any of these groups. It is
NAS Lorna Wing Centre for Autism, Bromley, possible for one person to change from one type
Kent, United Kingdom of social interaction to another or may even
show different types of social interaction in dif-
ferent environments, with different people, in
Definition different states of health and at different ages.
However, at any one time describing the type of
Active but Odd social interaction is a helpful indicator in under-
Lorna Wing and Judith Gould (1979) put forward standing the needs and supporting the
the concept of a spectrum of autistic conditions. individual.
As part of the spectrum, they described differ-
ent manifestations of social interaction. These
were aloof, passive, active but odd in their inter- See Also
actions. Since their early work, an additional
group has been included referred to as “over ▶ Asperger, Hans
formal and stilted in their approach to others.” ▶ Wing, Lorna
The active-but-odd group are those individ-
uals who make spontaneous approaches to others,
but in a peculiar, naı̈ve, and one-sided way. These References and Readings
individuals are usually more able and they
approach others on their own terms and their Asperger, H. (1944). “Die ‘Autistischen Psychopathen’ im
Kindesalter (Autistic psychopats in childhood)” (in
behavior is not modified according to the needs, German). Archiv f€
ur psychiatrie und
interests, and responses of the person nervenkrankheiten 117: 76–136. http://www.
approached. Often the person seeks to indulge springerlink.com/content/u350x0683r1g6432
their special interest by talking at another person Wing, L., & Gould, J. (1979). Severe impairments of
social interaction and associated abnormalities in chil-
but not for the pleasure of reciprocal social dren: Epidemiology and classification. Journal of
interaction. Autism and Developmental Disorders, 9, 11–29.
Compared with the aloof and passive groups,
this group has much longer vocabularies and use
their language considerably more but their speech
characteristically is repetitive, long winded, often
pedantic with peculiar intonations. Activities of Daily Living
As children, many in this group have pretend
play but this is usually repetitive, stereotyped, ▶ Daily Living Skills
A 46 Activity Schedules
general names, such as embedded instruction,

Activity Schedules routine-based intervention, and integrated ther-
apy. Although there has been a recent focus on
▶ Daily Routines teaching intervention targets in the context of
children’s daily routines in the home, there are
also studies on embedding instruction in commu-
nity settings as well as many studies applying
Activity-Based Instruction ABI in daily classroom activities.
Howard Goldstein
Human Development and Family Science, Rationale or Underlying Theory
The Ohio State University, Columbus, OH, USA
Activity-based intervention sought to improve on
traditional teaching approaches in several ways.
Definition First, this approach was viewed as a way to
increase the amount of instruction provided to
Activity-based intervention (ABI) refers to children with disabilities by involving caregivers
instruction that is embedded within children’s as teachers in contexts that would fit into every-
and families’ daily activities and routines. The day activities and routines. The idea was to cap-
instructional strategies vary according to child italize on the natural instruction that many
goals and needs, but the approach emphasizes caregivers use with their young children and to
child-directed contexts for instruction and the expand upon the quantity and quality of those
use of naturally occurring antecedents and con- teaching opportunities. Second, the focus on
sequences to develop functional skills. using everyday contexts also provided an
approach that would lessen the need to program
generalization from contrived teaching situations
Historical Background into everyday contexts. This approach sought to
take advantage of the child’s interest in stimuli
Diane Bricker and Juliann Woods-Cripe (1992) consistently present in the natural environment
distinguished activity-based intervention from and the naturally occurring reinforcers that
more traditional approaches to early intervention accompany interactions around those everyday
in the early 1990s. Procedurally, ABI is similar to events. Third, by focusing on everyday activities,
intervention practices that came earlier, such as early interventionists, educators, and families
incidental language teaching (Hart & Risley, might more carefully consider what objectives
1968), environmental language intervention would be most functional for children with dis-
(MacDonald, Blott, Gordon, Spiegel, & abilities in present and future environments that
Hartmann, 1974), embedded instruction (Neef, they would naturally encounter in their everyday
Walters, & Egel, 1984), and routine-based inter- lives. Analyzing those natural contexts could pro-
vention (Dunst et al., 1987). ABI emphasizes the vide insight into what typically occurring ante-
role of parents as teachers and how to capitalize cedents might evoke learned skills and what
on the potential advantages of parents teaching natural consequences might maintain or
their children with disabilities during daily activ- strengthen their use.
ities and routines. Likewise, educators can be
encouraged to embed instruction into naturally
occurring, daily classroom activities. Activity- Goals and Objectives
based intervention has provided a foundation for
the development and evaluation of a number of The goal of ABI is to teach functional skills in the
related interventions that go by a number of context of daily activities. The specific objectives
Activity-Based Instruction 47 A
cut across developmental domains, such as com- rather predictable. Thus, caregivers are often
munication, social, cognitive, adaptive or self- taught how to prompt and reinforce targeted
help, and motor skills. responses using a range of facilitative strategies A
that seem appropriate for the child and the care-
giver. For example, some caregivers might be
Treatment Participants taught how to wait and look expectantly to
prompt a response, while others might be taught
ABI has been applied to a variety of populations to prompt the child to ask for help before the child
of individuals with developmental disabilities. gets frustrated. Some caregivers may be encour-
The bulk of literature has come from early inter- aged to model targeted responses, and others may
vention with participants ranging from infants to be encouraged to prompt more elaborated
school age children. Applicability to children responses from their child. Sometimes the focus
with autism is obvious, especially with a focus is limited to getting the caregiver to implement
on social and communication skills, which tend a facilitative strategy in one daily activity, and
to be domains of weakness typically addressed to sometimes the focus is on getting the caregiver to
promote the socialization of individuals with generalize the use of facilitative strategies to
autism in natural environments. multiple activities across the day.
Woods, Kashinath, and Goldstein (2004),
McWilliam (2010a), Dunst (2001), and their col-
Treatment Procedures leagues are among the investigators who have
outlined taxonomies for describing daily activi-
ABI represents a departure from practices that ties. For example, Kashinath and Woods (2007)
were clinician-directed and that took place in highlighted four major categories of family rou-
clinical or contrived settings. ABI embraced the tines: (a) play routines (including constructive
idea of “natural environments” as a concept that play, pretend play, physical play, and social
means more than a location for service delivery. games), (b) caregiving routines (including dis-
It also recognizes that learning should occur in ability-, dressing-, hygiene-, and food-related
intervention contexts that represent families’ typ- activities), preacademic routines (including read-
ical and valued activities, routines, and events. ing, singing, watching electronic media (TV,
Because children learn through participating in computer, video), and writing or drawing), and
their everyday activities and meaningful experi- (d) community and home routines (including
ences, ABI seeks to take advantage of these activ- community errands, home chores, arts, cultural,
ities as intervention settings. By teaching and recreational activities). Such frameworks can
caregivers, parents, and teachers to take advan- help families identify the activities that might
tage of these learning opportunities, intervention provide ample learning opportunities for func-
can be dispersed throughout the day to enhance tional skill development in their child.
learning and generalization for the child. Implementation of ABI has been character-
Although daily routines may be similar across ized as child-centered and family-centered. The
families, they vary in how and when they are child-centered approach emphasizes following
completed. Daily activities that follow consistent, the child’s lead and being responsive to the
predictable sequences, that are repeated fre- child’s interests, desires, and initiations espe-
quently, and that produce meaningful, cially in educational settings. The family-
reinforcing outcomes are especially useful for centered approach to ABI requires a great deal
teaching functional skills. Functional skills of sensitivity on the part of early interventionists
improve the child’s ability to participate more to follow the family’s lead and to form
fully and independently in their natural environ- a productive partnership. It may take some time
ments. During familiar routines, opportunities for to develop a relationship with caregivers that is
communication, social, or other responses can be conducive to open information exchange,
A 48 Activity-Based Instruction
observation and discussion of teaching and learn- teaching strategies within daily routines; their
ing opportunities, joint problem-solving around toddlers with developmental disabilities learned
which routine and facilitative strategies will be communication skills and demonstrated general-
most effective, and thoughtful selection of func- ization across routines to varying extents. This
tional target behaviors that will have work was extended to children with autism
a meaningful effect on the child’s life. The early (Kashinath, Woods, & Goldstein, 2006).
interventionist must be aware of the varied ABI has broad applicability to teaching
values, goals, and circumstances in families’ a variety of skills, using a variety of intervention
lives that must be navigated for ABI to be suc- agents in a variety of natural contexts or activi-
cessfully implemented with sufficient frequency ties. Although evidence indicates that ABI
and accuracy to be effective. approaches can be effective, procedures for
selecting functional goals and teaching them
effectively in everyday activities are increasingly
Efficacy Information being developed. Moreover, as these treatment
approaches are better refined, comparative stud-
Reviews of naturalistic instruction approaches ies will be needed to investigate whether ABI is
highlight the difficulty in summarizing the empir- shown to increase generalization and improve
ical support for ABI and similar interventions functioning in natural environments in compari-
(Hepting & Goldstein, 1996; Milagros-Santos & son to other approaches.
Lignugaris/Kraft, 1997; Rule, Losardo,
Dinnebeil, Kaiser, & Rowland, 1998). That is,
examples of ABI found in the literature differ Outcome Measurement
quite a bit procedurally, even when called the
same thing. Nevertheless, there are numerous Any IEP goals that are amenable to use in natural
studies that have found positive effects from environments could serve as outcome measures.
implementing ABI to teach a variety of behav- ABI promotes the identification of functional
iors, e.g., social skills, picture naming, instruction goals that enhance the ability of the child to
following, and counting (Pretti-Frontczak, Barr, participate in daily activities with more mean-
Macy, & Carter, 2003). The bulk of the studies ingful involvement and independence. Thus, the
summarized by Pretti-Frontczak et al. investi- outcome measures that are targeted and mea-
gated ABI within classroom settings. sured cut across developmental domains (e.g.,
Few of the studies compared ABI to other communication, social, cognitive, adaptive or
approaches, such as direct instruction interven- self-help, and motor skills). Most often, the
tions. The advantage of ABI is not necessarily occurrence of the targeted behaviors is captured
seen during skill acquisition. However, better through observational data collection. Some-
results tend to be seen in the demonstrations of times, the environment is arranged to enhance
the generalized use of those skills (e.g., Losardo the opportunities for the behavior of interest to
& Bricker, 1994). When teaching strategies are be demonstrated.
not embedded in activities frequently, then pro-
gress on children’s targeted objectives tends to be
diminished. Milagros-Santos and Lignugaris/ Qualifications of Treatment Providers
Kraft (1997) provide an analysis of instructional
features that are likely to affect learning of new ABI has been implemented by a variety of indi-
skills. viduals, typically with training provided by an
ABI also has been investigated in parent train- early intervention professional. Parents, care-
ing programs (McWilliam, 2010b; Woods, givers, general and special educators, related ser-
Kashinath, & Goldstein, 2004). For example, vice personnel, and paraprofessionals have been
Woods et al. taught caregivers to implement responsible for implementing ABI.
Acuity 49 A
See Also Neef, N. A., Walters, J., & Egel, A. L. (1984). Establishing
generative yes/no responses in developmentally dis-
abled children. Journal of Applied Behavior Analysis,
▶ Daily Routines 17, 453–460. A
▶ Early Intervention Pretti-Frontczak, K. L., Barr, D. M., Macy, M., & Carter,
▶ Functional Routines (FR), Teaching A. (2003). Research and resources relate to activity-
▶ Home-Based Programs based intervention, embedded learning opportunities,
and routines-based instruction: An annotated bibliog-
▶ Natural Environment raphy. Topics in Early Childhood Special Education,
▶ Naturalistic Interventions 23(1), 29–39.
Pretti-Frontczak, K., & Bricker, D. (2004). An activity-
based approach to early intervention (3rd ed.).
Baltimore: Paul H. Brookes.
Rakap, S., & Parlak-Rakap, A. (2011). Effectiveness of
References and Readings embedded instruction in early childhood special edu-
cation: A literature review. European Early Childhood
Bricker, D., & Woods-Cripe, J. (1992). An activity-based Education Research Journal, 19(1), 79–96.
approach to early intervention. Baltimore: Paul H. Rule, S., Losardo, A., Dinnebeil, L., Kaiser, A., & Row-
Brookes. land, C. (1998). Translating research on naturalistic
Dunst, C. J. (2001). Participation of young children with instruction into practice. Journal of Early Intervention,
disabilities in community learning activities. In M. J. 21, 283–293.
Guralnick (Ed.), Early childhood inclusion: Focus on Schwartz, I. S., Billingsley, F. F., & McBride, B. M.
change (pp. 307–333). Baltimore: Paul H. Brookes. (1998). Including children with Autism in inclusive
Dunst, C. J., Herter, S., Shields, H., & Bennis, L. (2001). preschools: Strategies that work. Young Exceptional
Mapping community-based natural learning opportu- Children, 1(2), 19–26.
nities. Young Exceptional Children, 4(4), 16–24. Woods, J. J., & Kashinath, S. (2007). Expanding opportu-
Dunst, C. J., Lesko, J., Holbert, K., Wilson, L., Sharpe, K., nities for social communication into daily routines.
& Liles, R. (1987). A systemic approach to infant Early Childhood Services, 1(2), 137–154.
intervention. Topics in Early Childhood Special Edu- Woods, J. J., Kashinath, S., & Goldstein, H. (2004).
cation, 7(2), 19–37. Effects of embedding caregiver-implemented teaching
Hart, B. M., & Risley, T. R. (1968). Establishing use of strategies in daily routines on children’s communica-
descriptive adjectives in the spontaneous speech of tion outcomes. Journal of Early Intervention, 26(3),
disadvantaged preschool children. Journal of Applied 175–193.
Behavior Analysis, 1, 109–120.
Hepting, N. H., & Goldstein, H. (1996). What’s natural
about naturalistic language intervention? Journal of
Early Intervention, 20(3), 249–264.
Kashinath, S., Woods, J., & Goldstein, H. (2006). Enhanc-
ing generalized teaching strategy use in daily routines Acuity
by parents of children with autism. Journal of Speech,
Language, and Hearing Research, 49(3), 466–485. Armando Bertone
Losardo, A., & Bricker, D. D. (1994). Activity-based
intervention and direct instruction: A comparison
McGill University, Montreal, Canada
study. American Journal of Mental Retardation, 98,
744–765.
MacDonald, J. D., Blott, J. P., Gordon, K., Spiegel, B., & Definition
Hartmann, M. (1974). An experimental parent-assisted
treatment program for preschool language-delayed
children. The Journal of Speech and Hearing Disor- Given that detailed or locally oriented perception
ders, 39, 395–415. is a central tenet of visual cognition in autism
McWilliam, R. A. (2010a). Routines-based early interven- (Behrmann, Thomas, & Humphreys, 2006;
tion: Supporting young children and their families.
Dakin & Frith, 2005; Mottron, Dawson,
McWilliam, R. A. (Ed.). (2010b). Working with families of Soulieres, Hubert, & Burack, 2006), several stud-
young children with special needs. New York: ies have systematically assessed the spatial reso-
Guilford. lution of vision in autism by measuring visual
Milagros-Santos, R., & Lignugaris-Kraft, B. (1997). Inte-
grating research on effective instruction with instruc-
acuity (VA). VA is generally defined as the abil-
tion in the natural environment for young children with ity to perceive targets such as optotypes, letters,
disabilities. Exceptionality, 7(2), 97–129. or numbers of a specific size at a given distance.
A 50 Acuity
For example, “normal” Snellen VA, often high-spatial frequency information. However, in
referred to as 20/20 vision, is a clinical term that the only published behavioral assessment of con-
reflects a person’s ability to recognize a target trast sensitivity function (CSF) in ASD to date,
(i.e., letter E) from 20 ft away when its defining Koh, Milne, and Dobkins (2010) demonstrated
spatial features (i.e., spacing of lines composing unremarkable visual acuity, peak spatial fre-
an E target) are separated by a visual angle of 1 quency, peak contrast sensitivity, and contrast
arc minute. sensitivity at a low-spatial frequency in a small
Several studies have assessed VA in ASD group of participants with ASD.
using a variety of clinical screening charts. For
the most part, VA has been demonstrated to be
unremarkable in ASD when assessed with either References and Readings
the Crowded LogMAR test (Milne, Griffiths,
Ashwin, E., Ashwin, C., Rhydderch, D., Howells, J., &
Buckley, & Scope, 2009), chart and/or com-
Baron-Cohen, S. (2009). Eagle-eyed visual acuity: An
puter-based Landolt-C optotype paradigms (De experimental investigation of enhanced perception in
Jonge et al., 2007; Keita, Mottron, & Bertone, autism. Biological Psychiatry, 65, 17–21.
2010; Tavassoli, Latham, Bach, Dakin, & Baron- Bach, M., & Dakin, S. C. (2009). Regarding “Eagle-eyed
visual acuity: An experimental investigation of
Cohen, 2011; but see Ashwin, Ashwin,
enhanced perception in autism”. Biological Psychia-
Rhydderch, Howells, & Baron-Cohen, 2009 try, 66, e19–e20. author reply e23–14.
with replies from Bach and Dakin (2009)), or Behrmann, M., Thomas, C., & Humphreys, K. (2006).
Snellen-type visual charts (Falkmer et al., Seeing it differently: Visual processing in autism.
Trends in Cognitive Sciences, 10(6), 258–264.
2011). These demonstrations of unaffected visual
Crewther, D. P., & Sutherland, A. (2009). The more he
acuity in ASD suggest that detailed or locally looked inside, the more piglet wasn’t there: Is autism
oriented visual perception in autism is not of really blessed with visual hyperacuity? Biological Psy-
peripheral or ocular origin. chiatry, 66, e21–e22. author reply e23-24.
Dakin, S., & Frith, U. (2005). Vagaries of visual percep-
A more direct method of assessing the spatial
tion in autism. Neuron, 48(3), 497–507.
resolution of the visual system is to measure de Jonge, M. V., Kemner, C., de Haan, E. H., Coppens,
contrast sensitivity as a function of spatial fre- J. E., van den Berg, T. J., & van Engeland, H. (2007).
quency, thus defining a contrast sensitivity func- Visual information processing in high-functioning
individuals with autism spectrum disorders and their
tion (CSF) that describes the variation of
parents. Neuropsychology, 21, 65–73.
sensitivity over a range of spatial frequencies Falkmer, M., Stuart, G. W., Danielsson, H., Bram, S.,
(defined by cycles per degree or cpd) from Lönebrink, M., & Falkmer, T. (2011). Visual acuity
detailed (or high-spatial frequency) to less- in adults with Asperger’s syndrome: No evidence for
“eagle-eyed” vision. Biological Psychiatry, 70,
detailed (or lower spatial frequency) information.
812–816.
Surprisingly, relatively few direct assessments of Jemel, B., Mimeault, D., Saint-Amour, D., Hosein, A., &
contrast sensitivity are available for ASD. de Mottron, L. (2010). VEP contrast sensitivity responses
Jonge et al. (2007) assessed contrast sensitivity reveal reduced functional segregation of mid and high
filters of visual channels in autism. Journal of Vision,
using the Vistech contrast sensitivity chart, which
10(6), 13.
included spatial frequency gratings of 3, 6, 12, Keita, L., Mottron, L., & Bertone, A. (2010). Far visual
and 18 cpd. Albeit nonsignificant, their ASD acuity is unremarkable in autism: Do we need to focus
group demonstrated increased sensitivity from on crowding? Autism Research, 3, 333–341.
Koh, H. C., Milne, E., & Dobkins, K. (2010). Spatial
the mid- to high-spatial frequencies. This trend
contrast sensitivity in adolescents with autism spec-
was consistent with the electrophysiological find- trum disorders. Journal of Autism and Developmental
ings of Jemel et al. (2010), who demonstrated that Disorders, 40, 978–987.
mid- and high-frequency gratings elicited similar Milne, E., Griffiths, H., Buckley, D., & Scope, A. (2009).
Vision in children and adolescents with autistic spec-
brain responses in their ASD group only
trum disorder: Evidence for reduced convergence.
(responses segregated in control group), Journal of Autism and Developmental Disorders, 39,
suggesting a response bias toward detailed or 965–975.
Adaptive Behavior 51 A
Mottron, L., Dawson, M., Soulieres, I., Hubert, B., & Burack, See Also
J. (2006). Enhanced perceptual functioning in autism: An
update, and eight principles of autistic perception. Journal
of Autism and Developmental Disorders, 36(1), 27–43. ▶ Age Appropriate A
Tavassoli, T., Latham, K., Bach, M., Dakin, S. C., & ▶ Age Equivalents
Baron-Cohen, S. (2011). Psychophysical measures of ▶ Daily Living Skills
visual acuity in autism spectrum conditions. Vision ▶ Developmental Delay
Research, 51, 1778–1780.
▶ Developmental Milestones
▶ Functional Life Skills
▶ Self-help Skills
Adaptive Behavior
Arlette Cassidy References and Readings

Psychologist, The Gengras Center, University of
Saint Joseph, West Hartford, CT, USA American Association on Mental Retardation. (2002).
Mental retardation: Definition, classification, and
systems of support (10th ed.). Washington, DC:
Author.
Synonyms Anderson, S. R., Jablonski, A. L., Thomeer, M. L., &
Knapp, V. M. (2007). Self-help skills for people with
Functional life skills autism. Bethesda, MD: Woodbine House.
Carter, A. S., Gillham, J. E., Sparrow, S. S., & Volkmar,
F. R. (1996). Adaptive behavior in autism. Mental
Retardation, 5, 945–960.
Definition Chawarska, K., & Volkmar, F. R. (2005). Autism in
infancy and early childhood. In F. R. Volkmar, R.
The American Association on Mental Retardation Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism
and pervasive developmental disorders, volume one:
(AAMR, 2002) defines adaptive behavior as “the Diagnosis, development, neurobiology, and behavior.
collection of conceptual, social, and practical skills Hoboken, NJ: Wiley.
that have been learned by people in order to function Harrison, P., & Oakland, T. (2003). Adaptive behavior
in everyday lives.” Adaptive behavior is best under- assessment system (2nd ed.). San Antonio, TX: The
Psychological Corporation.
stood as the degree to which individuals are able to National Research Council. (2001). Educating children
function and maintain themselves independently with autism. Committee on Educational Interven-
and meet cultural expectations for personal and tions for Children with Autism. (C. Lord &
social responsibility at various ages. As such, adap- J.P. McGee, Eds.) Division of Behavioral and Social
Sciences and Education. Washington DC: National
tive behavior involves the person’s physical skills, Academy Press.
cognitive ability, affect, motivation, culture, socio- Openden, D., Whalen, C., Cernich, S., & Vaupel, M.
economic status, family, and environment. Persons (2009). Generalization and autism spectrum disorders.
with autism spectrum disorders often demonstrate In C. Whalen (Ed.), Real life, real progress for
children with autism spectrum disorders (pp. 1–18).
a discrepancy between intellectual potential and Baltimore: Brookes.
consistently displayed adaptive skills. Assessing Sattler, J. M., & Hoge, R. D. (2006). Assessment of chil-
adaptive behavior can include standardized adap- dren: Behavioral, social, and clinical foundations. San
tive behavior scales, observation, interview, or Diego, CA: Jerome M. Sattler.
Shea, V., & Mesibov, G. B. (2005). Adolescents and
review of anecdotal records. Some commonly adults with autism. In F. R. Volkmar, R. Paul, A.
used ratings include the Vineland Adaptive Behav- Klin, & D. Cohen (Eds.), Handbook of autism and
ior Scales, Second Edition; Scales of Independent pervasive developmental disorders, volume one: Diag-
Behavior – Revised (SIB-R); Adaptive Behavior nosis, development, neurobiology, and behavior.
Hoboken, NJ: Wiley.
Assessment System – Second Edition (ABAS-II); Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005).
and the Battelle Developmental Inventory, Second Vineland adaptive behavior scales (2nd ed.). Circle
Edition (BDI-2). Pines, MN: American Guidance Service.
A 52 Adaptive Behavior Assessment System, Second Edition
organized according to the specifications of

Adaptive Behavior Assessment the Diagnostic and Statistical Manual of Mental
System, Second Edition Disorders (▶ DSM-IV), which is published by the
American Psychiatric Association and provides
Sarah A. O. Gray and Alice S. Carter standard criteria for the classification of mental
Department of Psychology, University of disorders. These ten skill areas are Communica-
Massachusetts, Boston, Boston, MA, USA tion (e.g., “speaks clearly), Community Use (e.g.,
“finds the restroom in public places”), Functional
Academics (e.g., “tells time correctly, using
Synonyms a watch or a clock with hands”), Health and Safety
(e.g., “carries scissors safely”), Home or School
ABAS-II; ABAS, Second Edition Living (e.g., “sweeps the floor”), Leisure (e.g.,
“invites others home for fun activity”), Self-Care
(e.g., “washes hands with soap”), Self-Direction
Description (e.g., “controls temper when disagreeing with
friends”), Social (e.g., “says ‘please’ when asking
The Adaptive Behavior Assessment System is for something”), Work (e.g., “performs tasks at
a reliable, valid, and norms-based questionnaire work neatly”). The Work skills area is optional.
assessment of adaptive behavior, or the personal Communication, Functional Academics, and Self-
and social skills necessary for everyday indepen- Direction areas are a part of the Conceptual
dent living. Because children and adults with domain; Social and Leisure skill areas are a part
autism spectrum disorders often struggle with of the Social domain; and Self-Care, Home or
practical independent functioning and effective School Living, Community Use, Health and
interactions with others, the assessment of adap- Safety, and Work are a part of the Practical
tive behavior is a crucial part of a comprehensive domain. The Motor skills area is not a part of any
assessment of individuals on the spectrum. domain score.
Now in its second edition, the ABAS-II can be The ABAS-II is available in a five forms, all
used for individuals across the life span, with norm which assess the same areas of adaptive function-
referenced scores available for ages 0–89. Like ing. Parents of children aged 5–21 may use
other assessments of adaptive behavior, this assess- a rating form; a new form for parents of children
ment can be used with individuals with autism aged 0–5 was developed for the second edition.
spectrum disorders to determine how an individual There is also a teacher rating form for individuals
is responding to day-to-day demands compared to aged 5–21, as well as a teacher/day care form for
others his/her age, to develop treatment and training children aged 2–5 (also new to the second edi-
goals, to determine eligibility for services and tion). Finally, there is an adult form for individ-
Social Security benefits, and to assess the capability uals aged 16–89, with which adult individuals
of adults to live independently. The test may also be can report on their own adaptive behavior.
used to assess adaptive behavior in individuals with Forms include between 193 and 241 items, and
other impairments, including intellectual disability, items are rated on a 4-point scale, with 0 ¼ is not
learning difficulties, or ADHD. The test is able, 1 ¼ never when needed, 2 ¼ sometimes
published by the Psychological Corporation, and when needed, and 2 ¼ always or almost always
the authors are Patti Harrison & Thomas Oakland. when needed. An additional category is “check if
The ABAS-II assesses three general areas of you guessed,” which helps examiners determine
adaptive behavior: Conceptual, Social, and how much confidence to place in responses.
Practical. These domains were selected according The questionnaire takes approximately 15–20
to guidelines of the American Association of min to complete and around 5 min to score.
Intellectual Disabilities. These three domain areas Scoring assistance software can aid with the
are divided into ten specific adaptive skill areas, speed and accuracy.
Adaptive Behavior Assessment System, Second Edition 53 A
A limited amount of research with the ABAS-II scores, also with means of 100 and a standard
in individuals with autism confirms patterns of deviation of 15, are yielded. Skill area standard
adaptive behavior deficits similar to those observed scores have a mean of 10 and a standard deviation A
with other assessments of adaptive behavior. of 3. Confidence intervals and descriptive classi-
For example, in a sample of 40 individuals with fications are also provided. Finally, for individ-
high-functioning autism and 30 typically develop- uals up to 22 years, age-based percentile ranks
ing controls, individuals with autism demonstrated and age equivalencies are yielded. The GAC has
lower general adaptive composites, as well as a lowest possible score of 40, and the GAC ceil-
specific deficits in social skills. The general ing for 0–5 is 160, and for adults and children
adaptive composite was negatively associated over 8 it is 120. In addition to scaled scores,
with autism symptomatology (Kenworthy, Case, information about relative strengths and weak-
Harms, Martin, & Wallace, 2010). nesses by skill area as well as base rates in the
standardization sample are provided.
On the school-aged parent and teacher data
Historical Background from the standardization sample, girls scored sig-
nificantly higher than boys on the General Adap-
The Adaptive Behavior Assessment System, Sec- tive Composite, and this gender effect was
ond Edition, is a revision and a downward exten- stronger in teachers; however, gender accounted
sion of an earlier first-edition version of the test for only a small amount of variance (.6% and
by the same authors, the Adaptive Behavior 2.7%). These gender differences are consistent
Assessment System, published just 3 years prior with some other adaptive behavior tests (e.g., the
in 2000. The update was in response to the 2002 Adaptive Behavior Inventory for Children, which
AAMR guidelines that suggested looking within showed similar patterns), though not all measures
conceptual, social, and practical domains of of adaptive behavior (e.g., the Vineland Adaptive
adaptive behavior. The ABAS-II added domain Behavior Scales does not demonstrates sex differ-
scores for these three areas. ences). Effects of race were also observed in the
Whereas the first edition was available only standardization sample, with white children scor-
for school-aged children and adults, the ABAS-II ing higher than Latino children. Again, an ethnic-
has two new Infant/Preschool forms to allow for ity main effect has been observed in some but not
administration to parents of children aged 0–5. all other assessments of adaptive behavior. Given
that adaptive behavior is defined according to the
cultural norms and expectations regarding inde-
Psychometric Data pendent behavior and social functioning, sensitiv-
ity to cultural context is a critical part of the
The ABAS-II provides scores based on age-related sensitive assessment of adaptive behavior.
norms, based on a standardization sample that drew The ABAS-II has shown very strong reliabil-
from the US Census data from 1999 to 2000. ity. Most skill areas have internal consistency
Thirty-one age groups were assessed for each of .90 or higher. In studies examining test-retest
form, with at least 100 participants per group. In reliability over a 2-week period, General
addition to normative samples, the standardization Adaptive Composite correlations were near or
included 20 clinical samples, including a clinical above .90 for all versions of the ABAS-II.
sample for autism. However, these clinical samples The test also demonstrates adequate validity.
were small and not randomly selected, so no Factor analysis supports both the three-factor
autism-specific norms exist for the ABAS-II. model and the GAC factor. The factor model is
A General Adaptive Composite, with a mean similar for boys and girls (Wei, Oakland, Algina
of 100 and a standard deviation of 15, is yielded & MacLean, 2008). Comparisons to other adap-
as an overall measure of an individual’s adaptive tive behavior measures, such as the Vineland,
skills. In the second edition, domain composite show correlations ranging between .70 and .84,
A 54 Adaptive Behavior Assessment System, Second Edition
demonstrating concurrent validity. Clinical specific behavioral interventions can be built

validity studies have also suggested that the around the specific deficits documented in testing.
ABAS-II is highly sensitive when differentiating Assessing adaptive behaviors across a range of
clinical and nonclinical samples. Correlations settings (e.g., home and school) can also provide
with the Wechsler Intelligence Scale for Chil- information about the generalization of skills.
dren-Third Edition, the Wechsler Adult Intelli- Moreover, using a measure like the ABAS-II over
gence Scale-Third Edition, and the Wechsler time can document progress in adaptive skills or
Abbreviated Scale of Intelligence were medium- capture students’ response to intervention, a critical
sized, confirming that intelligence and adaptive component of special education service planning.
functioning are inter-related but distinct con- The ABAS-II can also be used to determine
structs. No predictive validity studies are known. eligibility for services, such as Social Security and
Items were selected from an original pool of special education services under the Individuals
1,500 generated items, from which a third to with Disabilities Education Act. A documented
a half were used in standardization sampling. deficit in adaptive behavior is necessary for
The test has been criticized for requiring a diagnosis of intellectual disability, which often
a high level of reading comprehension for some co-occurs with ASDs. Investigating profiles of
items (seventh grade) and for its relatively low adaptive skill strengths and weaknesses using the
ceiling (120) (Sattler, 2002). ABAS can also be helpful in differential diagnosis,
as children and adults on the spectrum tend to have
particular adaptive skill deficits in social and com-
Clinical Uses munication areas of adaptive skills.
Adaptive skills generate opportunities for indepen-

dence and meaningful social interaction. Given that See Also
core deficits in social and communication skills are
at the heart of a diagnosis of Autism Spectrum ▶ Maladaptive Behavior
Disorder, measurement of the adaptive skills that ▶ Vineland Adaptive Behavior Scales
children and adults are using – and where they may
need remediation – is a key component of assess-
ment and treatment planning for individuals with References and Readings
ASDs. Indeed, some conceptualizations of devel-
opmental disabilities suggest more emphasis be Harrison, P. L., & Oakland, T. (2000). Adaptive behavior
placed on adaptive skills than on IQ, as adaptive assessment system. San Antonio, TX: The Psychological
Corporation.
skills are modifiable and capture real-world imple-
Harrison, P. L., & Oakland, T. (2003). Adaptive behavior
mentation, whereas intellectual ability does not assessment system (2nd ed.). San Antonio, TX: The
necessarily capture the skills an individual is using Psychological Corporation.
in a day-to-day context (Schalock, 1999). Individ- Kenworthy, L., Case, L., Harms, M. B., Martin, A., &
Wallace, G. L. (2010). Adaptive behavior ratings cor-
uals with autism, particularly high-functioning
relate with symptomatology and IQ among individuals
ones, typically have a profile that includes adaptive with high-functioning autism spectrum disorders.
skill levels that are lower than intelligence levels. Journal of Autism and Developmental Disorders,
The ABAS-II provides a categorical and age- 40(4), 416–423.
Oakland, T., & Algina, J. (2011). Adaptive behavior assess-
normed assessment of individuals’ adaptive skills, ment system-II parent/primary caregiver form: Ages 0–
which can be used to guide treatment planning. The 5: Its factor structure and other implications for practice.
ABAS-II can also be used to generate a profile of an Journal of Applied School Psychology, 27(2).
individual’s adaptive skills, so that areas of relative Oakland, T., & Harrison, P. L. (Eds.). (2008). Adaptive
behavior assessment system II: Clinical use and
strength and weakness can be better understood.
interpretation. San Diego, CA: Academic Press.
For example, if an individual is shown to demon- Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2005).
strate deficits in a skill area (e.g., Social), then Evidence-based assessment of autism spectrum
Adaptive Behavior Scales 55 A
disorders in children and adolescents. Journal of Clini- to adapt to the demands of everyday life, that is,
cal Child and Adolescent Psychology, 34(3), 523–540. adaptive behavior, was emphasized as a main
Rust, J., & Wallace, M. (2004). Book review: Adaptive
behavior assesment system – second edition. Journal descriptor of people considered to have mental A
of Psychoeducational Assessment, 22, 367–373. retardation (Bothwick-Duffy, 2007). Adaptive
Sattler, J. M. (2002). Assessment of children: Behavioral behavior scales were developed to identify
and clinical applications. San Diego, CA: Author. behavior deficits needing treatment in people
Schalock, R. L. (Ed.). (1999). Adaptive behavior and
its measurement in the field of mental retardation. who were already known to have a disability.
Washington, DC: American Association on Mental Eventually, assessment of adaptive behavior
Retardation. became used for the purposes of diagnosis and
Wei, Y., Oakland, T., Algina, J., & MacLean, W. E. (2008). eligibility for special services (Bothwick-Duffy,
Multigroup confirmatory factor analysis for the
adaptive behavior assessment system-II parent form, 2007). Although social factors are currently
ages 5–21. American Journal on Mental Retardation, viewed as a central defining characteristic of the
113(3), 178–186. autistic syndrome, earlier research did not sys-
tematically evaluate social dysfunction in autistic
individuals; therefore, the utility of a well-
standardized, normative assessment instrument
Adaptive Behavior Scales for documenting autistic social dysfunction in
terms of daily adaptive functioning became
Marisa O’Boyle clear (Volkmar, Sparrow, Goudreau, & Cicchetti,
Clinical Psychology, University of 1987).
Massachusetts, Boston, Boston, MA, USA Literature describing adaptive deficits in
autism emerged with Sparrow et al. (1984) and
Volkmar et al. (1987) in the 1980s. The assess-
Definition ment of adaptive behavior in individuals with
autism along with standardized measures of intel-
Adaptive behavior scales can provide informa- lectual functioning was developed to determine
tion about children’s communication, socializa- whether or not to assign a diagnosis of mental
tion, and other everyday behavior relative to their retardation or intellectual disability as well as to
age (Demchak & Drinkwater, 1998; Gillham, distinguish between Autism Spectrum Disorders
Carter, Volkmar, & Sparrow, 2000). Adaptive and other intellectual and developmental disabil-
behavior scales are different from intelligence ities (Carter et al., 1998).
tests in that they measure what a child does in Multiple assessments were created to measure
the real world versus what a child is capable of in these adaptive skills. The Behavior Inventory for
a structured testing situation (Volkmar, 2003). Rating Development (BIRD) was designed to
The most widely used adaptive behavior scale assess types and levels of adaptive behaviors.
is the Vineland Adaptive Behavior Scales The BIRD is classified into several subscales of
(Sparrow, Balla, & Cicchetti, 1984; Sparrow, adaptive behavior; Cognitive Development, Self-
Cicchetti, & Balla, 2005); which is a semi- Help, Physical Development, Social Behavior,
structured interview with parents or caregivers and Self-Control (Sparrow & Cicchetti, 1984).
to assess capacities for self-sufficiency in various Other measures of adaptive behavior include the
areas, including communication, daily living, and Comprehensive Test of Adaptive Behavior
social, as well as for young children, motor skills. (Adams, 1984); Scales of Independent Behavior
(Bruinicks, Woodcock, Weatherman, & Hill,
1984); and the Adaptive Behavior Inventory
Historical Background (Brown & Leigh, 1986). The more widely used
measure, the Vineland Adaptive Behavior
Beginning with the first descriptions of mental Scales-Survey Form evaluates children’s per-
retardation in the 1800s, limits to or an inability sonal and social sufficiency in a semi-structured
A 56 Adaptive Behavior Scales
interview with a primary caregiver (Sparrow significant difficulty in motor development is

et al., 1984). This instrument assesses four areas suspected. Additionally, the Vineland also con-
of adaptive behavior: Communication, Daily tains a Maladaptive Behavior Domain, which
Living Skills, Socialization, and Motor Skills assesses the presence of problematic behaviors
(Carter et al., 1998; Sparrow et al., 1984). that interfere with an individual’s functioning.
The Maladaptive Behavior Domain can be
administered to children aged 5 and older and
Current Knowledge includes both behaviors that are common in
early development but are less common as chil-
Adaptive skills include whatever capacities an dren get older and more serious behaviors that are
individual possesses to function within their of concern throughout development (Carter et al.,
everyday environment, encompassing self- 1998; Sparrow et al., 1984). Further explanation
sufficiency as well as social competence of these scales is as follows: the Communication
(Demchak & Drinkwater, 1998; Paul et al., scale includes expressive, which is what an indi-
2004). These skills are particularly important in vidual says, while receptive is what an individual
individuals with autism and related conditions understands, and written is what an individual
because they contribute the most to an individ- reads and writes. The Daily Living scale includes
ual’s ability to function successfully and indepen- personal information such as how an individual
dently in the world (Liss et al., 2001). Adaptive eats, dresses, and practices personal hygiene, as
behavior, or children’s ability to take care of well as domestic information such as what house-
themselves and get along with others, is an hold tasks an individual performs, and finally
extremely important aspect of multidimensional community, such as how an individual uses
assessment and interventions for preschool and time, money, the telephone, and job skills. The
school-aged children as well as for adolescents Socialization scale includes interpersonal infor-
and adults. Adaptive behavior assessment is use- mation such as how an individual interacts with
ful for diagnosing possible disabilities and devel- others, as well as play and leisure, such as how an
opmental problems of preschoolers, which then individual plays and uses leisure time, as well as
can lead to planning effective home, family, and coping, or how an individual shows responsibility
school programs (Harrison & Raineri, 2007). and sensitivity to others (Paul et al., 2004).
Given that adaptive behavior is modifiable, it Volkmar and colleagues evaluated the ability
can lead to planning effective home, family, of the Vineland Adaptive Behavior Scales to diag-
school, community, and vocational planning nose autism by looking at multiple regression
through the life span. equations to predict expected socialization and
As noted, the most widely used measurement communication skills on the basis of age, parent
of adaptive behavior is the Vineland Adaptive education, and sex of the child (Volkmar, Carter,
Behavior Scales, which are broken down into Sparrow, & Cicchetti, 1993). While deficits in
four scales. The Communication scale refers to both communication and socialization are charac-
skills required for receptive, expressive, and writ- teristic of the disorder, individuals with autism
ten language; Daily Living Skills scale includes tend to evidence greater impairment in socializa-
the practical skills needed to take care of oneself tion relative to both communication and daily
and contribute to a household and community; living skills (Carter, Gillham, Sparrow, &
Socialization scale includes skills needed to Volkmar, 1996). Children with autism display sig-
get along with others, regulate emotions and nificantly poorer daily living skills and more seri-
behavior, as well as skills involved in leisure ous maladaptive behaviors than those with other
activities such as play; and finally the Motor developmental disorders (Gillham et al., 2000).
Skills scale, comprising both fine and gross Multiple studies have confirmed that the
motor items, which is typically assessed in indi- Vineland Adaptive Behavior Scales (Sparrow
viduals below the age of 6 years or when et al., 1984), is a well-standardized,
Adaptive Behavior Scales 57 A
semi-structured instrument for assessing adaptive potential comorbid intellectual disability. Addi-
behavior. Gillham et al. (2000) reported that tionally, determining strengths and weaknesses in
autism could be differentiated from both PDD- everyday skills has important implications for A
NOS and nonautistic developmental disorder intervention planning and family support (Perry,
(DD) with the Socialization and Daily Living Flanagan, Geier, & Freeman, 2009) and can
scales of the Vineland Adaptive Behavior Scales inform recommendations for educational and psy-
(Paul et al., 2004; Sparrow et al., 1984). Children chotherapeutic interventions for high- and
with PDD-NOS, when compared with those with low-functioning individuals (Carter et al., 1996).
autism, differ only in very specific areas, primar- Adaptive behavior scales have been applied to
ily the use of expressive language for communi- instructional program planning for disabled pre-
cation – particularly syntax and pragmatics – and school and school-aged children, adolescents, and
the areas of adaptive function on which these adults (Demchak & Drinkwater, 1998). Addition-
skills have a direct effect, such as phone use, ally, the assessment of adaptive behavior can be
manners in conversation, and using language to used as an outcome measure to document the effi-
identify and initiate interaction with others (Paul cacy of intervention programs (Carter et al., 1998).
et al., 2004).
Studies have compared the Vineland Adaptive
Behavior Scales with other Adaptive Behavior Future Directions
measures and found significant between score cor-
relations (Villa et al., 2010). An international While considerable gains have been made in the
study that compared the Scales of Independent development of adaptive behavior scales, contin-
Behavior (SIB) and the revised Vineland Adaptive ued research into their generalizability and cultural
Behavior Scales revealed one similar significant sensitivity is imperative, as with all measures. The
factor, demonstrating personal independence for impact of adaptive behavior scales is widely felt,
both tests. The summary scores of both tests were as they are integral to the diagnosis of intellectual
found to correlate moderately with IQ as well as disability and have become a key component of
with the extent of integration children achieved in assessment and intervention planning for individ-
their subsequent school placement (Roberts, uals with autism spectrum disorders. Therefore, it
McCoy, Reidy, & Crucitti, 1993). is critical that individuals designing intervention
There are state and local differences in the programs set attainable goals across domains of
adoption of specific criteria for deficits in adaptive functioning to lead to increased self-
adaptive behavior. However, the development of efficacy for all involved (Carter et al., 1998). Fur-
instruments that provide national norms such as the ther research could explore the connections
Comprehensive Test of Adaptive Behavior between outcomes of adaptive behavior scales
(Adams, 1984) and Vineland Adaptive Behavior and successful intervention, providing further
Scales (Sparrow et al., 1984) have enabled more guidance for practitioners who design these inter-
normalized and quantifiable guidelines that could vention goals. The importance of intensive inter-
be widely used (Carter et al., 1998). vention in the area of adaptive behavior,
Adaptive behavior scales have multiple impli- particularly for children with autism spectrum dis-
cations for clinical practice, including assessment, orders, remains clear and continued research into
diagnosis, and treatment planning. In contrast to successful interventions is necessary.
intellectual functioning, adaptive behavior is mod-
ifiable (Carter et al., 1998). For all individuals,
however, cognitive functioning will set some con- See Also
straints on the level of adaptive functioning that
can be achieved. The adaptive behavior scales are ▶ Adaptive Behavior Assessment System,
a crucial component of a developmental and diag- Second Edition
nostic assessment for children with autism and ▶ Intellectual Disability
A 58 ADD
▶ Maladaptive Behavior behavior in pre-school children with developmental

▶ Mental Retardation disabilities. Australia & New Zealand Journal of
Developmental Disabilities, 18(4), 261–272.
▶ Vineland Adaptive Behavior Scales Sparrow, S. S., Balla, D., & Cicchetti, D. (1984). Vineland
adaptive behavior scales (expanded form). Circle
Pines, MN: American Guidance Service.
Sparrow, S. S., & Cicchetti, D. V. (1984). The behavior
References and Readings inventory for rating development (BIRD): Assessment
of reliability and factorial validity. Applied Research
Adams, G. L. (1984). Comprehensive test of adaptive in Mental Retardation, 5(2), 219–231.
behavior. San Antonio, TX: Psychological Corporation. Sparrow, S. S., Cicchetti, D., & Balla, D. (2005). A revision of
Bothwick-Duffy, S. (2007). Adaptive behavior. In J. the Vineland adpative behavior scales: Survey/caregiver
Jacobson, J. Mulick, & J. Rojahn (Eds.), Handbook form. Circle Pines, MN: American Guidance Service.
of intellectual and developmental disabilities Villa, S., Micheli, E., Villa, L., Pastore, V., Crippa, A., &
(pp. 279–293). New York: Springer. Molteni, M. (2010). Further empirical data on the
Brown, L., & Leigh, J. E. (1986). Adaptive behavior scale. psychoeducational profile- revised (PEP-R): Reliability
Austin, TX: PRO-ED. and validation with the Vineland adaptive behavior
Bruinicks, R. H., Woodcock, R. W., Weatherman, R. F., & scales. Journal of Autism and Developmental Disorders,
Hill, B. K. (1984). Scales of independent behavior. 40, 334–341.
Allen, TX: DLM Teaching Resources. Volkmar, F. (2003). Adaptive skills. Journal of Autism
Carter, A., Gillham, J., Sparrow, S., & Volkmar, F. (1996). and Developmental Disorders, 33(1).
Adaptive behavior in autism. Child and Adolescent Volkmar, F., Carter, A., Sparrow, S., & Cicchetti, D. (1993).
Pscyhiatric Clinics of North America, 5(4), 945–961. Quantifying social development in autism. Journal of the
Carter, A., Volkmar, F., Sparrow, S., Wang, J., Lord, C., American Academy of Child Psychiatry, 32(3), 627–632.
Dawson, G., Fombonne, E., Loveland, K., Mesibov, G., Volkmar, F., Sparrow, S., Goudreau, D., & Cicchetti, D.
& Schopler, E. (1998). The Vineland adaptive behavior (1987). Social deficits in autism: An operational
scales: Supplementary norms for individuals with autism. approach using the Vineland adaptive behavior scales.
Journal of Autism and Developmental Disorders, 28(4). Journal of the American Academy of Child & Adoles-
Demchak, M., & Drinkwater, S. (1998). Assessing adap- cent Psychiatry, 26(2), 156–161.
tive behavior. In V. Booney (Ed.), Psychological
assessment of children: Best practices for school and
clinical settings (2nd ed., pp. 297–322). Hoboken, NJ:
John Wiley & Sons.
Gillham, J. E., Carter, A. S., Volkmar, F. R., & Sparrow, S. S. ADD
(2000). Toward a developmental operational definition
of autism. Journal of Autism and Developmental ▶ Attention Deficit/Hyperactivity Disorder
Disorders, 30(4).
Harrison, P., & Raineri, G. (2007). Adaptive behavior
assessment for preschool children. In B. A. Bruce &
R. J. Nagle (Eds.), Psychoeducational assessment of
preschool children (4th ed., pp. 195–218). Mahwah, Adderall
NJ: Lawrence Erlbaum Associates.
Liss, M., Harel, B., Fein, D., Allen, D., Dunn, M.,
Feinstein, C., Morris, R., Waterhouse, L., & Rapin, I. ▶ Dexedrine
(2001). Predictors and correlates of adaptive function- ▶ Dextroamphetamine
ing in children with developmental disorders. Journal
of Autism and Developmental Disorders, 31, 219–230.
Paul, R., Miles, S., Cicchetti, D., Sparrow, S., Klin, A.,
Volkmar, F., Coflin, M., & Booker, S. (2004). Adap-
tive behavior in autism and pervasive developmental Adding
disorder- not otherwise specified: Microanalysis of
scores on the Vineland adaptive behavior scales. Jour-
▶ Reinforcement
nal of Autism and Developmental Disorders, 34(2).
Perry, A., Flanagan, H., Geier, J. D., & Freeman, N. L.
(2009). Brief report: The Vineland adaptive behavior
scales in young children with autism spectrum disor-
ders at different cognitive levels. Journal of Autism
Addison-Schilder Disease
Roberts, C., McCoy, M., Reidy, D., & Crucitti, F. (1993).
A comparison of methods of assessing adaptive ▶ Adrenoleukodystrophy
Admission, Review, and Dismissal Committee (ARD Committee) 59 A
IDEA Part B, Assistance for Education of All
ADHD Children with Disabilities, mandates educational
services for children from ages three 3 to 21. The A
▶ Attention Deficit/Hyperactivity Disorder educational requirements of Part B include an
Individualized Education Program (IEP) for each
child and demand the placement of each child in
the least restrictive environment (LRE) possible.
ADI-R An “appropriate” education must address
a child’s specific educational needs. Determining
▶ Autism Diagnostic Interview-Revised what is appropriate entails several steps. The
responsible state actor must conduct an individu-
alized assessment to ascertain a student’s
strengths and weaknesses. Next, an IEP Team,
Adjustment comprising representative of the school district,
a teacher, the child’s parents, and if appropriate,
▶ Reasonable Accommodation the child, must identify appropriate goals and
objectives for the student and construct an IEP
designed to aid the student in meeting the goals
and objectives. Finally, the IEP Team is charged
Admission, Review, and Dismissal with identifying the aids and services necessary
Committee (ARD Committee) for the child to succeed in the IEP.
States have discretion regarding the title
John W. Thomas assigned to the IEP Team. The Texas regulatory
Quinnipiac University School of Law, Hamden, framework denotes an IEP Team “The Admis-
CT, USA sion, Review, and Dismissal Committee.” Like
any IEP Team, and ARD is charged with deter-
mining eligibility for special services (“admis-
Synonyms sion”), conducting periodic reviews of IEPs
(“review”), and determining the appropriateness
ARD committee of any disciplinary actions (“dismissal”).
IDEA prohibits students from being punished
for actions caused by their disabilities. The IEP
Definition Team/ARD must review any proposed disciplinary
actions to determine whether the targeted behavior
The Individuals with Disabilities Education Act was a manifestation of the student’s disability. If
(IDEA) is a federal law that mandates the availabil- the IEP Team/ARD determines that the behavior
ity of a free appropriate public education (FAPE) was not a manifestation of the disability, the school
for all eligible children with disabilities. IDEA may impose the sanctions that it would impose for
defines “disability” as a person “(1) with mental the same behavior committed by a student without
retardation, hearing impairments . . . speech or disability. Those sanctions may include suspension
language impairments, visual impairments . . . seri- or expulsion. Because IDEA mandates a free,
ous emotional disturbance . . . orthopedic impair- appropriate, public education, educational services
ments, autism, traumatic brain injury, other health must be offered during the suspension or expulsion.
impairments, or specific learning disabilities . . .
(2) who needs special education and related ser-
vices because of his or her disability or disabilities” See Also
(IDEA } 802, emphasis supplied). Thus, children
with ASD are eligible for IDEA-related services. ▶ Individual Education Plan
A 60 ADOS
19 Texas Administrative Code }89.1050. The Admission, This rare genetic condition is one of a group of
Review, and Dismissal (ARD) Committee 34 CFR }
disorders termed the leukodystrophies in which
300.523 (2011).
Holland, C. D. (2010). Autism, insurance, and the IDEA: myelin (the sheath surrounding nerve cell
Providing a comprehensive legal framework. Cornell axons) is damaged. The condition is associated
Law Review, 95, 1253–1282. as well with severe damage both to the brain and
IDEA Regulations, } 300.8 Child with a disability (2010).
peripheral nervous system as well as to the
Individuals with Disabilities Education Act, }} 614(d)(1)
(B), 615(k)(4), 20 USC }} 1414 & 1415 (2011). adrenal glands. Associated problems can
include seizures, movement problems, and loss
of function in many areas. Although onset in
infancy and adulthood is possible, the onset is
usually during childhood and there may be
ADOS some confusion early on with other conditions
like childhood disintegrative disorder. An ado-
▶ Autism Diagnostic Observation Schedule lescent onset type is observed, frequently in
males, with more prominent involvement of
the spinal cord.
The onset of the condition can be character-
ized by visual or auditory problems, motor and
ADOS-T
motor coordination issues, seizures, and
increased behavioral difficulties. Characteristic
▶ Autism Diagnostic Observation Schedule
laboratory findings and MRI findings are
(ADOS): Toddler Module
observed. A genetic test is available. The prog-
nosis is poor with death after a period of some
years of illness. Some dietary interventions are
available and new therapeutic approaches are
Adrenaline being investigated.
▶ Epinephrine
See Also
▶ Childhood Disintegrative Disorder

Adrenoleukodystrophy
Fred R. Volkmar References and Readings

Director – Child Study Center, Irving B. Harris
Professor of Child Psychiatry, Pediatrics and Corbett, J., & Harris, R. (1977). Progressive disintegra-
Psychology, School of Medicine, tive psychosis of childhood. Journal of Child Psy-
Yale University, New Haven, chology & Psychiatry & Allied Disciplines, 18(3),
211–219.
CT, USA Darby, J. K. (1976). Neuropathologic aspects of psychosis
in children. Journal of Autism & Childhood Schizo-
phrenia, 6(4), 339–352.
Synonyms Volkmar, F. R., Koenig, K., & State, M. (2005). Child-
hood disintegrative disorder. In F. R. Volkmar, A.
Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of
Addison-Schilder disease; ALD; Siemerling- Autism and pervasive developmental disorders
Creutzfeldt disease (Vol. 1, pp. 70–78). Hoboken, NJ: Wiley.
Adult Follow-Up Studies 61 A
range of independence and “success” in adult
Adult Follow-Up Studies life as defined in developed Western societies
inclusive of gainful employment, a household A
Megan Farley1 and William McMahon2 independent of their parents, and a circle of recip-
1
Psychiatry, University of Utah School of rocal friendships and romantic relationships.
Medicine, University Neuropsychiatric Institute, Those with average-range intellectual abilities
Salt Lake City, UT, USA (i.e., 70) have widely varying adult outcomes.
2
Department of Psychiatry, University of Utah, Several longitudinal studies have demonstrated
Salt Lake City, UT, USA that communicative phrase speech before age 6
and an average-range childhood intelligence quo-
tient (IQ) are necessary for a chance at adult
Definition independence but in no way guarantee it
(Billstedt, Gillberg, & Gillberg, 2005; Farley
Predicting outcome and planning for adult ser- et al., 2009; Howlin, Goode, Hutton, & Rutter,
vice needs for children with Autism Spectrum 2004; Kobayashi, Murata, & Yoshinaga, 1992).
Disorders (ASDs) is limited by gaps in current When assessed in adulthood, barriers to indepen-
knowledge. The best quality information about dence in people with ASD and average-range
autism in adulthood comes from a few popula- intellectual abilities appear to include co-
tion-based longitudinal studies that estimate the occurring psychiatric conditions, difficulty with
full picture of outcomes. However, changes in initiation of goal-oriented activities, and poor
diagnostic criteria in the 1990s from social skills. There may also be specific genetic
a comparatively narrow definition to the broader variations, developmental processes, educational
current criteria for ASD means that studies of opportunities, ecological factors, and specialized
adults originally diagnosed as children with his- adult supports that influence levels of indepen-
torical criteria have limited application to later dence in adulthood.
generations. In addition, longitudinal research
that depends on information from aging care-
givers has inherent challenges. For example, Current Knowledge
recall of symptoms from earlier life may be
compromised by memory problems and health Natural Course
problems of the aging informant. An alternative While ASD is a lifetime diagnosis, several longi-
research design using cross-sectional samples of tudinal studies have shown improvements in autis-
adults diagnosed with current, broader criteria tic symptoms over the life span (Billstedt et al.,
can provide data relevant to the future of children 2005; Cederlund, Hagberg, Billstedt, Gillberg, &
being diagnosed today. Such cross-sectional Gillbergm, 2008; Piven, Harper, Palmer, & Arndt,
studies are useful adjuncts to population-based, 1996; Rumsey, Rapaport, & Sceery, 1985; Seltzer
longitudinal research, as they give a more com- et al., 2003). The trend is toward improvement in
prehensive understanding of ASD in adulthood symptom severity in participants as a group, with
and can bring focus to specific issues. For exam- the greatest amount of behavioral improvement in
ple, the prevalence and variety of behaviors that individuals who had the highest IQs and the least
lead to encounters with law enforcement have severe symptom presentation at the initial evalua-
been described by Allen et al. (2008). tion. These studies also show that a small propor-
Two useful prognostic factors for adult out- tion of affected individuals no longer meet full
come in ASD are childhood intellectual ability diagnostic criteria in adulthood. Importantly,
and onset of communicative speech. Like other most of these individuals retain subtle impair-
people with intellectual disabilities (ID), people ments that continue to present daily challenges to
with ASD and ID generally achieve a limited fully independent functioning.
A 62 Adult Follow-Up Studies
There also appears to be a small subgroup that with ASD. As children, one-third obtained IQ
experiences significant deterioration in cognitive scores in the mildly mentally retarded range and
or behavioral functioning in adolescence 26% achieved scores in the normal or near nor-
(Ballaban-Gil, Rapin, Tuchman, & Shinnar, mal ranges. Eight (35%) had communicative
1996; Eaves & Ho, 2008; Kobayashi et al., speech at age 6. These 23 participants were
1992; Venter, Lord, & Schopler, 1992). Causes aged 16–23 years at the time of the follow-up.
for this deterioration are unknown as yet, but One person (4% of the sample) obtained
appear unrelated to adolescent seizure-onset that a “Good” outcome. Thirty-five percent experi-
occurs in some individuals with ASD. enced the “Fair, but restricted outcome.” (i.e.,
characteristics of “poor” outcome status, but
Mortality accepted by and included in some social commu-
Studies of mortality in autism have identified nity). Thirteen percent had a “Fair” outcome, and
a higher rate of mortality for populations with 44% had “Poor” or “Very Poor” outcomes. Child-
ASD than in the general population, owing hood IQ and use of communicative speech at age
largely to complications related to epilepsy and 6 were useful predictors of outcome status. Epi-
other medical conditions and to accidental deaths leptic seizures were present in one-third of the
that may be associated with ID. Standardized population, often associated with severe mental
mortality ratios (i.e., the ratio of observed deaths retardation and pubertal symptom aggravation.
in a specific sample to expected mortality in the Kobayashi et al. (1992) conducted a follow-up
general population matched on variables such as investigation of 201 adults identified with ASD in
age, gender, and length of follow-up period) childhood through clinical services in Japan. Four
range from 1.9 to 2.4, approximately twice the of the people had died. The mean age for the
expected rate for the general population (Isager, remaining 197 young adults was 21 years, 8 months
Mouridsen, & Rich,1999; Pickett, Paculdo, (SD ¼ 3.6). About one-fourth of the sample had an
Shavelle, & Strauss, 2006; Shavelle, Strauss, & IQ score of 70 or better at age 6, and about 20%
Pickett, 2001). Females have had higher mortal- were able to speak without echolalia at that age. An
ity rates than males in studied populations, prob- additional 31% used communicative language at
ably associated with a higher rate of ID. age 6 but also used echolalic speech. Forty percent
of the sample began school in a general education
Selected Longitudinal Outcome Studies class, but only 27% remained in general education
A number of authors have categorized outcomes at the age of 12. At follow-up, 43 (21%) were
of adults with AD using broad social and educa- employed and 11 (6%) were enrolled in higher
tional or occupational criteria (Howlin et al., education or vocational training programs. Out-
2004). Outcome classifications usually include come adjustment for 47% was “Good” or “Very
five nodes and range from Very Poor (i.e., the Good,” was “Fair” for 32%, and was “Poor” or
person cannot function independently in any “Very Poor” for 46%. Childhood IQ was the only
way) to Very Good (i.e., achieving great indepen- strong predictor of outcome in this investigation.
dence, having friends and a job). Findings from Although there were similarities between the sam-
outcome studies are quite disparate, in spite of ple in this study and others reported, the outcome
considerable similarities between outcome for these participants was strikingly better, overall.
criteria and samples. A consistent finding from The authors provided some possible explanations
published outcome studies is that outcome for including the sociodemographic factors in Japan,
a majority (approximately 60%) of individuals advances in public education standards for people
with ASD was Fair, Poor, or Very Poor (Billstedt with disabilities, intensive intervention histories,
et al., 2005; Eaves & Ho, 2008; Farley et al., and a high proportion of people with ASD and
2009; Howlin et al., 2004). average-range IQ scores at baseline.
Gillberg and Steffenburg (1987) studied out- Howlin et al. (2004) studied adult outcome for
come for a population-based sample of 23 people 68 people with ASD who also had a childhood
nonverbal IQ score of 50 or better. The mean age special education support during their compulsory
at the initial evaluation was 7.24 (SD ¼ 3.10) and schooling years, and 30% engaged in some kind of
at follow-up was 29.33 (SD ¼ 7.97). Nonverbal postsecondary educational program. Overall out- A
IQ scores averaged 80.21 (SD ¼ 19.28). At fol- come adjustment ratings were that 21% had
low-up, the average nonverbal IQ was 75 “Good” or “Very Good” outcomes, 32% had
(SD ¼ 21.52). Almost all of the subjects were “fair” outcomes, and 46% had “poor” outcomes.
known to have attended compulsory schooling; No participants fell within the “Very Poor” out-
however, only 22% left school having achieved come categorization. Sixty percent of the sample
formal qualifications. At the time of the follow- resided at home with their parents, 19% lived in
up investigation, 23 people were employed. Eight group homes, and 13% lived in foster care. Almost
worked in regular, independent jobs; 1 was self- 80% received a government disability pension and
employed as an artist but was unable to earn used the services of social workers. In this sample,
a living wage; and 14 worked in sheltered or childhood verbal IQ was most predictive of out-
supported employment. Twenty-seven people come status. However, the proportion of individ-
were occupied in general work/leisure programs uals who were capable of completing an
at day centers for adults with disabilities. Out- assessment of verbal IQ was not reported.
come adjustment ratings for the sample were that Also in 2008, Cederlund et al. released their
22% had “Good” or “Very Good” outcomes, 19% study of outcome for 70 adults with autism and
had “Fair” outcomes, and 58% had “Poor” or 70 adults with Asperger Disorder, after 5 or more
“Very Poor” outcomes. Analyses of the assess- years elapsed from original diagnosis. This
ment results revealed that childhood IQ was research team used the same outcome categoriza-
a useful predictor of adult adjustment in that tion scheme as Gillberg and Steffenberg (1987),
those with childhood nonverbal IQ scores of 70 with categories of “Good,” “Fair,” “Restricted,”
or more were more likely to do well than those “Poor,” and “Very Poor.” Twenty-seven percent
with scores below 70. Furthermore, a score of 100 (n ¼ 19) of this sample obtained an outcome cat-
or better did not increase the likelihood that egorization of “Good,” and 47% (n ¼ 33) were
a person would do well in adulthood. For those categorized as having a “Fair” outcome. Sixteen
who were capable of completing a childhood ver- people, or 23%, obtained “Restricted” outcome
bal IQ measure, the combination of verbal and status, and two people, or 3%, fell within the
nonverbal IQ scores in childhood provided “Poor” category. There were no participants with
a more precise indication of outcome classifica- “Very poor” outcome ratings.
tion, with scores above 70 in both domains yield- Farley et al. (2009) studied 41 adults who had
ing the greatest likelihood of a “Fair” outcome or been identified through a population-based study of
better. Specifically, among those with childhood ASD in Utah in the 1980s. All of these individuals
nonverbal IQ scores of 70 or more, 7 had a “Very had previous IQ scores of 70 or greater. Mean age at
Good” outcome, 7 had a “Good” outcome, 10 the first assessment was 7.2 years (SD ¼ 4.1) and
obtained a “Fair” outcome, and 20 had “poor” in adulthood was 32.5 years (SD ¼ 5.7). Outcome
or “Very Poor” outcomes. Language level at age adjustment was somewhat better for this sample
5 was useful in predicting overall outcome and than previous samples, with 48% in the “Very
residential status but none of the other outcome Good” and “Good” categories, 34% in the “Fair”
variables studied demonstrated predictive utility. category, and 17% in the “Poor” category. No
Eaves and Ho (2008) followed 48 individuals participants fit within the “Very Poor” category of
with ASDs from childhood (mean age ¼ 6.8) to outcome categorization. Six participants did not
adulthood (mean age ¼ 24) in Canada. Fifty- meet diagnostic criteria for current ASD using
seven percent of this sample had Autistic Disorder, gold standard diagnostic procedures, but five of
while the remainder had less severe variants of these still retained significant social difficulties
ASD. Eight of the participants had a childhood reported by themselves or significant others. Half
IQ score above 70. All participants received were employed on a full- or part-time basis, and
39% had attended some kind of formal presence of significant co-occurring psychiatric
postsecondary education. Over half of the sample and medical diagnoses is the proportion of individ-
(56%) continued to live with their parents, and uals who are prescribed anticonvulsant and psy-
almost 25% lived in supported living arrangements chotropic medications. Eaves and Ho (2008)
including a state residential center for people with reported that 40% of their sample was prescribed
significant disabilities. Almost 60% of the sample medication for behavioral difficulties. Similarly,
reported co-occurring psychiatric diagnoses. 40% of the participants in the population-based
Reported chronic medical conditions were those study by Billstedt et al. (2005) were prescribed
commonly seen in the general population (e.g., medication for psychiatric disorders, and 40% of
seasonal allergies, gout, high blood pressure). the adolescents and adults in another study were
prescribed psychotropic medications to control
Cognitive Function behavior (Ballaban-Gil et al., 1996). Thirty-seven
Evidence to date reflects uneven development of percent of those studied by Farley et al. (2009)
cognitive abilities across people with ASD. Initial were described as taking prescription medications
evaluations during childhood often indicate better aimed at managing behavioral difficulties.
nonverbal than verbal abilities. However, many Epilepsy is a chronic condition involving recur-
studies show evidence increases in verbal ability ring seizures and is more common in individuals
and decreases in nonverbal ability during adoles- with ASD than in the general population, with an
cence and adulthood. Group results for individuals average prevalence rate of 16.8% across epidemi-
with ASD and average-range IQ scores demon- ological studies of ASD (Fombonne, 1999). This
strate consistency in the distribution of subtest disorder occurs more frequently in individuals with
scores on Wechsler scales. However, some indi- ASD and ID. The onset of seizures typically occurs
viduals who have relatively high IQs in childhood early in childhood (i.e., before age 2) or in adoles-
demonstrate significant increases in overall ability cence (Danielsson et al., 2005; Kobayashi et al.,
at follow-up (Gonzales, Murray, Shay, Campbell, 1992). Seizures remit in a fraction of those afflicted
& Small, 1993). Disparities among findings may (Danielsson et al., 2005). Kobayashi et al. (1992)
have several causes. Selection of tests at initial reported that 19% of their sample, representing the
evaluation and follow-up for their appropriateness full range of functioning within ASD, had epilepsy,
to the research question and participants’ behavior and all took antiepileptic medication. Nine percent
may influence results. Furthermore, tests may not of a sample of adults with ASD and average-range
be sufficiently parallel for comparison, so that IQ scores took antiepileptics (Howlin et al., 2004).
some of the variance is attributable to inequality Affective disorders challenge a person’s capac-
across measures. Variation of tests from the initial ity to regulate mood and include depression, mania,
evaluation to follow-up further obscures results and bipolar disorder. It is estimated that over 60%
since within-group variation on measures may be of people with AD suffer from a co-occurring
considerable (Howlin et al., 2004). Age at initial IQ affective disorder. In a study of 35 individuals
also appears to be an important factor, with non- with Asperger syndrome, Ghaziuddin, Weidmer-
verbal abilities varying more among children ini- Mikhail, and Ghaziuddin (1998) found that
tially tested before age 5 (Howlin et al.). affective disorders were the most common type of
psychiatric condition co-occurring in adults, affect-
Associated Co-Occurring Conditions ing over half of their sample. Figures from outcome
Many of the outcome studies concerning adults studies with adult samples range from 1% to 30%
with AD provide information concerning co- (Billstedt et al., 2005; Farley et al., 2009).
occurring medical and psychiatric conditions. Results of several outcome studies demonstrate
Few have analyzed the specific contributions that anxiety disorders are present in a large propor-
these disorders make to restrictions in overall out- tion of adults with AD. Rumsey et al. (1985) deter-
come (Danielsson, Gillberg, Billstedt, Gillberg, & mined that 50% of their sample was suffering from
Olsson, 2005). One of the clearest indicators of the chronic, generalized anxiety, which they suggested
could account for the attention difficulties observed reported in up to 69% of adults with ASD with no
in one-fifth of the sample. Another study of adults overall difference in frequency between males
with ASD and average-range IQ scores concluded and females (Ballaban-Gil et al., 1996, Eaves & A
that 40% of their sample had OCD or chronic Ho, 2008). Maladaptive behaviors may be rela-
anxiety (Szatmari, Bartolucci, Bremmer, Bond, & tively infrequent in adults with ASD and average-
Rich, 1989). Figures from other outcome studies range IQ scores, but odd or severe enough to
are much smaller; however, these results may be preclude acceptance into general social settings
confounded by the presence of ritualistic character- over time (Rumsey et al., 1985). Self-injurious
istics and hyperactivity commonly associated with behaviors were reported to have occurred in 50%
ASD (Ghaziuddin et al., 1998). of the sample studied by Billstedt et al. (2005),
Hyperactivity and short attention span are and have been reported to be more common in
common in people with ASD. These have been females than in males (Ballaban-Gil et al., 1996).
most commonly noted in children, yet some adults Difficulties with toileting and feeding appear to
present with behavioral characteristics of Attention persist in lower functioning individuals, but dif-
Deficit-Hyperactivity Disorder (ADHD) as well ficulties with compulsive rituals may develop
(Ghaziuddin et al., 1998). Forty (33%) of the adults around these tasks in higher functioning adults
in the study by Billstedt and colleagues (2005) as well. Aggression among adults is rarely
presented with hyperactivity. designed to harm others, but property damage or
Psychiatric conditions evident in a small num- harm to self may occur intermittently, sometimes
ber of people with ASD include tic disorders, in response to unimportant changes or problems
psychotic features, and catatonia. Almost 20% in the environment (Rumsey et al., 1985).
of the sample examined by Billstedt et al.
(2005) demonstrated tics and 10% of the adults Social Relationships
studied by Eaves and Ho (2008) had Tourette’s Few adults with ASD develop significant relation-
disorder. One of the 15 adults in another investi- ships outside of the family of origin in spite of
gation presented with Tourette’s disorder common increases in interest in developing social
(Ghaziuddin et al., 1998). A small number of relationships as individuals with AD age (Rumsey
individuals with ASD genuinely have co- et al., 1985). Almost 75% of family members
occurring psychotic conditions. Eight percent of interviewed in the study by Eaves and Ho (2008)
the sample in the study of adults with ASD reported that they enjoyed good to excellent rela-
conducted by Billstedt and colleagues (2005) tionships with their affected relative; however, only
and 38% of those examined by Szatmari et al., one-third of the sample of affected adults had one or
(1989) had characteristics of psychosis. Catatonia more friendships outside of the family. Similar
is another type of psychiatric disturbance that is results have been found in other studies of adults
rarely observed, but notable in ASD. One of the with ASD (Howlin, 2003; Howlin et al., 2004).
15 adults studied by Patricia Howlin et al., Females have reportedly experienced greater suc-
(2000) had a sudden-onset catatonic episode dur- cess with peer relationships than males (Piven et al.,
ing puberty. Billstedt et al., (2005) reported 1996). Ten percent of adults in the study by Eaves
a much higher percentage (12%) in their sample & Ho (2008) had a romantic relationship at some
of 120 adults. time in the past, but none of the participants was
While not psychiatric disorders in their own romantically involved at the time of the investiga-
right, maladaptive behaviors are significant devi- tion. Nineteen percent of the men with Asperger
ations from expected behavior for a person’s Disorder in the Cederlund et al. (2008) study and
developmental level. They are often disruptive 3% of the men with Autistic Disorder were or had
and sometimes dangerous. Maladaptive behav- been in long-term romantic relationships. Thirty-
iors are frequently observed in people with ASD two percent of those studied by Farley et al. (2009)
of all levels of ability and developmental age. In had dated, and 20% were involved in a serious
general terms, maladaptive behaviors have been relationship at the time of the study. In general,
very few adults with ASD have been reported to enforcement officers, but the remainder was
have successful, long-term romantic relationships described as very law-abiding. None of the indi-
(Howlin, 2003; Howlin et al., 2004). viduals in their lower functioning sample with
autistic disorder had committed legal offenses.
Education and Employment In the study by Farley et al. (2009), 29% of the
Approximately, 15% of adults with ASD studied sample was involved with law enforcement offi-
in outcome research attend postsecondary educa- cers for infractions after childhood, but these
tion programs (Ballaban-Gil et al., 1996; Farley were related exclusively to “suspicious” behav-
et al., 2009; Kobayashi et al., 1992; Rumsey iors deriving from special interests, participants
et al., 1985; Szatmari et al., 1989; Venter et al., being coerced to engage in antisocial behavior by
1992). In general, gainful employment for adults peers, and social misunderstandings.
with ASD is rare, as is sheltered employment,
occupying less than 40% of adults with AD
(Howlin, 2003; Howlin et al., 2004). While out- Future Directions
come studies of autism into adulthood conducted
since 1992 reflect some steady improvements in The prognosis for a majority of adults with ASD,
employment rates, with 22–54% of participants based on studies conducted to date, is guarded.
reporting gainful employment on a full- or part- Future studies are needed to further define the
time basis (Ballaban-Gil et al., 1996; Farley et al., subtypes of ASD, and the factors that influence
2009; Howlin et al., 2004; Kobayashi et al., 1992; adult outcome. Studies of genetics, brain imag-
Venter et al., 1992), many of these individuals are ing, and responses to interventions are likely to
underemployed based on their cognitive abilities yield important information.
and academic credentials.
Forensic Problems See Also

Involvement with police officers and other law
enforcement agents has been recognized as ▶ Adulthood, Transition to
a major concern for parents of adolescents and ▶ Advocacy
adults with ASD. A study of offending behavior ▶ Americans with Disabilities Act
in 33 individuals with Asperger Disorder (Allen, ▶ Asperger Syndrome Follow-Up Studies
Evans, Hider, Hawkins, Peckett, & Morgan, ▶ Community Services
2008) revealed that most engaged in violent or ▶ Community-Integrated Residential Services
threatening behavior that was related to interper- for Adults with Autism
sonal problems including social or sexual rejec- ▶ Competitive Employment
tion, bullying, or family conflict. Investigators ▶ Comprehensive Transition Program
have suggested offending behavior in ASD ▶ Course of Development
populations was likely to result from coercion ▶ Employment
by others, misinterpretation of social situations, ▶ Employment in Adult Life
or obsessional interests, while many with ASD ▶ Employment Specialist
may be protected by their tendency to adhere ▶ Functional Life Skills
strictly to rules. Allen et al. (2008) found evi- ▶ Group Homes
dence of this insight in that the least common ▶ Guardianship
offenses identified among their population of ▶ Independent Living
offenders with Asperger Disorder were drug ▶ Individualized Plan for Employment (IPE)
offenses, theft, fraud, sexual offending, and ▶ Job Carving
motor offenses. Cederlund et al. (2008) found ▶ Job Coach
that 10% (n ¼ 7) of their sample with Asperger ▶ Law Enforcement Agencies and Autism
Disorder had been involved with law ▶ Legal Competency
▶ Living Arrangements in Adulthood Fombonne, E. (1999). The epidemiology of autism:
▶ Residential Services A review. Psychological Medicine, 29, 769–786.
Ghaziuddin, M., Weidmer-Mikhail, E., & Ghaziuddin, N.
▶ Secure Employment (1998). Comorbidity of Asperger syndrome: A
▶ Self-Advocacy A preliminary report. Journal of Intellectual Disability
▶ Sexuality in Autism Research, 42(4), 279–283.
▶ Sheltered Employment Gillberg, C., & Steffenburg, S. (1987). Outcome and
prognostic factors in infantile autism and similar con-
▶ Sheltered Workshops ditions: A population-based study of 46 cases followed
▶ Suicide Rates in Adults with Autism through puberty. Journal of Autism and Developmen-
▶ Supported Employment tal Disorders, 17(2), 273–288.
▶ Transitional Living Gonzales, N. M., Murray, A., Shay, J., Campbell, M., &
Small, A. M. (1993). Autistic children at follow-up:
▶ Transition Planning Change of diagnosis. Psychopharmacology Bulletin,
▶ Travel Training 29(3), 353–358.
▶ Trust Howlin, P. (2003). Outcome in high-functioning adults
▶ Violent/Criminal Behavior in Autism with autism with and without early language delays:
Implications for the differentiation between autism
▶ Vocational Evaluator and Asperger syndrome. Journal of Autism and Devel-
▶ Vocational Rehabilitation Act of 1973 opmental Disorders, 33(1), 3–13.
▶ Vocational Training Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004).
Adult outcome for children with autism. Journal of
Child Psychology and Psychiatry, 45(2), 212–229.
Isager, T., Mouridsen, S. E., & Rich, B. (1999). Mortality
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& Morgan, H. (2008). Offending behaviour in adults Kobayashi, R., Murata, T., & Yoshinaga, K. (1992).
with Asperger syndrome. Journal of Autism and A follow-up study of 201 children with autism in
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Danielsson, S., Gillberg, I. C., Billstedt, E., Gillberg, C., & Rumsey, J. M., Rapoport, J. L., & Sceery, W. R. (1985).
Olsson, I. (2005). Epilepsy in young adults with Autistic children as adults: Psychiatric, social, and
autism: A prospective population-based follow-up behavioral outcomes. Journal of the American Acad-
study of 120 individuals diagnosed in childhood. emy of Child and Adolescent Psychiatry, 24(4), 465–
Epilepsia, 46(6), 918–923. 473.
Eaves, L. C., & Ho, H. (2008). Young adult outcome of Seltzer, M. M., Krauss, M. W., Shattuck, P. T., Orsmond,
autism spectrum disorders. Journal of Autism and G., Swe, A., & Lord, C. (2003). The symptoms of
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W. R., Miller, J., Gardner, M., et al. (2009). Twenty- ders, 33(6), 565–581.
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A 68 Adult/Clinician/Teacher-Directed Approaches
Szatmari, P., Bartolucci, G., Bremmer, R., Bond, S., & completing a number of developmental tasks of
Rich, S. (1989). A follow-up study of high-functioning adulthood. These tasks been well identified,
autistic children. Journal of Autism and Developmen-
tal Disorders, 19(2), 213–225. stemming from Freud’s notion of “love and
Venter, A., Lord, C., & Schopler, E. (1992). A follow-up work” (cited by Hazan & Shaver, 1990), and
study of high-functioning autistic children. Journal of most often include leaving the parental home,
Child Psychology and Psychiatry, 33(3), 489–507. finishing school and starting employment, and
doi:10.1111/j.1469-7610.1992.tb00887.x.
marrying and having children (Fussell &
Furstenberg, 2005). In recent years, however,
the entry into adulthood for typically developing
individuals has become much more ambiguous
Adult/Clinician/Teacher-Directed and prolonged and these markers are often
Approaches achieved more gradually, and not necessarily in
as fixed an order as in the past (Furstenberg,
▶ Didactic Approaches Rumbaut, & Settersten, 2005). It is increasingly
common, for example, for youth to move out of
the parental home and into a university residence,
but then move back into the parental home for
Adulthood, Transition to a time after the completion of their university
studies. Additionally, it is often the case that
Julie Lounds Taylor1 and men and women are living independently, have
Marsha Mailick Seltzer2 finished their schooling, and are engaged in full-
1
Vanderbilt Kennedy Center and Department time work activities but have not yet married or
of Pediatrics, Vanderbilt University, Nashville, had children.
TN, USA Arnett (2000) proposed the concept of emerg-
2
Waisman Center, University of ing adulthood as a way to account for this hetero-
Wisconsin-Madison, Madison, WI, USA geneity in how individuals transition from
adolescence to adulthood. The emerging adult-
hood period, Arnett (2000) explained, is distinct
Definition from adolescence and early adulthood because of
its relative freedom from social roles and societal
For the purposes of this entry, the transition to expectations. He suggested that the transition to
adulthood is defined as exiting the secondary adulthood is no longer best represented by demo-
school system, resulting in the termination of ser- graphic transitions, such as ending formal school-
vices received through the school system. High ing, getting married, or having children. Instead,
school “exit” is differentiated from “graduation,” the criteria for the transition to adulthood are
as some individuals with Autism Spectrum Disor- individualistic, encompassing concepts such as
der (ASD) “graduate” with same-aged peers, but independence in decision making, being respon-
continue to receive secondary school services sible for one’s own person, and financial inde-
until age 22. We expect that these youth will be pendence (Arnett, 2000).
more affected by losing school services than by When the adolescent in transition has ASD,
graduation. Thus, high school “exit” refers to the the complexity implicit in defining the transition
termination of school-based services. to adulthood is multiplied. Some developmental
tasks of adulthood are obtained by most individ-
uals with ASD, such as exiting school. Other
Historical Background tasks, such as moving out of the parental home
or finding regular employment, are only achieved
The transition to adulthood for adolescents with- by a fraction of individuals with ASD, but these
out disabilities has traditionally been identified as milestones can be modified to be attainable by
Adulthood, Transition to 69 A
many more (e.g., structured or semi-structured for youth with ASD (and other disabilities) has
living arrangements, supported employment). long been recognized by professionals and policy
Finally, some tasks are attained by few individ- makers as an important turning point that sets the A
uals with ASD, such as getting married or having stage for later adult outcomes. Perhaps the
children. The criteria proposed by the emerging greatest evidence of this is the existence of fed-
adulthood literature are similarly complicated; eral legislation mandating specific requirements
many individuals with ASD may never have for transition planning for youth with disabilities,
complete independence in decision making nor found in the IDEA of 1997 and the Individuals
have financial independence from both their fam- with Disabilities Education Improvement Act
ilies and federal or state agencies. (IDEIA) of 2004. These legislative landmarks
Because of these difficulties in definition, mandate that a transition plan must be included
many researchers have forgone theory-based in the Individualized Education Plan when
ideas of transition and instead defined the transi- a student is 16 years of age (although planning
tion period for those with intellectual and devel- can start sooner) which facilitates “real-world”
opmental disabilities using specific ages (such as outcomes by focusing on improvement in educa-
ages 18–26 in Blacher, 2001). Alternatively, our tion (postsecondary, vocational skills), adult ser-
research has chosen high school exit as a key vices, independent living skills, and community
indicator of the transition to adulthood for two participation. Furthermore, measurable goals
reasons: (1) of all developmental tasks of adult- must be developed that take into account the
hood, it is the most commonly attained by indi- student’s needs, strengths, interests, and
viduals with ASD; and (2) nearly all transition preferences.
studies on individuals with intellectual and devel- By examining the corpus of research on the
opmental disabilities (not ASD) center around transition to adulthood, it is clear that autism
high school exit. researchers have lagged behind policy makers
In contrast to typically developing adolescents and practitioners in recognizing the importance
in the USA – who exit high school at a prescribed of this transition for youth with ASD. The few
time (at the end of twelfth grade) – considerable existing studies are summarized below.
variability exists in the age at which adolescents
and young adults with ASD exit the school
system. Some exit with their same-aged, Current Knowledge
nondisabled peers, while others take advantage
of the Individuals with Disabilities Education Act The transition to adulthood is associated with
(IDEA) and remain in secondary school until a slowing of improvement of the autism behavioral
their 22nd birthday. Although it may be simplis- phenotype. (Taylor & Seltzer, 2010) examined
tic to only consider high school exit as a marker change over nearly 10 years in autism symptoms
of the transition to adulthood, this milestone pro- and behavior problems for a community sample of
vides a focused lens through which to examine over 240 youth with ASD. The vast majority of
the research related to the transition to adulthood these youth exited high school over the study
for people with ASD. period, allowing us to test changes in symptoms
Although few studies have focused on high and behaviors while youth were in high school, as
school exit for youth with ASD, there is consid- well as whether leaving high school impacted that
erable research among adults with ASD change. We found that all subscales of symptoms
suggesting that they have difficulties integrating and behaviors were significantly improving while
into adult society. Adults with ASD tend to live youth were in high school and that, in general,
fairly dependent lives, are underemployed, with improvement significantly slowed down after
those who have employment often holding jobs youth with ASD exited the secondary school sys-
that do not provide a living wage (for a review see tem. Although youth with ASD who did not have
Howlin, 2005). The transition out of high school an intellectual disability (ID) had less severe
A 70 Adulthood, Transition to
symptoms and behavior problems than those who have no day activities than youths with ASD who
had ID as well as ASD throughout the study period, also had comorbid ID. This divergent pattern
the slowing of improvement following high school likely does not represent a lack of abilities on
exit was more pronounced for youth with ASD the part of the youth with ASD, but instead the
who did not have ID, relative to those who had inadequacy of the current service system to
a comorbid ID. Furthermore, youth with ASD accommodate the needs of youth with ASD who
whose families had lower incomes were more neg- do not have ID as they are transitioning to adult-
atively impacted by high school exit relative to hood. Indeed, in this sample, only 18% of young
youth whose families had higher incomes. adults without ID were getting some sort of
Similar patterns were observed in follow-up employment or vocational services (e.g.,
analyses (Taylor & Seltzer, 2011a), which exam- supported employment, sheltered workshop)
ined the impact of exiting high school on changes compared to 86% of young adults with ID.
in the mother-child relationship over a 7-year Thus, the lack of appropriate services and limited
period. We found improvements in three indices options for educational/vocational activities for
of the mother-child relationship – mother-child youth with ASD without ID after high school exit
positive affect, subjective burden, and warmth – may be responsible for the slowing of improve-
while youth with ASD were in high school. After ment observed during this time. Youth with ASD
high school exit, however, that improvement and a comorbid ID may be less affected as they
stopped – even after controlling for concurrent more easily fit into the existing adult disability
slowing of improvement in behavior problems. service system.
Once again, whether the youth with ASD had Limited services and opportunities after high
a comorbid ID significantly predicted change in school exit might also play a role in the greater
maternal warmth; those without an ID were more negative impact of high school exit on youth with
negatively affected by high school exit relative to ASD whose families have lower incomes, rela-
those with a comorbid ID. Further, the number of tive to those whose families have higher income.
needed services that were currently not being A recent study by Shattuck, Wagner, Narendorf,
received also predicted change in the mother- Sterzing, and Hensley (2011) supports this
child relationship. There was greater slowing of hypothesis. Using a nationally representative
improvement in mother-child positive affect for sample, the authors found that nearly 40% of
youth who had more unmet service needs, rela- youth with ASD were receiving no services in
tive to those who had fewer unmet needs. In sum, the 2 years following their exit from high school.
these studies provide evidence of a disruption in Furthermore, youth whose families had lower
phenotypic improvement and parent-child rela- incomes were more likely to be without formal
tions in the years following high school exit for services relative to youth whose families had
youth with ASD. higher incomes. It appears then that youth with
Youth with ASD without an ID might be more ASD whose families have fewer economic
negatively impacted by exiting high school resources also receive fewer adult services once
because they have a difficult time finding appro- they exit high school and services are no longer
priate vocational or educational activities. This mandated, which likely explains (at least in part)
hypothesis was supported in a study by (Taylor & why the pattern of improvement in their behavior
Seltzer 2011b), who examined the post- problems that was observed while they were in
secondary educational and vocational activities high school is more negatively impacted by
of young adults with ASD who had exited high exiting high school.
school an average of 2 years previous to data In sum, the small body of existing research
collection. We found that nearly 25% of the focused on the transition to adulthood for youth
young adults who had ASD without ID had no with ASD suggests that it is a disruptive influence
or minimal vocational/educational activities, and in the lives of these families, with the greatest
those without ID were three times more likely to disruption occurring for those who do not have
Adulthood, Transition to 71 A
ID, those whose families have fewer resources, as Maladaptive behaviors can be extremely disrup-
well as those who are underserved by the formal tive for all adults with disabilities, including
service system. In the following section we dis- those with ASD. Taylor and Seltzer (2011b) A
cuss the numerous directions for future research. found that young adults with ASD who had
lower levels of maladaptive behaviors were
more likely to be in college or working indepen-
Future Directions dently in the community in the years after high
school exit. Those young adults with higher
Although our knowledge of how youth with ASD levels of maladaptive behaviors tended to either
and their families are impacted by the transition spend their time in sheltered settings (day activity
to adulthood is in its infancy, it is critical that we programs, sheltered workshops) or to have no
better understand the mutable factors associated vocational activities. Maladaptive behaviors can
with a positive transition. As previously men- be changed through both behavioral and pharma-
tioned, employment and vocational outcomes of cological interventions (Aman et al., 2009;
adults with ASD have much room for improve- Matson, Mahan, & Matson, 2009; McCracken
ment. Furthermore, adults with ASD seem to be et al., 2002; Vismara & Rogers, 2010), and thus
at additional risk for poor outcomes relative to constitute a promising factor that, if alleviated,
even adults with other types of developmental could promote independence and employment
disabilities. Esbensen, Bishop, Seltzer, among adults with ASD.
Greenberg, and Taylor (2010) found that adults Environmental resources are another set of
with ASD had less optimal outcomes (as defined malleable factors that have virtually been ignored
by less independence in their living arrange- by researchers studying outcomes for adults with
ments, in their vocational placements, and less ASD. Not only are the quality and availability of
social connectedness) relative to a matched group formal services likely important in promoting
of adults with Down syndrome. It appears then a positive transition to adulthood, but also the
that adults with ASD might be a particularly vul- family environment. Family environments, char-
nerable group as they move out of high school acterized by high levels of criticism of the indi-
and into adult life. vidual with ASD, predict significant increases in
Future research should focus on the mutable behavior problems (Greenberg, Seltzer, Hong, &
factors that promote a successful transition to Orsmond, 2006); alternatively, supportive, warm
adulthood and optimal adult outcomes. So far, family environments predict decreases in behav-
studies of risk factors for poor adult outcomes ior problems for these adults (Smith, Greenberg,
have focused on factors that are static and diffi- Seltzer, & Hong, 2008). Environmental resources
cult to change. Adults with ASD who require can be altered through advocacy for better dis-
substantial supports tend to have lower IQ scores, ability-related services and psychoeducational
fewer functional abilities, and poor early lan- intervention to improve positivity in the family
guage skills (Billstedt, Gillberg, & Gillberg, environment (Bernhard et al., 2006), and thus are
2007; Eaves & Ho, 2008; Farley et al., 2009; also promising avenues for future research
Howlin, Goode, Hutton, & Rutter, 2004; Howlin, focused on promoting a positive transition to
Mawhood, & Rutter, 2000). But while knowing adulthood for youth with ASD.
an individual’s IQ and early language abilities Finally, researchers should continue to con-
helps predict adult outcomes, this information is sider what is meant by a “positive” transition to
less helpful in considering ways to improve out- adulthood. Based on the current criteria for suc-
comes. Malleable factors that impede positive cessful adult outcomes – living independently,
outcomes or exacerbate negative outcomes may working independently, and friendships – it is
provide better avenues for intervention. not difficult to come up with examples of young
One promising factor is behavioral function- adults with ASD who appear to be transitioning
ing, and specifically maladaptive behaviors. “unsuccessfully,” but in actuality may be doing
A 72 Adulthood, Transition to
quite well in adulthood. A more holistic view of Billstedt, E., Gillberg, I. C., & Gillberg, C. (2007). Autism
the transition to adulthood would be garnered by in adults: Symptom patterns and early childhood
predictors. Use of the DISCO in a community sample
including measures of life satisfaction, commu- followed from childhood. Journal of Child Psychology
nity engagement, sense of purpose, or even by and Psychiatry, 48, 1102–1110.
judging outcomes based on individualistic goals Blacher, J. (2001). Transition to adulthood: Mental
for adult life. Measuring constructs broader than retardation, families, and culture. American Journal
on Mental Retardation, 106, 173–188.
employment and living arrangements when Eaves, L. C., & Ho, H. H. (2008). Young adult outcome of
examining an individual’s transition success autism spectrum disorders. Journal of Autism and
may also alleviate some of the bias against Developmental Disorders, 38, 739–747.
a successful transition for those young adults Esbensen, A. J., Bishop, S. L., Seltzer, M. M.,
Greenberg, J. S., & Taylor, J. L. (2010). Compari-
who have more functional limitations. Advocat- sons between individuals with autism spectrum dis-
ing the inclusion of measures of life satisfaction orders and individuals with Down syndrome in
or purpose does not mean to imply that the diffi- adulthood. American Journal on Intellectual and
culties faced by individuals with ASD in attaining Developmental Disabilities, 115, 277–290.
Farley, M. A., McMahon, W. M., Fombonne, E.,
community employment and independence are Jenson, W. R., Miller, J., Gardner, M., et al.
not concerning, only that it does not represent (2009). Twenty-year outcome for individuals with
the entirety of the transition to adulthood. autism and average or near-average cognitive abil-
ities. Autism Research, 2, 109–118.
Furstenberg, F. F., Rumbaut, R. G., & Settersten, R. A.
(2005). On the frontier of adulthood: Emerging theme
See Also and new directions. In R. A. Settersten, F. F.
Furstenberg, & R. G. Rumbaut (Eds.), On the frontier
▶ Adult Follow-up Studies of adulthood: Theory, research and public policy
(pp. 3–28). Chicago: University of Chicago Press.
▶ Course of Development Fussell, E., & Furstenberg, F. F. (2005). The transition to
▶ Employment adulthood during the twentieth century. In R. A.
▶ Employment in Adult Life Settersten, F. F. Furstenberg, & R. G. Rumbaut
▶ Factors Affecting Outcomes (Eds.), On the frontier of adulthood: Theory, research
and public policy (pp. 29–75). Chicago: University of
▶ Individual Education Plan Chicago Press.
▶ Individualized Plan for Employment (IPE) Greenberg, J. S., Seltzer, M. M., Hong, J., & Orsmond,
▶ Individualized Transition Plan (ITP) G. I. (2006). Bidirectional effects of expressed
▶ Individuals with Disabilities Education Act emotion and behavior problems and symptoms in
adolescents and adults with autism. American Journal
(IDEA) on Mental Retardation, 111, 229–249.
Hazan, C., & Shaver, P. R. (1990). Love and work: An
attachment-theoretical perspective. Journal of
Personality and Social Psychology, 59, 270–280.
References and Readings Howlin, P. (2005). Outcomes in autism spectrum
disorders. In F. R. Volkmar, R. Paul, A. Klin, & D.
Aman, M. G., McDougle, C. J., Scahill, L., Handen, B., Cohen (Eds.), Handbook of autism and pervasive
Arnold, L. E., Johnson, C., et al. (2009). Medication developmental disorders (3rd ed., Vol. 1,
and parent training in children with pervasive pp. 201–220). Hoboken, NJ: John Wiley & Sons.
developmental disorders and serious behavior Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004).
problems: Results from a randomized clinical trial. Adult outcome for children with autism. Journal of
Journal of the American Academy of Child and Child Psychology and Psychiatry, 45, 212–229.
Adolescent Psychiatry, 48, 1143–1154. Howlin, P., Mawhood, L., & Rutter, M. (2000). Autism
Arnett, J. J. (2000). Emerging adulthood: A theory of and developmental receptive language disorder –
development from the late teens through the twenties. a follow-up comparison in early adult life. II: Social,
American Psychologist, 55, 469–480. behavioural, and psychiatric outcomes. Journal of
Bernhard, B., Schaub, A., Kummler, P., Dittmann, S., Child Psychology and Psychiatry, 41, 561–578.
Severus, E., Seemuller, F., et al. (2006). Impact of Matson, M. L., Mahan, S., & Matson, J. L. (2009). Parent
cognitive-psychoeducational interventions in bipolar training: A review of methods for children with autism
patients and their relatives. European Psychiatry, 21, spectrum disorders. Research in Autism Spectrum Dis-
81–86. orders, 3, 868–875.
Advocacy 73 A
McCracken, J. T., McGough, J., Shah, B., Cronin, P., Advocacy exists on multiple levels, ranging
Hong, D., Aman, M. G., et al. (2002). Risperidone in from the individual level to advocacy related to
children with autism and serious behavioral problems.
The New England Journal of Medicine, 347, 314–321. change of social policy. A
Shattuck, P. T., Wagner, M., Narendorf, S., Sterzing, P.,
& Hensley, M. (2011). Post-high school service use
among young adults with an autism spectrum disorder. Historical Background
Archives of Pediatrics & Adolescent Medicine, 165,
141–146.
Smith, L. E., Greenberg, J. S., Seltzer, M. M., & Hong, J. Historically, advocates have been involved in
(2008). Symptoms and behavior problems of adoles- many different issues, including education,
cents and adults with autism: Effects of mother-child healthcare, employment, housing, social opportu-
relationship quality, warmth, and praise. American
Journal on Mental Retardation, 113, 378–393. nities, and more. In the education arena, advocates
Taylor, J. L. (2009). The transition to adulthood for have been responsible for much of the legislation
individuals with autism spectrum disorders and their related to the special education laws in the United
families. International Review of Research in Mental States. For example, a group of parents working
Retardation and Developmental Disabilities, 38, 1–32.
Taylor, J. L., & Seltzer, M. M. (2010). Changes in the with the Pennsylvania Association of Retarded
autism behavioral phenotype during the transition to Citizens (now known as the ARC) filed
adulthood. Journal of Autism and Developmental Dis- a complaint which eventually led to the passage
orders, 40, 1431–1446. of The Education for All Handicapped Children
Taylor, J. L., & Seltzer, M. M. (2011a). Changes in the
mother-child relationship during the transition to Act, the precursor to today’s Individuals with Dis-
adulthood for youth with autism spectrum disorder. abilities Education Improvement Act (IDEIA).
Journal of Autism and Developmental Disorders, 41, Through advocating at the national and state
1397–1410. level, these advocates have sought to ensure that
Taylor, J. L., & Seltzer, M. M. (2011b). Employment and
post-secondary educational activities for young adults all children with disabilities receive a free and
with Autism spectrum disorders during the transition appropriate public education. With regard to
to adulthood. Journal of Autism and Developmental autism spectrum disorders (ASD), many advocates
Disorders, 41, 556–574. have pushed states to pass autism insurance legis-
Vismara, L. A., & Rogers, S. J. (2010). Behavioral
treatments in autism spectrum disorder: What do we lation, in an attempt to prevent insurance compa-
know? Annual Review of Clinical Psychology, 6, nies from denying services to individuals with
447–468. ASD. Currently, almost every state in the country
has adopted or is considering autism insurance
legislation. Advocates have also been involved in
protecting the personal rights of individuals with
Advocacy disabilities. For example, advocates in states such
as Pennsylvania have proposed adult protective
Debra Dunn services laws, which would protect adults who
The Center for Autism Research at The are physically abused but unable to testify in
Children’s Hospital of Philadelphia, court due to communication difficulties. This is
Philadelphia, PA, USA particularly important in cases where physical evi-
dence points to abuse, but a disability such as
autism prevents the victim from testifying.
Definition On an individual level, parents have always
needed to advocate for services for their children
Advocacy refers to the process by which an indi- with disabilities. In the education system, Con-
vidual or a group of individuals support(s) a cause gress has encouraged the development of parent
or protect(s) the rights of an individual or group advocates by increasingly including provisions in
of individuals. Disability advocates can be par- legislation which encourage parent involvement
ents, professionals, or individuals with disabil- in educational decisions for their children. For
ities themselves (known as self-advocates). example, parents are mandated participants in
A 74 Advocacy
the process of developing individualized educa- Autism Speaks, AutismNOW, Autism National
tion programs (IEPs) for their children and are an Committee (AUTCOM), Autism Network Inter-
integral part of IEP teams. national, the Autism Self Advocacy Network
Similarly, Congress has empowered individ- (ASAN), and the Global and Regional Asperger
uals with disabilities with rights to participate in Syndrome Partnership (GRASP). The last four of
their own education decisions. This has helped to these groups are self-advocacy organizations.
create a new generation of self-advocates. At the Local autism support groups may also function
age of 14, students with disabilities are invited to as advocacy organizations; additionally, these
take part in the IEP process. Many IEPs for stu- groups can be effective at teaching parents to
dents with disabilities, including autism, include become more effective advocates.
self-advocacy goals to help students learn to
effectively communicate their needs and opin-
ions. As a result, more and more individuals Future Directions
with disabilities are becoming adults who possess
effective self-advocacy skills. Not only are these Many advocacy organizations set short- and long-
adults adept at advocating on their own behalf, term agendas for their advocacy efforts. In the
many of them effectively advocate for broader autism community, insurance legislation remains
social change. Today, individuals with disabil- an area of concern in a handful of states across the
ities sit on national, state, and local advisory country. Furthermore, despite new insurance laws
boards, which are charged with developing pol- in many states, funding for autism services remains
icy that directly affects the disability community. incomplete and inadequate. Many advocates are
The role of the professional advocate has also expending great efforts to ensure that Medicaid
developed over time, particularly as the educa- and other federal and state programs are supported
tion and other service systems have expanded and in the budget processes. Other legislations that are
become more complex. Attorneys are advocates currently supported by autism advocates include
by virtue of their training, but increasingly other the IDEA Fairness Restoration Act (to override
professionals have labeled themselves as disabil- a Supreme Court decision disallowing parents to
ity or child “advocates.” These professionals are be reimbursed for expert witness fees), the Com-
not regulated nor accredited by any board. None- bating Autism Reauthorization Act of 2011 (pro-
theless, many of them have a wealth of experi- viding support for research into the causes and
ence, which families have found helpful in treatments for ASD), the Caring for Military Kids
advocating for services for their children. with Autism Act (to reverse a Department of
Defense healthcare provision which does not rec-
ognize autism as a treatable condition), and the
Current Knowledge Autism Service and Workforce Acceleration Act
of 2011 (to develop comprehensive treatment cen-
There are a number of different disability advo- ters and to improve the transition into adulthood for
cacy organizations that exist today. Two of the youth with ASD). When legislation is involved,
oldest are the ARC (formerly Association of some advocacy organizations will distribute action
Retarded Citizens) and TASH (formerly American alerts to their constituencies to encourage inter-
Association on Mental Deficiency). The National ested parties to send letters to legislators and public
Disability Rights Network (formerly the National officials.
Association of Protection and Advocacy Systems) In addition to legislation, court cases may
began more recently in the 1980s. As the preva- arise which affect the rights of individuals with
lence of autism spectrum disorders has increased disabilities. Advocacy organizations may submit
over time, advocacy organizations specific to ASD amicus briefs related to a particular issue that
have been formed. Current autism advocacy orga- affects their constituency. The self-advocacy
nizations include the Autism Society of America, organizations, in particular, have submitted
Affective Development 75 A
amicus briefs in employment cases and cases References and Readings
involving restraint and seclusion.
Disability Rights Florida. Self-advocacy. Retrieved
Going forward, as more and more children
from http://www.disabilityrightsflorida.org/resources/ A
with ASD age into adulthood, advocacy efforts
disability_topic_info/category/self-advocacy
may begin to focus even more toward issues Education for all Handicapped Children Act of 1975, Pub.
related to employment, housing, and adult ser- L., No. 94-142, 89 Stat. 773.
vices. New legislation regarding autism insur- http://autismnow.org
http://autreat.com
ance will lead to more questions related to its
http://grasp.org
interpretation, and advocates will be needed to http://tash.org
represent the interests of individuals with ASD http://www.autcom.org
and their families. Indeed, funding will likely http://www.autism-society.org/
http://www.autismspeaks.org
always remain a key area of advocacy efforts,
http://www.autismvotes.org
given persistent budgetary constraints. In the http://www.autisticadvocacy.org
education arena, in addition to the pending legis- http://www.ncd.gov
lation related to expert witness fees in special http://www.ndrn.org
http://www.thearc.org
education cases, federal legislation regarding
http://www.wrightslaw.com
the allocation of burden of proof in special edu- Individuals with Disabilities Education Improvement
cation cases may be proposed. Currently states Act of 2004, 20 U.S.C. }} 1400 et seq., Pub. L. No.
differ as to who has the responsibility to prove the 108-446, 118 Stat. 2803.
Kamleiter, M. (n.d.). Role of the advocate. Retrieved from
case when the parent files the lawsuit but the
http://www.flspedlaw.com/Adv_Roles.html
educational authority (the school district) has Katsiyannis, A., et al. (2001). Reflections on the 25th
the most access to evidence. Anniversary of the Individuals with Disabilities Edu-
Another development related to advocacy cation Act. Remedial and Special Education, 22(6),
324–334.
may be the development of more training pro-
Pennsylvania Association for Retarded Citizens (PARC)
grams for professional advocates. There are v. Commonwealth of Pennsylvania, 343 F. Suppl. 279
advocate training programs hosted by a range of (E.D. Pa. 1972).
organizations, from law schools, to educational PL 94-142: policy, evolution, and landscape shift
(2007). Retrieved May 2, 2011, from http://www.
agencies, to private individuals and companies.
thefreelibrary.com/PL+94-142%3a+policy%2c+evolu-
Many of these training opportunities have been tion%2c+and+landscape+shift.-a0173465140
helpful in educating parents about their own US Office of Special Education Programs. (2000).
rights and may offer a broader perspective that Twenty-five years of progress in educating children
with disabilities through IDEA. Retrieved May 2,
enable these parents to better assist other parents
2011, from http://www2.ed.gov/policy/speced/leg/
as well. Nonetheless, as advocates become more idea/history.html
involved in assisting parents in special education
due process proceedings, there could be momen-
tum to regulate advocate certificates (insofar as
the certificates being offered do not provide
licensure or credentialing). Affective Development
Nurit Yirmiya and Ifat Seidman

See Also Department of Psychology, The Hebrew
University of Jerusalem, Jerusalem, Israel
▶ Individuals with Disabilities Education Act
(IDEA)
▶ Legal Education Rights Definition
▶ PL94-142
▶ Procedural Safeguards Affective development pertains to the emergence
▶ Self-advocacy of the emotional capacity to experience,
A 76 Affective Development
recognize, and express a range of emotions and to and the first studies regarding affective develop-
adequately respond to emotional cues in others. ment in autism examined this issue of children’s
Emotions such as happiness or fear are defined as emotional expressiveness. Early reports indicated
subjective reactions to experience that are asso- that children with autism did not appear less
ciated with physiological and behavioral emotionally expressive than children with mental
changes. Emotional functioning comprises sev- retardation or than typically developing children
eral aspects, including the inducement and elici- (Capps, Kasari, Yirmiya, & Sigman, 1993; Ricks
tation of internal physiological states, the & Wing, 1975). However, parents reported that
physiological pathways that mediate these inter- their children with autism experienced higher
nal states, the emotional expressions, and the levels of negative emotions such as fear, sadness,
perception of affect. Overt manifestations of and anger and lower levels of positive emotions
affective expressions and responses include such as joy and interest, compared to the reports
facial expressions, voice, postures, and move- of parents of children with mental retardation and
ments. Affective development is intertwined typically developing children (Capps et al.,
with the development of social skills, and this 1993). Researchers investigated whether
psychosocial combination reflects one’s distinc- children’s emotional expressions and responses
tive personality and tendencies when responding (e.g., smiles, laughter, or even temper tantrums)
to others, engaging in social interactions, and were socially adequate and context appropriate.
adapting to the interpersonal world (Saarni, Findings revealed that children with autism
Campos, Camras, & Witherington, 2006). sometimes manifested discordant affects or defi-
Individuals with autism have difficulties in cits in displaying positive affect and coordinating
emotional expressiveness and responsiveness and gaze with emotional expression to reveal sharing
in the appropriateness of these emotional manifes- of emotional experience (Kasari, Sigman,
tations to the social context. Individuals with Baumgartner, & Stipek, 1993; Kasari, Sigman,
autism may exhibit limited empathic responsive- Mundy, & Yirmiya, 1990; Yirmiya, Kasari,
ness and may demonstrate specific difficulties in Sigman, & Mundy, 1989). For example, children
face perception and face recognition, emotional with autism generally did not look up at their
regulation, and engagement in affective and social parents and smile when responding to parental
behaviors and contact with others. Some individ- praise for an accomplishment, whereas children
uals with autism seem to manifest emotional with typical development or mental retardation
flatness or aloofness and seem unresponsive to generally did. Other studies on children with
the social environment. It is most challenging for autism pinpointed difficulties in coordinating
individuals with autism to reason about the emo- and pairing facial expressions with vocal expres-
tional world of oneself and others, thus making it sions of emotions, with prosodic and linguistic
more difficult to successfully engage in social sit- expressions of emotions, or with body gestures
uations (Sigman & Capps, 1997). (Hobson, 1986; Van lancker, Cornelius, &
Kreiman, 1989). Interestingly, most studies on
children and adolescents with high-functioning
Historical Background autism or Asperger syndrome revealed no diffi-
culties in labeling facial expressions, especially
Kanner (1943) originally wrote that children with of the basic emotions of happiness, sadness,
autism “have come into the world with innate anger, fear, surprise, and disgust (Braverman,
inability to form the usual, biologically provided Fein, Lucci, & Waterhouse, 1989; Capps,
affective contact with people, just as other Yirmiya, & Sigman, 1992; Hobson, Ouston, &
children come into the world with innate physical Lee, 1989; MacDonald et al., 1989; Ozonoff,
or intellectual handicaps.” (p. 250). Children with Pennington, & Rogers, 1990; Yirmiya & Sigman,
autism were originally described as aloof, 1991). Current studies are now focusing on mea-
unresponsive, or even emotionally detached, suring emotional recognition abilities and more
subtle emotions in individuals with autism with and the caregiver communicate emotional states
normal intelligence using more fine-grain mea- to each other and respond appropriately and
sures (Golan, Baron-Cohen, & Golan, 2008; sensitively (Jaffe, Beebe, Feldstein, Crown, A
Golan, Baron-Cohen, & Hill, 2006; Happé, & Jasnow, 2001; Kogan & Carter, 1996; Stern,
1994). 1985; Trevarthen, 1993; Tronick, 1989;
These atypicalities in affective development Weinberg & Tronick, 1996). In the first weeks
are currently widely accepted as features of of life, babies fluctuate between several states of
autism, but their underlying causes remain arousal such as crying, sleeping, drowsiness, and
a matter of debate. Some investigators consider alertness, with limited ability to control and reg-
the difficulties in affective development as sec- ulate these shifts. As the neurological and physi-
ondary to, or as the result of, impairments in the ological system becomes more mature and
development of social-cognitive abilities such as integrated, and the environment provides respon-
perspective-taking capacities or theory of mind sive parental care, infants become better able to
(ToM) abilities (Baron-Cohen, Leslie, & Frith, regulate states of arousal. They spend more time
1985; Happé & Frith, 2006), whereas other awake, looking around and exploring social stim-
investigators consider abnormal affective devel- uli such as faces, as well as smiling, cooing, and
opment to be a core deficit in autism (Hobson, laughing. Their emotional states can be easily
1993). According to the latter approach, individ- seen during parent–child face-to-face interac-
uals with autism reveal difficulties in their tions, in which infants take an active part in
biologically based and innate capacity to per- mutual regulation by sending and signaling
ceive, decode, and understand emotional cues behavioral and emotional cues such as smiles,
and expressions, which results in a failure to gazes, or vocalizations. This synchronized
establish the mentalizing functions needed for match or “dance” between parent and child is an
appropriate social interactions. Today, there is important mechanism underlying socio-affective
growing awareness that mentalizing and ToM development and is considered a prerequisite for
abilities contribute to the understanding of emo- later emotional functioning, empathy, and
tions and vice versa. Two-year-old toddlers are prosocial behaviors (Feldman, 2007; Feldman,
already able to decode facial expressions, but Greenbaum, & Yirmiya, 1999). It was found
only a year later – using the emerging ToM abil- that toddlers who showed high sensitivity and
ities – can they also recognize the internal mental attention to emotional cues at the age of 2 years
or emotional states that are reflected by these were more socially responsive with their peers,
facial expressions. In turn, young children’s both at age 2 and at age 5. These factors may also
growing understanding of basic emotions facili- render reciprocal effects, where children learn
tates and promotes their mentalizing abilities and about emotions through their relationships with
their comprehension that desires differ from real- others. In sum, affective development in the first
ity (Sigman & Capps, 1997). years is influenced by genetic, biological, and
environmental factors and is strongly related to
children’s temperament and to the development
Current Knowledge of the parent–child relationship and attachment.
Recent evidence is accumulating regarding
Affective Development in the Early Years different affective developmental trajectories of
Caregivers facilitate the affective development of young children with autism, compared to chil-
their children by supporting and scaffolding the dren with typical development. Retrospective
emerging emotional capacities of their children. accounts, obtained from parents’ reports and
Infants come into the world equipped with home videotape analyses of the first 2 years,
a strong drive to emotionally engage with others. revealed that children with autism differ from
Newborns are prepared to engage in mutual children with typical development in social-
affective regulation, a process by which the infant emotional behaviors, describing difficulties in
affect regulation as well as increased negative empathic behaviors, and show more acceptable
affect and ambiguous affective expressions emotional expressions. Through interacting with
(Baranek, 1999; Maestro et al., 2005; Osterling, peers and their emerging friendships, children
Dawson, & Munson, 2002). learn about their own emotions, become aware
Prospective studies of siblings of children with that individuals have different emotional reac-
autism – a group considered at risk for the tions, and can better reflect on others’ motives
development of autism and related difficulties – and intentions during complex social-emotional
demonstrated that 12- to 18-month-old infants situations. Children must also cope with the emo-
later diagnosed with autism are distinguishable tional challenges associated with social develop-
from other infants who were not later diagnosed mental milestones during childhood, such as
with autism in several social-emotional aspects, demands for social conformity, overt competition
such as reductions in expression of positive emo- with others, and mastery of different academic
tion, social smiling, reactivity, and social interest skills (Saarni et al., 2006).
as well as atypicalities in eye gaze, imitation, and Children with autism face the same challenges
orienting to name (Ozonoff et al., 2010; Young, as do typically developing children. Although
Merin, Rogers, & Ozonoff, 2009; Zwaigenbaum, some children with autism may master many
Bryson, et al., 2009; Zwaigenbaum et al., 2005). academic skills, they have great difficulties man-
Interestingly, these early manifestations were not aging everyday emotional and social situations in
extended downward; 6-month-old infants later which an array of emotional and social cues must
diagnosed with autism were not distinguishable be recognized, interpreted, and synthesized
from 6-month-old infants who were not later quickly and simultaneously (Baron-Cohen,
diagnosed with autism in their affective expres- 1995; Bauminger et al., 2008). Clearly, children
sions or in their social use of gaze and affect with autism manifest great variation in their
during social interactions with mutual sharing of desire to form emotional connections with peers
attention and affect (Rozga et al., 2011). Further- and adults, as well as in their ability to perceive
more, 24-month-old toddlers later diagnosed with and respond to the emotions of others. Studies
autism were also distinguishable from their regarding the understanding and experience of
nondiagnosed peers in their temperament prosocial emotions such as pride, embarrassment,
files, as marked by lower positive affect, difficul- or empathy revealed that school-age children
ties in regulating negative affect, as well as lower with autism reported having these feelings as
feelings of excitement in situations of anticipa- often as typically developing children; however,
tion (Brian et al., 2008; Bryson et al., 2007). in their description of situations containing social
Thus, these important studies on the early affec- emotions, they tended to describe more basic
tive development of young children with autism emotions (e.g., happy instead of proud) and to
provide evidence regarding the presence of diffi- describe them more generally and less personally
culties in affect displays and emotional regula- or interpersonally (Kasari, Chamberlain, &
tion in the first years of life. Bauminger, 2001).
Researchers examining affective development
Affective Development in Childhood of children with autism also revealed strong asso-
Emotional development and sense of self are ciations between higher cognitive abilities and
rooted in the experience of early childhood and better understanding of emotional situations
continue to develop over the childhood years. (Dyck, Ferguson, & Shochet, 2001; Golan et al.,
Typical affective development in these years per- 2006), suggesting that cognition is an important
tains to understanding and regulating emotions moderating variable in affective development, as
and to the organization of self-concept. As they well as in compensatory strategies that children
grow, children become more aware of their own use to cope in emotional or social situations
and other people’s emotions, can better regulate (Capps et al., 1992; Kasari et al., 2001). It has
and control their feelings, respond with more been suggested that the impaired performance of
children with autism on measures of emotional of others compared to adolescents with typical
functioning may be secondary to difficulties in development who are matched on gender and on
cognitive or ToM abilities, as well as to difficul- verbal and cognitive abilities (Capps et al., A
ties in linguistic and pragmatic capacities. 1992). In their descriptions of subjective expe-
Indeed, emotion perception difficulties are not riences, adolescents with autism tend to attribute
specific to autism but have also been detected in emotions to material circumstances and events
individuals with other disabilities such as learn- rather than to interpersonal interactions or the
ing disabilities, mental retardation, and schizo- attainment of a goal to a greater extent than do
phrenia (Davis & Gibson, 2000; Edwards, adolescents with mental retardation or adoles-
Pattison, Jackson, & Wales, 2001; Zaja & cents with typical development (Jaedicke,
Rojahn, 2008). Storoschuk, & Lord, 1994). For example, the
Most of the evidence regarding affective descriptions of emotions by adolescents with
development during childhood comes from stud- autism tend to be more idiosyncratic and pecu-
ies of high-functioning children with autism. liar than the descriptions of emotions by adoles-
Children with autism who are low functioning cents in the comparison groups, who tend to link
in terms of cognitive abilities and are unable to emotions to academic, social, and athletic suc-
speak and comprehend language continue to cesses or failures. Furthermore, the task of
struggle with earlier affective developmental talking about feelings was more distressful for
tasks even in childhood. They usually remain adolescents with autism; they appeared to strug-
more engaged with objects and have few social gle with the task and needed prompting and
interactions with peers, and they face challenges more time to respond compared to adolescents
in learning alternative ways to communicate with typical development (Yirmiya & Sigman,
(Sigman & Capps, 1997). 1991). Interestingly, it has been demonstrated
that adolescents with autism showed better emo-
Affective Development in Adolescence and tional responsiveness abilities than younger
Adulthood children with autism when asked to respond to
Adolescence, the developmental transition videotaped stories about children experiencing
between childhood and adulthood, entails major different events and emotions such as happiness,
physical, cognitive, and psychosocial changes. anger, or sadness (e.g., a boy is sad because he
Adolescence enables vast opportunities for lost his dog). These findings suggest that as
growth and autonomy and for its major develop- children with autism get older, their emotional
mental task – the search for personal identity. responsiveness improves. However, these find-
Adolescents must deal with physical alterations ings were not yet examined using longitudinal
and sexual maturity as well as with the develop- research designs and thus need further investi-
ment of emotional independence from their gation (Sigman & Capps, 1997).
parents and families by reorganizing their rela- As in childhood, during adolescence verbal
tionships with parents, siblings, and peers. Their and cognitive capacities play a major role in
emerging metacognitive thinking enables better navigating one’s developmental course. For
comprehension and understanding of complex some adolescents with autism, the widening gap
social and emotional situations, facilitating the with typical development may be associated with
capacity for self-consciousness and empathic an aggravation of behavioral symptoms and
responsiveness (Saarni et al., 2006). poorer social functioning. It appears that the
Adolescents with autism have difficulties increasing complexity of adolescents’ social and
talking about their emotional experiences as emotional world, and their engagement in more
well as about more complex social emotions sophisticated interpersonal interactions, outstrips
other than the basic emotions such as happiness their advances in social and emotional function-
or fear. They also exhibit difficulties in their ing. Furthermore, difficulties in cognition and
ability to empathize and recognize the emotions social understanding hinder adolescents’
adjustment to their own growing physical and (e.g., embarrassment, irony) may strongly
psychological alterations, making the adaptation enhance problem solving abilities in social situa-
process for this new developmental phase more tions and social engagement (Lopata et al., 2010).
challenging (Sigman & Capps, 1997). Indeed, the issue of generalization of acquired
Few longitudinal studies have been social-emotional abilities to other social situa-
conducted to follow children and adolescents tions and to everyday life social interactions is
with autism into adulthood; therefore, little most challenging, and further research is needed
information is available on affective develop- to evaluate the efficacy of social-emotional
ment after this important turning point in life. intervention.
The transition from adolescence to adulthood
for individuals with autism is usually associated
with exiting the school system and entering the See Also
adult service system, which is sometimes
accompanied by the loss of many entitled ser- ▶ Attachment
vices. There is evidence for social and psychiat- ▶ Emotion
ric disorders in adults with autism that appear to ▶ Emotion Regulation
increase with age. For example, adults with ▶ Empathy
autism were found to engage in fewer social ▶ Friendships
and recreational activities and also reported ▶ Interpersonal Skills
fewer friendships and peer relationships than at ▶ Self-concept
younger ages. However, other studies revealed ▶ Self-recognition
that compared to typically developing individ- ▶ Social Cognition
uals, adults with autism did not spend more time ▶ Social Interventions
alone and were equally involved in social activ- ▶ Temperament
ities; however, they experienced increased
social anxiety when in the company of less
familiar people. Indeed, more longitudinal References and Readings
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Age Equivalents 83 A
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Age Appropriate Vineland adaptive behavior scales (2nd ed.). Circle
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A
Arlette Cassidy
Saint Joseph, West Hartford, CT, USA
Age Equivalents
Definition Grace Gengoux

Child and Adolescent Psychiatry, Stanford
Age appropriate refers to a developmental concept University School of Medicine, Lucile Packard
whereby certain activities may be deemed appro- Children’s Hospital, Stanford, CA, USA
priate or inappropriate to a child’s “stage” or level
of development. Specific disabilities as well as
lack of exposure to age-appropriate activities and Synonyms
experiences are commonly thought to prevent
a child from gaining the skills necessary for their Mental age; Test age
current and thus their next stage of development. It
is thought that development most often occurs in
rather predictable stages. Although every child Definition
develops in a unique way, all children are expected
to interact with their environment at an age- Age equivalent scores provide an estimate of
appropriate level. Looking at a child’s functional the chronological age at which typically devel-
development involves observing whether or not oping children demonstrate the skills exhibited
the child has mastered certain developmental by the child being assessed. The age equivalent
milestones and expectations for his or her age. score is based on the mean raw score on a test
With this understanding of typical child devel- obtained by the group of children in the norma-
opment, a child may have a special need when he tive sample at a specific age. In simple terms, if
or she has a delay in one or more areas of on average children at 36 months of age obtain
development listed below: a score of 10 correct responses on a particular
Body movement test, then any child obtaining a score of 10
Thinking and learning correct will receive an age equivalent of
Communication 36 months. Age equivalent scores are often
Senses and their integration expressed in years and months (e.g., 5–0 for
Relating to self and others 5 years, 0 months).
Self-care and daily living skills Though age equivalent scores are appealing in
that they appear to provide convenient descrip-
tive information, they can be misleading and do
See Also not necessarily represent the level of functioning
of the individual. For example, a 3-year-old child
▶ Developmental Milestones who receives an age equivalent of 4–6 on a test of
expressive vocabulary is only similar to
a 4½-year-old child in the number of items
answered correctly on the test and does not nec-
essarily share other characteristics of 4-year-old
Sattler, J. M., & Hoge, R. D. (2006). Assessment of level expressive language ability. As an overall
children: Behavior, social, and clinical foundations average of abilities, any age equivalent score
(5th ed.). San Diego, CA: Jerome M. Sattler. should be interpreted with caution as the child
A 84 Age of Onset
may actually possess individual skills which fall

above or below that level. Especially for children Age of Recognition
with significant scatter within their profile of
abilities, these summary scores may provide an ▶ Onset
oversimplified picture of the child’s skills. As
development of skills is not linear, age equivalent
scores do not represent equal units. Therefore
a 6-month delay will have a different meaning Age Period Cohort Analysis
for a 2-year-old child than for a 10-year-old
child. Because they are based on ordinal scales, Gayle C. Windham
statistical computations such as standard error of Division of Environmental and Occupational
measurement cannot be performed and confi- Disease Control, CA Department of Public
dence intervals cannot be determined. Correct Health, Richmond, CA, USA
interpretation of age equivalent scores must take
these issues into account. In spite of these limita-
tions, age equivalent scores may be especially Definition
useful when standard scores are not available,
such as when a test is administered to a child A “cohort” is a component of the population
with significant developmental delays whose who share a significant experience at a certain
chronological age falls outside the normative period of time or have one or more similar char-
range for that test. acteristics. A common usage is for people born
in the same time period to be called a birth
cohort (or generation). In epidemiological
See Also terms, it is used to denote a group of individuals
sharing a common characteristic or experience,
▶ Developmental Milestones such as the same workplace or living near
a dumpsite, who are observed over time for
disease incidence and compared to a group with-
References and Readings out the characteristic, or to a general population
(e.g., cohort study).
Anastasi, A. (1988). Psychological testing. New York: “Cohort analysis” is the calculation and anal-
Macmillan.
ysis of morbidity (or mortality) rates for a partic-
Gilliam, W. S., & Mayes, L. C. (2007). Clinical assess-
ment of infants and toddlers. In A. Martin & ular disease in a birth cohort as they pass through
F. Volkmar (Eds.), Lewis’s child and adolescent psy- various ages, with different cohorts overlapping
chiatry: A comprehensive textbook (pp. 309–322). at different ages in the same period.
Philadelphia: Lippincott Williams & Wilkins.
Sattler, J. M. (2001). Assessment of children: Cognitive
applications. San Diego: Sattler.
Tsatsanis, K. (2007). Psychological and neuropsycholog- Historical Background
ical assessment of children. In A. Martin & F. Volkmar
(Eds.), Lewis’s child and adolescent psychiatry:
Cohort analysis began as a tool to describe and
A comprehensive textbook (pp. 357–371).
Philadelphia: Lippincott Williams & Wilkins. understand mortality trends and is now com-
monly used to identify birth cohorts at higher
risk for certain diseases, providing information
for both public health surveillance and for the
identification of etiologic factors. Age-period-
Age of Onset cohort (APC) analysis refers to the interpreta-
tion of temporal trends in disease incidence or
▶ Onset mortality rates in terms of three scales all related
Age Period Cohort Analysis 85 A
to time: age, calendar date (period), and year of Current Knowledge
birth (cohort). An age effect reflects the change
in disease risk as a function of the age of indi- Relevance to Autism A
viduals, such as cardiovascular disease, so dif- The reporting or prevalence of autism has greatly
ferences in the age structure of a population increased over the past few decades, but the rea-
being studied could appear to affect disease sons for the temporal increase continue to be
incidence rates. A period effect refers to debated (Croen, Grether, Hoogstrate, & Selvin,
a change over time that tends to affect everyone 2002; Fombonne, 2003; Hertz-Picciotto &
regardless of age, such as an epidemic or new Delwiche, 2009; King & Bearman, 2009; Parner,
exposure. A cohort effect is a variation in dis- Schendel, & Thorsen, 2008; Rice et al., 2010;
ease risk that applies to all individuals sharing Schecter & Grether, 2008). The reasons most
a common experience associated with being commonly cited or examined include (1) younger
born around the same time or in the same gen- age at diagnosis; (2) changes in diagnostic
eration, such as change in exposure to a risk criteria, including shifts from other diagnoses
factor. Disentangling these effects can be quite (primarily mental retardation); (3) increased
difficult due to their interdependence; e.g., awareness of autism, so that ascertainment is
cohort effects are tied to both age and period improved or milder cases ascertained; and
effects (Fombonne, 1994; Keyes, Utz, Robin- (4) changes in the frequency or introduction of
son, & Li, 2010). a variety of nongenetic risk factors.
Various graphical and analytic methods, Autism diagnosis is strongly related to age of
including parametric and nonparametric the child, so shifts to younger ages at diagnosis
approaches, for understanding trends in disease could artificially inflate prevalence rates among
rates have been developed and received consid- later cohorts if not taken into account in compar-
erable attention in the literature (Glenn, 1976; isons (Parner et al., 2008). Further complicating
Holford, 1983, 2005; Keyes et al., 2010; Kupper, interpretation, age at diagnosis may be related to
Janis, Karmous, & Greenberg, 1985; Robertson other factors such as child gender, ethnicity, IQ,
& Boyle, 1998). An early method of statistical and degree of impairment, as well as parental
modeling of APC data was the multiple classifi- education, whose distribution could differ across
cation model, a model containing the effects of cohorts. As there is no biologic test or marker of
age groups (rows), periods of observation autism, diagnosis is somewhat subjective. The
(columns), and birth cohorts (diagonals of the medical and psychiatric criteria for diagnosis
age-by-period table) (Kupper et al., 1985). have changed over time since the 1980s, gener-
The interpretation of such models is difficult ally broadening, which might be reflected as
due to the linear dependence between the three period effects. However, the magnitude of effect
APC variables, which must be accounted for in of this change on prevalence rates is not agreed
the models. The various models basically treat upon across investigators (Leonard et al., 2010).
the definition of the cohort effect in a different Nor have studies shown consistent effects of
way; simplified, some models treat age and diagnostic shift or substitution on temporal
period effects as confounders of a cohort effect trends, although its occurrence has been
whereas others model the interaction, or effect supported (King & Bearman, 2009; Leonard
modification, of age and period on the cohort. et al., 2010). Differences in autism rates by
The decision of how to treat these variables is race/ethnicity could reflect differential awareness
not really a statistical issue but rather depends on and thus temporal trends as awareness increases
the study question of interest and how it is posed. and the racial distribution of cohorts change
Thus the APC models are best used to organize (Rice et al., 2010; Windham et al., 2011).
and summarize data, potentially pointing out Two studies using data from California calcu-
directions for future research to determine the lated age and birth year (cohort) rates in order to
true factors for which time is acting as a proxy. examine the impact of various factors, but
A 86 Age Period Cohort Analysis
without conducting formal APC analysis (Hertz- References and Readings

Picciotto & Delwiche, 2009; Schecter & Grether,
2008). Both showed that for each successive year Croen, L. A., Grether, J. K., Hoogstrate, J., & Selvin, S.
(2002). The changing prevalence of autism in Califor-
of birth, incidence increased for each age,
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the 2009 analysis. Hertz-Picciotto and Delwiche Fombonne, E. (1994). Increased rates of depression:
(2009) further attempted to calculate the propor- Update of the epidemiological findings and analytical
problems. Acta Psychiatrica Scandinavica, 90,
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145–146.
at diagnosis, diagnostic criteria, or inclusion of Fombonne, E. (2003). The prevalence of autism. Journal
milder cases and found that while these explained of the American Medical Association, 289(1), 87–89.
some, they accounted for only about a third of the Glenn, N. D. (1976). Cohort Analysts’ futile quest: Statis-
tical attempts to separate Age, period, and cohort
overall change. One recent study based on similar
effects. American Sociological Review, 41, 900–905.
California data but using an APC model (Keyes Hertz-Picciotto, I., & Delwiche, L. (2009). The rise in
et al., 2012) reported strong cohort effects so that autism and the role of age at diagnosis. Epidemiology,
each successively younger cohort had higher 20, 84–90.
Holford, T. R. (1983). The estimation of age, period and
odds of autism diagnosis, controlling for age
cohort effects for vital rates. Biometrics, 39, 311–324.
and period effects. They concluded that the Holford, T. R. (2005). Age-period-cohort analysis. Ency-
drivers of the increase in autism must be factors clopedia of Biostatistics. doi:10.1002/0470011815.
that have increased linearly year to year and b2a03003.
Keyes, K. M., Susser, E., Cheslack-Postave, K.,
aggregate in birth cohorts, but did not examine
Fountain, C., Liu, K., & Bearman, P. S. (2012). Cohort
specific causes. effects explain the increase in autism diagnosis among
children born from 1992 to 2003 in California. Inter-
national Journal of Epidemiology, 41(2), 495–503.
Keyes, K. M., Utz, R. L., Robinson, W., & Li, G. (2010).
Future Directions What is a cohort effect? Comparison of three statistical
methods for modeling cohort effects in obesity preva-
Explaining the reasons for temporal trends of lence in the United States, 1971-2006. Social Science
a health condition may provide important infor- & Medicine, 70, 1100–1108.
King, M., & Bearman, P. (2009). Diagnostic change and
mation for identifying, and thereby potentially
the increased prevalence of autism. International Jour-
ameliorating, risk factors for the disease. Studies nal of Epidemiology, 38(5), 1224–1234.
show rising rates of autism by birth cohort that Kogan, M. D., Blumberg, S. J., Schieve, L. A.,
are not fully explained by diagnostic changes or Boyle, C. A., Perrin, J. M., Ghandour, R. M., et al.
(2009). Prevalence of parent-reported diagnosis of
awareness, so research to explain the increase is
autism spectrum disorder among children in the US,
still much needed. A variety of risk factors, from 2007. Pediatrics, 124, 1–9.
endogenous (such as parental age) to exogenous Kupper, L. L., Janis, J. M., Karmous, A., & Greenberg,
(such as environmental exposures or maternal B. G. (1985). Statistical age-period-cohort analysis:
A review and critique. Journal of Chronic Diseases,
infection), are currently being investigated
38(10), 811–830.
(Newschaffer et al., 2007). Formal APC analysis Leonard, H., Dixon, G., Whitehouse, A. J. O., Bourke, J.,
might shed some light by focusing investigators Aiberti, K., Nassar, N., et al. (2010). Unpacking the
on factors that vary over time by birth cohort. The complex nature of the autism epidemic. Research in
Autism Spectrum Disorders, 4, 548–554.
one study conducted thus far was based on only
Newschaffer, C. J., Croen, L. A., Daniels, J., Giarelli, E.,
one of the possible models, however, so other Grether, J. K., Levy, S. E., et al. (2007). The epidemi-
models might not yield consistent results. ology of autism spectrum disorders. Annual Review of
Public Health, 28, 21.1–21.24.
Parner, E. T., Schendel, D. E., & Thorsen, P. (2008). Autism
See Also prevalence trends over time in Denmark: Changes in
prevalence and age at diagnosis. Archives of Pediatrics
& Adolescent Medicine, 162(12), 1150–1156.
▶ Diagnostic Substitution Rice, C., Nicholas, J., Baio, J., Pettygrove, S., Lee, L.-C.,
▶ Epidemiology Braun, K. V. N., et al. (2010). Changes in autism
Agenesis of Corpus Callosum 87 A
spectrum disorder prevalence in 4 areas of the United Categorization
States. Disability and Health Journal, 3(3), 186–201.
Robertson, C., & Boyle, P. (1998). Age-period-cohort
analysis of chronic disease rates I: Modeling approach. The CC is divided into seven subregions A
Statistics in Medicine, 17(12), 1305–1323. (see definition of the corpus callosum).
Schecter, R., & Grether, J. K. (2008). Continuing AgCC is divided into partial (Fig. 1) and
increases in autism reported to California’s Develop- complete (Fig. 2) based on whether one or more
mental Services system. Archives of General Psychia-
try, 65, 19–24. subregions are missing (Fig. 1) or whether the
Windham, G. C., Anderson, M. C., Croen, L. A., Smith, entire corpus callosum is absent (Fig. 2). In both
K. S., Collins, J., & Grether, J. K. (2011). Birth prev- cases, the anterior commissure – a smaller white
alence of autism spectrum disorders in the San matter tract connecting ventral frontal regions –
Francisco Bay Area by demographic and ascertain-
ment source characteristics. Journal of Autism and is almost always intact, with abnormalities lim-
Developmental Disorders, 41, 1362–1372. ited to the CC.
Commissurotomy is a surgical procedure that
typically involves severing all fiber tracts
connecting the hemispheres, including the CC,
to treat intractable epilepsy in which seizures
Agenesis of Corpus Callosum that start in one hemisphere propagate to the
other hemisphere. Callosotomy is a subtype of
Thomas Frazier1 and Antonio Hardan2 commissurotomy that involves only severing of
1
Research Center for Autism, The Cleveland the CC.
Clinic, Cleveland, OH, USA
2
Department of Psychiatry and Behavioral
Sciences, Stanford University, Stanford, Epidemiology
CA, USA
AgCC has been estimated to occur in at least 1 in
4,000 births, with one study identifying 2 cases in
Synonyms 2,309 neonates (Wang, Huang, & Yeh, 2004).
AgCC is often associated with other developmen-
Acallosal syndrome; Callosotomy (surgical tal or neurogenetic syndromes including Arnold-
severing); Complete agenesis; Dysgenesis (mal- Chiari malformation, Dandy-Walker syndrome,
formation); Hypogenesis (partial formation); Aicardi’s syndrome, holoprosencephaly, and
Hypoplasia (underdevelopment); Partial agenesis numerous others. Approximately 30–45%
of AgCC cases have currently identifiable genetic
syndromes or chromosomal abnormalities.
Short Description or Definition This percentage is likely to increase
with advances in the sensitivity of genetic testing
The corpus callosum (CC) is the largest white and the identification of new genetic disorders
matter fiber tract (also known as commissure) (Paul et al., 2007).
connecting the two hemispheres of the brain.
Agenesis of the corpus callosum (AgCC) is
present at birth and encompasses structural Natural History, Prognostic Factors, and
defects of the development of the corpus Outcomes
callosum that range from partial to complete
loss of these connective fiber tracts. Primary The CC is the largest and most important struc-
AgCC is a complete loss of the CC without ture for interhemispheric transfer of information.
other accompanying brain changes. A rare indi- It contains fibers that connect both homotopic and
vidual diagnosed with autism or ASD is found to heterotopic regions, meaning some fibers connect
have AgCC. regions of the left and right hemispheres that are
A 88 Agenesis of Corpus Callosum
information about the contributions of the CC to

cognitive and brain development. More recent
studies of babies and children with AgCC are
providing data about the developmental role of
the CC.
AgCC involves abnormal formation of the
CC, typically between the 3rd and 12th weeks
of pregnancy, and is observable at birth via neu-
roimaging methods such as MRI. Several genetic
disorders and syndromes have been associated
with AgCC, and evidence from animal work has
shown the important roles specific genes play in
the normal development of the CC. AgCC also
occurs in the context of fetal alcohol syndrome
with 7% of individuals with fetal alcohol syn-
drome showing near complete AgCC and
Agenesis of Corpus Callosum, Fig. 1 Partial AgCC a greater proportion having partial AgCC or
other CC malformations (Roebuck, Mattson, &
Riley, 1998).
The cognitive impairments associated with
AgCC are quite variable, although some consis-
tent findings have emerged. Studies of younger
children have identified developmental delay,
learning difficulties, or behavior problems in the
majority of AgCC cases (Goodyear, Bannister,
Russell, & Rimmer, 2001; Shevell, 2002). Indi-
viduals with complete AgCC may have worse
cognitive function and outcomes (Paul et al.,
2007), although this has not been consistent
across studies. Interestingly, although AgCC
patients tend to show at least mild cognitive or
behavioral difficulties, they do not exhibit the
classic disconnection pattern shown by adult
“split-brain” patients who had all commissures
Agenesis of Corpus Callosum, Fig. 2 Complete AgCC
surgically severed, including the CC. Thus, indi-
viduals with congenital AgCC frequently show
directly analogous (e.g., the left and right supe- intact ability to transfer visual and auditory infor-
rior temporal regions), while others connect mation across the left and right hemispheres. This
regions that are not directly analogous (e.g., the may be because most AgCC patients have an
left superior temporal and right middle temporal intact anterior commissure and this structure
regions). CC function was first examined by may support some compensation of
studying the cognitive skills of individuals who interhemispheric transfer.
underwent commissurotomy or callosotomy, AgCC can have substantial impact on specific
often called “split-brain” patients. These studies cognitive functions. For example, many individ-
were useful for demonstrating specialization of uals with AgCC show significant differences in
the left and right halves of the brain. However, their verbal and nonverbal (visual) abilities,
because these patients typically had surgical although which area is stronger varies across
severing later in life, these studies did not provide individuals (Chiarello, 1980; Sauerwein, Nolin,
Agenesis of Corpus Callosum 89 A
& Lasonde, 1994). The most prominent deficits others showing significant intellectual disability
are in complex tasks that involve integration of and dependence on caregivers for even basic
multiple facets of information or rapid processing needs. Important prognostic factors may include A
of complex arrays of stimuli. Thus, impairments the level of agenesis (mentioned above) and the
may involve abstract reasoning (Brown & Paul, extent of other brain abnormalities.
2000), problem solving (Fischer, Ryan, &
Dobyns, 1992), and the ability to generalize
a rule from one situation to another (Solursh, Clinical Expression and
Margulies, Ashem, & Stasiak, 1965) and to Pathophysiology
quickly generate examples from a category
(e.g., specific names of animals or fruits and As mentioned above, clinical features are highly
vegetables) (David, Wacharasindhu, & Lishman, variable but include variable deficits in general
1993). Deficits have also been observed in under- cognitive ability, large differences between ver-
standing pragmatic aspects of language, includ- bal and nonverbal abilities, fairly consistent def-
ing problems in understanding idioms, icits in specific tasks that require rapid processing
metaphors, sarcasm, and other forms of nonliteral of complex information, social perception and
language and humor. Individuals with AgCC skill weaknesses, and alexithymia. Developmen-
often show alexithymia or difficulty with verbally tal manifestations are not well known but are
reporting emotional states and experiences. likely to be also highly variable with some indi-
Parents of individuals with AgCC also frequently viduals showing mild early delays with relatively
report social skill deficits. intact functioning later and others showing con-
Not surprisingly, given deficits in the processing sistently low levels of ability and functioning
of complex social and contextual information and throughout the life span.
parent reports of social weaknesses, AgCC has
been identified in individuals diagnosed with
autism or Asperger’s syndrome, or perhaps more Evaluation and Differential Diagnosis
accurately, some individuals with AgCC have been
diagnosed with Asperger’s disorder or other ASD. Asymptomatic AgCC is by definition hard to iden-
However, it is important to note that the vast tify or diagnose since neuroimaging studies are not
majority of individuals with autism do not have conducted without an indication. However, with
AgCC and not all individuals with AgCC would be prenatal ultrasound examination becoming more
diagnosed with an autism spectrum disorder. Thus, common, it is possible that identification of corpus
the two conditions overlap, but are not redundant. callosum abnormalities may become more fre-
The best known example of this overlap is Kim quent. These alterations can be detected at
Peek, the inspiration for the movie Rain Man who 20 weeks of gestation, and once identified, associ-
was widely known for his savant skills. These skills ated features should be investigated (Vergani et al.,
included photographic memory and an amazing 1994). In the majority of cases, a specific syndrome
ability to read and remember vast amounts of is diagnosed either during pregnancy or immedi-
information in a short period of time. However, ately after birth. In young children and older indi-
Kim Peek was not a typical example of primary viduals, the presence of associated features such as
AgCC because, in addition to having complete seizures or developmental delays can prompt
AgCC, he also was missing the anterior commis- a comprehensive evaluation, including brain imag-
sure, had macrocephaly and cerebellar malforma- ing that leads to diagnosis (see ▶ American
tion, and may have had a genetic syndrome (FG Academy of Neurology). When AgCC is associ-
syndrome) linked to the X chromosome. ated with a neurogenetic condition, the clinical
Adult outcomes of AgCC, even primary features of this syndrome will be more evident.
AgCC, are highly variable with some individuals The list of conditions associated with anomalies
showing intact overall ability and functioning and of the CC is long and includes Chiari II
A 90 Ages and Stages Learning Activities
malformations, Andermann’s syndrome (intellec- the corpus callosum: Genetic, developmental and
tual disability and polyneuropathy), and Joubert’s functional aspects of connectivity. Nature Reviews
Neuroscience, 8, 287–299.
syndrome type III (absence of cerebellar vermis Roebuck, T. M., Mattson, S. N., & Riley, E. P. (1998).
and polymicrogyria). A review of the neuroanatomical findings in children
with fetal alcohol syndrome or prenatal exposure to
alcohol. Alcoholism, Clinical and Experimental
Research, 22(2), 339–344.
Treatment Sauerwein, H. C., Nolin, P., & Lasonde, M. (1994).
Callosal agenesis: A natural split brain. New York:
There is no treatment for complete or partial Plenum.
AgCC. CC fibers will not regenerate and appro- Shevell, M. I. (2002). Clinical and diagnostic profile of
agenesis of the corpus callosum. Journal of Child
priately localize after that initial in utero critical Neurology, 17(12), 896–900.
period. Through greater understanding of the Solursh, L. P., Margulies, A. I., Ashem, B., & Stasiak,
genes and biological pathways involved, it may E. A. (1965). The relationships of agenesis of the
be possible in the future for a combination of corpus callosum to perception and learning. The Jour-
nal of Nervous and Mental Disease, 141(2), 180–189.
early detection and personalized genetic thera- Vergani, P., Ghidini, A., Strobelt, N., Locatelli, A.,
pies addressing the specific molecular problems Mariani, S., Bertalero, C., & Cavallone, M. (1994).
could produce improved outcomes in individuals Prognostic indicators in the prenatal diagnosis of agen-
with AgCC. Certainly, eliminating alcohol use in esis of corpus callosum. American Journal of Obstet-
rics and Gynecology, 170(3), 753–758.
pregnancy, particularly in the first trimester, will Wang, L. W., Huang, C. C., & Yeh, T. F. (2004). Major
reduce the number of cases of AgCC. brain lesions detected on sonographic screening of
apparently normal term neonates. Neuroradiology,
46(5), 368–373. doi:10.1007/s00234-003-1160-4.
See Also
▶ Corpus Callosum
▶ Corpus Callosum Abnormalities in Autism Ages and Stages Learning Activities
▶ Ages and Stages Questionnaire, Second Edition

Brown, W. S., & Paul, L. K. (2000). Cognitive and psy-

chosocial deficits in agenesis of the corpus callosum Ages and Stages Questionnaire,
with normal intelligence. Cognitive Neuropsychiatry, Second Edition
5, 135–157.
Chiarello, C. (1980). A house divided? Cognitive func-
tioning with callosal agenesis. Brain and Language, Tina R. Goldsmith
11(1), 128–158. Center for Development and Disability,
David, A. S., Wacharasindhu, A., & Lishman, W. A. University of New Mexico, Albuquerque,
(1993). Severe psychiatric disturbance and abnormal-
NM, USA
ities of the corpus callosum: Review and case series.
Journal of Neurology, Neurosurgery, and Psychiatry,
56(1), 85–93.
Fischer, M., Ryan, S. B., & Dobyns, W. B. (1992). Mech- Synonyms
anisms of interhemispheric transfer and patterns of
cognitive function in acallosal patients of normal intel-
ligence. Archives of Neurology, 49(3), 271–277. Ages and stages learning activities; ASQ family
Goodyear, P. W., Bannister, C. M., Russell, S., & Rimmer, access; ASQ Hub (for monitoring screening
S. (2001). Outcome in prenatally diagnosed fetal agen- programs of multiple organizations); ASQ Pro
esis of the corpus callosum. Fetal Diagnosis and Ther-
apy, 16(3), 139–145. doi:53898 (pii).
(for single-site programs) and ASQ Enterprise
Paul, L. K., Brown, W. S., Adolphs, R., Tyszka, J. M., (for multisite programs); ASQ:SE; ASQ-3 Mate-
Richards, L. J., & Mukherjee, P. (2007). Agenesis of rials Kit; ASQ-3™
Ages and Stages Questionnaire, Second Edition 91 A
Description interaction with people. Like the ASQ-3, the
ASQ:SE relies on parents to observe their child
The Ages and Stages Questionnaires (ASQ-3): and complete the measure. Each questionnaire A
A Parent-Completed Child Monitoring System, discusses social-emotional activities tied to the
Third Edition (Squires & Bricker, 2009) is a first- age of the child being screened, and by virtue of
level comprehensive screening and monitoring completing the questionnaire, parents learn about
program designed to identify infants and young social-emotional milestones as well as their child’s
children who require more extensive assessment strengths and vulnerabilities. For each item, par-
to determine whether early intervention is ents mark “most of the time” to indicate that their
warranted. It is designed to be easy to administer, child performs the behavior, “sometimes” to indi-
low-cost, and appropriate for diverse cate an occasional or emerging response, or
populations, including children suspected of hav- “rarely or never” to indicate that their child does
ing an autism spectrum disorder. The monitoring not yet perform the behavior. Parents are also
system consists of two measures and associated asked to check whether the behavior in question
user materials, the ASQ-3 and the ASQ:SE. is a concern for them, and space is provided to
The ASQ-3 includes 21 questionnaires, one for allow for open-ended, narrative responding about
each of the following ages: 2, 3, 6, 8, 9, 10, 12, 14, certain aspects of their child’s social-emotional
16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and development. Much like the ASQ-3, each
60 months. The questionnaires are designed to be response is converted to a point value, values are
completed by parents or other primary caregivers in totaled, and totals are then compared to established
less than 15 min and scored by a professional in less screening cutoff points. Following completion of
than 3 min. Each questionnaire contains 30 devel- the questionnaire, professionals may proceed with
opmental items which are organized into five areas: a referral for additional assessment and/or provide
Communication, Gross Motor, Fine Motor, Prob- learning activity sheets to support the parent in
lem Solving, and Personal-Social. An Overall sec- further promoting social-emotional development.
tion addresses general parental concerns. In order to
make the questionnaires user-friendly, items are
written at a fourth to sixth grade level and illustra- Historical Background
tions are provided. For the 30 developmental items
on each questionnaire, parents mark “yes” to indi- In the 1970s, researchers at the University of Ore-
cate that their child performs the behavior, “some- gon, led by Dr. Diane Bricker, recognized the need
times” to indicate an occasional or emerging for economical, valid, and culturally sensitive
response, or “not yet” to indicate that their child screening tools to identify young children who
does not yet perform the behavior. During the scor- might be at risk for developmental delays. Follow-
ing process, each response is converted to a point ing a landmark study on parents’ ability to report on
value, values are totaled, and totals are then com- their child’s early development (Knobloch, 1979),
pared to established screening cutoff points. Each researchers including Dr. Bricker and Dr. Jane
questionnaire comes with instructions, an informa- Squires conducted an extensive review of standard-
tion sheet for identification, activities for each ized developmental assessments and associated lit-
social-emotional area, and an information summary erature, and they selected a set of skills easily
sheet for scoring and general comments. observed or elicited by parents within the home
The ASQ:SE, which is used to screen for the environment. Using these skills, Drs. Bricker and
presence of social-emotional delays, includes Squires created a series of questionnaires that asked
eight questionnaires, one for each of the following parents simple questions about their child’s devel-
ages: 6, 12, 18, 24, 30, 36, 48, and 60 months. The opment. In response to pilot data, the questionnaires
measure addresses seven social-emotional areas: were expanded and refined, and in 1995, the
self-regulation, compliance, communication, questionnaires were first published commercially
adaptive behaviors, autonomy, affect, and by Brookes Publishing as the Ages & Stages
A 92 Ages and Stages Questionnaire, Second Edition
Questionnaires® (ASQ): A Parent-Completed, from 71% at 24 months to 85% at 60 months,

Child-Monitoring System. In 1999, a revised and with 78% overall sensitivity. Specificity of the
expanded edition of ASQ was published based on questionnaires ranged from 90% at 30 months to
continuing research and user feedback. Data collec- 98% at 6 months, with 94% overall. Percent agree-
tion on the third edition, ASQ-3, began in 2002, and ment between questionnaires and standardized
in 2009, the revised measure was published and an assessments/disability status ranged from 88% at
online management and questionnaire completion 30 months to 94% at 60 months, with overall agree-
system was launched. ment of 92%. Under-referral ranged from 2.4% at
The ASQ:SE was created in response to grow- 60 months to 4.7% at 12 months, while over-
ing demand for a screening tool for social- referral ranged from 3.0% at 18 months to 8.6% at
emotional concerns in young children. In 1995, 30 months. The ability of the ASQ:SE to detect
the development process was initiated, and the atypical social-emotional development (sensitivity)
first version of the Ages & Stages Questionnaires®: was generally lower across intervals, while speci-
Social-Emotional (ASQ:SE) took form. Items in ficity, or the ability of the ASQ:SE to correctly
the early version of the ASQ:SE were developed identify typically developing children, was high.
using multiple sources, such as standardized Specificity may have been elevated in the 6-, 12-,
social-emotional and developmental assessments, and 18-month intervals because of the large number
textbooks and other resources in developmental of “identified” children in these samples and the
and abnormal psychology, language and commu- small number of low-moderate risk children.
nication materials, and education and intervention ASQ-3: The ASQ-3 has a new standardization
resources. In 1996, validity, reliability, and utility based on a sample that closely mirrors the US
studies on a field-test version of the ASQ:SE were population in geography and ethnicity and includes
initiated. The field-test version was called the children of all socioeconomic statuses. The sample
Behavior-Ages & Stages Questionnaires (B-ASQ; includes 15,138 children whose parents completed
Squires, Bricker, Twombly, Yockelson, & Kim, 18,232 questionnaires. According to the publisher,
1996). Following initial refinement, studies reliability, validity, sensitivity, and specificity
continued between 1996 and 2001 to determine are all excellent: Test-Retest Reliability ¼ .92;
the psychometric properties of the screening Inter-rater Reliability ¼ .93; Validity ¼ .82 to
instrument, and in 2002, the Ages & Stages .88; Sensitivity ¼ .86; Specificity ¼ .85.
Questionnaires®: Social-Emotional (ASQ:SE):
A Parent-Completed, Child-Monitoring System
for Social-Emotional Behaviors was first published Clinical Uses
commercially by Brookes Publishing. Research on
ASQ:SE is ongoing. Parents or caregivers complete the ASQ-3 and
ASQ:SE questionnaires independently, or, if
necessary, with the assistance of a professional.
Psychometric Data With online questionnaire completion through the
web-based ASQ Family Access, parents are able to
ASQ:SE: According to the publisher, normative complete the ASQ-3 anytime, anywhere. The
data for the ASQ:SE were based on 3,014 com- ASQ-3 and ASQ:SE questionnaires can also be
pleted questionnaires, and validity studies were completed on paper at home; during home visits
conducted using 1,041 children. Internal consis- by nurses, social workers, or program staff; in
tency measured by coefficient alpha was found to waiting areas; or in educational centers. According
be high across intervals, ranging from .67 to .91 to the authors, the measures can be adapted to
with an overall alpha of .82. Test-retest reliability, a variety of settings, including primary care clinics,
measured as the agreement between two ASQ:SE child care settings, and teen parenting programs.
questionnaires completed by parents at 1- to Both measures are designed for easy use and gen-
3-week intervals was 94%. Sensitivity ranged erally require little training, although it is important
Agnosia 93 A
for professionals to be familiar with the information olfactory, gustatory, or tactile agnosia. It can
contained in the User’s Guide. Many programs use result from strokes, dementia, or other neurolog-
the available DVD training tools to introduce the ical disorders and illnesses. It may also be A
ASQ and show staff how to screen, score, and trauma-induced by a head injury, brain infection,
interpret results, and for programs desiring more or hereditary. Some forms of agnosia have been
training, the publishing company regularly hosts found to be genetic. It often results from damage
remote and on-site training seminars. to specific brain areas in the occipital or parietal
lobes of the brain (Kolb & Whishaw, 2003).
Agnosia is found in Landau-Kleffner syn-
See Also drome, a disorder that is included on the differ-
ential diagnosis for autism (Johnson & Myers,
▶ Developmental Milestones 2007). Landau-Kleffner syndrome (also known
▶ Early Intervention as LKS and acquired epileptic aphasia) is a rare
▶ Screening Measures childhood neurological disorder characterized by
the loss of previously acquired language mile-
stones, an inability to understand the spoken
References and Readings word and an abnormal electroencephalogram
(EEG). These children develop normally until
Squires, J., Bricker, D., Twombly, E., Yockelson, S., & between the ages of 3 to 6 in contrast to autism,
Kim, Y. (1996). Behavior-ages and stages question-
which is manifest prior to the age of 3 (Landau &
naires. Eugene: University of Oregon, Center on
Human Development. Kleffner, 1957; Teplin, 1999).
Squires, J., & Bricker, D., Twombly, E., Nickel, R., Regardless of cause, there is no direct cure for
Clifford, J., Murphy, K., Hoselton, R., Potter, L., the agnosia. Patients may improve if information
Mounts, L., & Farrell, J. (2009) Ages & stages ques-
is presented in other modalities than the damaged
tionnaires ®, 3rd edn. (ASQ-3™). Baltimore: Paul H.
Brookes. one. Different types of therapies can help to
Knobloch, H., Stevens, F., Malone, A., Ellison, P., & reverse the effects of agnosia. In some cases,
Risemberg, H. (1979). The validity of parental occupational therapy or speech therapy can
reporting of infant development. Pediatrics, 63(6),
improve agnosia, depending on its etiology.
872–878.
See Also
Agnosia
▶ Aphasia
Claudia Califano ▶ Electroencephalogram (EEG)
Yale-New Haven Hospital, New Haven, ▶ Occipital Lobe
CT, USA ▶ Occupational Therapy (OT)
▶ Parietal Lobe
▶ Speech Therapy
Definition
It is a partial or complete loss of the ability to

recognize and identify familiar objects or persons
through sensory stimuli. The specific sense is not Johnson, C. P., & Myers, S. M. (2007). American Acad-
defective nor is there any significant memory emy of Pediatrics Council on Children with Disabil-
loss. People with agnosia may retain their cogni- ities. Identification and evaluation of children
with autism spectrum disorders. Pediatrics, 120(5),
tive abilities in other areas.
1183–1215.
Agnosia may affect any of the senses and is Kolb, B., & Whishaw, Q. (2003). Fundamentals of human
classified accordingly as auditory, visual, neuropsychology. New York: Worth.
A 94 Agraphia
Landau, W. M., & Kleffner, F. R. (1957). Syndrome of See Also

acquired aphasia with convulsive disorder in children.
Neurology, 7(8), 523–530.
Teplin, S. W. (1999). Autism and related disorders. In ▶ Dysgraphia
M. D. Levine, W. B. Carey, & A. C. Crocker (Eds.),
Developmental behavioral pediatrics (3rd ed., p. 589).
Philadelphia: WB Saunders. References and Readings
Beeson, P. M., & Rapczak, S. Z. (2004). Agraphia.

In R. D. Kent (Ed.), The MIT encyclopedia of communi-
cation disorders (pp. 233–236). Cambridge, MA: MIT
Agraphia Press.
Diana B. Newman
Communication Disorders Department, Southern
Connecticut State University, New Haven,
CT, USA Aicardi Syndrome
Fred R. Volkmar
Synonyms Director – Child Study Center, Irving B. Harris
Professor of Child Psychiatry, Pediatrics and
Acquired dysgraphia Psychology, School of Medicine, Yale
Definition
Definition
Agraphia is an impairment or loss in the ability to
write in individuals (most often adults) who had A rare genetic in which the corpus callosum
typical spelling and/or handwriting prior to brain (the major connection between the right and
damage, either sudden or progressive. Agraphia left hemispheres of the brain) is either totally or
occurs as a result of damage to the cognitive, lin- partially missing. It is associated with other abnor-
guistic, and/or sensorimotor areas of the brain that malities including seizures and a form of infantile
support spelling and writing (Beeson & Rapczak, spasms as well as characteristic eye abnormalities.
2004). Lesions in specific regions in these areas It is thought likely that the source of the condition
affect the ability to retrieve words and/or their is on the X chromosome (it is observed only in
spellings and/or to form the letters to write the girls or in boys with Klinefelter’s syndrome); it is
words. also possible that the condition is lethal to males
Agraphia may be broadly categorized into two with typical XY chromosome patterns – i.e., that
types: central or peripheral. Central agraphia affects the pregnancies miscarry.
an individual’s ability to spell, while peripheral First recognized by Jean Aicardi, a French
agraphia is characterized by handwriting difficul- neurologist, in 1976, the condition usually has
ties (Beeson & Rapczak, 2004). Additionally, its onset in the first months of life. The condition
visual perceptual changes that impair handwriting is rare. Although very likely to have a genetic
are not uncommon in those with brain injury. cause, it is thought that all cases arise as a result
Although the characteristics of agraphia are of new mutations.
similar to those of developmental dysgraphia, the Treatment involves symptomatic management
defining feature of agraphia is a history of typical and treatment of associated problems, e.g., seizures,
writing skills before writing difficulties appeared; feeding problems, and sometimes hydrocephalus.
therefore, agraphia is not seen in children and Although outcome appears to vary, the condition is
adolescents with autism spectrum disorders (ASD). associated with significant cognitive delays.
Aler-Cap [OTC] 95 A
See Also inhibitors. In the class of antipsychotic medica-
tions, akathisia is more likely to occur with the
▶ Infantile Spasms/West Syndrome older antipsychotics such as haloperidol, but it A
may occur with the newer antipsychotics such as
risperidone. Patients typically describe a feeling of
References and Readings internal restlessness and an inability to sit still. The
observer might see the patient jiggling a leg while
Booth, R., Wallace, G. L., et al. (2011). Connectivity and sitting or even kicking the leg out from the sitting
the corpus callosum in autism spectrum conditions:
position. In more extreme cases, the person may be
Insights from comparison of autism and callosal
agenesis. Progress in Brain Research, 189, 303–317. unable to sit at all and will get up and pace around
Glasmacher, M. A., Vr, S., Hopkins, B., Eble, T., Lewis, the room.
R. A., Park Parsons, D., et al. (2007). Phenotype and The cause of akathisia is not completely under-
management of Aicardi syndrome: New findings from
stood. It usually does not improve with anticholin-
a survey of 69 children. Journal of Child Neurology,
22, 176–184. ergic medications that are often effective for other
Kinsman, S. L., & Johnston, M. V. (2007). Congenital neurologically based adverse effects of antipsy-
abnormalities of the central nervous system, chap 592. chotic medications. The first response is to lower
In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. F.
the medication, beta blockers, or switching to
Stanton (Eds.), Nelson textbook of pediatrics (18th ed.).
Philadelphia: Saunders Elsevier. another antipsychotic medication may be helpful.
BARNES AKATHISIA SCALE: Barnes
Akathisia Rating Scale (BAS) was introduced in
late 1980s. It consists of four items that are
Aide divided into objective item, subjective item, and
an overall global scale. It is the most commonly
▶ Para-educator used scale for measuring akathisia.
▶ Paraprofessional

AIMS
Barnes, T. (1989). A rating scale for drug-induced
akathisia. British Journal of Psychiatry: Journal of
▶ Abnormal Involuntary Movement Scale Mental Science, 154, 672–676.
Akathisia Alcohol-Related
Neurodevelopmental Disorder
Lawrence David Scahill
Nursing & Child Psychiatry, Yale University ▶ Fetal Alcohol Spectrum Disorder
School of Nursing, Yale Child Study Center,
New Haven, CT, USA
ALD
Definition ▶ Adrenoleukodystrophy
AKATHISIA: Akathisia is an adverse medication
effect described as an unpleasant feeling
of restlessness. It is most often associated with Aler-Cap [OTC]
antipsychotic medication, but may occur with anti-
depressant medications such as serotonin reuptake ▶ Diphenhydramine
A 96 Aler-Dryl [OTC]
Principal Investigator for the Autism Subproject –

Aler-Dryl [OTC] Diagnosis and classification of autistic children –
of the NIH program project grant: Nosology:
▶ Diphenhydramine Higher Cerebral Function Disorders in Children
(NS 20489) (1985–1993).
Aler-Tab [OTC] Major Honors and Awards
▶ Diphenhydramine President’s Scholarship, Teachers College,

Columbia University (1964–1966).
Principal Investigator, NIH grant: The develop-
ment of communicative competence in
Allele Similarity prematurely born children (1977).
Assistant Professor to Professor of Clinical Child
▶ Zygosity Psychiatry and Clinical Pediatrics, Albert Ein-
stein College of Medicine, 1977–2002.
Principal Investigator for the Autism Subproject –
Diagnosis and classification of autistic
Allen, Doris children – of the NIH program project grant:
Nosology: Higher Cerebral Function Disor-
Isabelle Rapin ders in Children (NS 20489) (1985–1993).
Neurology and Pediatrics (Neurology), Albert
Einstein College of Medicine, Bronx,
NY, USA Landmark Clinical, Scientific, and
Professional Contributions
Name and Degrees (All at Albert Einstein College of Medicine,

Bronx NY, USA)
Allen, Doris A., 1932–2002 • Director of the Therapeutic Nursery in the
BA – English/Speech Pathology/Audiology (1954) Division of Child Psychiatry of the Albert
MA – Applied Linguistics, Teachers College, Einstein College of Medicine, 1978–1995.
Columbia University, New York City (1964) Director after its move to Tenafly NJ:
MA – Psychology, Teachers College, Columbia 1995–2002.
University, New York City (1971) • Developed a parent-child intervention model
EdD – Psycholinguistics, Teachers College, in the Nursery for educating preschool chil-
Columbia University, New York City (1973) dren with autism spectrum disorders without
mental retardation.
• Trained generations of residents/fellows in
Major Appointments (Institution, child psychiatry, child neurology, and pediat-
Location, Dates) rics to recognize milder autism spectrum disor-
ders and how they can be managed effectively.
Post doctoral Multidisciplinary Fellowship in • Trained many graduate students and postdoc-
Neuroscience, Albert Einstein College of toral neuropsychology and speech/language
Medicine, Bronx, NY (1974–1976) pathology fellows in the diagnosis, education,
Assistant Professor to Professor of Clinical Child and management of children with autism.
Psychiatry and Clinical Pediatrics, Albert Ein- • Led the Einstein research group on language
stein College of Medicine, 1977–2002. disorders in preschoolers.
Allen, Doris 97 A
• Was principal investigator of the autism with tremendous improvement in the quality
subproject and investigator of the Autism of life for everyone.
Subproject of the multidisciplinary multiinsti- While at Einstein – and even now – the Nurs- A
tutional Nosology project. ery served as laboratory for research. Equally
• With I. Rapin developed a neurologically and important, it provided the opportunity for physi-
linguistically based clinical classification of cian trainees in child psychiatry, child neurology,
developmental language disorders in pre- and pediatrics to learn to spot mildly affected
schoolers with/without autism for clinicians’ children likely to respond to appropriate educa-
use in their offices. tional intervention. Dr. Allen trained child psy-
chiatrists, as well as graduate students and
postdoctoral fellows, in psychology and speech/
Short Biography language pathology in the diagnosis, education,
and treatment of children with autism. She was
Born and brought up in Indiana, Dr. Doris A. invited to lecture by many parent groups and at
Allen started her professional life as an English professional meetings in the USA and abroad.
teacher and mother of three sons. She subse- Among her distinguished trainees are the child
quently relocated to New York, was remarried neuropsychologists Dr. Michelle A Dunn, an Ein-
to Dr. Robert L. Allen, Professor of Linguistics stein Professor, and Dr. Hilary Gomes,
at Columbia University where she obtained mas- a Professor at City University of New York Grad-
ter’s degrees in both psychology and applied uate Center, who use electrophysiology to study
developmental psycholinguistics and language in autism (Dunn, Vaughan, Kreutzer, &
a doctorate in linguistics. After a 2-year post- Kurtzberg, 1999; Dunn, Gomes, & Sebastian,
doctoral fellowship in neuroscience at Albert 1996). Dr. Dunn has developed an innovative
Einstein College of Medicine, she was visually based curriculum for children with
appointed to the faculty and as Director of the ASD of all ages mainstreamed to regular classes
Therapeutic Nursery in the Division of Child (Dunn, 2005; Fein & Dunn, 2007). Another
Psychiatry. She turned it around from Freudian trainee, Dr. Mary Jure, has replicated with suc-
therapy of mothers to education of high func- cess the Einstein nursery in Cordoba, Argentina.
tioning preschoolers with autism spectrum dis- Still another, Dr. Sylvie Goldman, studies narra-
orders (ASD), with a curriculum focused on tive in children with autism (Goldman, 2008), its
social skills, communicative language, and male preponderance (Pfaff, Rapin, & Goldman,
self-management (Allen & Mendelson, 2000). 2011), and repetitive movements viewed as
Dr. Allen recognized much earlier than most movement disorder rather than self-stimulation
investigators that, besides severely impaired (Goldman et al., 2009).
and intellectually deficient children with classic Dr. Allen was the leader of the Einstein
autistic disorder, there are many intelligent chil- research group on language deficits in pre-
dren on the autism spectrum for whom early, schoolers (Allen, 1988; Rapin & Allen, 1987)
intensive, specialized intervention may enable and Co-principal Investigator for autism in the
them to grow up to become independent or Nosology project (Fein et al., 1996). She stressed
nearly independent adults. that effective remediation required subtyping of
Dr. Allen developed the novel and highly language deficits in order to address each child’s
effective parent-child model for the Nursery needs individually (Allen, Mendelson, & Rapin,
in which a caretaker attends school daily with 1989; Allen, 1994). She teamed with Dr. Isabelle
the preschooler and is trained “in the Rapin, a child neurologist, to develop a neurolog-
trenches” to manage severe behavioral out- ically and linguistically based clinical classifica-
bursts (“meltdowns”) and to communicate tion of developmental language disorders for
more effectively with their child. Other family nonspecialists applicable to any young child,
members receive some counseling as well, whether on the autism spectrum or not. They
A 98 Allen, Doris
found that there are several subtypes of language dysphasia. In J. H. French, S. Harel, P. Casaer, M. I.
disorders in autism, including some affecting Gottlieb, I. Rapin, & D. C. De Vivo (Eds.), Child neu-
rology and developmental disabilities (pp. 233–243).
phonology and grammar (Allen & Rapin, 1992; Baltimore: Paul Brookes.
Rapin, Dunn, Allen, Stevens, & Fein, 2009). Allen, D. A., & Rapin, I. (1992). Autistic children are also
Major distinctions between autism and develop- dysphasic. In H. Naruse & E. Ornitz (Eds.), Neurobi-
mental language disorders are different subtype ology of infantile autism (pp. 73–80). Amsterdam:
Excerpta Medica.
prevalences, together with defective comprehen- Dunn, M. (2005). S.O.S.: Social skills in our schools
sion and universal and persistently impaired program (A Social Skills program for children with
pragmatics (communication skills) in ASD. Pervasive Developmental Disorders and their typical
Dr. Allen coined the term semantic-pragmatic peers). Shawnee Mission, KS: Autism and Asperger.
Dunn, M., Gomes, H., & Sebastian, M. (1996).
language disorder, now widely used, to describe Prototypicality of responses in autistic language disor-
chatty children whose expressive language is dered and normal children in a verbal fluency task.
superior to their comprehension of discourse, Child Neuropsychology, 2, 99–108.
whether or not they fulfill criteria for an ASD Dunn, M., Vaughan, H. G., Jr., Kreutzer, J., & Kurtzberg,
D. (1999). Electrophysiologic correlates of semantic
(Rapin & Allen, 1998). classification in autistic and normal children. Develop-
In short, Dr. Allen’s interest in preschoolers mental Neuropsychology, 16, 75–99.
with inadequate language and behavior and their Fein, D., & Dunn, M. A. (2007). Autism in your class-
treatment led to many publications, lectures, and room: A general educator’s guide to students with
autism spectrum disorders (1st ed.). Bethesda, MD:
the training of many professionals in the USA and Woodbine House.
abroad. Perhaps her most enduring contribution is Fein, D., Dunn, M., Allen, D. A., Aram, D. M., Hall, N.,
the innovative and effective model for educating Morris, R., et al. (1996). Language and neuropsycho-
preschoolers with ASD, as indicated by the logical findings. In I. Rapin (Ed.), Preschool children
with inadequate communication: Developmental lan-
majority of the graduates of her therapeutic nurs- guage disorder, autism, low IQ (pp. 123–154). Lon-
ery able to be educated in regular classrooms with don: Mac Keith Press.
or without the need for an aide and many among Goldman, S. (2008). Narrative abilities of children with
the older ones graduating from college or other autism and developmental language disorders: Scripts
versus stories. Journal of Autism and Developmental
higher education who are now independently Disorders, 38, 1982–1988.
employed. Goldman, S., Wang, C., Salgado, M. W., Greene, P. E.,
Kim, M., & Rapin, I. (2009). Motor stereotypies in
children with autism and other developmental disor-
ders. Developmental Medicine & Child Neurology, 51,
References and Readings 30–38.
Pfaff, D. W., Rapin, I., & Goldman, S. (2011). Male
Allen, D. A. (1988). Autistic spectrum disorders: Clinical preponderance in autism: Neuroendocrine influences
presentation in preschool children. Journal of Child on arousal and social anxiety. Autism Research, 4,
Neurology, 3, s48–s56. 1–14.
Allen, D. A. (1994). Tratamiento educativo para ninos Rapin, I., & Allen, D. A. (1987). Developmental dyspha-
autistas preescolares. In N. Fejerman, H. A. Arroyo, sia and autism in preschool children: characteristics
M. E. Massaro, & V. L. Riggieri (Eds.), Autismo and subtypes. In J. Martin, P. Fletcher, P. Grunwell, &
Infantil Y Otros Trastornos del Desarrollo (pp. 109– D. Hall (Eds.), Proceedings of the first international
121). Buenos Aires: Paidos. symposium on specific speech and language disorders
Allen, D. A., & Mendelson, L. (2000). Parent, child, and in children (pp. 20–35). London: AFASIC.
professional: meeting the needs of young autistic chil- Rapin, I., & Allen, D. A. (1998). The semantic-pragmatic
dren and their families in a multidisciplinary therapeu- deficit disorder: Classification issues. International
tic nursery model. In S. Epstein (Ed.), Autistic Journal of Language & Communication Disorders,
spectrum disorders and psychoanalytic ideas: 33, 82–87.
Reassessing the fit (pp. 704–731). Hillsdale, NJ: The Rapin, I., Dunn, M., Allen, D. A., Stevens, M., & Fein, D.
Analytic Press. (2009). Subtypes of language disorders in schoolage
Allen, D. A., Mendelson, L., & Rapin, I. (1989). Syndrome children with autism. Developmental Neuropsychol-
specific remediation in preschool developmental ogy, 34, 1–9.
Allergies 99 A
common food allergens are milk, fish, shellfish,
Allergies peanuts, tree nuts, eggs, wheat, and soy. Allergy
workup may be initiated after a history of symp- A
Susan Hyman toms after exposure to an allergen. Blood tests
Division of Neurodevelopmental and Behavioral such as the enzyme linked immunosorbent
Pediatrics, University of Rochester Golisano assay (ELISA) or radioallergosorbent testing
Children’s Hospital, Rochester, (RAST) may detect specific IgE antibodies
NY, USA associated with allergic response. Blood testing
is not as accurate as skin testing. Skin prick,
intradermal, or patch testing characterizes an
Synonyms individual’s response to allergens administered
using standard procedures and measurement of
Hay fever response.
The best treatment for allergies is to avoid the
allergen responsible for symptoms. Symptom-
Definition atic relief may be possible with antihistamines,
eyedrops, and topical or oral steroid prepara-
An allergy is the body’s exaggerated response to tions depending on the type of symptom. Treat-
a foreign antigen (substance) or allergen that ment of asthma may require both management
results in an immune response leading to of the allergy and medication to address lung
a reaction such as allergic conjunctivitis (itchy function. People who respond to allergens with
eyes), allergic rhinitis (runny nose), anaphy- anaphylaxis must carry epinephrine for injec-
laxis (allergic shock), asthma, atopic dermatitis, tion since anaphylaxis may be fatal. Allergy
eczema, hives, serum sickness, or contact der- shots or immunoprophylaxis is a type of treat-
matitis (skin rash). The body makes antibodies ment that is usually supervised by a medical
(immunoglobins) that attach to foreign particles doctor specializing in allergy and immunology
like allergens and viruses to allow the immune where small amounts of the target allergen are
system to dispose of them. People who are aller- injected into a patient to help build up antibody
gic to a compound will make the immunoglobin response.
type IgE in response to exposure to that com-
pound. Common allergens include dust mites,
animal dander, pollen, and foods. Allergic con- See Also
tact dermatitis is not mediated through IgE.
While there is genetic predisposition to aller- ▶ Food Intolerance
gies, it requires a period of exposure (sensitiza-
tion) for a person to make antibodies and
develop symptoms. The production of anti- References and Readings
bodies in response to an allergen leads to aller-
gic symptoms through release of chemicals such http://familydoctor.org/online/famdocen/home/common/
allergies/basics/083.printerview.html
as histamine from the body’s own cells which
http://www.jacionline.org/article/S0091-6749%2810%29
leads to inflammation. Allergies may start at any 01566-6/fulltext
age. Some allergic manifestations such as http://www.medicinenet.com/allergy/article.htm
asthma may be more problematic in childhood. http://www.webmd.com/a-to-z-guides/allergy-tests
NAIAD Sponsored Expert Panel. (2010). Guideline for
Food allergies may present as tingling or swell-
diagnosis and management of food allergy in the US:
ing of the throat and tongue, nausea, diarrhea, Report of the NAIAD sponsored expert panel. Journal
skin reactions, or even anaphylaxis. The most of Allergy and Immunology, 126(6), S1–S58.
A 100 AllerMax ® [OTC]
phrases. If they reach this level of communica-

AllerMax ® [OTC] tion, they will use the minimum number of words
to convey basic needs. Most importantly, these
▶ Diphenhydramine children do not use speech as a means of social
interaction. Speech is simply a way of getting
what they want.
As children, most of the aloof group have no
Aloof Group symbolic pretend play. They may manipulate
objects but show no signs of pretending that
Judith Gould toys represent real things. They do not build up
NAS Lorna Wing Centre for Autism, Bromley, an inner world of imagination for themselves.
Kent, United Kingdom Instead, they fill their time with repetitive, stereo-
typed activities. Such children may engage for
hours on one pursuit which totally absorbs them
Definition such as lining up toys or twiddling an object close
to their eyes.
Lorna Wing and Judith Gould (1979) in their The more able aloof individuals may have
epidemiological study identified individual complex elaborate repetitive routines such as
children who did not fit neatly into definitive collecting objects, organizing objects into pat-
categories but whose pattern of skills and behav- terns, bedtime rituals, and taking the same
ior could be described as part of a spectrum of route to places. Aloofness and indifference to
autistic conditions. others are most likely to persist throughout
There were three aspects, social interaction, childhood into adult life in individuals who
communication (verbal and nonverbal), and are severely intellectually disabled. The more
imagination. Children with difficulties in intellectually able aloof group may demon-
these areas also showed repetitive patterns of strate special skills usually in visuospatial
behavior. The manifestations of different prob- skills and rote memory.
lems in social interaction could be grouped
into three types, Aloof, Passive, and Active
but Odd. See Also
The aloof group closely resembled the then
popular image of autism which had been ▶ Kanner, Leo
described by Kanner (1943) and Kanner & ▶ Wing, Lorna
Eisenberg (1956). These individuals are the
most cut off from social contact. If they do
make contact, it is essentially needs led. They References and Readings
may respond to (and may initiate) physical con-
tact only, including rough and tumble games, Kanner, L. (1943). Autistic disturbances of affective con-
chasing, cuddling but are otherwise indifferent. tact. Nervous Child 2:217–250. “Reprint”. Acta
This pattern of social interaction is linked with Paedopsychiatr 35(4):100–136. 1968. PMID
4880460.
problems in understanding and use of verbal and
Kanner, L., & Eisenberg, L. (1956). Early infantile Autism
nonverbal communication. Many persons in this 1943–1955. The American Journal of Orthopsychia-
group lack communication skills all their lives. If try, 26, 55–65.
they do develop speech there are often unusual Wing, L., & Gould, J. (1979). Severe impairments of
social interaction and associated abnormalities
aspects of communication, e.g., echolalia, rever- in children: Epidemiology and classification.
sal of pronouns, repetitiveness, idiosyncratic use Journal of Autism and Developmental Disorders, 9,
of words or phrases, and abbreviations of 11–29.
Alprazolam 101 A
tricyclic antidepressant-related jitteriness
Alpha (a) Error syndrome, and valproate-induced tremors.
Observed side effects include drowsiness, light- A
▶ False Positive headedness, dizziness, depression, tiredness,
nausea, insomnia, and diarrhea.
Alpha-Amino Acid N
N
▶ Amino Acids
N
Cl
Alprazolam
Maureen Early1, Logan Wink1,2,

Craig Erickson1,2 and Christopher J. McDougle3
1
Christian Sarkine Autism Treatment Center,
Indianapolis, IN, USA
2
Department of Psychiatry, Indiana University
3
Lurie Center for Autism/Harvard Medical See Also
▶ Benzodiazepines
Synonyms
8-Chloro-1-methyl-6-phenyl-4H-s-triazolo [4,3-a]
[1,4] benzodiazepine; Niravam; Xanax; Xanax XR Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J.
(2001). Principles and practice of psychopharma-
cotherapy (3rd ed.). Philadelphia: Lippincott Williams
& Wilkins.
Definition Oswald, D. P., & Sonenklar, N. A. (2007). Medication
use among children with autism-spectrum disorders.
A prescription drug in the group of triazoloben- Journal of Child and Adolescent Psychopharmacology,
zodiazepines in the family of benzodiazepines 17, 348–355.
Raj, A., & Sheehan, D. (2006). Benzodiazepines. In
initially FDA-approved for medical use in the A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials
year 1981 with the chemical formula of clinical psychopharmacology (2nd ed.,
C17H13ClN4. This compound has low water pp. 181–197). Washington, DC: American Psychiat-
solubility and high lipid solubility. This drug ric Publishing.
Stahl, S. M. (2000). Benzodiazepines. Drug treatments for
acts as a central nervous system depressant and obsessive-compulsive, panic, and phobic disorders.
is mostly metabolized by cytochrome P450 In S. M. Stahl (Ed.), Essential psychopharmacology:
(CYP450) enzyme 3A4. This high-potency Neuroscientific basis and clinical applications
benzodiazepine with a half-life of 10–15 h is (pp. 354–355). Cambridge: Cambridge University
Press.
FDA-approved for the treatment of panic disor- U.S. Food and Drug Administration. (2011).
der and anxiety disorders and can also be used to Drugs@FDA. Retrieved from http://www.accessdata.
treat seizures, premenstrual dysphoric disorder, fda.gov/scripts/cder/drugsatfda/index.cfm
A 102 Altaryl [OTC]
Alternative Communication (ISAAC) in 1983.

Altaryl [OTC] Before this, AAC was not a unified field and existed
as a combination of interventions (communication
▶ Diphenhydramine boards and sign language) and products designed
for individuals with speech and motor impairments.
In fact, the use of augmentative or alternative com-
munication for individuals with speech impair-
Alterations in Chromosome ments may have first been introduced in the 1920s
Structure or Number in the form of communication boards for individ-
uals with cerebral palsy. The 1960s and 1970s saw
▶ Chromosomal Abnormalities an increase in the use of technology for AAC
purposes. Typewriters that used innovative input
methods such as a sip-and-puff switch were
invented. Speech-output devices were invented
Alternative Communication in the 1970s, and portable speech-output devices
were available shortly thereafter. For a more
Vannesa T. Mueller detailed look at the early history of AAC, see
Speech-Language Pathology Program, Vanderheiden (2002).
University of Texas at El Paso College of Health The field of AAC has seen many changes in
Science, El Paso, TX, USA terms of application and philosophies. Early
assessment models focused on AAC candidacy.
Often much time and thought was spent examin-
Definition ing a client’s qualifications for AAC interven-
tions. This resulted in the thought that many
Alternative communication (also called augmenta- individuals were too “something” for AAC and
tive and alternative communication or AAC) is an therefore not deemed appropriate for AAC
area of clinical practice within the field of speech services. Individuals may have been seen as hav-
pathology. A definition of AAC is provided by the ing too little linguistic functioning, too much
American Speech-Language-Hearing Association linguistic functioning, too cognitively impaired,
(ASHA). According to ASHA, AAC “includes all too high functioning, having too limited motor
forms of communication (other than oral speech) abilities, etc. This resulted in many individuals
that are used to express thoughts, needs, wants, and who could have benefited from AAC technolo-
ideas” (ASHA, 1997). The types of AAC include gies not receiving proper services.
aided and unaided communication systems. Aided Another factor which resulted in missed
systems are those that require something other than opportunities to provide AAC solutions was the
the individuals’ body to communicate. That “some- erroneous idea that the use of augmentative com-
thing” could be picture symbols, written words, or munication would act as a crutch for individuals
a high-tech, speech generating device. Conversely, with speech impairments. It was feared by many
unaided systems are those that do not require any- in the field that those who used AAC would not
thing separate from one’s own body to communi- learn to communication vocally despite research
cation. Essentially, gestures, body language, and to the contrary.
sign language are examples of unaided systems.
Rationale or Underlying Theory

The rationale for augmentative and alternative
The field of AAC began with the development of communication can be found in the term itself.
the International Society for Augmentative and AAC is first augmentative. The purpose for this
Alternative Communication 103 A
type of intervention is to augment or supplement focus on allowing an individual with speech
the speech an individual naturally possesses. For impairment to participate in their environment
some individuals, however, this intervention is an to the same extent as that of their peers. A
alternative form of communication. These individ- Beukelman and Mirenda (2005) also give strate-
uals have no means of verbal speech and so need to gies and recommendations for implementing
implement an alternative form. AAC is the means AAC for both nonsymbolic and symbolic begin-
by which these individuals communicate. ning communicators. Nonsymbolic beginning
communicators are those who use nonsymbolic
communication such as gestures, facial expres-
Goals and Objectives sion, cries, or grunts. Symbolic beginning
communicators use some form of symbolic com-
The goal of AAC is functional communication. munication such as words (spoken or written) or
Rate of message transfer is different for the dif- symbols with low- or high-tech communication
ferent forms of AAC. Sign language, when pro- devices. The authors state that “opportunity for
duced by a fluent signer, can be produced as communication is at least as important to the
quickly as spoken speech (Bellugi & Fischer, success of a communication intervention as the
1972). However, communication through means availability of an appropriate system” (p. 272).
of an alternative communication device occurs at Additionally, the authors provide techniques
an excruciatingly slow 15 words per minute related to shaping intentional communication,
(Foulds, 1987) compared to 150–250 words per using scripted routines, providing natural conse-
minute for speakers (Goldman-Eisler, 1986). quences, and using structured instructional tech-
Therefore, rate of communication should not be niques such as the adapted strategic instruction
expected to occur as fast as spoken communica- model (A-SIM), structured practice, and conver-
tion for individuals who use aided systems. sational coaching.
Treatment Participants Efficacy Information
Any individual who has impaired communication Efficacy research in the field of AAC is
is a candidate for AAC. Therefore, because com- a relatively new addition to the literature.
munication impairments are a hallmark of autism Bedrosian (1999) states that much early research
spectrum disorders (ASDs) (Mirenda, 2009), in the field, as it should have been, was devoted to
most individuals with ASDs are candidates for descriptive studies relating to describing the com-
a total communication approach. munication of AAC users. Since that publication,
The currently used assessment model is called many more research studies have been conducted
the participation model (see Beukelman & that are devoted to the efficacy of AAC for
Mirenda, 2005 for a thorough description of the specific populations. Autism is one of those
model). The model emphasizes those areas that an populations that has been widely studied. Over-
individual is not able to take part in due to their whelmingly, the use of AAC has resulted in
communication impairments. As such, this model increased language skills in children with autism
is inclusive and appropriate for any individual who over treatment approaches that focus on speech
has communication needs in any area of their life. alone. For most individuals with autism,
accessing their relative strength in the visual
domain has resulted in faster and more complex
Treatment Procedures language growth in both signing and speaking.
The use of manual signing in combination with
Using the participation model (Beukelman & speech training has been shown to increase lan-
Mirenda, 2005) as a guide, AAC interventions guage skill. The use of nonelectronic-aided
A 104 Alternative Communication
systems such as picture use has also been shown found on their website. A few short questions
to increase functional communication, and a wide posed to the speech-language pathologist can
range of individuals with autism have been able reveal whether they are comfortable with the
to make use of this type of communication. High- area of AAC.
tech AAC use has been shown to increase lan-
guage abilities and speech output in individuals
with autism as well. See Goldstein (2002) and See Also
Mirenda (2002) for reviews.
A meta-analysis of available research related ▶ American Sign Language (ASL)
to AAC use was conducted by Millar, Light, and ▶ Assistive Devices
Schlosser (2006). Although the meta-analysis ▶ Communication Board
was not focused only on individuals with autism, ▶ Low-Technology Device
the major finding was that use of AAC does “not ▶ Manual Sign
have a negative impact on speech production” ▶ Pictorial Cues/Visual Supports (CR)
(p. 257) and, in fact, speech production increased ▶ Sign Language
in individuals ages 2 years to 60 years as a result ▶ Total Communication (TC) Approach
of AAC interventions and across a range of dif- ▶ Voice Output Communication Aids
ferent AAC interventions (aided and unaided).
Outcome Measurement References and Readings
ASHA (1997). Augmentative and alternative communica-

Because the goal of AAC use is functional com- tion (AAC). Retrieved on 20 July 2011, from http://
munication, the outcome measurement should be www.asha.org/public/speech/disorders/AAC.htm.
the same. Functional communication of course Bedrosian, J. L. (1999). AAC efficacy research: Chal-
lenges for the new century. Augmentative and Alter-
will be defined differently based on the cognitive
native Communication, 15, 2–3.
skills of the individual and the type of AAC Bellugi, U., & Fischer, S. (1972). A comparison of sign
system that is in place. language and spoken language. Cognition, 1, 173–200.
Beukelman, D. R., & Mirenda, P. (2005). Augmentative
and alternative communication: Supporting children
and adults with complex communication needs. Balti-
Qualifications of Treatment Providers more: Brooks Publishing.
Foulds, R. (1987). Guest editorial. Augmentative and
AAC interventions are most typically introduced Alternative Communication, 3, 169.
Goldman-Eisler, F. (1986). Cycle linguistics: Experiments
by a speech-language pathologist. Unfortunately,
in spontaneous speech. New York: Academic.
many speech-language pathologists do not report Goldstein, H. (2002). Communication intervention for
having adequate training or education in the field children with autism: A review of treatment efficacy.
of AAC (King, 1998; Marvin, Montano, Fusco, & Journal of Autism and Developmental Disorders, 32,
373–396.
Gould, 2003; Simpson, Beukelman, & Bird,
King, J. (1998). Preliminary survey of speech-language
1999), and a survey of education programs for pathologists providing AAC services in health care
speech-language pathologists has uncovered settings in Nebraska. Augmentative and Alternative
a need for better education in this area (Ratcliff, Communication, 14, 222–227.
Marvin, L. A., Montano, J. J., Fusco, L. M., & Gould, E. P.
Koul, & Lloyd, 2008). Although this is the case, (2003). Speech-language pathologists’ perception of
speech-language pathologists are the best their training and experience in using Alternative and
equipped of all professionals who work with Augmentative Communication. Contemporary Issues
individuals with autism to provide intervention in Communication Sciences and Disorders, 30, 76–83.
Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The
that includes AAC. A listing of speech-language
impact of augmentative and alternative communica-
pathologists who are certified by the American tion intervention on the speech production of individ-
Speech-Language-Hearing Association can be uals with developmental disability: A research review.
Alternative Diagnostic Concepts 105 A
Journal of Speech, Language, Hearing Research, 49, American Psychiatric Association Diagnostic
248–264. and Statistical Manual of Mental Disorders
Mirenda, P. (2002). Toward functional augmentative and
alternative communication for students with autism: (DSM) (APA, 1994, 2011). However, there are A
Manual signs, graphic symbols, and voice output com- also factor analytic models, signal detection
munication aids. Language, Speech, and Hearing models, continuous distribution models with
Services in Schools, 34, 203–216. statistically predetermined cutoff arbiters, and
Mirenda, P. (2009). Introduction to AAC for individuals
with autism spectrum disorders. In P. Mirenda & artificial network models, but these, in spite of
T. Iacono (Eds.), Autism spectrum disorders and being important for the development of new
AAC. Baltimore, MD: Paul H. Brookes. operationalized criteria for categorical diagnoses,
Ratcliff, A., Koul, R., & Lloyd, L. L. (2008). Preparation have, so far, had relatively little impact in clinical
in augmentative and alternative communication: An
update for speech-Language Pathology training. practice. There are also taxonomies proposed by
American Journal of Speech-Language Pathology, individual research groups who have developed
17, 48–59. alternative diagnostic systems that may – or may
Simpson, K., Beukelman, D., & Bird, A. (1999). Survey of not – take into account the existence of the other
school speech and language service provision to
students with severe communication impairments in clinically based models. This entry cannot avoid
Nebraska. Augmentative and Alternative Communica- discussing modeling issues and the most com-
tion, 14, 212–221. monly used clinically based systems, before
Vanderheiden, G. C. (2002). A journey though early going on to take a look at alternative diagnostic
augmentative communication and computer access.
Journal of Rehabilitation Research and Development, systems, including issues relating to multiple
39, 39–54. complex developmental disorder (MCDD), defi-
cits in attention, motor control, and perception
(DAMP), empathy disorders, nonverbal learning
disability, and early symptomatic syndromes
Alternative Diagnostic Concepts eliciting neurodevelopmental clinical examina-
tions (ESSENCE).
Christopher Gillberg
Department of Child and Adolescent Psychiatry,
Gillberg Neuropsychiatry Centre, University of Historical Background
Gothenburg, Gothenburg, Sweden
The ICD
The ICD is the international standard diagnostic
Definition classification for clinical practice and epidemio-
logical and health management purposes. The
Clinical medical work without diagnosis is point- current version (ICD-10) has a section for
less. There can be no medical epidemiological psychiatric disorder (including for autism or
study of psychiatric or developmental disorder “▶ Pervasive Developmental Disorders”) that is
without a consideration of diagnostic boundaries. similar, but not identical, to that of the DSM-IV,
Diagnostic systems in psychiatric and devel- which was published at about the same time as
opmental medicine are overarching models of the ICD-10. Attempts were made during the
symptoms, problems, functional restrictions, development of the psychiatric section of the
impairments, traits, signs, and psychological ICD-10 and the DSM-IV to streamline the two
and biological test markers that constitute manuals. This was partly successful, but there are
a particular disease, disorder, or group of disor- still considerable differences across the texts,
ders. Among these, the most influential are criteria, and algorithms for diagnosing particular
clinically based, generally agreed models such disorders, and some disorders appear only in one
as the World Health Organization International of the manuals.
Classification of Diseases and Disorders (ICD) Given that the DSM, compared to the ICD, has
(WHO, 1993) and, for psychiatric disorders, the a much longer history when it comes to
A 106 Alternative Diagnostic Concepts
developing and analyzing operationalized criteria which criteria required change, with instructions
for psychiatric disorder, there will be a more to be conservative. Finally, they conducted field
detailed focus on the DSM than on the ICD. trials relating diagnoses to clinical practice.
Much of what will be said about the DSM-IV A change from previous versions was the inclu-
(and the development of the DSM-5) applies in sion of a clinical significance criterion to about
principle to the ICD-10 (and the development of half of the categories. A “text revision” of the
the ICD-11, which is scheduled for publication in DSM-IV, known as the DSM-IV-TR, was
2013). published in 2000. The diagnostic categories
and the vast majority of the specific criteria for
The DSM diagnosis were unchanged (www.wikipedia.com).
The Diagnostic and Statistical Manual of Mental
Disorders (DSM-I) was published in 1952. The Factor Analytic and Latent Class Models
DSM-II, published in 1968, was 134-page long Perhaps the most illustrative example of how fac-
and listed 182 disorders. Both the DSM-I and the tor analysis has been applied in clinical child and
DSM-II reflected the predominantly psychody- adolescent psychiatric/developmental diagnosis
namic psychiatry, although they also included comes from the much-researched – and used –
biological perspectives and concepts from material developed by Thomas Achenbach (origi-
Kraepelin’s system of classification. Symptoms nally with colleague Edelbrock), often referred to
were not operationalized. as the “Child Behavior Checklist” (CBCL) or the
The criteria adopted for many of the mental ASEBA (Achenbach System of Empirically
disorders in the DSM-III (1980) were taken from Based Assessment; Achenbach et al., 2008).
the Research Diagnostic Criteria (RDC) and the The CBCL/1.5–5 and the CBCL/6–18
Feighner Criteria, which had already been devel- includes 99/118 problem items that can be scored
oped by a group of research-oriented psychia- by parents of children aged 1–18 years. The items
trists. Other criteria, and potential new refer to problem behaviors and emotions often
categories of disorder, were established by con- encountered in children. A total problem score
sensus during meetings of the DSM committee. (comprising an internalizing and an externalizing
A key aim was to base categorization on descrip- score) is computed by adding scores for individ-
tive language rather than assumptions of ual items. Subscores for aggressive behavior,
etiology. A new “multiaxial” system attempted anxious/depressed, attention problems, rule-
to yield a “bigger picture.” When published, the breaking behavior, social problems, somatic
DSM-III was almost 500-page long and listed complaints, thought problems, and withdrawn/
265 diagnostic categories. It rapidly came into depressed can also be calculated. The six DSM-
widespread international use by multiple oriented scales are affective problems, anxiety
stakeholders and has been termed a revolution problems, somatic problems, attention deficit/
or transformation in psychiatry. hyperactivity problems, oppositional defiant
In 1987, the DSM-III-R was published as problems, and conduct problems. The preschool
a revision of DSM-III. Six categories were 99-item version for 1.5–5-year-olds also has
deleted while others were added. The DSM-III-R a DSM-oriented scale for autism/“pervasive
contained 292 diagnoses and was 70 pages longer developmental disorder.” Several studies have
than the DSM-III. shown that combinations of subscales and indi-
In 1994, the DSM-IV was published, listing vidual items on the CBCL have good sensitivity
almost 300 disorders in just under 900 pages. The and specificity for ASD in school-age children.
steering committee had created 13 work groups, In addition to the CBCL for parent rating, there is
who conducted a three-step process. First, each a related Teacher’s Report Form (TRF) and
group conducted literature reviews of their a Youth Self Report (YSR) for 11–18-year-olds.
diagnoses. Then they requested data from Each item on the CBCL is given the same
researchers, conducting analyses to determine weight in the scoring system. The various
subscales have been developed on the basis of lowest, that is, at the inflection point on the
factor and principal component analytic studies, curve. The value of TPR times FPR at this point
and the DSM-oriented scales have been devel- represents the area under the curve (AUC). When A
oped on the basis of a combination of statistical the AUC approaches 1.0, the diagnostic precision
and clinical studies. One of the problems with the of the screening instrument is excellent, but when
factor analytic approach relates to the fact that it approaches 0.5, the precision is extremely poor.
many of the individual items are completely The use of the AUC concept as a measure in the
unrelated and clearly do not have the same clin- evaluation of new diagnostic screening tools
ical weight. In fact, it can be argued that the has become something of a “gold standard” in
individual items represent 118 different problems recent years.
and that the subscales, to a considerable extent,
represent artificial statistically derived constructs Continuous Distribution Models
that do not necessarily correspond to recogniz- Many human traits, functions, or markers of
able clinical entities (in spite of having been functional systems can be construed as existing
assigned names that would suggest a clear corre- on a normal distribution scale which will be
lation between the research and clinical concept). relatively smooth when the range of possible
This problem is not unique to the development of scores is large. “Abnormality” is often defined
the CBCL (and related material) but applies as a specified distance from the mean or median
equally to a number of other much used scales, score of such a scale (e.g., 2 standard deviations
including those with subscales or full scales from the mean or under or over the second/98%).
designed for screening and diagnosis of autism, A disease or pathological state can be construed
for example, the Strengths and Difficulties Ques- as existing when the value of a marker for
tionnaire (SDQ) (Goodman, 1999) and the a biological or psychological function is below
Autism Spectrum Screening Questionnaire a specified level (such as in pathological short-
(ASSQ) (Ehlers & Gillberg, 1993). ness/“dwarfism” or intellectual developmental
disorder/mental retardation) or above a set limit
Signal Detection Models and Receiver (such as in hyperthyroidism).
Operating Characteristic (ROC) Much can be said for diagnosing a number of
Many diagnostic systems are used to distinguish psychiatric disorders along continuous distribu-
between two classes of events, essentially “sig- tion curves. Autism spectrum disorder (ASD),
nals” and “noise,” or “diagnosis” and “no diag- intellectual developmental disorder, and atten-
nosis.” For such systems, analysis in terms of the tion-deficit/hyperactivity disorder (ADHD) are
“relative (or receiver) operating characteristic” but three examples of “disorders” that can, in
(ROC) of signal detection theory provides many instances, be seen as extremes of “condi-
a fairly precise and valid measure of diagnostic tions” that exist along a normally/continuously
accuracy. It is uninfluenced by decision biases distributed spectrum (Posserud, Lundervold, &
and prior probabilities, and it puts the perfor- Gillberg, 2006). However, problems arise when
mances of diverse systems on a common, easily it comes to specificity and determining exactly
interpreted scale. which specific trait should be considered the key
The ROC model applied to a diagnostic marker function for the disorder. For instance, in
screening instrument with a wide range of possi- ADHD, it is still not possible to determine
ble scores (such as the CBCL, the SDQ, or the whether attention, activity, or impulsivity
ASSQ) is best presented in a graph detailing the aspects/functions should be considered core fea-
true positive rate (TPR ¼ sensitivity) on the tures of the “disorder.” Similarly, in ASD, it is not
y-axis and the false positive rate (FPR ¼ 1 possible to assess the core quality of repetitive
minus specificity) on the x-axis. The best trade- behaviors or, for that matter, perceptual func-
off for diagnostic purposes is usually seen at the tions, when it comes to delineating the “syn-
point where the TPR is highest and the FPR drome” of ASD. In the latter case – to “fully
cover” the clinical spectrum of the “autistic state” dimensional elements in the psychiatric diagnos-
in a given individual – it might be necessary to tic systems has been advocated for many years.
provide centile values for three or more continu- However, it has been resisted due to concerns
ous distribution curves, for example, empathy, about clinical utility.
central coherence, and rigidity-flexibility, and The categories in DSM are prototypes;
this would entail a great deal of conceptual and a patient with a close approximation to the pro-
practical problems in clinical practice. totype is said to have that disorder. Each category
There are other problems with the continuous of disorder has a numeric code taken from the
distribution model. First, it is as difficult to rea- ICD system, used for administrative purposes.
sonably determine cutoff for abnormality under One problem with this approach to diagnosis is
this model as it is in the general medical model of that it does not properly deal with all those
categorical disorders. Second, there are quite instances when a patient is severely impaired
a number of instances, for instance, in ASD, but does not meet all the criteria for a given
when the model is totally inappropriate. It discrete disorder. Every day in clinical practice
would not be correct or logical to categorize (and in research), this is illustrated by diagnosis
a case of autism caused by herpes encephalitis in the field of autism and related disorders. Many
as being on a distribution curve shading into Western societies now have legislation specifi-
“normality.” Third, and not the least, there is cally for autism. This means that having
a need for quick and dirty labels such as ASD a “correct” diagnosis (i.e., one that fits with
and ADHD, much like there is a need for terms federal legislation) is extremely important. In
like “fever” and “pneumonia” (imprecise and needy clinical patients and in research prevalence
even more vague terms than those used in neuro- studies, the categorical nature of the DSM system
psychiatry). One of the most important features can be the arbiter between help and no help in
of a diagnostic label is its “door-opening” qual- terms of service provision and between case and
ity; by having a label, one will have easy access to noncase in epidemiological studies.
knowledge. Having been given a percentage on The way in which authors have articulated the
a normal distribution curve, or worse, multiple multiple manifestations of autism has differed
different percentages on different curves will over time. Progress has been made in recent
possibly be closer to “the truth” but will often years, and this has brought about a convergence
lead to more confusion than clarity. Having said on a shared definition of autism, including
this, the continuous distribution model has much methods of assessment that are acceptable to
to offer in second-level diagnostics: once workers from clinical and research centers across
a diagnosis of, for instance, ASD has been the world. Structured interviews (e.g., the
made, providing information about the individ- DISCO-11, the ADI-R, and the ASDI) and obser-
ual’s level of functioning on a number of contin- vation schedules (including the ADOS-G) have
uous distribution curves might actually help brought organizational focus to the traditional
create a much more detailed (and holistic) view psychiatric interview and developmental assess-
of that person’s functioning. ment. Such methods have provided a stricter
format and directions to the interviewer, which,
in turn, have enabled systematic assessment of all
Current Knowledge the criteria necessary for a diagnosis according to
the given diagnostic (e.g., DSM) system. Having
The DSM with a Particular Focus on Autism a consensually shared set of diagnostic criteria as
As more and more research has documented the well as structured assessment devices has helped
dimensional nature of so many core psychiatric ensure a more common unit of analysis in clinical
disorders (including autism), the rigid structure practice and research across the globe. Though
and algorithmic nature of the DSM have come most workers would consider the operationa-
under increasing criticism. The inclusion of lization of diagnostic criteria as an advance in
psychiatry and developmental medicine, there Although the DSM-5 may move away from
remain concerns about the impact that the quest this categorical approach in some limited areas,
for increased diagnostic reliability might have on some argue that a fully dimensional spectrum or A
validity. complaint-oriented approach would better reflect
the evidence (Krueger, Watson, & Barlow,
Current Clinical Practice and Research Use of 2005). Nevertheless, it is very difficult to
the DSM envisage an overall change leading to fully
The DSM is primarily concerned with the symp- dimensional diagnostics in psychiatry, given
toms and behavioral manifestation of mental that it would not only be very difficult in practice
disorders. With the exception of a small number but that it would entail a break with the tradition
of disorders (including “reactive attachment of categorical medical diagnosis that has a history
disorder”), it does not generally attempt to ana- of thousands of years.
lyze or explain the conditions included in the
manual. Alternative Diagnostic Categories and
The DSM-IV organizes each psychiatric diag- Systems
nosis into five levels (axes) relating to different Multiple Complex Developmental Disorder
aspects of disorder or disability. Appropriate use (MCDD)
of the DSM diagnostic criteria requires extensive The concept of MCDD was introduced by Donald
clinical training, and its contents cannot be Cohen (Towbin et al., 1993) in an attempt to
applied in a cookbook fashion. There is a risk “define and validate criteria for an early onset,
that patients and nonmedical professionals may chronic syndrome of disturbances in affect mod-
use the DSM in a checklist fashion and make ulation, social relatedness, and thinking.” This
“diagnosis” according to number of checked syndrome, combining elements of autism,
symptoms. It needs to be stressed that the DSM psychosis, and affective disorder, was considered
is a manual for medical psychiatric diagnosis. In possible to delineate and to be related to earlier
practice, this means that it can only be used by onset of symptoms, very poor social and overall
highly skilled professionals making a definitive functioning, often long periods of inpatient treat-
clinical diagnosis (i.e., medical doctors with spe- ment, and poor outcome.
cialist training in psychiatry and for some disor-
ders, including autism, ADHD, DCD, etc., those Deficits in Attention, Motor Control, and
with training in neurology and developmental Perception (DAMP)
medicine). The concept of DAMP was introduced by
Other, highly skilled, professionals use the I Carina Gillberg (1987). It refers to the combi-
DSM in clinical research. However, research nation of problems in the domain of attentional
diagnoses should not uncritically be equated abilities and motor-perceptual capacities in indi-
with clinical diagnoses, and if a psychiatrist or viduals who do not meet criteria for cerebral
other specifically trained medical doctor has not palsy. She and her colleagues had researched
been involved in the diagnostic process, the the clinical concept of minimal brain dysfunction
“DSM diagnosis” should not be considered (MBD) for a long time and had found that chil-
a psychiatric or medical diagnosis. dren thus diagnosed usually had this particular
The DSM-5 published proposed diagnostic combination of problems (referred to as “percep-
criteria in 2010 and revised proposed criteria in tual, motor, and attentional deficits” as early as
2011. There was opportunity for specialists and 1982). In later publications (e.g., Kadesjö &
the general public to react to these, and criteria Gillberg, 1999; Rasmussen & Gillberg, 2000),
were revised in the process. Once this was DAMP was seen to correspond to the combina-
accomplished, the criteria were then tested in tion of ADHD and DCD. Gillberg (1983) noted
field trials. The results of these trials are not at that “severe” DAMP was strongly associated
hand at the publication of this volume. with marked autistic features and found that
a large proportion of those diagnosed with (Rourke, Young, & Leenaars, 1989). The “diag-
“DAMP with autistic features” (¼ADHD + nosis” – which is not in any of the official
DCD + autistic traits) actually met full diagnostic diagnostic manuals – rests on a considerable
criteria for Asperger syndrome. discrepancy between verbal and nonverbal skills
on tests in individuals who are relatively profi-
Disorders of Empathy cient in expressive language skills. Affected
In the early 1990s, Gillberg launched the label of individuals are often motor clumsy, perceptually
disorders of empathy and suggested that empathy abnormal, socially awkward, “dyspraxic,” and
and theory of mind were concepts that referred to with poor pragmatic skills (in spite of sometimes
closely related or perhaps even identical human superior formal verbal skills). Rourke has
functions (Gillberg, 1992). He also proposed the suggested that the overlap between nonverbal
concept of an empathy quotient (EQ) that might learning disability and ASD/Asperger syndrome
be used in a fashion similar to IQ when thinking is substantial.
about how ASD and related disorders could best
be delineated from each other, from autistic traits Early Symptomatic Syndromes Eliciting
and so-called normality. It was envisaged that Neurodevelopmental Clinical Examinations
a battery of tests of empathy including precursors (ESSENCE)
of and mature-level theory of mind (and possibly The ESSENCE concept was introduced by
subtests of facial recognition, central coherence, Gillberg (2010). The acronym refers to early
and set-shifting) would be developed so that dis- symptomatic syndromes eliciting neurodeve-
orders within the field could be diagnosed along lopmental clinical examinations. Gillberg coined
a scale where an EQ of 70 might be set to demar- this acronym with a view to alerting clinicians
cate cutoff for milder disorders (including that and researchers to the reality of a very large
associated with the “Asperger phenotype”) and number of children (and their parents) presenting
an EQ of 50 for more severe disorders (including in clinical settings with impairing, persistent
the phenotype of “classic autism”). symptoms before age 3 (to 5) years – symptoms
Unfortunately, even though progress has been that will endure and overlap for many years,
made regarding the understanding of the relation- usually into adulthood – in the fields of (a)
ship between theory of mind, central coherence, general development, (b) communication and
executive function, and various types of disor- language, (c) social interrelatedness, (d) motor
ders, no “IQ-similar” EQ-test battery has been coordination, (e) attention, (f) activity, (g) behav-
developed over the past two decades. Neverthe- ior, (h) mood, and/or (i) sleep. Children with
less, the concept of disorders of empathy (with major difficulties in one or more (usually several)
autistic traits blending into “normality”) has of these fields, will be referred to and seen by
gained considerable theoretical support over the health visitors, nurses, social workers, education
last 20 years. It is still envisaged that having specialists, pediatricians, GPs, speech and
access to a test battery covering the basic language therapists, audiologists, child neurolo-
functions and dysfunctions that have been gists, child psychiatrists, psychologists,
shown to be clearly related to autistic symptoms neurophysiologists, dentists, clinical geneticists,
would be extremely helpful and would pave the occupational therapists, and physiotherapists.
way for a “real” alternative ASD diagnostic Usually they will be seen only by one of these
system, clearly conceptually different from the specialists, when they would have needed the
one that will still be espoused in the DSM-5. input of two or more of the experts referred to.
Major problems in at least one ESSENCE domain
Nonverbal Learning Disability before age 5 years usually signal major problems
The concept of nonverbal learning disorder or in the same or overlapping domains years later.
disability was introduced in a book by Rourke “There is no time to wait; something needs to be
in 1988 and in an influential paper in 1989 done, and that something is unlikely to be just in
the area of speech and language, just in the area of clinical course of a patient having an index
autism or just in special education.” disease. This term has recently become very
ESSENCE is not a new proposed diagnosis but fashionable in psychiatry and developmental A
represents an alternative way of approaching the medicine to indicate not only those cases in
problem of diagnosis in “child neuropsychiatry” which a patient receives both a psychiatric and
and “developmental medicine.” At very young a general medical diagnosis (e.g., autism and
ages, children with developmental problems pre- tuberous sclerosis) but also those cases in which
sent for diagnosis in a variety of settings, and a patient receives two or more psychiatric diag-
depending on the type of specialist in charge, noses (e.g., autism and Tourette syndrome).
one or another of the many possible diagnoses Gillberg (1983) pointed to this overlap of “dis-
contained in the ESSENCE basket is likely to be crete” psychiatric diagnoses in young children
made (or not made for that matter). The risk is long before the word “psychiatric comorbidity”
obvious that only the diagnosed problem type came into common parlance. The co-occurrence
will be intervened for (or that the child excluded of two or more psychiatric diagnoses has been
from, say, the autism category will not be worked reported to be very frequent. For instance, in
up for his/her very real ADHD and hence a general population study, 85% of young chil-
excluded from relevant therapy). ESSENCE dren with ADHD had at least one additional DSM
may be the “only safe label” at an early age. diagnosis leading to impairment (Kadesjö &
However, ESSENCE is not a diagnosis but Gillberg, 2001). In the case of severe autism, it
a reminder that the child with that “label” will, is virtually impossible to find one single case in
sooner or later, have one, two, three, or even more which there was no other mental or physical
diagnoses made. ESSENCE is a label that disorder. If a diagnosis of autistic disorder
acknowledges the universal coexistence of symp- according to the DSM-IV-TR is made, one
toms and problems across diagnostic borderlines. would have to be on the lookout for intellectual
All the problems need to be addressed, not just developmental disorder/mental retardation/learn-
those associated with one discrete diagnostic ing disability, epilepsy, a medical disorder such
category. as tuberous sclerosis or 22q11deletion syndrome,
neuropsychiatric disorder such as Tourette syn-
drome or ADHD, mood disorder, anxiety disor-
Future Directions der, eating disorder, sleep disorder, or a specific
developmental disorder such as developmental
The DSM-5 and the ICD-11 coordination disorder (DCD). There is a further
Major attempts are being made to streamline the diagnostic problem stemming from the fact that
DSM-5 and the ICD-11. Several of the personal- a majority of these other named disorders have
ity disorder categories will be gone from the a large subgroup with ASD, that the symptoms of
DSM-5, and a few new categories of psychiatric all the disorders first appear and overlap at a very
disorder will be included. It is expected that early age, and that it can be very difficult to
autism will become one category (no longer decide from the start which of the problem types
referred to as pervasive developmental disorder is going to be the “main diagnosis,” that is, the
but, most probably, “autism spectrum disorder”) one (or the ones) that will warrant intervention.
and that subgrouping will be done on the basis of The acronym ESSENCE has been introduced in
a number of “nonautism” demographics such as order to draw attention to this state of affairs
level of IQ, language competence, and severity. (Gillberg, 2010).
The co-occurrence of multiple registered psy-
Comorbidity and the DSM System chiatric diagnoses is now common. This is to
The term “comorbidity” was introduced in med- some extent due to the use of standardized diag-
icine to denote those cases in which a “distinct nostic interviews, which helps to identify several
additional clinical entity” occurred during the clinical aspects that in the past remained
unnoticed after the principal diagnosis had been gold standard clinical diagnosis and that they
made. Fragmenting a complex clinical condition will never, in themselves, be better than such
into several pieces may prevent a holistic diagnoses. It is envisaged that the heyday of
approach to the individual. these instruments will be over in the next few
An obvious determinant of the emergence of years and that they will be replaced by measures
the phenomenon of “psychiatric comorbidity” more accurately acknowledging and reflecting
(see below) has been the proliferation of diagnos- the developmental and overlapping nature of the
tic categories in recent classifications. If demar- conditions in question.
cations are made where they do not “really” exist, The frequent co-occurrence of the mental dis-
the probability that several diagnoses have to be orders has been taken as evidence against the idea
made in an individual case will obviously that these disorders represent discrete disease
increase. entities (Cloninger, 2002). The point has been
A coveted tradition in psychiatry and develop- made that psychopathology is usually complex
mental medicine has been to establish a hierarchy and variable and that what is currently conceptu-
of diagnostic categories so that, for example, if alized as the co-occurrence of multiple disorders
autism were present, the possibly concomitant could be better reformulated as the complexity of
anxiety, depression, or ADHD would not be diag- many psychiatric conditions (with increasing
nosed because they would be regarded as part of complexity being a predictor of greater severity,
the clinical picture of autism. disability, and service utilization). Even
Because everyone has now been using Kraepelin, in one of his later works, dismissed
operationalized diagnostic criteria for three the model of discrete disease entities even for
decades or more, diagnoses such as autistic dis- dementia praecox and manic-depressive disorder
order have, by some, come to be regarded as more (Kraepelin, 1920).
reliable than traditional clinical diagnoses. The However, an alternative possibility is that psy-
old clinical descriptions provided a gestalt of chopathology does consist of discrete entities, but
each diagnostic entity. Different emphasis was these entities are not well delineated by current
put on the various clinical aspects, whereas cur- diagnostic categories. If this is the case, then
rent operational definitions usually give equal current clinical research on “psychiatric comor-
weight to a variety of clinical manifestations, bidity” may be helpful in the search for “true”
counting symptoms rather than weighing them. disease entities, contributing in the long term to
Traditional clinical assessment demanded arbiter a rearrangement of present classifications.
differential diagnosis, whereas current opera- There is, of course, another possibility,
tional definitions really open up for multiple namely, that the nature of psychopathology is
diagnoses (even though the DSM-IV often intrinsically heterogeneous, consisting partly of
actively resists this), possibly in part because disease entities and categorical disorders, and
they are less able to convey the “essence” of partly of maladaptive response patterns or of
each diagnostic entity. exaggeration of traits that are more or less nor-
Along with the trend as regards reliance on mally distributed in the general population.
operationalized algorithms for diagnosis, has
emerged a new insistence on “specific” instru- ASD in the DSM-IV and the DSM-5
ments for these checklist categorical disorders. The DSM-IV comprised of five different autism
This is particularly true in autism, where both spectrum disorder categories. The DSM-5 con-
clinicians and researchers have been overtaken tains only one autism category, incorporating
by an industry of diagnostic interviews and obser- autistic disorder, Asperger’s disorder, childhood
vation schedules that purportedly increase the disintegrative disorder, and PDDNOS into one
quality of the (single) diagnosis per se. It is common coded condition referred to as “ASD”
important to remember that these instruments (and leaving, reasonably, Rett syndrome out of
were developed on the basis of studies using the equation).
The change reflects increasing awareness that DSM-IV) and PDDNOS “criteria” (that are really
much of the DSM-IV subgrouping of autism was extremely vague) would probably fall short of
based on attitudes and personal stance rather than diagnostic status under the DSM-5. The A
empirical evidence. For instance, most system- Gillberg’s Asperger syndrome category would,
atic studies have not found support for a clear on the other hand, at least at a glance usually
distinction between autistic disorder and meet criteria for ASD under the DSM-5. How-
Asperger’s disorder. It is also unclear to what ever, all of this is, of course, pure speculation at
extent CDD should be seen as different from the present time. Changing the diagnostic
autistic disorder with regression, and whether or criteria, as with the introduction of the DSM-5
not “mild” or highly atypical cases of PDDNOS (ICD-11), will definitely lead to changes in num-
are really related to autistic disorder at all. bers of cases diagnosed. This, in the case of
There are only seven symptoms in the proposed autism, will, almost certainly, lead to claims of
DSM-5 as compared with 12 in the DSM-IV. “autism epidemics” or “autism disappearing” in
There are only two subgroups of symptoms rather the headlines of many major newspapers from
than three. The change in number of symptoms about 2015 onward. This is the extent of what
superficially gives the impression of a major can be reasonably predicted as a result of the
reconceptualization of the whole category. How- introduction of the new diagnostic manuals.
ever, on closer inspection, what has been achieved
is a pruning of several symptoms that were felt by Alternative Diagnostic Systems
many to be vague and relatively unimportant or to MCDD
be hallmarks of other conditions (such as severe The following diagnostic criteria for MCDD (or
learning disability or severe expressive language multiplex developmental disorder) have been
disorder), a collapsing of some of the remaining suggested by the Yale Autism Study Group:
ones, and the addition of a behavioral criterion of (1) impaired social behavior/sensitivity, similar
perceptual abnormality. Also, the social and com- to that seen in autism, such as (a) social disinter-
munication categories have been collapsed into est, (b) detachment, avoidance of others, or with-
one. This mirrors the now generally accepted drawal, (c) impaired peer relations, (d) highly
notion that at the root of both the social and com- ambivalent attachments, (e) limited capacity for
munication problems in autism is a shared deficit empathy or understanding what others are think-
in intuitive understanding of the meaning of reci- ing or feeling; (2) affective symptoms, including
procity. Finally, the three specific social- (a) impaired regulation of feelings, (b) intense,
communication symptoms in the DSM-5 must all inappropriate anxiety, (c) recurrent panic, (d)
be met for a diagnosis to be considered (compared emotional lability without obvious cause;
to only two out of four in the DSM-IV), and there (3) thought disorder symptoms, such as (a) sud-
must be at least five of the seven total number of den, irrational intrusions on normal thoughts, (b)
symptoms met (compared to “only” 6 of the 12 magical thinking, (c) confusion between reality
autistic disorder criteria in the DSM-IV). The age and fantasy, (d) delusions such as paranoid
criterion has been changed from delay or abnormal thoughts or fantasies of special powers.
functioning being evident before age 3 years A few studies have tried to examine the rela-
(DSM-IV) to symptoms having been present tive proportion of MCDD cases within the
from early childhood (DSM-5). broader category of ASD. They have found the
Taken together, it would seem that the pro- “condition” to be rare, accounting for fewer than
posed DSM-5 might actually restrict somewhat one in ten of all relatively high-functioning cases
the number of cases of autistic disorder meeting (Sturm et al., 2004).
full criteria for autism spectrum disorder com- It is clear that the combination of problems
pared to the DSM-IV. Also, many of the cases subsumed under the MCDD heading exists in
meeting Asperger’s disorder symptom criteria a small number of individuals and that those
(only three symptoms in total needed in the affected are very severely impaired. However,
studies that have attempted to separate out chil- functions, and certain executive functions (includ-
dren with MCDD from those with other “vari- ing set-shifting) will possibly pave the way for
ants” of PDD or schizophrenia have usually not development of age normed EQ tests that will
been able to clearly differentiate them from those allow a dimensional approach to diagnosis within
with other diagnoses. Nevertheless, MCDD, if it the empathy spectrum disorders (or, using another
will remain as an alternative category, is term, ASD). Again, it is possible that the word
a diagnostic label that will only be applied in empathy in itself might be seen by some to be too
a limited number of patients presenting with provocative, seeing as it has come to be associated
ASD symptomatology. In some ways, it resem- with a positive (emotional) value (even though this
bles the DAMP concept (see below) in that it was not its original meaning when the word was
could possibly be categorized as the concomitant coined over a century ago). It could be that “disor-
presence of two “discrete” disorders, namely, ders of social communication” will be a preferred
ASD and schizophreniform disorder. term. Even so, it is likely that the concept of EQ (or
SCQ, social communication quotient) will get
DAMP rooted and upon up new avenues of diagnosing
DAMP, when defined as the combination of autistic traits across a range of problem types, just
ADHD and DCD, is a common clinical problem as the concept of IQ has come to be accepted as
(affecting several percent of all school-age chil- something useful when considering any type of
dren) that has well-documented ramifications both problem, regardless of “other diagnoses.”
as regards need for intervention and prognosis
(Rasmussen & Gillberg, 2000). There are about Nonverbal Learning Disability
50 publications in the scientific literature. Stimu- One of the problems with the concept of nonver-
lant treatment, cognitive behavioral therapy, spe- bal learning disability is that there does not seem
cial education measures, and occupational therapy to be any consensus regarding how it should be
are likely to be needed in any intervention pro- diagnosed. Most published studies have relied on
gram. Autistic features are very common and may results of IQ testing (often with one of the
need special approaches, and there is usually Wechsler scales), and the diagnosis has been
a speech and language component to be taken made in cases with a verbal IQ that is 15 points
into account when designing the intervention (or 15–20% in some studies) higher than perfor-
plan. DAMP has been an accepted alternative mance IQ. However, other authors, including
clinical diagnostic concept in the Scandinavian Rourke, would instead use variations on the
countries for many years. However, given its lit- following diagnostic algorithm: a nonverbal
eral meaning when read out as a word rather than learning disability refers to a subtype of learn-
as an acronym, it is unlikely that it will become ing-disabled children who have outstanding
generally accepted as an internationally used diag- deficits in interpersonal relationships, visual
nostic concept. However, the insight into the com- spatial organization, organization and planning
mon comorbidity of ADHD with DCD (and of skills, flexible concept formation, study skills,
these two problem types with ASD) and the grad- specific academic areas, and social judgment.
ually growing awareness among clinicians that Several studies have attempted to delineate the
DCD is often a problem that should be treated boundaries between nonverbal learning disability
“in its own right” will probably lead to acceptance on the one hand and Asperger syndrome on the
of the importance of the underlying construct. other. One study has found a very high rate of
nonverbal learning disability in young boys
Disorders of Empathy with Asperger syndrome; in fact, at least half of
The gradual refinement of concepts such as self- all young males with the syndrome had
initiated joint attention, theory of mind, central the typical verbal-nonverbal discrepancy
coherence/local-global processing and “connectiv- (Cederlund & Gillberg, 2004). However, when
ity,” facial emotion-recognition, mirror-neuron the same individuals were followed up in adult
age, only one in five had clear test results indi- It is envisaged that over time, ESSENCE clinics,
cating persistence of such a discrepancy, mean- rather than (“overspecialized”) autism clinics, will
ing that at least half of all those who had be seen as the way forward. Children, adolescents, A
childhood indicators had “grown out” of “test adults, and their families with one or more (usually
evidence” of nonverbal problems after adoles- several) of the problem types subsumed under the
cence. Some studies have found no indication of ESSENCE acronym (and remember that in many
a link between the “neuropsychological disorder” “ASD cases,” there is not only ESSENCE “comor-
and the clinical syndrome of Asperger. bidity” in the individual referred for diagnostic
workup but one or more of close relatives will
ESSENCE also have ESSENCE problems) will need good
It is likely that ESSENCE – or a similar concept – diagnostic workup and intervention for all
will become influential over the next several years. impairing problems, not “just” for ASD. This is
As has already been pointed out, ESSENCE is not not to say that good autism diagnostics and focused
in itself a diagnosis but a broader category cover- autism intervention will not be needed – quite the
ing a variety of neurodevelopmental, psychiatric, opposite – but that the strong emphasis on autism as
and neurological conditions that are sometimes a unique and separate syndrome may lead to inad-
behavioral phenotypes with a known etiology, vertent, underdiagnosis, and undertreatment of
sometimes empirically derived symptom clusters associated, highly treatable ESSENCE problems.
related to neuronal dysfunction, and sometimes
the extreme on curves of normally distributed
traits in the general population. See Also
The term ESSENCE acknowledges the very
common existence of such conditions and the fact ▶ Asperger Syndrome
that they are almost always “comorbid” with each ▶ Atypical Autism
other, that the comorbidities (and, indeed, the “main ▶ Autism
diagnosis”) may vary over time, weave in and out of ▶ Autistic Disorder
each other, and that therefore the clinical picture ▶ Broader Autism Phenotype
tends to vary with age and time. ASD is but one ▶ Child Behavior Checklist in AUTISM
category (or endpoint on a dimensionally distributed ▶ Childhood Disintegrative Disorder
set of traits) within ESSENCE. ASD is virtually ▶ Clinical Assessment
never an individual’s only problem; there is perhaps ▶ Comorbidity
always an additional impairment that warrants clin- ▶ Dimensional versus Categorical Classification
ical diagnosis and intervention (including ADHD, ▶ DISCO
tics, depression, anxiety, anorexia nervosa, an asso- ▶ DSM-IV
ciated medical condition, epilepsy, DCD, cerebral ▶ Early Diagnosis
palsy, hydrocephalus, catatonia, hyperlexia, dys- ▶ Endophenotypes
lexia, speech and language disorder, intellectual ▶ Epidemiology
developmental disorder, nonverbal learning disabil- ▶ Face Validity
ity). ESSENCE also flags up the possibility that ▶ Facilitated Communication
ASD (or ADHD, tics, etc.) may not be the major ▶ ICD 10 Research Diagnostic Guidelines
clinically impairing problem throughout a person’s ▶ Medical Conditions Associated with Autism
life that it can become less impairing with time (to ▶ Nonverbal Learning Disabilities (NLD)
the point that the need for a clinical diagnosis may ▶ Psychotic Disorder
be called into question) but that other so-called ▶ Schizophrenia
comorbidities (such as ADHD, depression, DCD, ▶ Screening Measures
intellectual developmental disorder) may be seen as ▶ Semantic Pragmatic Disorder
much more impairing and could, in fact, be main ▶ Sensitivity and Specificity
drivers of a poor outcome. ▶ Spectrum/Continuum of Autism
A 116 Alti-Haloperidol
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Introduction to the special section: Toward
Achenbach, T. M., Becker, A., Dopfner, M., a dimensionally based taxonomy of psychopathology.
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Cloninger, C. R. (2002). The discovery of susceptibility afflicted to adolescent and adult depression and suicide
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Goodman, R. (1999). The extended version of the Amantadine
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Allied Disciplines, 40, 791–799. Director – Child Study Center, Irving B. Harris
Kadesjö, B., & Gillberg, C. (1999). Developmental coor- Professor of Child Psychiatry, Pediatrics and
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Adolescent Psychiatry, 38, 820–828.
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ur die gesamte Neurologie und This drug (known as 1-adamantylamine or
Psychiatrie, 62, 1–29. 1-aminoadamantane) was first approved by the
American Academy of Clinical Neuropsychology (AACN) 117 A
FDA in 1966 for the treatment of influenza; its
effectiveness for the treatment of symptoms of American Academy of Clinical
Parkinson’s disease and drug-induced move- Neuropsychology (AACN) A
ment problems (extrapyramidal effects and
akathisia) was discovered accidentally. For the Linas Bieliauskas
treatment of Parkinson’s disease, it is used alone Departments of Psychology and Psychiatry,
or in combination with other agents. The effi- University of Michigan Ann Arbor VA
cacy of its use for Parkinson’s disease has been Healthcare System, Ann Arbor, MI, USA
questioned in a recent review (Crosby et al.,
2003). Because of growing resistance, it is not
now recommended for use in influenza Major Areas or Mission Statement
treatment.
There appear to be several mechanisms of AACN has 817 active members, 416 affiliate
action since the agent impacts multiple brain members, and 138 student members as of May
neurotransmitter systems. Central nervous sys- 1, 2012.
tem side effects include anxiety, agitation, and AACN is the organization for those
increased seizure activity. Other side effects psychologists who have achieved board
have included skin problem and suicidal certification in the specialty of clinical neuropsy-
thoughts. chology, under the auspices of the American
The drug has been used without FDA Board of Clinical Neuropsychology (ABCN).
approval for various other purposes including Board certification covers neuropsychological
in autism. In the largest study, King and col- aspects, brain-behavior disorders in children,
leagues (2001) treated a group of children adults, and the elderly. AACN supports contin-
and adolescents with amantadine using both ued maintenance of standards in clinical neuro-
parent- and clinician-based report measures in psychology through the established board
a placebo-controlled study. They noted a large certification process of ABCN. AACN supports
placebo effect overall with clinician ratings the continued development of the ABCN exami-
but not parent ratings suggesting some possi- nation process and advocates for the standards
ble benefit of the agent over placebo. Aman- represented by board certification.
tadine was well tolerated. The drug remains
one of many agents which deserve study in Landmark Contributions
autism.
1. Support of board certification by the American
Board of Clinical Neuropsychology.
References and Readings 2. American Academy of Clinical Neuropsy-
chology Foundation, to support outcome
Babington, P. W., & Spiegel, D. R. (2007). Treatment of research in Clinical Neuropsychology.
catatonia with olanzapine and amantadine. Psychoso-
matics, 48(6), 534–536.
3. Major policy, survey, and research papers can
Crosby, N. J., Deane, K., & Clarke, C. E. (2003). Aman- be found on the website www.theaacn.org.
tadine in Parkinson’s disease. Cochrane Database of
Systematic Reviews(1). doi:10.1002/14651858.
CD003468. Art. No.: CD003468.
King, B. H., Wright, D. M., et al. (2001). Double-
Major Activities
blind, placebo-controlled study of amantadine
hydrochloride in the treatment of children with AACN has an annual meeting open both to
autistic disorder. Journal of the American Academy members and nonmembers. The meeting
of Child and Adolescent Psychiatry, 40(6),
includes an extensive continuing education pro-
658–665.
Webb, S. (2010). Drugmakers dance with autism. Nature gram which will be of interest to all, including
Biotechnology, 28(8), 772–774. special courses for candidates for board
A 118 American Academy of Neurology
certification and for AACN members and others Saint Paul, MN 55116
to maintain specialty knowledge. The Clinical (800) 879–1960
Neuropsychologist is the official journal of www.aan.com
AACN. In addition to copies of AACN policy Child Neurology Society (CNS)
statements which can be accessed by the link on 1000 W. County Road E, Suite 290
the right, The Clinical Neuropsychologist pub- Saint Paul, MN 55126
lishes all AACN official policies and (651) 486–9447
documents. www.childneurologysociety.org
The AAN is an international professional
References and Readings association of over 22,000 neurologists and neu-
roscience professionals dedicated to promoting
Jeantin, A., Blanc, R., Fontaine, R., & Barthelemy, C. neurologic care. Members include both adult
(2009). Neuropsychology approach of social adapta- and child neurologists. The AAN is the primary
tion difficulties in children with autism in the process
professional society for clinical neurologists. It is
of being sent to non-specialized schools: A review of
issues. A N A E Approche Neuropsychologique des dedicated to maintaining awareness among its
Apprentissages chez l’Enfant, 21(1[101]; 101), 59–68. membership of clinical and scientific advances
Ozonoff, S. (2010). Autism spectrum disorders. In that impact clinical care and to providing educa-
K. O. Trates, M. D. Ris & H. G. Taylor (Eds.),
tional opportunities for maintaining the knowl-
Pediatric neuropsychology: Research, theory, and prac-
tice (2nd ed., pp. 418–446). New York: Guilford Press. edge and skills of its members. The AAN also
Papers, policies, and research can be found on the website commissions subcommittees to develop practice
www.theaacn.org guidelines that disseminate the state of the sci-
Sokol, D. K. (2010). Review of diagnosing learning
ence on specific clinical issues that confront neu-
disorders (second edition): A neuropsychological
framework. Journal of Autism and Developmental rologists in their daily practices.
Disorders, 40(9), 1165–1166. The CNS is a professional association of pedi-
Spek, A. A., Scholte, E. M., & Van Berckelaer-Onnes, atric neurologists and developmental pediatri-
I. A. (2011). Local information processing in
cians in the United States, Canada, and
adults with high functioning autism and Asperger syn-
drome: The usefulness of neuropsychological tests and worldwide devoted to optimizing the care of chil-
self-reports. Journal of Autism and Developmental dren with neurological and neurodevelopmental
Disorders, 41(7), 859–869. disorders. There are over 1,500 members. Like
Townsend, J., & Westerfield, M. (2010). Autism and
the AAN, the CNS has an annual meeting with
Asperger’s syndrome: A cognitive neuroscience
perspective. In C. L. Armstrong & L. Morrow (Eds.), a program designed to disseminate the latest sci-
Handbook of medical neuropsychology: Applications entific and clinical advances related to child neu-
of cognitive neuroscience (pp. 165–191). New York: rology and to maintain the skills and knowledge
Springer Science + Business Media.
of its clinicians. The CNS provides practice
guidelines, maintenance of certification support,
and CME programming in child neurology and
American Academy of Neurology developmental pediatrics, including autism.
The AAN and CNS are dedicated to promot-
Miya Asato ing the highest quality patient-centered neuro-
Pediatrics and Psychiatry, University of logic care and enhancing member competence
Pittsburgh School of Medicine Children’s and career satisfaction.
Hospital of Pittsburgh, Pittsburgh, PA, USA
Major Activities
Major Areas or Mission Statement
The AAN and CNS provide scientific and clinical
American Academy of Neurology (AAN) education for its members in many formats, com-
1080 Montreal Avenue mission the development of practice guidelines to
American Academy of Pediatrics 119 A
support improved standards of care, and public Shevell M., Ashwal S., Donley D., Flint J., Gingold M.,
leadership and advocacy for individuals impacted Hirtz D., Majnemer A., Noetzel M., & Sheth R. D.
(2003). Practice parameter: Evaluation of the child
by neurologic and neurodevelopmental disorders. with global developmental delay: Report of the A
Both organizations have provided educational Quality Standards Subcommittee of the American
sessions and practice guidelines on autism and Academy of Neurology and the Practice Committee
on many related/overlapping issues (see Read- of the Child Neurology Society. Neurology, 60,
367–380. Update in progress.
ings for examples).
Ashwal, S., Michelson, D., Plawner, L., & Dobyns, B. American Academy of Pediatrics
(2009). Practice parameter: Evaluation of the child
with microcephaly (an evidence-based review): Report
Susan Hyman
of the Quality Standards Subcommittee of the
American Academy of Neurology and the Child Division of Neurodevelopmental and Behavioral
Neurology Society. Neurology, 73, 887–897. Current Pediatrics, University of Rochester Golisano
guideline. Children’s Hospital, Rochester,
Ashwal, S., Russman, B., Blasco, P., Miller, G., Sandler,
NY, USA
A., Shevell, M., et al. (2004). Practice parameter:
Diagnostic assessment of the child with cerebral
palsy. Report of the Quality Standards Subcommittee
of the American Academy of Neurology and the Major Areas or Mission Statement
Practice Committee of the Child Neurology Society.
Neurology, 62, 851–863. Current guideline.
Filipek, P. A., Accardo, P. J., Ashwal, S., et al. (2000). Membership as of May 2011: Approximately
Practice parameter: screening and diagnosis of 60,000 members in the United States, Canada,
autism: Report of the Quality Standards Subcommittee Mexico, and internationally including pediatri-
of the American Academy of Neurology and the Child
cians, pediatric subspecialists, surgical subspe-
Neurology Society. Neurology, 55(4), 468–479.
Current guideline. cialists belong to the American Academy of
French J. A., Kanner A. M., Bautista J., Abou-Khalil B., Pediatrics (AAP). Thirty-four thousand members
Browne T., Harden C. L., Theodore W. H., Bazil C., are Board Certified in Pediatrics and can be listed
Stern J., Schachter S. C., Bergen D., Hirtz D.,
as Fellows of the American Academy of Pediat-
Montouris G. D., Nespeca M., Gidal B., Marks W. J.
Jr, Turk W. R., Fischer J. H., Bourgeois B., Wilner A., rics or FAAP.
Faught R. E. Jr, Sachdeo R. C., Beydoun A., & Major Areas or Mission Statement: “The
Glauser T. A. (2004). Efficacy and tolerability of the mission of the AAP is to attain optimal physi-
new antiepileptic drugs I: Treatment of new onset
cal, mental, and social health and well-being
epilepsy: Report of the Therapeutics and Technology
Assessment Subcommittee and Quality Standards for all infants, children, adolescents, and
Subcommittee of the Neurology and the American young adults. To accomplish this mission, the
Epilepsy Society. Neurology, 62, 1252–1260. Update AAP shall support the professional needs of its
in progress.
members.”
Hirtz, D., Berg, A., Bettis, D., Camfield, C., Camfield, P.,
Crumrine, P., et al. (2003). Practice parameter:
Treatment of the child with a first unprovoked
seizures. Report of the Quality Standards Landmark Contributions
Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child
Neurology Society. Neurology, 166–175. Current Landmark Contributions: It was not until the late
guideline. 1800s that the care of children began to emerge as
Michelson, D. J., Shevell, M. I., Sherr, E. H., Moeschler, a separate area of specialization within medicine.
J. B., Gropman, A. L., & Ashwal, S., (2011). Evidence
The recognition that growth and development,
report: Genetic and metabolic testing on children with
global developmental delay. Neurology, 77(17), nutrition, and prevention of infectious diseases
1629–1635. in increasingly urbanized communities required
A 120 American Academy of Pediatrics
focused research led to the founding of the management of infectious diseases. The efforts
American Pediatric Society in 1888. The increas- of the AAP have been critical in the passage of
ing number of physicians who limited their prac- legislation such as supporting health insurance
tices to the primary care of children in office for children (SCHIP) and Head Start. The poli-
settings resulted in the formation of the American cies and recommendations of the AAP guide the
Medical Association section on pediatrics in health care provided to children by pediatricians
1880. Proposed federal legislation to provide and serve to advise other organizations and agen-
matching funds to states for infant welfare clinics cies. In addition to the headquarters in Elk Grove
was supported by the American Medical Associ- Village, Illinois, it maintains an office in Wash-
ation section on pediatrics in 1922, but not the ington, DC.
leadership of the American Medical Association
who saw it a potential initial step to socialized
medicine. The commitment by physicians who Major Activities
cared for children to advocate for the welfare of
children led to the formation of an independent The AAP’s major activities address member edu-
organization, the American Academy of Pediat- cation, public education, advocacy for children
rics, in 1929. The original 35 members met in and youth, and promotion of community-based
Detroit to establish a professional organization research and demonstration projects.
that recognized that the needs for disease preven- Organization: The AAP is divided into 10
tion and health promotion in children were dif- regional districts and 59 state chapters each with
ferent than those for adults. In 1930 there were elected officials who represent the chapters in the
304 members. national organization. It is also organized by
The AAP set out to support and develop the interest areas within pediatrics into 7 councils
field of pediatrics. The Journal of Pediatrics and 49 sections. Twenty-nine committees advise
began publication in 1932 and was the official the elected leadership of the AAP in the develop-
journal until Pediatrics assumed that status in ment of the AAP’s positions and programs. Com-
1948. In collaboration with the American Pedi- mittees have interests as varied as injury and
atric Society and the AMA section on pediat- poison prevention, children with disabilities,
rics, the AAP supported development of the sports medicine, nutrition, and child health
American Board of Pediatrics in 1934 as an financing.
independent organization to establish formal Activities related to autism are primarily
training criteria and certification of expertise managed by the Council on Children with Dis-
in the specialty of pediatrics as well as to abilities, and its Autism Subcommittee, and the
approve and certify subspecialists within pedi- Section on Developmental and Behavioral Pedi-
atrics. Specialists and subspecialists must now atrics. Other groups with specific interests
demonstrate an ongoing commitment to profes- related to autism include the sections on General
sional education and incorporate quality Pediatrics in Office Settings, Complementary,
improvement into their practices to maintain Holistic, and Integrative Medicine; Genetics;
certification. Gastroenterology, Hepatology, and Nutrition;
The AAP has major initiatives regarding the Injury, Violence, and Poison Prevention; and
education of professionals and of the public on Neurology and the Council on Environmental
disorders of childhood in addition to advocacy for Health.
the health and well-being of children and families Education: The AAP coordinates continuing
including areas as diverse as disease prevention, education courses, annual scientific meetings,
behavioral health, education, and the environ- seminars, and online education for pediatricians
ment. Publications such as the Red Book to address ongoing educational needs. It pub-
guide practice related to immunization and lishes the journal Pediatrics to promote
American Academy of Pediatrics 121 A
academic understanding of the health needs that assure access to care for low-income
of children and youth. It also publishes children.
Pediatrics in Review as a journal for continuing Research: Through the Pediatric Research in A
education, AAP News as a member’s news mag- Office Settings (PROS) network and CATCH
azine, and manuals on topics important to child grant mechanisms, the AAP promotes research
health such as infectious diseases and school in the community that addresses health needs as
health. Books are written for families on topical well as program development. Interest areas
areas such as toilet training, Attention Deficit include social, economic, and behavioral
Hyperactivity Disorder, and others. Brochures research in addition to provision of medical care
on many areas relevant to child health, develop- and disease prevention.
ment, behavior, and safety are available to pedi-
atricians to provide information to their patients.
To assist child health professionals and policy
makers, the AAP committees prepare technical
reports and policy statements to summarize cur- Johnson, C. P., Myers, S. M., & Council on Children with
rent information for the providers and recom- Disabilities. (2007). Identification and evaluation of
mend health-care practices. Policies which children with autism spectrum disorders. Pediatrics,
recommend practice and clinical reports that 120, 1183–1215.
Myers, S. M., Johnson, C. P., & Council on Children with
summarize the medical literature are posted on Disabilities. (2007). Management of children with autism
the AAP website. spectrum disorders. Pediatrics, 120, 1162–1182.
Publications related to autism include the Pearson, H. A. (2006). The 75th anniversary of the
informational brochures for families on autism American Academy of Pediatrics. Pediatrics, 117,
1759–1762.
and language delays published in 2007. That
year, two clinical reports were published in
Pediatrics on the assessment and the manage- Partial List of Other Policies and Technical
ment of children with autism. Policies of related Reports of Interest
interest include developmental screening American Academy of Pediatrics, American Academy of
(2006), use of complementary and alternative Family Physicians, & American College of Physi-
cians-American Society of Internal Medicine. (2002).
medicine by children with chronic illness
A consensus statement on health care transitions for
(2001), learning disabilities, dyslexia, and young adults with special health care needs. Pediat-
vision (2011). A full listing is accessible at rics, 110(6), 1304–1306.
www.aap.org. Committee on Children with Disabilities. (2001).
Counseling families who choose complementary and
Public Education: Educational materials for
alternative medicine for their child with chronic illness
families on common topics are published for or disability. Pediatrics, 107, 598–601.
distribution in the context of anticipatory guid- Council on Children With Disabilities, Section on Devel-
ance in well child care and as information related opmental Behavioral Pediatrics, Bright Futures
Steering Committee, & Medical Home Initiatives for
to specific concerns, as well as books on topics
Children With Special Needs Project Advisory
such as toilet training and ADHD. Web-based Committee. (2006). Identifying infants and young
information for families is a priority of the children with developmental disorders in the medical
www.healthychildren.org website. home: an algorithm for developmental surveillance
and screening. Pediatrics, 118(1), 405–420.
Advocacy: The AAP has an office in Washing-
Council on Children With Disabilities. (2007). Provision
ton, DC that advocates at the federal level for of educationally related services for children and ado-
children’s health needs in emerging policies and lescents with chronic diseases and disabling condi-
legislation. AAP staff assist the state chapters of tions. Pediatrics, 119(6), 1218–1223.
Council on Children With Disabilities. (2009). Sup-
the AAP in state and local advocacy around plemental security income (SSI) for children
issues such as child safety legislation, Autism and youth with disabilities. Pediatrics, 124(6),
insurance legislation, and insurance legislation 1702–1708.
A 122 American Association on Intellectual and Developmental Disabilities (AAIDD)
Handler, S. M., Fierson, W. M., The Section on Ophthal- etc.), and four action groups (e.g., health and
mology and Council on Children with Disabilities, wellness, criminal justice, etc.).
American Academy of Ophthalmology, American
Association for Pediatric Ophthalmology and Strabis-
mus, & American Association of Certified Orthoptists. Mission Statement
(2011). Learning disabilities, dyslexia, and vision. AAIDD promotes progressive policies, sound
Pediatrics, 127(3), e818–e856. research, effective practices, and universal
http://www.aap.org/about.html
Weiss, J. I., & Committee on Violence, and Poison Pre- human rights for people with intellectual and
vention. (2010). Prevention of drowning. Pediatrics, developmental disabilities.
126(1), e253–e262.
AAIDD Has Adopted a 13-Point Set of
Principles (or Core Values) Relative to its
Mission
• Achieving full societal inclusion and partici-
American Association on Intellectual pation of people with intellectual and devel-
and Developmental Disabilities opmental disabilities
(AAIDD) • Advocating for equality, individual dignity,
and other human rights
Marc J. Tassé1 and Matthew Grover2 • Expanding opportunities for choice and self-
1
Nisonger Center – UCEDD, Departments of determination
Psychology and Psychiatry, The Ohio State • Influencing positive attitudes and public
University, Columbus, OH, USA awareness by recognizing the contributions
2
Nisonger Center – UCEDD, The Ohio State of people with intellectual disabilities
University, Columbus, OH, USA • Promoting genuine accommodations to
expand participation in all aspects of life
• Aiding families and other caregivers to
Major Areas or Mission Statement provide support in the community
• Increasing access to quality health, education,
The American Association on Intellectual and vocational, and other human services and
Developmental Disabilities counts approxi- supports
mately 3,500 interdisciplinary members. The • Advancing basic and applied research to
membership structure includes professionals prevent or minimize the effects of intellectual
working in the field of intellectual and develop- disability and to enhance the quality of life
mental disabilities. Members can select from • Cultivating and providing leadership in the
a tiered membership menu: basic, classic, stan- field
dard, and premium. AAIDD is primarily • Seeking a diversity of disciplines, cultures,
a North American professional association, but and perspectives in our work
it also offers an “international” membership • Enhancing skills, knowledge, rewards, and
option and has international members from 55 conditions of people working in the field
countries. Finally, there is also a corporate • Encouraging promising students to pursue
membership where an agency can join, garner- careers in the field of disabilities
ing a reduction on membership dues for • Establishing partnerships and strategic
employees affiliated with the corporate alliances with organizations that share our
member. values and goals
Association members have the option of
joining any of its ten professional divisions AAIDD’s Goals
(e.g., administration, education, psychology, 1. Enhance the capacity of professionals who
etc.), seven special interest groups (e.g., DD and work with individuals with intellectual and
co-occurring mental health problems, technology, developmental disabilities.
American Association on Intellectual and Developmental Disabilities (AAIDD) 123 A
2. Participate in the development of a society that Stevens, 1976), where it was founded under the
fully includes individuals with intellectual and name of “Association of Medical Officers of
developmental disabilities. American Institutions for Idiotic and Feeble- A
3. Build an effective, responsive, well managed, minded Persons” (Sloan & Stevens).
responsibly governed, and sustainable The association’s first constitution provided
organization. a framework for the goals of the association dur-
ing its earliest days (Sloan & Stevens, 1976, p. 1):
Article II: The object of the association shall
Landmark Contributions be the discussion of all questions relating to the
causes, conditions, and statistics of idiocy and to
AAIDD was founded in 1876 and has since been the management, training, and education of idiots
the leader in setting the practice standards; pub- and feebleminded persons; it will also lend its
lishing books, tests, and other resources; and influence to the establishment and fostering of
influencing policy. AAIDD’s first president in institutions for this purpose.
1876 was the French physician Édouard Séguin, Although the association’s policies have
MD, regarded by many as the father of special evolved over time, the common goal of reaching
education in the USA. a better understanding of intellectual disability
The AAIDD has led the field in establishing and serving to improve the lives of those with
the definition and diagnostic criteria for intellec- intellectual disability has remained unchanged
tual disability for over a century. It is well throughout the years.
established that a significant proportion of indi- Changes in the association’s name serve as
viduals with an autism spectrum disorder also somewhat of a barometer for the shifting attitudes
have a co-occurring diagnosis of intellectual dis- towards individuals with intellectual disability
ability. Since its first definition of intellectual within society at large. Association name
disability in 1910, AAIDD has revised its defini- changes have largely been driven by a move
tion 10 times to reflect the changes in research away from historical terminology that has
and understanding of this condition. The AAIDD acquired increasingly pejorative connotations.
definition of intellectual disability has histori- In 1910, the name of the association was changed
cally been adopted by all federal and state gov- to “American Association for the Study of the
ernments as well as the American Psychiatric Feebleminded.” This was the first of several
Association’s Diagnostic and Statistical Manual name changes for the association. The name
(DSM) in defining intellectual disability. AAIDD was changed again in 1933 to “ American Asso-
is considered the professional authority in the ciation on Mental Deficiency,” which it remained
area of intellectual disability. until 1987, when it officially became known as
In examining the history of the American the “American Association on Mental Retarda-
Association on Intellectual and Developmental tion.” The most recent change came in 2007,
Disabilities (AAIDD), one quickly discovers bringing with it the current name “American
that the association has undergone a number of Association on Intellectual and Developmental
changes since it was founded in 1876. Chief Disabilities.” This change was driven by the
among these changes is the position of the orga- increasing acceptance of intellectual disability
nization with regards to issues such as (a) etiol- as the replacement terminology for mental retar-
ogy of the disability (b) systems of classification, dation. AAMR also chose to include “develop-
and (c) systems of support/intervention. The mental disabilities” in its name to reflect its
AAIDD was founded by a small group of mission and influence in areas such as autism
superintendants of institutions for people with spectrum disorders and other related develop-
disabilities. The AAIDD’s first annual meeting mental disabilities.
was held at the Pennsylvania Training School in A landmark change brought about by AAIDD
Media, Pennsylvania, on June 6, 1876 (Sloan & was in 1959 when it introduced the construct of
A 124 American Association on Intellectual and Developmental Disabilities (AAIDD)
adaptive behavior into its definition of intellec- AAIDD publishes books, journals, assessment
tual disability (Heber, 1959). The 1959 AAIDD instruments, and training materials. Among its
terminology and classification manual first intro- publications, AAIDD publishes two of the mostly
duced deficits in adaptive functioning as part of highly cited professional journals in the field of
the diagnostic criteria for intellectual disability. disabilities: American Journal on Intellectual
All other major diagnostic systems (e.g., World and Developmental Disabilities and Intellectual
Health Organization’s International Classifica- and Developmental Disabilities. Many of its
tion of Diseases, American Psychiatric Associa- publications have been translated into dozens of
tion’s Diagnostic and Statistical Manual for languages and are disseminated and used
Mental Disorders) as well as federal and state worldwide.
agencies followed suit. AAIDD also published
the first standardized measure of adaptive behav-
ior in 1969 – titled the AAMD Adaptive Behavior See Also
Scale (Nihira, Foster, Shellhaas, & Leland,
1969). ▶ Developmental Disabilities
AAIDD has long been active in influencing ▶ Diagnosis and Classification
legislation and social action towards improving ▶ Intellectual Disability
treatment and supports for persons with ▶ Mental Retardation
intellectual and developmental disabilities. In
recent years, the organization has joined with
other like-minded organizations such as The
Arc of the United States to form the Consor-
tium for Citizens with Disabilities, which Association on Intellectual and Developmental Disabil-
advocates for public policy dedicated to the ities. (2010). Consortium for Citizens with Disabilities.
empowerment of people with disabilities Retrieved January 30, 2011, from AAIDD: http://
www.aaidd.org/content_28.cfm?navID¼7
(Association on Intellectual and Developmen-
Blatt, B., & Kaplan, F. (1974). Christmas in purgatory.
tal Disabilities, 2010). Syracuse, NY: Human Policy.
Throughout the years, AAIDD has served as Croser, M. D. (1999). Federal disability legislation: 1975–
amicus curiae in many cases regarding the rights 1999. In R. L. Schalock, P. C. Baker, & M. D. Croser
(Eds.), Embarking on a new century: Mental retarda-
of persons with intellectual disability (Croser,
tion at the end of the 20th century (pp. 3–16). Wash-
1999; Herr, 1999). James W. Ellis, JD, ington, DC: American Association on Mental
a University of New Mexico law professor and Retardation.
past president of AAIDD, successfully argued Heber, R. (1959). A manual on terminology and classifica-
tion in mental retardation: A monograph supplement.
before the US Supreme Court (Atkins v. Virginia,
American Journal of Mental Deficiency, 64(2), 1–111.
2002) that the execution of persons with ID was Herr, S. S. (1999). Presidential address 1999 – working for
cruel and unusual punishment. The Atkins v. Vir- justice: Responsibilities for the next millennium. Mental
ginia Supreme Court ruling led to the banning of Retardation, 37(5), 407–419.
Nihira, K., Foster, R., Shellhaas, M., & Leland, H. (1969).
capital punishment for all persons diagnosed with
AAMD adaptive behavior scale. Washington: Ameri-
ID. AAIDD was prominently mentioned in the can Association on Mental Deficiency.
2002 Atkins v. Virginia Supreme Court decision Schalock, R. L. (1999). Definitional issues. In R. L.
as a leading national organization in defining intel- Schalock, P. C. Baker, & M. D. Croser (Eds.),
Embarking on a new century: Mental retardation at
lectual disability (then called mental retardation). the end of the 20th century (pp. 45–66). Washington:
American Association on Mental Retardation.
Schalock, R. L., Buntinx, W. H. E., Borthwick-Duffy, S.,
Major Activities Bradley, V., Craig, E. M., Coulter, D. L., et al. (2010).
Intellectual disability: Definition, classification, and
system of supports (11e). Washington: American
The association offers a wide array of trainings, Association on Intellectual and Developmental
including an annual professional meeting. Disabilities.
American Board of Genetic Counseling 125 A
Schalock, R. L., Buntinx, W. H. E., Borthwick-Duffy, S., through recertification. The ABGC credentials
Luckasson, R., Snell, M. E., Tassé, M. J., & have become recognized as the gold standard in
Wehmeyer, M. L. (2007). User’s guide: Mental
retardation: Definition, classification, and systems of the health care industry. A
supports, 10th edition. Applications for clinicians, The ABGC organization is led by ten elected
educators, disability program managers, and policy board members who serve a 5-year term. Board
makers. Washington: American Association on Intel- members along with ABGC diplomates run com-
lectual and Developmental Disabilities.
Sloan, W., & Stevens, H. E. (1976). A century of concern: mittees, volunteer as item writers, and supervise
A history of the American association on mental defi- genetic counseling training programs.
ciency. Washington: American Association on Mental
Deficiency.
Thompson, J. R., Bryant, B., Campbell, E. M., Craig,
E. M., Hughes, C., Rotholz, D., et al. (2004). Supports Landmark Contributions
intensity scale: User manual. Washington: American
Association on Mental Retardation. The first genetic counseling training program
graduated its master’s-level genetic counselors in
1971. Since 1981, the American Board of Medical
Genetics (ABMG) had been the body responsible
American Board of Genetic for the certification of genetic counselors.
Counseling A decade later, the American Board of Medical
Specialties recognized genetics as a medical spe-
Erin Loring cialty and offered the ABMG an invitation to join.
Yale Department of Genetics, New Haven, A condition of the membership was that the
CT, USA ABMG was required to exclude non-doctoral-
level candidates from its certification process. An
agreement was made for the formation of the
Major Areas or Mission Statement ABGC. On October 23, 1992, the American
Board of Genetic Counseling was incorporated to
American Board of Genetic Counseling (ABGC) be the new accrediting and credentialing body for
the genetic counseling profession.
Mission Statement The ABGC saw the opportunity to restructure
The American Board of Genetic Counseling estab- the accreditation guidelines and the overall
lishes standards of competence through accredita- approach to accreditation. After carefully examin-
tion of graduate training programs and certification ing the accreditation practices of other specialties,
and recertification of genetic counselors to advance it elected to accredit entire genetic counseling pro-
the profession and protect the public.
grams instead of only clinical training sites as had
been done previously under the ABMG. In Janu-
Membership ary 1994, a meeting was convened with board
Currently there are 3,026 ABGC Certified members of the ABGC and the genetic counseling
Genetic Counselors. program directors. A major objective of the meet-
The American Board of Genetic Counseling is ing was to draft a set of practice-based competen-
a nonprofit organization incorporated in 1993 as cies that an entry-level genetic counselor needs to
the accrediting and credentialing body for the demonstrate to effectively manage a genetic
genetic counseling profession. The ABGC cre- counseling session. These competencies served
dential, Certified Genetic Counselor (CGC ®), as the basis for the Requirements for Graduate
identifies counselors who have met established Programs in Genetic Counseling Seeking Accred-
standards for graduate training with practical itation by the American Board of Genetic Counsel-
clinical experience, passed a comprehensive ing, adopted by the ABGC in January 1996. The
genetic counseling board examination, and dem- 27 competencies are grouped into four domains
onstrate a commitment to maintain knowledge (communication skills; critical-thinking skills;
A 126 American Congress of Rehabilitation Medicine
interpersonal, counseling, and psychosocial See Also

assessment skills; and professional ethics and
values). These skills have become the cornerstone ▶ Genetics
for curriculum design for programs seeking to
achieve accreditation. The ABGC moved away
from the content-driven accreditation process References and Readings
developed under the ABMG with lists of courses
and clinical contact hours, to an accreditation Begleiter, M. (2002). Training for genetic counsellors.
Nature Reviews, 3, 557–561.
model that encourages the development of prac-
Boughman, J. (2007). Looking back; moving forward.
tice-based skills that integrate knowledge from American Journal of Human Genetics, 81, 422–423.
several disciplines. With these practice-based Fiddler, B., Fine, B., Baker, D., & ABGC Consensus
competencies, the ABGC can hold the profession Development Consortium. (1996). A case-based
approach to the development of practice-based com-
to a common set of expectations. The accreditation
petencies for accreditation of and training in graduate
criteria for training programs are based on the programs in genetic counseling. Journal of Genetic
program’s ability to successfully develop these Counseling, 5, 105–112.
competencies in its genetic counseling graduates. Fine, B., Baker, D., Fiddler, M., & ABGC Consensus
Development Consortium. (1996). practice-based
Additionally, ABGC established a recertification
competencies for accreditation and training in gradu-
requirement for any diplomate certified in 1996 or ate programs in genetic counseling. Journal of Genetic
later. Recertification was initiated to demonstrate Counseling, 5, 113–121.
a diplomate’s commitment to maintaining knowl- www.abgc.net
www.nsgc.net
edge in a rapidly evolving field. Through the
recertification process, the ABGC strives to protect
the public by ensuring the continuing education of
genetic counselors. Recertification can be American Congress of Rehabilitation
achieved in one of two ways: by either success- Medicine
fully passing another board exam or by collecting
a specific number of continuing education units Beth Garrison
and professional activity credits over a specified Hartford Hospital Pain Treatment Center, Bristol,
period. Recertification has also proven significant CT, USA
for genetic counselors for licensing, professional
advancement, hospital credentialing, and insur-
ance reimbursement. Major Areas or Mission Statement
Since the formation of the ABGC, the number
of Certified Genetic Counselors has grown from The purpose of the American Congress of
495 to over 3,000. The number of accredited Rehabilitation Medicine (ACRM) is to advance
graduate training programs has increased from service delivery and research for people who
18 to 33. By accrediting training programs, have disabling conditions. There are four major
establishing competencies, and implementing areas of focus for this research:
recertification, the ABGC has been working 1. To meet the needs of people with disabilities
hard to protect the public and promote the ongo- 2. Educate providers for best practice delivery of
ing growth and development of practitioners in care
the genetic counseling profession. 3. Promote the health, independence, quality of
life, and productivity of disabled people
4. To ensure that future research projects are
Major Activities publicly funded
The primary mission of the ACRM is to enhance
The ABGC credentials genetic counselors and the lives of disabled people via a multidisciplinary
accredits genetic counseling training programs. rehabilitation approach. As a leader in the physical
American Congress of Rehabilitation Medicine 127 A
medicine and rehabilitation field, their mission is to this congress was initially founded in 1923 as the
promote innovative research and new technologies American College of Radiology and Physiother-
and encourage evidence-based practices in clinical apy. It began as a professional association of phy- A
settings as well as encourage information sharing. sicians who used physical agents to diagnose and
Leadership role ACRM creates forums where treat disability and illness. In 1925, with medicine
all rehabilitation professionals, including clini- already moving more toward specialization, the
cians, service managers, administrators, educa- radiology and physical medicine focuses split. It
tors, and researchers, can innovate. We call became the American Congress of Physical Ther-
upon the leaders in rehabilitation to identify cur- apy. At that time, the congress’ primary journal was
rent best practices and best providers at all levels the Archives of Physical Therapy, X-ray, Radium,
of care, and share this information via educa- which had been founded in 1920. In 1938, the name
tional meetings and the journal. was changed to Archives of Physical Therapy,
Archives of physical medicine and rehabilita- which more accurately reflected its focus.
tion. As rehabilitation science and medicine con- Over the next 6 years, the congress’ focus
tinues to evolve, the goal is to keep the narrowed further toward physical medicine, and
community connected by creating opportunities in 1944, the name was again changed to reflect this
to exchange and share information with rehabil- new direction. It was now the American Congress
itation professionals, corporate providers, health- of Physical Medicine, and in 1945, the name of its
care payers, and industry regulators. journal became the Archives of Physical Medi-
ACRM aims to provide multidisciplinary cine. This change in emphasis reflected the dis-
leadership and practice innovation to ensure that tinction that was growing between physical
people living with chronic disease and disabilities therapy and physical medicine. Physical medicine
have access to effective rehabilitation manage- moved away from a purely clinical approach
ment throughout their lives. It serves as a forum toward a scientific and diagnostic basis of the
for creating and discussing new treatment para- medical use of physical agents. It allowed
digms that define the composition of the rehabil- a distinction between physicians and technicians
itation team, the duration of care, and the venues of physical therapy in accord with the new stance
required to achieve optimal functional outcomes of the American Medical Association (AMA).
for people with chronic disease and disabilities. By 1952, the field of rehabilitation had signif-
ACRM is dedicated to icantly expanded following WWII. To reflect the
• Serving as advocates for public policy and leg- close relationship between physical medicine and
islative issues that support individuals with dis- rehabilitation, the name was changed to the Amer-
abilities and providers of rehabilitation services ican Congress of Physical Medicine and Rehabil-
• Helping develop innovative and cost-effective itation. The following year, the journal name was
models of collaborative care and comprehen- changed to its current version, Archives of Physi-
sive rehabilitation management cal Medicine and Rehabilitation.
• Leading research efforts that examine and In 1965, the congress formed the Professional
identify the most effective clinical technology Development Committee (PDC) which was piv-
and treatment paradigms otal in the management and direction of the
• Initiating dialogue with payers and regulators ACRM for the next 30 years. This committee’s
to communicate the collaborative care models accomplishments included a study of the objec-
that produce positive rehabilitation outcomes tives, constitution, and structure of the congress
as well as the sponsorship of interdisciplinary
forums and an expansion of the membership.
Landmark Contributions The following year, several physician members
recognized the need for a forum in which profes-
The current title of American Congress of Rehabil- sionals of other rehabilitation disciplines could
itation Medicine became official in 1966. However, share their professional, scientific, and technical
A 128 American Medical Association
talents. This led to an amendment to the congress’ References and Readings

constitution allowing membership privileges to be
extended to persons “holding an earned doctoral American Academy of Physical Medicine and Rehabilita-
tion (AAPM&R). www.aapmr.org
degree and active in and contributing to the
http://www.acrm.org
advancement of the field of rehabilitation medi- International Rehabilitation Medicine Association
cine.” This allowed the membership of psycholo- (IRMA). www.isprm.org
gists, nurses, physical therapists, occupational
therapists, speech pathologists, social workers,
vocational counselors, and others. And in the same
year, 1966, the name was officially changed to the American Medical Association
American Congress of Rehabilitation Medicine.
Fred R. Volkmar
Major Activities Professor of Child Psychiatry, Pediatrics and
Psychology, School of Medicine,
ACRM membership is focused on interdisciplin- Yale University, New Haven, CT, USA
ary communication and collaboration within the
rehabilitation professional community. This is
accomplished by providing special interest and Major Areas or Mission Statement
networking groups within the community, as well
as providing publications and conferences that Membership is limited to physicians (with an
facilitate ongoing research, reference resources, M.D. or D.O. degree or international equivalent)
and up-to-date developments in the field of phys- who are in practice of residents in the USA and its
ical rehabilitation medicine. Some of the possessions. Medical students can also enroll prior
resources available include the following: to completion of their training. About one quarter
• Fellows of ACRM of US physicians are members of the organization.
• Archives of Physical Medicine and Rehabili- The mission of the AMA is multifaceted and
tation – a leading journal in rehabilitation included improved public health, advocacy for
• Cognitive Rehabilitation Manual: Translating physicians and their patients, and medical educa-
Evidence-Based Recommendations into tion. The AMA plays a major role in maintenance
Practice of medical coding that health-care providers use
• ACRM eNews for reimbursement.
• Progress in Rehabilitation Research – an
annual conference that brings together experts
and participants from 20+ countries Landmark Contributions
• Midyear meeting for members and leaders
within the community to collaborate and share The organization was founded in 1847 and incor-
information and refine guideline development porated 50 years later. It has a strong record of
• Community calendar compiles a list of promotion of the scientific method in the practice
upcoming networking events and educational of medicine and in the improvement of medical
course offerings education. It also has had a major role in elaboration
of principles of medical ethics and public health
measures. It makes substantial contributions in sup-
See Also port of medical students in financial need as well as
grants for research and community projects. Over
▶ Certified Rehabilitation Counselor the years, many of its political positions have been
▶ Occupational Therapy (OT) controversial, e.g., including its initial opposition to
▶ Physical Therapy Medicare. In recent years, it has focused on the
American Psychiatric Association 129 A
disparities of health care and the special needs of the profession of psychiatry, and serve the
some groups to medical services. Criticism of the professional needs of its membership.
organization has come from several sources includ- A
ing the noted economist Milton Friedman who
argues that it has acted to limited competition. Landmark Contributions
The American Psychiatric Association, founded

Major Activities in 1844, is the oldest national medical profes-
sional association in the United States and the
The AMA publishes a series of journals in med- world’s largest psychiatric organization. Its
icine. Of these, the Journal of the American Med- member physicians work together to ensure
ical Association (JAMA) is the most prominent humane care and effective treatment for all per-
for the field of medicine in general, and the spe- sons with mental disorders, including intellectual
cialty journals of Archives of General Psychiatry disability and substance-related disorders.
and the Archives of Pediatric and Adolescent In 1948, APA formed a small task force to
Medicine are most relevant to individuals with create a new standardized psychiatric classifica-
autism and other developmental disabilities. tion system. This resulted in the 1952 publication
of the first Diagnostic and Statistical Manual of
Mental DisordersTM (DSM). The task force is
See Also currently developing DSM-5 to be published in
May of 2013.
▶ American Psychiatric Association
Major Activities
Cassedy, J. H. (1991). Medicine in America: A short his- The APA publishes scientific journals:
tory. Baltimore: Johns Hopkins University Press. The American Journal of Psychiatry publishes
Duffy, J. (1993). From humors to medical science: the latest advances in the diagnosis and treatment
A history of American medicine. Urbana, IL: Univer- of mental illness. The findings presented in this
sity of Illinois Press.
journal explore the full spectrum of issues related
to mental health diagnoses and treatment.
Psychiatric Services, a journal of the Ameri-
American Psychiatric Association can Psychiatric Association, is a journal for
mental health professionals and others concerned
Deborah Hales with treatment and services for persons with men-
Division of Education, American Psychiatric tal illnesses and mental disabilities.
Association, Arlington, VA, USA FOCUS: The Journal of Lifelong Learning in
Psychiatry addresses clinical issues in psychiatry,
featuring articles on current research including
Major Areas or Mission Statement influential works selected by experts in the field.
It also features an annual self-assessment exam
The mission of the American Psychiatric Associ- and assists psychiatrists with recertification.
ation is to promote the highest quality care for The APA’s annual meeting brings together
individuals with mental disorders (including psychiatrists from all over the world to under-
mental retardation and substance-related stand new research findings and acquire new
disorders) and their families, promote psychiatric knowledge and clinical issues in patient care.
education and research, advance and represent
A 130 American Psychological Association
See Also Psychological Association, 2002). This is accom-

plished by the organization’s efforts to be:
▶ American Medical Association • A uniting force for the discipline
▶ DSM-IV • The major catalyst for the stimulation, growth,
▶ Psychiatrist and dissemination of psychological science
and practice
• The primary resource for all psychologists
References and Readings • The premier innovator in the education, devel-
opment, and training of psychological scien-
American Psychiatric Association. (1944). One hundred tists, practitioners, and educators
years of American psychiatry. New York: Columbia
• The leading advocate for psychological
University Press.
American Psychiatric Association. (1966). History of the knowledge and practice informing policy
district branches and of the district branch assembly. makers and the public to improve public
Washington, DC: Author. policy and daily living
Barton, W. E. (1987). The history and influence of the
• A principal leader and global partner promot-
American psychiatric association. Washington, DC:
American Psychiatric Press. ing psychological knowledge and methods to
Baxter, W. E., & Hathcox, D. W., III. (1994). America’s facilitate the resolution of personal, societal,
care of the mentally Ill: A photographic history. and global challenges in diverse, multicul-
Washington, DC: American Psychiatric Press.
tural, and international contexts
Menninger, R. W., & Nemiah, J. C. (2000). American
psychiatry after World War II 1944–1994. Washing- • An effective champion of the application of
ton, DC: American Psychiatric Press. psychology to promote human rights, health,
Obenauf, W. H. (1959). The district branch of the APA: Its well-being, and dignity
origin, present status, and future developments.
The APA also notes its commitment to this
Journal of the American Psychiatric Association,
116, 416–422. vision through adherence and dedication to the
Sabshin, M. (2008). Changing American psychiatry: following values:
A personal perspective. Washington, DC: American • Continual pursuit of excellence
• Knowledge and application based on methods
of science
• Outstanding service to its members and to
society
American Psychological Association • Social justice, diversity, and inclusion
• Ethical action in all that we do
Beau Reilly The APA espouses the goal of seeking to
Psychiatry and Behavioral Sciences, University advance psychology as a science, a profession,
of Washington, Seattle, WA, USA and as a means of promoting health, education,
and human welfare by promoting and
maintaining the following actions:
Major Areas or Mission Statement • Encouraging the development and application
of psychology in the broadest manner
The primary mission of the APA is to “advance • Promoting research in psychology, the
the creation, communication and application of improvement of research methods and condi-
psychological knowledge to benefit society and tions, and the application of research findings
improve people’s lives” (APA.org). The APA • Improving the qualifications and usefulness of
states that within this mission contains the psychologists by establishing high standards of
aspiration and vision to excel as a valuable, effec- ethics, conduct, education, and achievement
tive, and influential organization advancing • Increasing and disseminating psychological
psychology as a science (American knowledge through meetings, professional
American Psychological Association 131 A
contacts, reports, papers, discussions, and • Assessment
publications • Therapy
Since 1955, the APA has provided the Model A
Act for State Licensure of Psychologists as
Landmark Contributions a prototype to aid in the drafting of each state’s
specific legislation regarding the practice and
The APA was founded in 1892 by G. Stanley Hall licensing of psychologists in their respective states.
at Clark University in Worcester, Massachusetts, The document is also meant to educate and inform
with approximately 26 individuals accepting legislators about the training and practice of psy-
membership at the time of its formation. Since chology. It has undergone periodic revisions and
the time of its inception, the APA has held prom- updates since its inception (APA Committee on
inent and historical members in the field of psy- Legislation, 1955). In 1984, the Council of Repre-
chology as its president including William James sentatives directed the Board of Professional
(1894), James McKeen Cattell (1895), Edward Affairs (BPA) to develop another revision of the
Thorndike (1912), Carl Rogers (1947), Harry existing 1967 Model Act for the council’s consid-
Harlow (1958), Abraham Maslow (1968), Albert eration. The Committee on Professional Practice
Bandura (1974), and Phillip Zimbardo (2002). (COPP) prepared the revised document, and it was
The APA was responsible for the formation, approved by the Council of Representatives in
review, and revision of the ethical codes of con- February 1987 (American Psychological Associa-
duct and standards of practice. The code itself “is tion, 1987). In 2006, the 1987 Model Act was again
intended to provide guidance for psychologists revised by a task force funded by the APA Board of
and standards of professional conduct that can Directors and Council of Representatives at the
be applied by the APA and by other bodies that recommendation of the Board of Professional
choose to adopt them” (APA, 2002). The Ethics Affairs and the Committee for the Advancement
Code contains the following five general princi- of Professional Practice. The primary reason for
ples that are aspirational in nature and intended to the changes in the existing Model Act was that it
be viewed as a guide to the highest possible did not reflect the developments in professional
standards of ethical practice: practice that had occurred over the preceding
• Beneficence and nonmaleficence 20 years across respective states. Specific develop-
• Fidelity and responsibility ments included the option for prescriptive authority
• Integrity in some states, changes to the provision of indus-
• Justice trial/organizational and consulting psychology ser-
• Respect for people’s rights and dignity vices encouraging licensure for psychologist
The APA also formulated ten ethical standards practicing in those arenas, and changes in the
of practices with specific guidelines in areas of recommended sequence of education and training
psychology’s application to a variety of domains. for psychologists. The task force provided
The standards set forth by the APA are enforce- a comprehensive review of the 1987 document as
able by law and provide a guiding framework for well as relevant APA policies and other documents
the competent and ethical practice of psychology. before creating a finalized draft of the new act. The
The ethical standard domains encompass: newest revision was approved by council in Feb-
• Resolving ethical issues ruary 2010 and includes commentary and guide-
• Competence lines for the following areas related to the practice
• Human relations of professional psychology (American Psycholog-
• Privacy and confidentiality ical Association, 2010):
• Advertising and other public statements • Declaration of policy
• Record keeping and fees • Definitions
• Education and training • State psychology boards
• Research and publication • Requirements for licensure
A 132 American Psychological Association
• Interstate practice of psychology use the Publication Manual as their specified style
• Temporary authorization to practice guide (APA, 2001).
• Limitations of practice, maintaining and
expanding competence
• Inactive status Major Activities
• Practice without a license
• Exemptions The APA exists and operates as an executive
• Grounds for suspensions or revocation of office, a publishing operation, and an office that
licenses addresses administrative, business, information
• Board hearing and investigations technology, and operational needs. It also contains
• Privileged communication five substantive directorates that address the needs
• Severability of the field of psychology in its respective areas:
• Effective date • The Education Directorate accredits doctoral
The Publication Manual of the American Psy- psychology programs and addresses issues
chological Association, currently in its sixth related to psychology education in secondary
edition, has provided guidelines and recommenda- through graduate education.
tions for publication style intended for writers, edi- • The Practice Directorate engages on behalf of
tors, students, and educators in the social and practicing psychologists and health-care
behavioral sciences. It has grown considerably consumers.
since its first publication in February of 1929 as • The Public Interest Directorate advances psy-
a seven-page instructional report (American chology as a means of addressing the funda-
Psychological Association, 2001). Over the mental problems of human welfare and
subsequent 70 years, these suggestions and instruc- promoting the equitable and just treatment of
tions were revised and expanded across six editions all segments of society.
to its present form. The current manual provides • The Public and Member Communications Direc-
guidance on all aspects of the scientific writing torate is responsible for APA’s outreach to its
process, from the ethics of authorship to the word members and affiliates and to the general public.
choice that best reduces bias in language. The man- • The Science Directorate provides support and
ual additionally provides guidance on choosing the voice for psychological scientists.
headings, tables, figures, and tone that will result in The American Psychologist is the APA’s offi-
strong, simple, and elegant scientific communica- cial journal and most highly circulated peer-
tion. Every edition of the Publication Manual has reviewed publication. The APA also publishes
been intended to aid authors in the preparation of 57 other journals across a wide range of specialty
manuscripts with the primary goal of providing and focus areas (APA.org). The APA also hosts
a standardized communication that will efficiently the largest national convention and gathering of
convey new ideas and research and to simplify the psychologists in the United States in a different
tasks of publishers, editors, authors, and readers. host city each year. The convention provides
This has further allowed for the linkages of elec- seminars, conferences, presentations, and
tronic files across publishers and manuscripts as networking for all areas of psychology in its
new technological advancements in communica- respective areas of research and practice.
tion and distribution have emerged. This includes Each year, the APA recognizes the work of
the maintenance and management of the abstract psychologists with its “Distinguished Contribu-
database, PyscINFO, which collects and distributes tions Award.” The awards are considered among
electronic information from approximately 2,500 the highest honors given and include recognition
journals dating from 1,800 to present (APA.org). in the following categories:
Over a thousand journals in psychology, the behav- • Distinguished Scientific Contributions to
ioral sciences, nursing, and personal administration Psychology
American Sign Language (ASL) 133 A
• Distinguished Contributions to Psychology in Mental Retardation and Developmental Disabil-
the Public Interest ities” three times per year and have access to the
• Distinguished Scientific Applications of division’s Listserv. A
Psychology
• Distinguished Contributions to Education and
Training in Psychology See Also
• Distinguished Professional Contributions to
Applied Research ▶ American Psychiatric Association
• Distinguished Professional Contributions to ▶ Clinical Psychology
Practice in the Public Sector ▶ Psychologist
• Distinguished Contributions to the Interna-
tional Advancement of Psychology
The APA participates in a commitment to be an
international partner with the global psychological American Psychological Association. (1987). Model act
community. Its office of International Affairs pro- for state licensure of psychologists. American Psychol-
motes exchange and collaboration with interna- ogist, 42, 696–703.
tional communities including the United Nations. American Psychological Association. (2001). Publication
manual of the American Psychological Association
There are over 7,000 international members and (5th ed.). Washington, DC: Author.
affiliates of the APA (APA.org). American Psychological Association. (2002). Ethical
The APA has periodically provided commen- principles of psychologists and code of conduct. Amer-
tary, guidelines, and recommendations to specific ican Psychologist, 57, 1060–1073.
American Psychological Association. (2007). American
issues of practice and applications of psychology Psychological Association: Psychology and Interroga-
that impact current world events and ethical tions. Submitted to the United States Senate Select
issues. Such issues and world topics have Committee on Intelligence. September 21, 2007.
included task force reports on appropriate thera- American Psychological Association. (2010). Model act
for state licensure of psychologists, Adopted by Coun-
peutic responses to sexual orientation (APA Task cil as APA Policy 02/20/2010, 1–16.
Force on Appropriate Therapeutic Responses to APA Committee on Legislation. (1955). Joint report of the
Sexual Orientation, 2009) as well as the use of APA and CSPA (Conference of State Psychological
military interrogation tactics (American Psycho- Associations). American Psychologist, 10, 727–756.
APA Task Force on Appropriate Therapeutic Responses to
logical Association, 2007). Sexual Orientation. (2009). Report of the task force on
Division 33 (Mental Retardation and Develop- appropriate therapeutic responses to sexual orientation.
mental Disabilities) of the American Psychological Washington, DC: American Psychological Association.
Association was formed in 1973 as a unified divi- http://www.apa.org
sion for psychologists committed to advancing psy-
chology practice and research for individuals with
mental retardation and developmental disabilities. American Sign Language (ASL)
In order to more accurately recognize the breadth of
conditions that are now recognized to constitute Vannesa T. Mueller
developmental disabilities (e.g., autism, Asperger’s Speech-Language Pathology Program,
disorder), the division changed its name from Men- University of Texas at El Paso College of Health
tal Retardation to Mental Retardation and Develop- Science, El Paso, TX, USA
mental Disabilities in 1988 and to Intellectual and
Developmental Disabilities in 2007 (APA.org).
The division consists of five special interest groups: Definition
behavior modification and technology, dual diag-
nosis, early intervention, aging and adult develop- American Sign Language (ASL) is the natural and
ment, and transitioning into adulthood. Members of national signed language of the deaf community in
Division 33 receive the newsletter “Psychology in the United States and parts of Canada (Neidel,
A 134 American Sign Language (ASL)
Kegl, MacLaughlin, Bahan, & Lee, 2000). It is languages in general. The field of linguistics has
a natural language because it has developed out a greater understanding of language thanks to
of a need for deaf individuals to communicate with comparisons made between spoken languages
each other, and it is a language that is in constant and signed languages. Like spoken languages,
evolution. It is a national language because it is sign language is comprised of syntax, semantics,
mutually unintelligible and separate from the morphology, and phonology (Sandler & Lillo-
signed languages that are used in other countries Martin, 2006). We have much greater under-
such as British Sign Language (Great Britain), standing of communication processes and
Mexican Sign Language (Mexico), and so forth. language universals due to research dealing with
ASL is a separate language from spoken English deaf adults who are victims of stroke or traumatic
(Lane, Hoffmeister, & Bahan, 1996), and it is brain injury with resulting aphasia in sign lan-
distinct from manual codes of English such as guage. The left hemisphere of the brain is largely
Seeing Essential English (SEE I), Signing Exact responsible for language processing of sign lan-
English (SEE II), Linguistics of Verbal English guage just as it is for spoken language (Corina,
(LOVE), or Conceptually Accurate Signed 1998; Poizner, Klima, & Bellugi, 1987). Both
English (CASE). Unlike most other languages, fluent and nonfluent aphasias in sign have been
ASL is typically learned from peers rather than documented as well as paraphasias resulting from
from one’s parents (Padden, 1980). This may be disordered phonology and morphology. See
due to the fact that most deaf children (about 90 %) Hickok, Bellugi and Klima (1998) and Woll and
are born to hearing parents (Mitchell & Karchmer, Sharma (2008) for a review of the literature.
2004) rather than to deaf parents who could pass Because users of spoken language use gestures
along the language to their children. to augment their messages, there is recent
research on the role of gesture for those who use
sign. Vermeerbergen and Demey (2007) show
Historical Background that gesture and sign can coexist and are often
combined into one sign. Also, interestingly, the
The American Sign Language that is used today is mouth and hands may trade tasks in fluent
a combination of Parisian sign language that was signers. For nonsigners, the mouth is responsible
introduced in 1817 by Laurent Clerc, a teacher of for transmitting verbal information, while the
the deaf from France, and the sign language that hands are largely responsible for gesturing to
was being used by the large community of Deaf augment the message. For signers, the mouth
Americans at Martha’s Vineyard (Baynton, 1996). may be responsible for gesturing, while the
Despite attempts by some members of the normally hands convey linguistic information.
hearing community to extinguish the language, the Much recent work has been focused on using
ASL that was used in the mid-1800s is still intelli- technology to enhance the lives of the deaf popu-
gible today to ASL users (Baynton, 1996). William lation. There is great potential for converting sign
C. Stokoe Jr. first described ASL in his publication to text and text to sign to create faster and more
Sign Language Structure (Stokoe, 1960). In it, he efficient exchanges between the deaf and hearing
argued that indeed American Sign Language was populations. The complexities of sign language,
a true and natural language and not merely gestures however, have made it difficult to automate
or pantomime. Stokoe followed this work with the a translation system to convert signed conversa-
first dictionary of American Sign Language. tions to text. Two of the most commonly used
input devices for capturing sign language gestures
are glove-type devices and computer vision sys-
Current Knowledge tems. Each system has advantages and drawbacks.
There have been a number of different glove-
Since the work of William Stokoe, much study based devices used for input purposes (Hernandez-
has been focused on ASL specifically and signed Rebollar, Kyriakopoulos, & Linderman, 2004).
American Sign Language (ASL) 135 A
These devices typically contain several sensors per Opponents of video-based gesture recognition
finger to measure the way the fingers move and the state that video-based systems are less able to rec-
angle of the fingers as well as sensors to measure ognize handshapes (Hernandez-Rebollar et al., A
the pitch and roll of the hand. Proponents of these 2004; Starner, Weaver, & Pentland, 1997; Starner
systems show that these input devices are able to & Pentland, 1998). Other challenges that video-
more precisely detect handshapes than video- based systems must overcome are specific lighting
based systems (Fels & Hinton, 1993; Hernandez- conditions needed to accurately capture the intended
Rebollar et al., 2004). There are several disadvan- target as well as camera placement. Additionally,
tages posed by data-glove devices (Wang, Chen, the subject being captured must remain in frame and
Zhang, Wang, & Gao, 2007). While extremely the camera must not be obscured while recognition
accurate, these devices were typically bulky and is underway. These limitations, particularly in ear-
cumbersome as an individual wearing this device lier systems, made video-based systems difficult to
needed to be physically attached by the device to use outside of the laboratory setting. Additionally
a computer by means of cables. This need to tether processing the collected information to extract nec-
the device to a computer limited how and where essary features requires large amounts of computa-
these devices could be used. The need to be phys- tion that makes real-time processing difficult.
ically connected is changing with advances in Current techniques in video-based gesture rec-
technology. Newer devices are employing tech- ognition address some of the earlier challenges
nology such as electro-optical or magnetic sensors including using multiple cameras, faster cameras,
and accelerometers along with wireless capabili- better controlled environments, and even having
ties to compensate for many of the early data- the users wear specially colored gloves (Murthy
glove limitations (Dipietro, Sabatini, & Dario, & Jadon, 2009; Wang et al., 2007). In addition,
2008). Even with advances in technology, these the processing of the data collected has improved
devices might interfere with natural movement by implementing processes such as hidden Mar-
and thus self-expression for individuals using kov models and the use of neural networks, but
them. Another factor that limits the use of these these tasks are still computationally expensive
devices is the expense, which is typically more (Murthy & Jadon, 2009).
than for vision-based systems, although some of
the costs have been reduced with new technology.
Gesture recognition based on computer vision Future Directions
systems utilizes a camera to detect hand movements
and handshapes. Generally, these systems detect The relationship between language and cognition is
movement or the skin color of the hand to segment an area of continued interest and research. Much
and extract features that can be used to model the more can be learned regarding the processing of
hand. While the actual processes that each system visual-spatial information from studies comparing
employs vary, three basic types of methods are used native deaf signers, hearing signers, and hearing
to extract hand features: (1) Model-based or kine- nonsigners. The area of normal sign language
matic methods seek to model the angles created by acquisition is in need of further exploration. With
the palm and joints of the hand. (2) View-based or a better understanding of how sign language
appearance-based methods use multiple two- develops normally, we would be better able to
dimensional intensity images to model gestures as identify disordered or delayed acquisition. The
a sequence of views to overcome some of the short- issue of bilingualism in sign language acquisition
comings of kinematic models. (3) Low-level fea- needs to be appraised more fully. Children who use
ture-based methods utilize low-level measurements ASL must become bilingual in their language of
of the hand region. These methods do not rely on re- conversation (ASL) and their language of instruc-
creating an exact model of the hand but rather tion which is most often English in many forms
attempt to capture just enough of the essential infor- (written, signed, and spoken). Therefore, more
mation needed to recognize gestures. studies should focus on bilingual acquisition. Few
A 136 American Speech-Language-Hearing Association Functional Assessment of Communication Skills
studies use a longitudinal design which would elu- Padden, C. (1980). The deaf community and the culture of
cidate patterns in the development of sign language deaf people. In C. Baker & R. Battison (Eds.), Sign
language and the deaf community: Essays in honor of
and help in the recognition of individual differ- William Stokoe. National Association of the Deaf:
ences. Finally, as technology becomes smaller, Silver Spring, MD.
less expensive, and more readily available, the Poizner, H., Klima, E., & Bellugi, U. (1987). What the hands
applications for those with disabilities are limitless. reveal about the brain. Cambridge, MA: The MIT Press.
Sandler, W., & Lillo-Martin, D. (2006). Sign language
and linguistic universals. Cambridge: Cambridge
University Press.
See Also Starner, T., & Pentland, A. (1998). Real-time American
Sign Language recognition using desk and wearable
computer based video. IEEE Transactions on Pattern
▶ Manual Sign Analysis and Machine Intelligence, 20, 1371–1375.
▶ Sign Language Starner, T., Weaver, J., & Pentland, A. (1997). A wearable
computer based American Sign Language recognizer.
In First International Symposium on Wearable
Computing. Cambridge, MA: IEEE Computer Society.
Stokoe, W. C. (1960). Sign language structure: An outline of
References and Readings the communication systems of the American deaf (Stud-
ies in Linguistics Occasional Papers 8). Buffalo: Dept. of
Baynton, D. C. (1996). Forbidden signs: American culture Anthropology and Linguistics, University of Buffalo.
and the campaign against sign language. Chicago, IL: Valli, C., Lucas, C., & Mulrooney, K. J. (2005). Linguis-
The University of Chicago Press. tics of American sign language (4th ed.). Washington,
Bellugi, U., & Fischer, S. (1972). A comparison of sign D.C.: Clerc Books.
language and spoken language. Cognition, 1, 173–200. Vermeerbergen, M., & Demey, E. (2007). Comparing
Corina, D. P. (1998). Aphasia in users of signed aspects of simultaneity in Flemish sign language to
languages. In P. Coppens, Y. Lebrun, & A. Basso instances of concurrent speech and gesture. In M.
(Eds.), Aphasia in atypical populations Vermeerbergen, L. Leeson, & O. Crasborn (Eds.),
(pp. 261–309). Mahwah, NJ: Lawrence Erlbaum. Simultaneity in sign languages: Form and function.
Dipietro, L., Sabatini, A. M., & Dario, P. (2008). A survey Philadelphia: John Benjamins.
of glove-based systems and their applications. IEEE Wang, Q., Chen, X., Zhang, L., Wang, C., & Gao, W.
Transactions on Systems, Man, and Cybernetics, Part (2007). Viewpoint invariant sign language recogni-
C: Applications and Reviews, 38, 461–482. tion. Computer Vision and Image Understanding,
Fels, S., & Hinton, G. (1993). Glove-Talk: A neural 108, 87–97.
network interface between a data-glove and a speech syn- Woll, B., & Sharma, S. (2008). Sign language and
thesizer. IEEE Transactions on Neural Networks, 3, 2–8. English: How the brain processes languages in
Hernandez-Rebollar, J., Kyriakopoulos, N., & Linderman, different modalities. In C. Bidoli & E. Ochse (Eds.),
R. (2004). A new instrumented approach for translat- English in international deaf communication. Bern,
ing American Sign Language into sound and text. In Germany: Lang.
Proceedings of the Sixth IEEE International
Conference on Automated Face and Gesture Recogni-
tion (FGR ’04), (pp. 547–552). New York: Association
for Computing Machinery.
Hickok, G., Bellugi, U., & Klima, E. S. (1998). The neural American Speech-Language-Hearing
organization of language: Evidence from sign language Association Functional Assessment
aphasia. Trends in Cognitive Sciences, 2, 129–136.
Lane, H., Hoffmeister, R., & Bahan, B. (1996). Journey
of Communication Skills
into the deaf-world. New York: Random House.
Mitchell, R. E., & Karchmer, M. A. (2004). Chasing the Sarita Austin
mythical ten percent: Parental hearing status of deaf Laboratory of Developmental Communication
and hard of hearing children in the United States. Sign
Disorders, Yale Child Study Center, New Haven,
Language Studies, 4, 138–163.
Murthy, G., & Jadon, R. (2009). A review of vision based CT, USA
hand gestures recognition. International Journal of
Information Technology and Knowledge Management,
2, 405–410.
Neidel, C., Kegl, J., MacLaughlin, C., Bahan, B., & Lee,
Synonyms
R. G. (2000). The syntax of American Sign Language.
Cambridge, MA: The MIT Press. ASHA FACS
American Speech-Language-Hearing Association Functional Assessment of Communication Skills 137 A
Description ASHA FACS should allow the clinician to examine
patterns of social communication and the compre-
The American Speech-Language-Hearing Asso- hension and use of oral and written language. A
ciation Functional Assessment of Communica-
tion Skills (ASHA FACS) measures and
provides tools to monitor the functional commu- Clinical Uses
nication of adults with certain speech, language,
and cognition disorders. Functional communica- The American Speech-Language-Hearing Asso-
tion is the ability to effectively and independently ciation Functional Assessment of Communica-
communicate by sending or receiving messages, tion Skills (ASHA FACS) is suggested for use
whether the individual uses speech, sign, pic- with adolescents (from age 16 years) and adults
tures, or a speech-generating machine to convey with speech, language, and cognitive difficulties
the message. following a stroke or traumatic brain injury or in
the presence of progressive neurological disease,
Alzheimer’s disease, and related dementias. The
Historical Background assessment looks at the following areas: social
communication, communication of needs, daily
This test was first published in 1995 to measure planning, reading, writing, and number concepts.
the ability of adults with left-hemisphere stroke Although not specifically designed or normed for
and traumatic brain injury to execute their daily the ASD population, the measure could be used
communication tasks. An addendum to this test informally to look at the daily communication
was published in 2004 that included normative abilities of adults and adolescents in this
data from individuals with right-hemisphere population.
stroke, progressive neurological disease, and
Alzheimer’s disease and related dementias, but
not adults with communication deficits related to See Also
autism spectrum disorders (ASD). The extended
validation of the test was also designed to support ▶ Augmentative and Alternative
the use of this measure with multicultural Communication (AAC) Device
populations in the United States and English- ▶ Communicative Functions
speaking populations internationally. ▶ Functional Communication Training
▶ Pragmatics
▶ Social Communication
Psychometric Data
Comparison data for the American Speech-Lan-

guage-Hearing Association Functional Assessment
of Communication Skills (ASHA FACS) test is
Adams, B. C. (2009). The language activities of daily
based on the performance of individuals with trau- living series (Sterling Edition). Winooski, VT: Laure-
matic brain injury, stroke, progressive neurological ate. Retrieved August 8, 2012 from www.laureatelear-
disease, and Alzheimer’s disease and related ningsystems.net/pdfs/laureate_ladl_monograph_ 09.
pdf
dementias. While it may not be appropriate to use Frattali, C. M., Holland, A. L., Thompson, C. K., Wohl,
this data to evaluate the performance of adults with C., & Ferketic, M. (2003). Functional assessment of
autism spectrum disorders (ASD), the test might be communication skills for adults. Rockville, MD:
used informally to identify specific behaviors American Speech-Language-Hearing Association.
Kleinman, L. I. (2003). Functional communication pro-
important to developing effective functional com-
file-revised. East Moline, IL: LinguiSystems.
munication in adults with ASD. An individual’s Light, J. C., Roberts, B., Dimarco, R., & Greiner, N.
ability to perform the activities outlined on the (1998). Augmentative and alternative communication
A 138 Americans with Disabilities Act
to support receptive and expressive communication for ADA Amendments Act of 2008, again expanding
people with autism. Journal of Communication Disor- the coverage of civil rights protections for people
ders, 31(2), 153–180.
Martos Perez, J., & Fortea Sevilla, M. S. (1993). Psycho- with disabilities.
logical assessment of adolescents and adults with
autism. Journal of Autism and Developmental Disor-
ders, 23(4), 653–664. Areas Covered by the ADA
Mesibov, G. B., Schopler, E., & Caison, W. (1989). The
adolescent and adult psychoeducational profile:
Assessment of adolescents and adults with severe Employment
developmental handicaps. Journal of Autism and The ADA stipulates that employers are not
Developmental Disorders, 19(1), 33–40. allowed to inquire about whether a person has a
Mirenda, P. (2001). Autism, augmentative communica-
tion, and assistance technology. Focus on Autism and disability, or the nature or severity of such dis-
Other Developmental Disabilities, 16(3), 141–151. ability, during the hiring or application process.
Mirenda, P. (2008). Toward functional augmentative and The ADA also required certain employers (such
alternative communication for students with autism: as employment agencies, labor organizations,
Manual signs, graphic symbols, and voice output com-
munication aids. Language, Speech, and Hearing Ser- and joint labor-management committees) to pro-
vices in Schools, 34, 203–216. vide “reasonable accommodations” to qualified
Persson, B. (2000). Brief report: A longitudinal study of individuals with a disability, unless it would
quality of life among adult men with autism. Journal of impose extreme hardship on the employer. Rea-
Autism and Developmental Disorders, 30(1), 61–66.
doi:10.1023/A:1005464128544. sonable accommodations include making
Van Bourgondien, M. E., Reichle, N. C., & Schopler, E. existing facilities accessible to people with
(2003). Effects of a model treatment approach on disabilities, changing work duties (including job
adults with autism. Journal of Autism and Develop- restructuring, part-time or modified work sched-
mental Disorders, 33(2), 131–140. doi:10.1023/
A:1022931224934. ules, reassignment to a vacant position) and also
the provision of equipment, devices, or inter-
preters to enable a qualified person with a disabil-
ity to perform the role. Determinations of
extreme hardship take into account the size of
Americans with Disabilities Act the firm and the nature and cost of the reasonable
accommodation, among other things.
Mark Sherry
Department of Sociology and Anthropology, Public Entities and Public Transportation
University of Toledo, Toledo, OH, USA The ADA also prohibits public entities (such as
state or local governments and federal transpor-
tation organizations) from engaging in discrimi-
Definition nation against people with disabilities in their
programs and services. This aspect of the law
The Americans with Disabilities Act (ADA) also requires public entities to provide paratransit
is a landmark piece of Federal civil rights legis- and other special transportation services for indi-
lation which provides equal rights for people with viduals with disabilities, including making pro-
disabilities throughout the United States. The visions for wheelchair users in public transport.
ADA provided civil rights protections for people
with disabilities in all programs funded by fed- Public Accommodations and Services
eral, state, and local governments. It prohibited Operated by Private Entities
discrimination on the basis of disability in the The ADA also prohibits discrimination against peo-
areas of employment, state and local government, ple with disabilities in terms of receiving goods,
public accommodations, transportation, telecom- services, facilities, privileges, advantages, or
munications, and commercial facilities. In 2008, accommodations from “any place of public accom-
the ADA was updated with the passage of the modation.” The term “public accommodation” is
Americans with Disabilities Act 139 A
defined very broadly to include such places as individual must prove they are prevented from
hotels and motels; restaurants and bars; movie cin- performing major life activities in daily life (and
emas and theaters; convention centers and audito- not just workplace issues associated with their A
riums; stores that sell food, clothing, or hardware; impairment) before they are considered “dis-
laundromats; travel centers; banks; pharmacies; abled” under the ADA.
parks and zoos; educational institutions (from nurs-
ery school to university); day care centers and
senior centers; and gyms and health spas. However, Historical Background
religious institutions are not included in the ADA.
Any new construction of such facilities must con- The Rehabilitation Act of 1973
form to the requirements of the ADA and be acces- In the early 1970s, the disability rights move-
sible to all users. ment, inspired by civil rights movement, had
increasingly defined itself as a minority which
Telecommunications was experiencing widespread discrimination. Its
Telecommunications carriers were required advocates played a key role in developing the
under the ADA to provide telecommunications legislative precursor to the ADA – the Rehabili-
relay services such as Teletype Writers and other tation Act of 1973. This Act was the first national
telecommunications devices, particularly for piece of civil rights and antidiscrimination legis-
people who are deaf or who have speech lation for people with disabilities. Section 504 of
impairments. the Rehabilitation Act of 1973 which stated that
“no qualified individual with a disability in the
United States shall be excluded from, denied the
Landmark ADA Cases benefits of, or be subjected to discrimination
under” any program receiving federal funding –
The ADA has been elaborated and refined under specifically the Federal Government, federal con-
case law – in other words, courts have made tractors, and recipients of federal financial
rulings about the areas covered under the law assistance.
over time. Some of the important cases which Section 504 of the Rehabilitation Act of 1973
have affected the way the ADA is interpreted was historic for a number of reasons, including
include Bragdon v. Abbott, 524 U.S. 624 the fact that it recognized that people with dis-
(1998) which found that people with HIV were abilities were “a class” who experienced inferior
included in the ADA; Sutton v. United Air Lines treatment and discrimination because of
Inc., 119S.Ct. 2139 (1999) which found that a widespread pattern of discrimination and prej-
when deciding whether an individual is dis- udice. From this viewpoint, people with disabil-
abled, courts should consider measures that mit- ities could legitimately be considered
igate the individual’s impairment, such as a “minority group” – indeed, some activists
eyeglasses and contact lenses; Board of Trustees called it “the biggest minority group in the coun-
of University of Alabama v. Garrett, 531 U.S. try” because they estimated 20% of the entire
356 (2001), which bars private money damages population had a disability. Section 504 also
actions for state violations of employment dis- involved treating people with different disabil-
crimination against people with disabilities; ities as members of the same minority group,
Barden v. The City of Sacramento 292F.3d replacing a long history of legislation aimed at
1073, 1076 (9th Cir. 2002), which ruled that specific groups of people with disabilities (such
local governments must make sidewalks acces- as veterans with disabilities, blind people, deaf
sible when they made street improvements; and people, and so on).
Toyota Motor Manufacturing, Kentucky, Inc. v. For 4 years, the disability rights movement
Williams, 534 U.S. 184 (2002), which narrowed engaged in continuous advocacy over the regula-
the definition of disability by ruling that an tions which would be used to enforce
A 140 Americans with Disabilities Act
Section 504. They argued that the regulations companies with 15 employees or more had to
must require actions that would remove physical insure their compliance with ADA. Most major
and communicational barriers, as well as provid- companies now employ at least one individual
ing accommodations. Throughout the USA, whose job is to insure compliance with the law.
disability activists engaged in “sit ins” – the lon- The penalties for noncompliance are similar to
gest of which occurred in San Francisco, lasting those where a company is found guilty of dis-
28 days. The final regulations did meet the criminating against a person based upon gender
demands of these disability activists. or race. Government agencies are expected to
In the early 1980s, under the leadership of comply with the law and face the same penalties
President Reagan, a task force was established as well.
to remove legislation which was excessively
burdensome on business. Section 504 was iden-
tified as a potential burden for business, but the Current Knowledge
disability movement waged a 2-year campaign
in defense of the legislation, and they were Current knowledge about civil rights legislation
again successful. The regulations stayed in for people with disabilities, and the ADA in
place. particular, relies on an updated version of the
Act, namely, the ADA Amendments Act of
Americans with Disabilities Act of 1990 2008. The central idea behind the ADA – that
(P.L. 101-336) discrimination against people with disabilities
President George H.W. Bush signed into law the was unlawful – is maintained in this Amendment,
Americans with Disabilities Act of 1990 (P.L. but other changes significantly alter the nature of
101-336). This was hailed as a major piece of disability rights in the USA.
civil rights legislation for people with disabil- Under the ADA Amendments Act of 2008,
ities. Whereas Section 504 of the Rehabilitation which came into effect on January 1, 2009, the
Act prohibited discrimination against individ- US Congress reversed a series of court rulings
uals on the basis of disability in public entities, which they viewed as limiting the rights of per-
and services that received federal funding, the sons with disabilities. The Act specifically criti-
ADA extended the prohibition to private com- cizes the findings of the judicial system in two of
panies as well. Employers were prohibited from the cases discussed above (Sutton v. United Air
engaging in discrimination in every phase of Lines and Toyota v. Williams) for moving away
employment: from recruitment and hiring to from the initial intent of the ADA, which was to
evaluation and promotion (Wehman, 2001). provide a broad-scale remedy to discrimination
Employers were again prohibited from discrim- for people with disabilities.
inating against “otherwise qualified” individuals The ADA Amendments Act of 2008 also
with a disability. The term “otherwise qualified” expanded the scope of those covered under the
being a specific legal term. The employer who law: it applies not only to programs receiving
had an employee or job candidate who was “oth- local, state or federal funding, but also to all
erwise qualified” had to make “reasonable private employers with 15 or more employees,
accommodations” in the workplace so that the as well as businesses with fewer than 15
individual could successfully perform his or her employees, if they are considered “places of pub-
job. The scope of this piece of legislation was lic accommodation.” Such “places of public
profound. According to Wehman (2001), this accommodation” include hotels, educational
was a considerable challenge to 660,000 private institutions, care providers, recreation facilities,
businesses at the time that employed 8.6 million transportation providers, and restaurants.
people. In fact, the law set up a timeline by While the ADA was marked by conflict
which companies of various sizes had to insure between the business community and disability
their compliance with the ADA. By 1994, advocates, the ADA Amendments Act of 2008
Americans with Disabilities Act 141 A
broke such patterns of conflict, in some ways, of ordinary eyeglasses should be included in
because both business and disability advocates determining whether someone has an impair-
agreed on a compromise which they unilaterally ment that limits a major life activity. It also A
supported in testimonies to Congress. This was states that the ADA regulations developed by
an interesting compromise because business the Equal Employment Opportunity Commis-
representatives had criticized some disability sion were inconsistent with congressional
activists for being “professional plaintiffs” who intent, relying on an excessively narrow defi-
sought to earn an income by being overly nition of disability.
litigious. The Act does not apply retrospectively; it only
applies after January 1, 2009.
New Disability Definition

Future Directions
This Act clarified the intent of Congress to
provide a broad definition of “major life activ- Future cases will test the redefinition of “disabil-
ities” which might be affected by a person’s ity” through the court system. Congress has indi-
disability. Specifically, it stated that “major cated that it wanted a more inclusive definition of
life activities include, but are not limited to, disability, but how that actually plays out in spe-
caring for oneself, performing manual tasks, cific cases and with specific disabilities (and
seeing, hearing, eating, sleeping, walking, degrees of disability) is yet to be determined.
standing, lifting, bending, speaking, breathing, Additionally, upcoming cases will explore issues
learning, reading, concentrating, thinking, of compliance with the Americans with Disabil-
communicating, and working.” The phrase ities Act Amendments of 2008.
“major life activity” also specifically included Another issue which will be a major concern
“the operation of a major bodily function, in the future is the degree to which the broad
including but not limited to, functions of the definition of disability within the Americans
immune system, normal cell growth, digestive, with Disabilities Act Amendments of 2008 relates
bowel, bladder, neurological, brain, respira- to other disability legislation such as the Individ-
tory, circulatory, endocrine, and reproductive uals with Disabilities Education Act (IDEA)
functions.” As well, the Act overrode the find- which potentially may result in confusion or
ings in the Sutton case that “an impairment that inconsistent treatment of students in elementary
substantially limits one major life activity need and secondary schools.
not limit other major life activities in order to
be considered a disability.” Furthermore, the
Act stated that defining disability should not See Also
be continuously reduced through a series of
restrictive court decisions; instead, it states ▶ Disability
that the definition “shall be construed in favor ▶ Rehabilitation Act of 1973
of broad coverage of individuals under this Act,
to the maximum extent permitted. . .”
The Act also stated that determining
whether an impairment substantially limits
a major life activity must be made without Feldblum, C. R., Barry, K., & Benfer, E. A. (2008). The
considering various mitigating measures such ADA Amendments Act of 2008. Texas Journal on
as medication, equipment, low-vision devices, Civil Liberties & Civil Rights, 13(2), 187–240.
Long, A. B. (2008). Introducing the new and improved
prosthetics, hearing aids or cochlear implants,
Americans with Disabilities Act: Assessing the ADA
oxygen therapy equipment, or assistive tech- Amendments Act of 2008. Northwestern University
nology. However, the Act states that the use Law Review, 103, 217–229.
A 142 Amino Acids
Rozalski, M., Katsiyannis, A., Ryan, J., Collins, T., &

Stewart, A. (2010). Americans with Disabilities Act Amitriptyline
amendments of 2008. Journal of Disability Policy
Studies, 21(1), 22–28.
Thomas, V. L., & Gostin, L. O. (2009). The Americans Jeffrey Glennon
with Disabilities Act: Shattered aspirations and new Department of Cognitive Neuroscience, Radboud
hope. JAMA, 301(1), 95–97. University Nijmegen Medical Centre, Nijmegen,
Wehman, P. (2001). Life beyond the classroom: Transi-
tion strategies for young people with disabilities The Netherlands
(3rd ed.). Baltimore: Paul H. Brookes Publishing.
Synonyms
Amino Acids Amitryptiline
Wouter Staal
Neuroscience, Radboud University Nijmegen Indications
Medical Centre Karakter, Nijmegen,
The Netherlands Depression, anxiety, enuresis nocturna, neuro-
pathic pain, attention deficit/hyperactivity disorder
(ADHD), obsessive-compulsive disorder (OCD).
Synonyms
Alpha-amino acid Mechanisms of Action
Amitriptyline’s key mechanism of action lies

Definition in the elevation of extracellular biogenic
amine levels notably those of noradrenaline and
Amino acids are molecules that contain an amine serotonin (with noradrenaline being affected
group, a carbolic acid group, and a side chain to a greater extent) by its blockade of cellular
built from carbon and hydrogen. Amino acids noradrenaline and serotonin reuptake trans-
always include the elements carbon, nitrogen, porters. In contrast, its metabolite nortriptyline
oxygen, and hydrogen. An amino acid has the has a more balanced action equally affecting
generic formula H2NCHRCOOH, where R is an both serotonin and noradrenaline levels. Amitrip-
organic substituent. The amino group is attached tyline exerts its function by blocking serotonin
to the carbon atom immediately adjacent to the and noradrenaline reuptake. It is an antagonist at
carboxylate group. Amino acids are the building a number of receptors, notably serotonin 5-HT2A,
blocks of proteins and important in various 5-HT2C, 5-HT3, 5-HT6, and 5-HT7, noradrenaline
metabolic processes. Essential amino acids can- a1, histamine H1, acetylcholine muscarinic
not be built by humans and need to be obtained receptors, and opiate s1 receptors.
through food intake. Amitriptyline is absorbed from the gastroin-
testinal tract with highly varying peak plasma
concentrations, occurring between 2 and 12 h
References and Readings after administration, where nearly all (95%) of
the available amitriptyline is protein bound.
Meierhenrich, U. J. (2008). Amino acids and the asymme- Like all tricyclic antidepressants, amitriptyline
try of life. Berlin, New York: Springer-Verlag. ISBN is water soluble. The bioavailability of the active
978-3-540-76885-2.
Nelson, D. L., & Cox, M. M. (2008). Lehninger principles
drug is between 30% and 60%, due to extensive
of biochemistry (5th ed.). New York: W.H. Freeman & first pass metabolism of the drug in the liver by
Company. Hardcover. ISBN 071677108X. the CYP2D6 enzyme.
Amitriptyline 143 A
The elimination half-life varies from 10 to improvement seen when TCAs are combined
50 h, with an average of 15 h. Within 24 h, with behavioral therapy.
approximately 25–50% of a dose of amitriptyline Amitriptyline is metabolized primarily in the A
is excreted in the urine as inactive metabolites; liver and is excreted both in feces and urine. In
small amounts are excreted in the bile. Amitrip- terms of its half-life, amitriptyline is typically
tyline is demethylated in the liver to its primary associated with a half-life of between 31 and
active metabolite, nortriptyline by CYP450 1A2. 36 h dependent on formulation and other factors.
Circulating therapeutic plasma levels typically In reality, the half-life varies dependent on ami-
lie between 110 and 250 ng/ml. triptyline use and indication with administration
for depression usually resorting to formulations
with a half-life of 9–25 h, while the treatment of
Specific Compounds and Properties nocturnal enuresis (in children) is associated
with dosages/formulations of between 18 and
Amitriptyline is known by several brand names 96 h – where the active metabolite of amitripty-
including Elavil, Laroxyl, Lentizol, and Sarotex. line, nortriptyline, plays a prominent role.
A generic version – Tryptizol – is also available. Typically, tricyclic antidepressants are not
In terms of formulation, amitriptyline is available successful in treating prepubertal depression
in solid tablet forms with intramuscular formula- showing marginally better efficacy in adolescents
tions available also. Typically, tablets are for this indication. As such, the pharmacological
available in 50 and 100 mg doses. treatment of choice for this indication remains
selective serotonin reuptake inhibitors. In those
child and adolescent subjects who do not respond
Clinical Use (Including Side Effects) to SSRIs, treatment of depression with tricyclic
antidepressants (such as amitriptyline) has not
Amitriptyline, whether administered orally or been shown to be very productive in clinical
via intramuscular formulation, reaches peak studies. Due to their higher rate of metabolism,
plasma concentrations in both cases approxi- younger subjects often require higher mg/kg
mately 2–12 h after administration with onset doses when compared to adults if amitriptyline
commencing after 45 min. As already mentioned, use is warranted in depression. Special attention
the primary indication for amitriptyline use is as should be directed toward the higher rate of
an antidepressant, but it also sometimes used cardiotoxicity with amitriptyline in young
for its sedative action. Therapeutic antidepressant subjects compared to adults, and this should be
effects are only seen after 2–3 weeks of carefully monitored by both baseline and
therapy. In terms of child and adolescent usage, on-treatment ECG. Coprescribing with medica-
TCAs in general have been employed for more tions that prolong the QTc interval is not advised.
than 40 years and have been indicated not only Dependent on the indication, dosing schedules
in depression but also in attention deficit/ of amitriptyline vary. For depression, it is advised
hyperactivity disorder (ADHD), obsessive- to start with a dose of 25–100 mg/day. The dose
compulsive disorder (OCD), separation anxiety, can be increased up to 300 mg/day, although
and nocturnal enuresis. In terms of its antidepres- 100–150 mg per day is the recommended dosage.
sant action in children, this is mixed with its In elderly subjects, doses for the treatment of
active metabolite nortriptyline showing more depression are typically half or one-third of
favorable effects. Other TCAs including desipra- the recommended adult dose, while its use for
mine and clomipramine have shown efficacy in childhood depression is not indicated.
ADHD and OCD, and as such, amitriptyline’s In the case of nocturnal enuresis,
usage in these disorders is off-label. In terms of recommended doses typically range between
the utility of TCAs in treating separation anxiety, 1 and 1.5 mg/kg of the body weight per day
this appears to be modest at best with further with doses to be taken in the afternoon. In children
A 144 Amitriptyline
between 5 and 10 years old, these doses are inhibition of the cytochrome CYP 2502D6. Other
usually in the range of 10–25 mg, while for ado- medications that can cause increased plasma
lescents between 11 and 16 years, these doses are levels are fluvoxamine, cimetidine, haloperidol,
typically 25–50 mg. cimetidine, and phenothiazines. Amitriptyline
The use of amitriptyline against pain typically may decrease the effect of antihypertensive med-
involves starting doses of 25 mg daily which can ication particularly guanethidine and clonidine,
be increased up to 100 mg daily with 75 mg daily while coadministration with monoamine oxidase
representing the active clinical dose in most inhibitors may even induce a hypertensive crisis
patients. The benefits of amitriptyline treatment and demonstrate atropine-like toxic effects.
against pain are usually seen between 1 and Coadministration with phenothiazines may
7 days after treatment onset. increase serum amitriptyline (or any other TCA
The efficacy of treatment with amitriptyline for that matter) levels, while the effect of
can be improved and the onset of therapeutic amitriptyline (or another TCA) is potentiated in
effect hastened by measuring plasma levels to the presence of thyroid preparations. Care should
accurately titrate the therapeutic doses required. also be exercised requiring careful ECG monitor-
By monitoring drug compliance, amitriptyline ing when coadministering with thyroid prepara-
dosing can be optimized. It is important that tions as these together can induce tachycardia and
dosing has been stable for about 1 week prior to cardiac arrhythmia. For those taking oral contra-
the assessment of blood samples with blood ceptives, these can inhibit the metabolism of
drawn between 10 and 14 h after the last intake TCAs including amitriptyline.
advised for accurate monitoring. When monitor- Amitriptyline is associated with strong
ing plasma levels of amitriptyline, it is advisable additive anticholinergic effects when given in
to also measure its metabolite nortriptyline combination with anticholinergic agents. This
as nortriptyline is an active metabolite. additive action is also seen with CNS depressant
Typically, therapeutic plasma levels of amitrip- ligands causing enhanced depressant effects or
tyline lie in the range of 50–200 mg/l, while those even severe cardiac effects such as heart block
for nortriptyline usually are between 100 and when combined with quinidine. Potentiation of
300 mg/l. With regard to drug safety, combined sympathomimetic effects is also possible when
amitriptyline and nortriptyline concentrations of amitriptyline is given in combination with
500 mg/l are toxic. sympathomimetics such as adrenaline.
Due to the high degree of plasma protein bind- Side Effects: Side effects associated with
ing associated with amitriptyline, patients amitriptyline use include sedation, anhydrosis
presenting with renal disorders often demonstrate (decreased sweating), increased appetite,
altered plasma levels of amitriptyline and require ataxia, anxiety, blurred vision, glaucoma, dry
careful dose monitoring. mouth, mydriasis (oversensitivity to light),
Contraindications: Administration of amitrip- headache, heartburn, decreased lacrimation, con-
tyline during the recovery phase of cardiac infarc- stipation, orthostatic hypotension, restlessness,
tion and glaucoma is highly contraindicated. sedation, sexual dysfunction (impotence,
Administration of amitriptyline in patients with decreased libido), and urinary hesitancy and
epilepsy, organic brain damage, urine retention, retention.
prostate hyperplasia, pyloric stenosis, cardiovas- The management of some of the minor side
cular disease, hyperthyroidism, and diminished effects is relatively straightforward, e.g., dry
liver and kidney function is not advised but is not mouth can be managed by dry candy or mouth
expressly contraindicated. rinsing, mydriasis with sunglasses, orthostatic
Interaction with Other Drugs: All selective hypotension with slow positional changes, and
serotonin reuptake inhibitors (SSRIs) such as decreased lacrimation with artificial tears.
fluvoxamine, with the exception of citalopram, Severe/life-threatening side effects associated
may increase amitriptyline concentrations due to with amitriptyline are rare events. However,
Amphetamine 145 A
these severe adverse events can include tachycar-
dia, arrhythmias, extrapyramidal symptoms, Amphetamine
glaucoma, hepatic failure, hyperthermia, suicidal A
ideations, mania, orthostatic hypotension, para- Lawrence David Scahill
lytic ileus, QTc prolongation, and seizures. Nursing & Child Psychiatry, Yale University
Precautions Associated with Amitriptyline School of Nursing, Yale Child Study Center,
Use: Prior to starting treatment, it is advisable New Haven, CT, USA
to take a medical history of cardiac problems,
glaucoma, and seizures. Due to weight gain asso-
ciated with amitriptyline use, it is important to Indications
measure weight, length, and BMI.
During treatment, it is important to address ADHD
suicidal ideations, manic symptoms, and side
unpleasant effects that might influence therapeu-
tic compliance (e.g., sexual dysfunction). Mechanisms of Action
Addressing suicidal ideations is important since
amitriptyline can increase suicidal ideations, and Amphetamines are stimulant medications that
fatal overdose does not require a huge increase in enhance the release and block the reuptake of
dosage. It is therefore also important to be aware dopamine in the brain. Taking at large doses,
of potential hoarding of amitriptyline by patients this mechanism of action can produce eupho-
which can be checked by careful monitoring of ria and increased energy. Because of these
drug compliance in blood samples. effects, amphetamines are subject to abuse.
Overdosing: Individuals with diminished In doses used to treat attention deficit hyper-
liver functions, plasma protein count/activity, activity disorder, however, these stimulant
and decreased total body water are at greater effects are not usually present. The enhanced
risk for overdose since metabolism occurs in release of dopamine is presumed to be the
the liver and usually nearly all ingested amitrip- source of improved attention and decreased
tyline is bound to plasma proteins. Symptoms of activity.
overdose include apathy, coma, convulsions,
cardiac arrhythmias, hypotension, and ulti-
mately death. Clinical Use (Including Side Effects)
Amphetamines are associated with many adverse

References and Readings effects that are relevant to children and adults
with autism. For example, they can cause insom-
Barbui, C., & Hotopf, M. (2001). Amitriptyline v. the rest: nia, decreased appetite, increased stereotypic
Still the leading antidepressant after 40 years of
behavior, and irritability. To date, the amphet-
randomised controlled trials. British Journal of
Psychiatry, 178, 129–144. amines have only been evaluated in small studies
Guaiana, G., Barbui, C., & Hotopf, M. (2007). Amitripty- in children with autism with equivocal results. It
line for depression. Cochrane Database of Systematic appears that the potency of the amphetamine
Reviews, 3, CD004186.
compounds makes it difficult to find a dose that
Johns, M. W. (1975). Sleepy and hypnotic drugs. Drugs,
9, 448–478. is helpful, but not associated with dose-limiting
adverse effects.
Amitryptiline See Also
▶ Amitriptyline ▶ Attention Deficit/Hyperactivity Disorder

A 146 Amygdala
References and Readings The largest subnucleus of the amygdala is the

lateral nucleus, which receives most of the
Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric sensory inputs to the amygdala. In particular,
psychopharmacology: Principles and practice
the lateral nucleus receives projections from
(2nd ed.). New York: Oxford University Press.
high-level visual cortex in the temporal lobe, as
well as from many other polymodal association
cortices. The basal nucleus of the amygdala,
Amygdala often lumped together with the lateral nucleus
into the basolateral nucleus, contains neurons
Daniel P. Kennedy and Ralph Adolphs that project back to those regions from which
Division of the Humanities and Social Sciences, the amygdala receives inputs. In primates, the
California Institute of Technology, Pasadena, basal nucleus also projects back to all of visual
CA, USA cortex, including early visual cortices (Freese &
Amaral, 2005). The medial nucleus likely serves
an important role in other mammals as it is
Synonyms closely connected with the olfactory system.
The central nucleus of the amygdala contains
Amygdaloid complex neurons that project to the hypothalamus and
brainstem and regulate emotional responses.
The internal circuitry of the amygdala is quite
Structure complex and is now being unraveled in great
detail using optogenetic methods in mice.
The amygdala is an almond-shaped structure
located in the medial temporal lobe bilaterally,
comprised of at least 13 nuclei in primates Function
(Amaral, Price, Pitkanen, & Carmichael, 1992;
LeDoux, 2007). It is a relatively small structure The amygdala’s function is extremely diverse,
(considerably smaller than the hippocampus, reflected in the wide web of anatomical connec-
which lies immediately anterior to), with approx- tions that it has with other brain regions. In
imately 12 million neurons in total occupying addition to bidirectional connections with
a volume of 4–5 cm3 in an adult human. It is polymodal sensory cortex, it is connected with
well-documented that the individual subnuclei basal forebrain (modulating attention and flight
of the amygdala have distinct functions and versus freeze responses), hypothalamus,
distinct anatomical connectivity with other brain brainstem nuclei, periaqueductal gray (mediating
regions (both cortically and subcortically). various emotional behaviors), hippocampus
However, given the difficulty in delineating the (modulating memory consolidation), prefrontal
subnuclei reliably in living humans, the amyg- cortex, and basal ganglia (modulating reward
dala is often discussed as a single unitary learning and decision-making), among other
structure (as in the remainder of this chapter). regions. This diversity of connections permits
There are probabilistic atlases for segmenting the amygdala to modulate a large array of cogni-
the amygdala into some of its subnuclei from tive processes and aspects of behavior, including
structural magnetic resonance imaging (MRI), attention, memory, and reward learning. What
and this can be used to define likely locations ties all these varied aspects of cognition and
that would fall within those nuclei, but not to behavior together is that the amygdala appears
precisely distinguish their boundaries. Detailed to serve a key role in processing those stimuli that
measures of the subnuclei, including stereologi- have emotional or social value for an animal.
cal counts of the number of neurons, are however There are two main lines of research that
possible using postmortem brain tissue. document the amygdala’s function in emotion
Amygdala 147 A
and social behavior. Classic lesion studies in the show responses to stimuli that predict both aver-
1930s suggested that the amygdala was needed sive and appetitive outcomes, and these neurons
for evaluating complex stimuli including social appear to be intermingled throughout the A
stimuli (Kluver & Bucy, 1939), and subsequent basolateral amygdala (Paton, Belova, Morrison,
lesion studies in monkeys (Emery et al., 2001; & Salzman, 2006). One current view of the amyg-
Machado & Bachevalier, 2006) and humans dala’s role in reward learning is thus that it is
(Adolphs, Tranel, Damasio, & Damasio, 1994) a primary locus for Pavlovian fear conditioning,
have verified this role. Lesions of the amygdala in but that it participates in other aspects of declar-
monkeys produce a lack of cautionary behavior ative and instrumental reward learning mostly
and a propensity to approach objects (including through its interconnections with other brain
other animals and people) regardless of the structures.
context. For instance, whereas normal monkeys Various attempts have been made to tie
are very cautious in approaching novel stimuli or together the diverse roles of the amygdala in
unfamiliar people, monkeys with amygdala emotional and social processing. One view is
lesions approach them readily without hesitation that the amygdala, at least in humans, is
(Machado, Kazama, & Bachevalier, 2009; somewhat specialized for aspects of social behav-
Mason, Capitanio, Machado, Mendoza, & ior or reward processing. Another view is that the
Amaral, 2006). Similarly, humans with amygdala amygdala carries out a much more basic and
lesions appear not to have a sense of personal abstract computation, such as allocating
space and show abnormally increased approach processing resources to any events that are
behaviors and ratings of trustworthiness and difficult to predict or novel. For instance, some
approachability of other people (Adolphs, Tranel, human studies have argued for a fairly special-
& Damasio, 1998; Kennedy, Gl€ascher, Tyszka, & ized role in recognizing social cues from facial
Adolphs, 2009). This aspect of amygdala func- expressions and perhaps especially from the eye
tion has been investigated in humans most com- region of faces (Adolphs et al., 2005). By
monly by showing participants pictures of people contrast, other studies have shown broader atten-
and asking them to rate how much they would tional modulation based on any unpredictable
like to approach that person, or how much they stimulus, regardless of its social meaning (Herry
would trust that person. et al., 2007; Whalen, 2007). These current frame-
A second line of research originates primarily works for understanding amygdala function are
on work on rodents and has shown that the amyg- important for interpreting the amygdala’s role in
dala is necessary for learning about stimuli that autism spectrum disorders, since they would
predict harmful outcomes. The most studied pro- point to different roles: in aspects of social
tocol here is called Pavlovian fear conditioning, dysfunction, or in sensory/attentional impair-
in which the animal must learn that a conditioned ments, for instance.
stimulus (such as a tone, or a particular color)
predicts electric shock (Davis, 2000; J. LeDoux,
2000). Healthy animals, including humans, learn Pathophysiology
this association rapidly, whereas animals (includ-
ing humans) with amygdala lesions do not. Many have hypothesized that the amygdala plays
However, the amygdala is now known to a key role in the pathophysiology of autism
subserve a much broader role: it is also involved (Bachevalier, 1994; Baron-Cohen et al., 2000;
in appetitive learning, and it is also known to Hetzler & Griffin, 1981). Initially, however,
modulate declarative memory and instrumental there was little direct support for amygdala
behavior based on the value of stimuli (through abnormality in autism, and much of the theory
projections to such structures as the hippocampus was drawn from observing parallels between the
and the basal ganglia) (McGaugh, 2004). autism phenotype and monkeys or rare humans
Neurons recorded in the monkey amygdala with amygdala lesions. More recent studies have
A 148 Amygdala
provided considerable additional evidence measures, such as social functioning, communi-

directly implicating the amygdala as a key region cative development, and gaze patterns to faces
of neural dysfunction in autism, although the (Mosconi et al., 2009; Munson et al., 2006;
precise nature of the dysfunction, its etiology, Nacewicz et al., 2006; Schumann et al., 2009).
and the extent of its contribution to the autism This altered growth trajectory, however, may not
phenotype all remain intensely debated. be specific to the amygdala alone, as total brain
The first direct neural evidence to suggest that volume in autism also undergoes a similar pattern
the amygdala might be abnormal in autism came of abnormal development (Redcay &
from postmortem examination of brain tissue Courchesne, 2005).
(M. Bauman & Kemper, 1985), where increased Studies that have examined the functioning of
cell-packing density and reduced cell size was the amygdala in autism have also identified
noted. A recent follow-up study using modern abnormalities. The primary methodology that is
quantitative methods did not replicate these find- used to measure subcortical (and cortical) brain
ings (Schumann & Amaral, 2006), likely due to activity is functional MRI (fMRI) – a noninvasive
methodological differences and differences in the technique that provides an indirect measure of
study sample (e.g., exclusion of individuals with neuronal activity based on changes in regional
a history of seizures). Importantly, however, they blood flow. FMRI provides reasonable spatial
did find significantly fewer neurons in the amyg- and temporal resolution, such that one can deter-
dala in the autism group. mine which stimuli or which cognitive process
Many studies have further examined the struc- activates a particular 3–4 mm3 volume of brain
ture of the amygdala in autism using volumetric tissue. However, subjects undergoing fMRI
magnetic resonance imaging (MRI). Although scanning are required to remain motionless for
this technique does not have anywhere near the extended periods of time, and because of this,
spatial resolution of postmortem studies, the much of what is known about the functioning of
advantages are that it is a noninvasive technique, the amygdala in autism comes from older
much larger sample sizes can be included, and children, adolescents, and adults and not young
one can obtain sufficient statistical power to infants and toddlers (although this is now chang-
examine clinical and behavioral correlates, as ing with several sites acquiring resting-state
well as changes across the lifespan. Although fMRI in sleeping infants). The first series of
volume is largely normal by adulthood, alter- studies of amygdala functioning in autism found
ations in the early growth trajectory, growth hypoactivation during performance of a variety
from infancy on to late childhood, have been of tasks, including making mental-state judg-
identified by cross-sectional and longitudinal ments from expressive eyes (Baron-Cohen
studies, as well as cross-study comparisons et al., 1999), implicit processing of emotional
(Mosconi et al., 2009; Schumann, Barnes, Lord, faces (Critchley et al., 2000), and passive viewing
& Courchesne, 2009; Schumann et al., 2004; of nonemotional faces (Pierce, Muller, Ambrose,
Sparks et al., 2002). Specifically, the amygdala Allen, & Courchesne, 2001). However, these
is enlarged early in development (before 2 years), findings are by no means consistent across the
but growth subsequently slows down and even- literature, possibly due to differences in the tasks
tually converges with typical volumes by adoles- and stimuli used, differences in eye movements
cence. In other words, the amygdala in autism of participants, or differences in subject samples
undergoes an altered growth trajectory, wherein that reflect the heterogeneity of autism spectrum
accelerated growth occurs early on but then disorders.
gradually slows, so it is at the younger ages (and Two notable studies have attempted to provide
not adulthood) that the largest volumetric abnor- a more mechanistic account of amygdala abnor-
malities can be observed. In addition, several mality in autism. One study found that amygdala
studies have shown amygdala volumes in autism activation in autism correlated positively with gaze
correlate with various behavioral and clinical to the eye region of faces (Dalton et al., 2005),
Amygdala 149 A
consistent with other studies implicating the amyg- thought to be the single cause of the autism phe-
dala as involved in guiding eye movements notype. First, whether or not the amygdala con-
towards eyes in faces (Adolphs et al., 2005; tributes to other aspects of the phenotype A
Gamer & Buechel, 2009). Given the well- (language delay, repetitive behaviors, restricted
documented behavioral abnormality that individ- interests) is quite unclear. Second, given that
uals with autism spend reduced time looking at the many regions of the brain are abnormal in autism,
eyes in faces (Klin, Jones, Schultz, Volkmar, & it seems likely that these brain regions also con-
Cohen, 2002; Pelphrey et al., 2002), this may help tribute to particular aspects of the autistic pheno-
to explain some of the above-described findings type. Finally, complete lesions of the amygdala in
regarding amygdala hypoactivity. Another study both monkeys (Emery et al., 2001; Machado
(Kleinhans et al., 2009) found that the amygdala in et al., 2009; Mason et al., 2006) and humans
autism exhibits abnormally reduced habituation (Paul, Corsello, Tranel, & Adolphs, 2010) do
overtime to repeatedly presented neutral faces, not result in autism and in several respects show
possibly pointing to a basic abnormality in habitu- symptoms that are the opposite of autism. There
ation responses that have been found for amygdala may be some more similarity in regard specifi-
neurons in other studies (Herry et al., 2007). The cally to infant monkeys who had neonatal amyg-
study in autism (Kleinhans et al.,, 2009) found that dala lesions (M. D. Bauman, Toscano, Babineau,
although the initial amygdala response was found Mason, & Amaral, 2008; Prather et al., 2001),
to be slightly attenuated, the response remained further emphasizing that autism needs to be
elevated for longer than that observed in controls. understood as emerging throughout a complex
The authors suggest that discrepancies across ear- and prolonged developmental trajectory.
lier studies might be explained by this altered time In sum, a convergence of evidence derived
course of habituation. from a wide variety of experimental methods sug-
Another promising approach to understanding gests that the amygdala is both structurally and
amygdala dysfunction in autism is to examine the functionally abnormal in autism. It is reasonable
functional interaction between the amygdala and to assume that the amygdala is one component
other brain regions. Individual brain regions do among a diverse set of brain regions that likely
not function in isolation from one another, but contribute to particular aspects of the autism phe-
rather comprise functional networks that exert notype. However, whether the amygdala plays
reciprocal influences on other brain regions and a causal role in producing the core symptoms of
other networks. So far, several studies have found autism or whether it is secondary in response to
that the amygdala exhibits abnormally reduced having autism has yet to be determined.
functional coupling with other brain regions, at
least in the context of face processing tasks
(Kleinhans et al., 2008; Rudie et al., 2012; See Also
Welchew et al., 2005). It is currently unclear,
however, whether the amygdala is the primary ▶ Functional Connectivity
source of this abnormality, or whether it ▶ Functional MRI
simply reflects altered synaptic input (i.e., the
abnormality is at the level of input rather than
output). Many brain regions exhibit structural
and functional abnormalities in autism, and
these likely provide altered input to the Adolphs, R., Gosselin, F., Buchanan, T. W., Tranel, D.,
amygdala. Schyns, P. G., & Damasio, A. (2005). A mechanism
It should be emphasized that although there is for impaired fear recognition after amygdala damage.
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499–500. ior is constructed so that all investigators can
A 152 Analysis of Verbal Behavior (AVB)
reliably observe the occurrence of the response. subject to equal requirements for reliable and
This definition is then associated with a data replicated implementation.
collection procedure that is applied throughout
all phases of the analysis. The conditions incor-
porated within the analysis must also be compre- See Also
hensively defined for identical implementation
through the assessment. Common conditions are ▶ Functional Analysis
typically based on those outlined by Iwata et al. ▶ Functional Behavior Assessment
and include escape, attention, control, and alone.
Additionally, a tangible condition is often incor-
porated within the analysis. Each condition is set References and Readings
up in a specific fashion based on certain environ-
mental factors, and there are specific protocols Carr, E. G., & Durand, M. V. (1985). Reducing behavior
problems through functional communication train-
for how the experimenter is to respond when the
ing. Journal of Applied Behavior Analysis, 18,
target behavior occurs. During the control condi- 111–126.
tion, the patient is provided with continual access Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., &
to high-preference materials, no demands, and Richman, G. S. (1994). Toward a functional analysis
of self-injury. Journal of Applied Behavior Analysis,
high levels of attention. There are no environ-
27, 197–209 (Reprinted from Analysis and Interven-
mental responses to the target behavior. During tion in Developmental Disabilities, 2, 3–20, 1982). 27,
the alone condition, the patient is observed in 215–240.
a room without any preferred materials, demands,
or attention. Again, there are no environmental
responses to the target behavior. The demand
condition requires continual presentation of spe- Analysis of Verbal Behavior (AVB)
cific demands to the patient. Upon an occurrence
of the target behavior, the demands are removed Trina D. Spencer
for a defined interval, thereby offering negative Institute for Human Development, Northern
reinforcement for the target behavior. The atten- Arizona University, Flagstaff, AZ, USA
tion condition incorporates an introductory
period of high-preference attention, which is
then removed. The investigator, upon removing Definition
attention, remains close by but engaged in other
activities. Following the occurrence of the target In his book Verbal Behavior (1957), B. F. Skinner
behavior, the patient is provided with a period of defined verbal behavior as “behavior reinforced
attention, thus offering positive reinforcement of through the mediation of other persons” (p.2).
the challenging behavior. The tangible condition Following this definition, filling a glass with
allows the patient an introductory period of water results in a filled glass and is not verbal
access to high-preference materials. These are behavior, whereas saying, “Can you fill my
then removed by the investigator but remain in glass?” depends on the behavior of another
view. The patient is provided defined periods of person to mediate the consequence of the request
access to the materials, contingent on the occur- to fill the glass. Because verbal behavior does not
rence of the target behavior, thereby establishing act on the environment directly but rather through
a positive reinforcement contingency for the tar- the behavior of others, it requires a separate anal-
get behavior. The conditions are randomly ysis. Nonetheless, Skinner asserts that the same
implemented and replicated until a reliable behavioral principles of reinforcement, punish-
trend emerges. Defined, individual-specific, ment, and discrimination can account for verbal
modifications to analog conditions are incorpo- behavior (i.e., language) as they do for any other
rated based upon the needs of the patient and are behavior.
Analysis of Verbal Behavior (AVB) 153 A
Historical Background occurring learning opportunities. In the Lovaas
approach, children are primarily taught in highly
In 1934, Alfred North Whitehead challenged structured learning environments. Second, the A
Skinner to use behavioral principles to account analysis of verbal behavior suggests that, in addi-
for language. Despite Whitehead’s cynicism, tion to antecedents and consequences, motivating
Skinner began his book Verbal Behavior (1957), variables are crucial in the development of lan-
which took him over 20 years to complete. guage. Understanding the motivating conditions
Shortly after its publication, Noam Chomsky, for the basic verbal behaviors influences the type
who had his own account of language, published of antecedents and consequences used during
a critical review of Verbal Behavior and behav- training. In contrast, the Lovaas approach
iorism. Chomsky’s criticisms were not surprising de-emphasizes the motivating variables of the
because Skinner’s analysis differed significantly different verbal behaviors and conducts training
from the popular linguist perspective in two using edible consequences and social praise
important ways. First, the analysis of verbal almost exclusively. Although generalization is
behavior involved considering units of language a key component of both approaches, interven-
based on their function instead of their structure. tions based on the analysis of verbal behavior are
Second, the analysis of verbal behavior proposed more likely to begin teaching under more
that language is learned behavior and maintained naturally occurring motivating conditions,
by environmental variables. whereas in the Lovaas approach, generalization
Despite the attention this debate attracted, trials are typically conducted after behaviors are
Skinner never responded to Chomsky’s review established in highly structured, analog
supposing that Chomsky misunderstood the phil- environments.
osophical foundations of behaviorism. In the
years since, many have interpreted Skinner’s
silence as a quiet loss. Although proponents of Rationale or Underlying Theory
the analysis of verbal behavior dispute this
assumption, it may have impeded widespread There are two kinds of language analyses: formal
adoption of Skinner’s analysis of verbal behavior. and functional. A formal analysis considers what
The linguistic theories that bind language devel- verbal behavior looks like or its form (also called
opment to physiological processes have topography). The linguistic perspective is formal
flourished despite criticisms about their limited because words and grammatical structures are the
value for language intervention and treatment. units of analysis. In contrast, Skinner analyzed
However, a theory of language that leads to verbal behavior in terms of functional units. This
useful and effective treatments is important, use of functional does not mean useful but rather
especially for individuals with autism. causal. In other words, the cause of the behavior
In the late 1980s, Ivar Lovaas developed and is more important to its understanding than what
evaluated a discrete trial training (DTT) model the behavior looks like. A functional unit takes
for teaching children with autism. Although into account the verbal behavior of interest (e.g.,
based on operant conditioning and behavioral mand, tact, intraverbal) and its related anteced-
principles, DTT does not align perfectly with ents, consequences, and motivating variables.
Skinner’s analysis of verbal behavior. There are According to this analysis, basic verbal behaviors
two primary differences between a DTT are defined by the conditions and variables that
approach to teaching children with autism and control them (i.e., their cause).
an approach based on Skinner’s Verbal Behavior. Defined specifically by the functional
First, although some instruction occurs in struc- variables controlling their use, Skinner proposed
tured settings, verbal behavior interventions a number of elementary verbal behaviors: mand,
emphasize the importance of natural environment tact, echoic, and intraverbal. Mands are under
teaching (NET) and make use of naturally the functional control of motivating variables
A 154 Analysis of Verbal Behavior (AVB)
(e.g., deprivation, aversive stimulation) and spe- draw from the analysis of verbal behavior to
cific reinforcement. Mands are like demands, make decisions regarding instructional
commands, or requests because they include approaches such as augmentative communica-
information about what is wanted or needed. tion, discrete trial training vs. natural environ-
For example, a speaker has not had a drink in ment teaching, and inclusion. For example, from
a long time (deprivation) says, “Can I have a verbal behavior perspective, a more complete
a Coke?” (mand) and receives a Coke (specific language repertoire can be acquired through
reinforcement) from a listener. A tact is a combination of discrete trial training (DTT)
controlled by nonverbal antecedent stimuli and and natural environment teaching (NET) proce-
generalized reinforcement such as attention or dures. For children with autism, inclusion in
approval. If a Coke sat on the counter (nonverbal regular education may be more effective once
antecedent stimulus) and upon seeing it the children master the basic verbal behaviors (i.e.,
speaker said, “Coke” and was given approval mand, tact, and intraverbal) necessary to benefit
(generalized reinforcement) from a listener, the from an integrated learning environment.
response “Coke” is a tact. Echoic behaviors are
those that are controlled by verbal antecedent
stimuli with a matching response form and gen- Treatment Participants
eralized reinforcement. For example, a person
(speaker 1) models the verbal response “Coke” The analysis of verbal behavior applies to all
(verbal antecedent stimulus), and a second person humans; however, interventions based on this
(speaker 2) repeats “Coke” (echoic) and receives analysis have been designed primarily for
praise (generalized reinforcement) from speaker children and adults with autism and other devel-
1 for making the response sound like the model. opmental disabilities. Skinner’s analysis is not
Intraverbals are also controlled by verbal ante- restricted to individuals with language deficits.
cedent stimuli and generalized reinforcement.
However, intraverbals are not similar in form to
their verbal antecedent stimuli like echoic behav- Treatment Procedures
iors. If instead of modeling the verbal behavior
“Coke” in the echoic example the first speaker Interventions based on the analysis of verbal
had asked, “What is your favorite drink?” (verbal behavior include a variety of procedures. There is
antecedent stimulus) and the second speaker said, not one standardized model of verbal behavior
“Coke” and received approval (generalized treatment. However, there are many teaching
reinforcement), the response “Coke” would be procedures that are common among them such as
an intraverbal. the manipulation of motivating variables,
prompting, shaping, fading, and transfer of
stimulus control. Verbal behavior interventions
Goals and Objectives are likely to balance opportunities for instruction
in highly structured, teacher-directed (e.g., discrete
Skinner’s Verbal Behavior is a theoretical frame- trial training) arrangements with opportunities for
work with direct implications for teaching verbal incidental, child-directed instruction (e.g., natural
behavior to individuals with language deficits environment teaching) to capture natural motivat-
(e.g., children with autism). A functional analysis ing conditions. See Verbal Behavior Interventions.
of language leads to informative language assess-
ment, a recognition of naturally occurring
motivating variables, an emphasis on mands as Efficacy Information
principal communication skills, and intraverbal
instruction to promote language development Based primarily on its conceptual logic,
beyond the basics. Parents and professionals can Skinner’s analysis has been applied in the
Analysis of Verbal Behavior (AVB) 155 A
treatment of children with autism for several behavior. Likewise, there are also no provider
decades. However, the research evidence for ver- qualifications. That being said, Skinner’s book
bal behavior interventions is only modest. There Verbal Behavior is incredibly complex. Its tech- A
are no studies that document the outcome of the nical content is appropriate for individuals with
long-term application of treatment based on the an invested interest. Summaries of Skinner’s
analysis of verbal behavior and only one study main tenets can be found in more beginner-
comparing verbal behavior and linguistic friendly formats (see References).
approaches to instruction (Carr & Firth, 2005). Professionals who apply the analysis of ver-
Nonetheless, there is a growing body of literature bal behavior in the treatment of individuals with
supporting the main premises of Skinner’s autism need to have advanced training in
analysis of verbal behavior and demonstrating applied behavior analysis, verbal behavior, and
efficacy of teaching procedures based on the anal- extensive supervised experience implementing
ysis (Sautter & LeBlanc, 2006). Much of this verbal behavior interventions. Preferably, ver-
literature involves individuals with autism as bal behavior providers have been credentialed
participants. by the Behavior Analysis Certification Board
(BACB) or have completed the equivalent train-
ing. In general, verbal behavior interventions
Outcome Measurement require that providers have more skill and train-
ing than discrete trial training (DTT) proce-
There are two widely used measurement tools dures do.
based on Skinner’s analysis of verbal behavior.
The Assessment of Basic Language and Learn-
ing Skills (ABLLS; Partington & Sundber, See Also
1998) is a criterion referenced assessment, cur-
riculum guide, and tracking system for children ▶ Applied Behavior Analysis
covering basic learner skills (e.g., imitation, ▶ Behavior Analyst Certification Board
requests, intraverbals), academic skills (e.g., ▶ Behavior Modification
reading, math), self-help skills, and motor ▶ Behaviorism
skills. A companion manual Teaching Lan- ▶ Language Acquisition
guage to Children with Autism or Other Devel- ▶ Language Interventions
opmental Disabilities (Sundberg & Pardington, ▶ Lovaas Approach
1998) was published at the same time as the ▶ Theories of Language Development
ABLLS. In 2008, Sundberg published an ▶ Verbal Behavior Interventions
improved assessment tool that integrates devel-
opmental milestones with key verbal behaviors.
The Verbal Behavior-Milestone Assessment
and Placement Program (VB-MAPP) includes
a stronger focus on placement and individual-
Barbera, M., & Rasmussen, R. (2007). The verbal behav-
ized education program (IEP) development and ior approach: How to teach children with autism and
subsections for milestones, barriers, and related disorders. Philadelphia: Jessica Kingsley.
transitions. Carr, J. E., & Firth, A. M. (2005). The verbal behavior
approach to early and intensive behavioral intervention
for autism: A call for additional empirical support.
Journal of Early and Intensive Behavioral Intervention,
Qualifications of Treatment Providers 2, 18–27.
Chomsky, N. (1959). A review of B.F. Sinner’s verbal
behavior. Language, 35(1), 26–58.
Although the analysis of verbal behavior can be
Hedge, M. N., & Maul, C. A. (2006). Language disorders
used to derive treatment procedures, Skinner did in children: An evidence-based approach to assess-
not specify a set of tactics to teach verbal ment and treatment. Boston: Pearson.
A 156 Analyst
Lovaas, O. I. (2003). Teaching individuals with develop-

mental delays: Basic intervention techniques. Austin, Anecdotal Observation
TX: PRO-ED.
Partington, J. W., & Sundberg, M. L. (1998). Assessment
of basic language and learning skills (The ABLLS): Jennifer Varley Gerdts
An assessment for language delayed students. Pleasant Department of Psychology, University
Hill, CA: Behavior Analysts. of Washington, Seattle, WA, USA
Pierce, W. D., & Cheney, C. D. (2004). Behavior analysis
and learning (3rd ed.). Mahwah, NJ: Lawrence
Erlbaum Associates.
Sautter, R. A., & LeBlanc, L. A. (2006). Empirical appli- Synonyms
cations of Skinner’s analysis of verbal behavior with
humans. The Analysis of Verbal Behavior, 22, 35–48.
Skinner, B. F. (1957). Verbal behavior. Acton, MA: Anecdotal record
Copley.
Sundberg, M. L. (2007). Verbal behavior. In J. O. Cooper,
T. E. Heron, & W. L. Heward (Eds.), Applied behavior Definition
analysis (2nd ed., pp. 526–547). Upper Saddle River,
NJ: Merrill/Prentice Hall.
Sundberg, M. L. (2008). Verbal behavior milestones An anecdotal observation is a factual account
assessment and placement program: The VB-MAPP. of an incident. The precise sequence of events
Concord, CA: AVB Press. is documented using descriptive language in
Sundberg, M. L., & Michael, J. (2001). The benefits of
Skinner’s analysis of verbal behavior for children with order to describe exactly what occurs during
autism. Behavior Modification, 25(5), 698–724. a given situation. The setting and context are also
Sundberg, M. L., & Partington, J. W. (1998). Teaching carefully described. Subjective statements and
language to children with autism or other developmental judgments should be avoided during anecdotal
disabilities. Danville, CA: Behavior Analysts.
Vargas, J. S. (2009). Behavior analysis for effective observations. Therefore, a written anecdotal obser-
teaching. New York: Routledge. vation should provide the reader with a clear pic-
ture of the event.
In autism, anecdotal observations are often
helpful in learning more about a child’s behav-
Analyst ior. Parents may be asked to make anecdotal
observations of their child in order to keep
▶ Psychologist a detailed record of their behavior, monitor
their response to particular events, track pro-
gress during intervention, or provide informa-
tion about their behavior following a change.
Analytic Processing Such information can be valuable for a service
provider during assessment or when developing
▶ Sequential Processing and/or maintaining a therapy program. School
staff and treatment providers may decide to use
their own anecdotal observations as evidence for
the need to implement or modify a treatment
Anatomy of Human Ear program or intervention strategy. For example,
an anecdotal observation during the school day
▶ Auditory System may reveal deterioration in a child’s behavior
whenever there is a school assembly. Tracking
these events and responses via direct observa-
tions can be useful in determining a pattern of
Androgens (Male Sex Hormones) behavioral challenges. They may provide the
support necessary to put strategies in place in
▶ Sex Hormones order to prepare the child for assembly days.
Angelman/Prader-Willi Syndromes 157 A
Parents and service providers can analyze anec-
dotal observations to determine patterns such as Angelman/Prader-Willi Syndromes
these and better serve children in need. A
Although anecdotal observations can provide Nicholas M. DiLullo1 and Abha R. Gupta2
1
a deeper understanding of behavior in one partic- Child Study Center, Yale University School of
ular individual, caution should be used when Medicine, New Haven, CT, USA
2
applying any conclusions drawn from the obser- Developmental-Behavioral Pediatrics, Child
vation to other individuals. Because anecdotal Study Center, Yale University, New Haven,
observations are individualized to a specific CT, USA
event and person, generalizations to other indi-
viduals may not be valid and can at times lead to
faulty conclusions, even for those in a similar Synonyms
situation or who have the same diagnosis.
Furthermore, anecdotal observations should Prader-Labhart-Willi syndrome
not replace controlled studies when making
judgments about causal relationships because
they do not include adequate sample sizes and Short Description or Definition
sets of observations that are representative of
many individuals. Prader-Willi syndrome (PWS) and Angelman
syndrome (AS) are two distinct neurodeve-
lopmental disorders caused by mutations in the
See Also same region of the genome, involving chromo-
some 15q11.2-15q13.3.
▶ Behavioral Assessment
▶ Direct Observation
▶ Functional Behavior Assessment Categorization
▶ Observational Assessments
Genetic syndromes, Neurodevelopmental
disorders.
Bentzen, W. R. (2000). Seeing young children: A guide to Epidemiology

observing and recording behavior (4th ed.). Albany,
NY: Delmar Learning.
Nicolson, S., & Shipstead, S. G. (2002). Through the The prevalence of PWS is approximately 1 in
looking glass: Observations in the early childhood 10,000 individuals (Dykens, Lee, & Roof, 2011).
classroom (3rd ed.). Upper Saddle River, NJ: Prentice The prevalence of AS is 1 in 12,000–20,000 indi-
Hall.
viduals (Williams, Driscoll, & Dagli, 2010).
Anecdotal Record Natural History, Prognostic Factors,

Outcomes
▶ Anecdotal Observation
Infants with PWS have severe hypotonia and
difficulties with feeding. The latter evolves into
hyperphagia (excessive eating) and morbid obe-
Angelman/Prader-Willi Locus sity. Obesity-related problems, such as non-insu-
lin-dependent diabetes mellitus, are the most
▶ Chromosome 15q11–q13 serious health issues. Weight control becomes
A 158 Angelman/Prader-Willi Syndromes
critical for maximizing health outcomes. Chil- deficiency of paternally expressed small nucleo-
dren with PWS experience multiple developmen- lar RNAs (snoRNAs) has been considered the
tal delays in cognition, language, motor skills, leading suspects. These RNAs regulate the
and physical growth. Short stature and expression of another gene which is involved in
hypogonadism are common, the latter affecting serotonin neurotransmission, the serotonin 2C
pubertal development and resulting in infertility. receptor (Dykens et al., 2011). AS is due to defi-
Children with AS also experience multiple ciency of the maternally expressed UBE3A gene.
developmental delays in cognition, language, This gene shows paternal imprinting, meaning it
motor skills (gait ataxia), and physical growth is silent on the paternal chromosome. Sixty-five
(microcephaly). Seizures, which typically occur to seventy-five percent of cases are due to dele-
during infancy and the toddler years, can be of tions of the maternal chromosome, 5–11% are
varied types. In contrast to PWS, individuals with due to mutations in the UBE3A gene, 3–7% are
AS have normal pubertal development and fertil- due to paternal uniparental disomy (both copies
ity. Aside from possible seizures, they typically of the chromosome are inherited from the father),
have good health and normal life spans. They and 3% of cases are due to imprinting mutations
require lifelong supervision. (Williams et al., 2010).
The chromosome 15q11.2-15q13.3 region has
also been implicated in autism spectrum disor-
Clinical Expression and ders (ASDs). A high proportion of patients with
Pathophysiology duplications at this locus meets diagnostic
criteria for ASD (Abrahams & Geschwind,
A key concept to understanding these syndromes 2008). Conversely, in some clinical ASD cohorts,
is genomic imprinting. Typically, a child inherits up to 1% of patients show maternal duplications
two copies of each gene, one transmitted from the of this interval (Sanders et al., 2011). It is among
father and one from the mother. In many the most common chromosomal rearrangements
instances, these pairs of genes work in concert seen in ASD. There are quite a few overlapping
to achieve full function. In the region denoted clinical features between PWS and ASD, and it
chromosome 15q11.2-15q13.3, there are has been suggested that the conventional autism
a number of genes which are only active (trans- diagnostic tests (ADOS and ADI-R) may not be
lated to proteins), depending on whether they are sufficient to discriminate between PWS and
inherited from the father or mother. This phe- ASDs (Dykens et al., 2011). Greater than 40%
nomenon, in which a gene or genes is silent on of patients with AS have ASD, although the con-
either maternally or paternally transmitted chro- verse is rare (proportion of patients with ASD
mosome, is termed imprinting. who have AS).
In PWS, 70% of cases are due to a deletion
involving the segment 15q11.2-15q13.3 of the
paternal chromosome. Because many of the Evaluation and Differential Diagnosis
genes in this region are imprinted (or silent) on
the maternal chromosome, this results in the loss PWS is a common cause of hypotonia at birth and
of all gene products. Another 25% of cases are may be identified early by genetic testing. If this
due to maternal uniparental disomy, a condition is not identified early, clinical diagnosis is
in which both copies of the chromosome are suspected based on the combination of short stat-
inherited from the mother. Five percent of cases ure, behavioral issues, and hyperphagia, typically
are due to chromosomal breakpoints which dis- after age 6. The diagnosis can be confirmed in the
rupt genes within the region or mutations which vast majority of cases via DNA testing. It is
affect the proper imprinting of this interval. characterized by a wide range of symptoms,
While it has not been definitively determined many of which are behavioral or endocrine in
which gene(s) in the interval cause PWS, recently nature. One of the most common symptoms
Angelman/Prader-Willi Syndromes 159 A
associated with the disorder is an insatiable appe- starting physical therapy early to help with mus-
tite that often leads to morbid obesity. This is due cle tone. Children should be placed in a structured
to dysfunction of the hypothalamus, the region of school environment with close teacher supervi- A
the brain which regulates feelings of satiety and sion. Occupational and speech therapy should be
hunger (Butler, 2011). Patients with PWS have provided if needed. Strict supervision of diet is
high levels of ghrelin, a compound that is found required to address hyperphagia and prevent mor-
in the lining of the stomach and stimulates hun- bid obesity and its attendant health problems.
ger, but whether this finding is a cause or conse- Clinical trials of growth hormone replacement
quence of primary problems in PWS is not therapy have shown cognitive as well as physical
known. The typical psychiatric difficulties faced benefits (Cassidy & Schwartz, 2009). The latter
by people with PWS include anxiety and compul- includes increasing height, lean body mass, and
sive behavior, including skin picking. Smaller mobility and decreasing fat. Adults with PWS
subsets of patients are affected by symptoms most often require supervised living situations
such as depression, hallucination, and paranoia. and work environments.
In almost all cases, people with PWS have below As with PWS, there is no cure for AS, but
average intelligence, with the median IQ being in medications are used to treat the various symp-
the 50–70 range. (Dykens et al., 2011). toms. This includes anticonvulsants to combat
The diagnosis of AS is usually suspected by the seizures, melatonin to encourage regular
early developmental delay and behavioral mani- sleep patterns, and laxatives for regular bowel
festations and can be confirmed by DNA testing. It movements. Beginning physical and occupa-
is characterized by severe cognitive and neurolog- tional therapy early is also important to promote
ical impairment. While the manifestation and muscle development and decrease joint stiffness.
severity of symptoms varies greatly, there are Given the typically severe speech impairment,
a few which are the most common, appearing in speech therapy should emphasize nonverbal
almost 100% of cases. Patients always experience methods of communication, such as picture
severe developmental delay as well as movement cards (Dagli & Williams, 2011). AS is not degen-
and balance issues. Consistently, patients are erative; in fact, many symptoms improve with
afflicted with speech impairment. Some are non- age, such as seizures, sleep issues, and conti-
verbal, while others have very limited vocabulary. nence. Life expectancy is average, and while
One characteristic trait of individuals with AS is people with AS may never be fully independent,
their apparently happy demeanor, frequent laugh- adults can learn basic daily living skills.
ter, and hand flapping. Slightly less common traits
are diminished head size and the onset of seizures
before the age of 3. Clinical diagnosis of AS can be See Also
complicated. Usually, a successful diagnosis
involves motor and speech delays, as well as the ▶ Chromosome 15q11–q13
characteristic motor mannerisms and demeanor
(Cassidy, Dykens, & Williams, 2000). If AS is
suspected, an EEG (electroencephalogram) may References and Readings
be performed to rule out gelastic seizure, a rare
type of seizure which is accompanied by a burst of Abrahams, B. S., & Geschwind, D. H. (2008). Advances in
autism genetics: On the threshold of a new neurobiol-
energy (Williams, 2005). ogy. Nature Reviews Genetics, 9, 341–355.
Buiting, K. (1995). Inherited microdeletions in the
Angelman and Prader-Willi syndromes define an
Treatment imprinting centre on human chromosome 15. Nature
Genetics, 9, 395–400.
Buiting, K. (2010). Prader-Willi syndrome and Angelman
There is no cure for PWS; however, there are syndrome. American Journal of Medical Genetics.
treatments to lessen symptoms. These include Part C, Seminars in Medical Genetics, 154C, 365–376.
A 160 Animal Models
Butler, M. G. (2011). Prader-Willi syndrome: Obesity due causes and symptoms of human psychiatric dis-
to genomic imprinting. Current Genomics, 12, orders and for systematically evaluating the
204–215.
Cassidy, S. B., Dykens, E., & Williams, C. A. (2000). effects of potential treatments. Though animal
Prader-Willi and Angelman syndromes: Sister models cannot fully encapsulate all aspects of
imprinted disorders. American Journal of Medical autism, mouse behaviors with strong conceptual
Genetics (Seminar Medical Genetics), 97, 136–146. analogies to the diagnostic symptoms of autism
Cassidy, S. B., & Schwartz, S. (2009). Prader-Willi syn-
drome. GeneReviews. Retrieved January, 2012, from have been identified. Assays currently in use
http://www.ncbi.nlm.nih.gov/books/NBK1330/#pws. include tests for social approach, reciprocal
REF.west.2004.565 social interactions, social communication, repet-
Christian, S. L., Fantes, J. A., Mewborn, S. K., Huang, B., itive behaviors, and restricted interests. These
& Ledbetter, D. H. (1999). Large genomic duplicons
map to sites of instability in the Prader-Willi/ tasks have been employed to test hypotheses
Angelman syndrome chromosome (15q11-q13). about the genetic and environmental causes of
Human Molecular Genetics, 8, 1025–1037. autism. Detection of rodent models with
Dagli, A. I., & Williams, C. A. (2011). Angelman syn- endophenotypes highly relevant to the symptoms
drome. GeneReviews. Retrieved January, 2012, from
http://www.ncbi.nlm.nih.gov/books/NBK1144/ of autism is likely to enable the discovery of
Dykens, E. M., Lee, E., & Roof, E. (2011). Prader-Willi effective therapeutic interventions.
syndrome an autism spectrum disorders: An evolving
story. Journal of Neurodevelopmental Disorders, 3,
225–237.
Geshwind, D. H. (2008). Autism: Many genes, common Historical Background
pathways? Cell, 135(3), 391–395.
Matsuura, T., Sutcliffe, J. S., Fang, P., Galjaard, R. J., Animal models of human neuropsychiatric disor-
Jiang, Y. H., Benton, C. S., et al. (1997). De novo ders are in widespread use for biomedical
truncating mutations in E6-AP ubiquitin-protein ligase
gene (UBE3A) in Angelman Syndrome. Nature research. Many rodent behavioral tasks relevant
Genetics, 15, 74–77. to the symptoms of these disorders have been
Sanders, S. J., Ercan-Sencicek, A. G., Hus, V., Luo, R., developed, and psychopharmacological treat-
Murtha, M. T., Moreno-De-Luca, D., et al. (2011). ments for many major mental illnesses and
Multiple recurrent de novo CNVs, including duplica-
tions of 7q11.23 Williams syndrome region, are neurological diseases have been evaluated in
strongly associated with autism. Neuron, 70, 863–885. translational rodent models (Covington, Vialou,
Williams, C. A. (2005). Neurological aspects of the & Nestler, 2010; Crawley, 2007b; Higgins &
Angelman syndrome. Brain & Development, 27, Jacobsen, 2003; Moore, 2010). Developing
88–94.
Williams, C. A., Driscoll, D. J., & Dagli, A. I. (2010). animal models relevant to the symptoms of
Clinical and genetic aspects of Angelman syndrome. autism spectrum disorders (ASDs) presents
Genetics in Medicine, 12(7), 385–395. a unique challenge to the biomedical research
community. Autism is a complex neurodeve-
lopmental disorder marked by considerable clin-
ical heterogeneity. The diagnostic criteria for
Animal Models autism are behaviorally defined by three criteria:
(1) aberrant reciprocal social interactions,
Jacqueline N. Crawley and Jennifer Brielmaier (2) impaired communication, and (3) stereotyped
Laboratory of Behavioral Neuroscience, National repetitive behaviors with restricted narrow inter-
Institute of Mental Health, NIH, Bethesda, ests (American Psychiatric Association, 1994;
MD, USA Dawson et al., 2002; Kanner, 1943; Piven,
Palmer, Jacobi, Childress, & Arndt, 1997;
Volkmar & Pauls, 2003). It is important to note
Definition that none of the currently available models fully
recapitulate all aspects of ASDs. However,
Animal models are useful for testing hypotheses fundamental symptoms of autism can be approx-
about biological mechanisms underlying the imated in animal models in order to test
Animal Models 161 A
hypotheses about mechanisms underlying the eti- behavioral phenotypes in some prominent genetic
ology and causes of the disorder and to evaluate mouse models of autism.
potential pharmacological, behavioral, and other A second approach, also using mouse models, A
treatments that may alleviate symptoms associ- addresses single-gene neurodevelopmental disor-
ated with ASDs. ders and those resulting from chromosomal dele-
tions and duplications (copy number variations,
CNVs), in which a high number of affected indi-
Current Knowledge viduals display autism-like symptoms. Lines of
mice have been generated with targeted gene
Strategies for Designing Rodent Models of mutations relevant to disorders such as Angelman
Autism syndrome, fragile X syndrome, Rett syndrome,
Twin and family studies indicate an extraordi- Timothy syndrome, and tuberous sclerosis
narily high degree of heritability for ASDs. Con- (Ehninger et al., 2010; Moretti et al., 2005;
cordance between monozygotic twins Spencer et al., 2011). A mutant mouse line with
approaches 90% for ASDs as compared with a duplicated chromosome orthologous to human
10% or less in dizygotic twins and approxi- chromosome 15q11–13 has also recently been
mately 0.6–1.0% occurrence in the general pop- generated (Nakatani et al., 2009). Table 2 sum-
ulation (Abrahams & Geschwind, 2008). marizes autism-relevant behavioral phenotypes
Several approaches have been used to generate in selected mouse models of single-gene
genetic mouse models of autism and to evaluate neurodevelopmental disorders and disorders
the contributions of specific genes to the symp- resulting from rare CNVs.
toms of ASDs. Genes implicated in autism A third approach is to generate defects in rats
include those coding for proteins involved in or mice that model reports of autism following
synapse development, neuronal signaling, neu- exposure to teratogenic drugs, environmental
rotransmission, neuron survival, RNA transcrip- toxins, or prenatal insults. For example, increased
tion, and DNA methylation. Targeted mutations risk for autism has been associated with prenatal
in genes homologous or orthologous to human exposure to the anticonvulsant drug valproic
candidate genes for autism have generated acid, the antiemetic drug thalidomide, and prena-
a large number of genetic mouse models tal viral infections. Models that address hypothe-
(Bozdagi et al., 2010; Cheh et al., 2006; ses regarding environmental causes of autism
DeLorey, Sahbaie, Hashemi, Homanics, & include offspring of pregnant rats and mice
Clark, 2008; Etherton, Blaiss, Powell, & treated with valproic acid or immunostimulant
Sudhof, 2009; Hines et al., 2008; Kwon et al., compounds that simulate viral infection
2006; Nakatani et al., 2009; Peca et al., 2011; (Ehninger et al., 2010; reviewed in Dufour-
Shu et al., 2005; Winslow & Insel, 2002). Mus Rainfray et al., 2011, and Patterson, 2009).
musculus, the house mouse species used in Table 3 summarizes findings of autism-relevant
molecular genetics research, is a social species behavioral phenotypes in mouse and rat models
that engages in high levels of reciprocal social used to test hypotheses about environmental
interaction and social communication, commu- factors implicated in autism.
nal nesting, sexual and parenting behaviors, ter- A final approach consists of utilizing naturally
ritorial scent marking, and aggressive behaviors occurring variation among genetically diverse
(Arakawa, Blanchard, Arakawa, Dunlap, & inbred mouse strains to identify behavioral
Blanchard, 2008; Bolivar, Walters, & Phoenix, phenotypes with strong face validity to ASD
2007; Miczek, Maxson, Fish, & Faccidomo, symptoms (Bolivar, Walters, & Phoenix, 2007;
2001; Moretti, Bouwknecht, Teague, Paylor, & Brodkin, Hagemann, Nemetski, & Silver, 2004;
Zoghbi, 2005; Scattoni, Crawley, & Ricceri, Moy et al., 2004, 2007, 2008b; Panksepp et al.,
2009; Terranova & Laviola, 2001; Winslow & 2007). Investigation of inbred strains expressing
Insel, 2002). Table 1 summarizes autism-relevant traits relevant to autism is referred to as
A 162 Animal Models
Animal Models, Table 1 Autism-relevant behavioral phenotypes in selected mouse models with targeted mutations in
genes homologous or orthologous to human candidate genes for autism
Autism-relevant behavioral
Gene Protein phenotypes
Synaptic cell adhesion molecules Nlgn2 Neuroligin 2 Low sociabilitya
Increased stereotyped jumping
behaviora
Neurexin- Neurexin-1a Increased repetitive self-
1a groomingb
Shank3 Shank3 Low sociabilityc
Reduced reciprocal social
interactionsc, d
Reduced ultrasonic
vocalizationsd
Increased repetitive
self-groomingd
Signaling, transcription, methylation, and En2 Engrailed-2 Reduced reciprocal social
neurotrophic factors interactionse
Foxp2 Forkhead box protein 2 Reduced pup ultrasonic
vocalizationsf
Pten Phosphatase and tensin Low sociabilityg
homolog Reduced reciprocal social
interactionsg
Neurotransmitters Gabrb3 GABA A receptor beta3 Low sociabilityh
subunit Lack of preference for social
noveltyh
Repetitive stereotyped circling
behaviorh
Oxt Oxytocin Impaired social recognitioni
Reduced pup ultrasonic
vocalizationsi
a
Hines et al. (2008)
b
Etherton et al. (2009)
c
Peca et al. (2011)
d
Bozdagi et al. (2010)
e
Cheh et al. (2006)
f
Shu et al. (2005)
g
Kwon et al. (2006
h
DeLorey et al. (2008)
i
Winslow and Insel (2002)
a “forward genetics” approach and is analogous which score well-defined behavioral symptoms.
to human linkage studies aimed at discovering In consultation with autism clinical experts,
genes linked to autism (Abrahams & Geschwind, behavioral neuroscientists are refining standard
2008). Table 4 lists examples of autism-relevant behavioral assays available in the literature and
behavioral phenotypes that have been detected in developing new behavioral assays which maxi-
different inbred strains of mice. mize face validity to the diagnostic symptoms of
Because no consistent biological markers for autism. Reviewed here are the tests that have
autism have been identified, the diagnosis been most useful, along with the essential control
of autism is currently based on standardized eval- measures, for modeling the diagnostic and asso-
uation instruments such as ADOS and ADI, ciated symptoms of autism in animals.
Animal Models 163 A
Animal Models, Table 2 Selected examples of mouse models of genetic syndromes in which a portion of patients
display autistic behaviors
Genetic
Autism-relevant
behavioral
A
syndrome Genetic syndrome characteristics Mouse model phenotypes
Fragile Lack of fragile X mental retardation Mice with a targeted mutation in the Low sociabilitya, b
X syndrome protein (FMRP) production; associated murine Fmr1 gene Reduced reciprocal
with cognitive impairments, social interactionsa
hyperactivity, social anxiety, attention Reduced social
problems, executive function interest during
impairments, and autistic-like behavior a partition testa
in affected males
High levels of self-
groominga
Increased motor
stereotypies and
repetitive marble
buryinga
Resistance to change
in a selective
attention taska
Rett Loss of function mutations in the Mice with a heterozygous mutation in Social avoidancec
syndrome X-linked gene methyl-CpG-binding the murine Mecp2 gene Reduced reciprocal
protein 2 (MECP2); characterized by social interactionsc
loss of acquired motor, social, and
language skills beginning at
6–18 months of age and nonsyndromic
mental retardation
Chromosome Duplication at chromosome 15q11–13; Duplication in the genomic region on Low sociabilityd
15q implicated in ASDs in several the mouse chromosome 7 homologous Ultrasonic
duplication association studies to the human genomic region vocalizations
syndrome 15q11–13 increased in pups and
reduced in adultsd
Impaired reversal
learningd
a
Spencer et al. (2011)
b
Moy et al. (2009)
c
Moretti et al. (2005)
d
Nakatani et al. (2009)
Rodent Behavioral Tasks Relevant to the Volkmar & Pauls, 2003). Assays used to detect
Diagnostic Symptoms of Autism social interaction abnormalities in rodent models
Sociability of autism include measures of social approach,
The first DSM-IV criterion for autism is qualita- the partition test, reciprocal social interactions,
tive and quantitative impairments in social the visible burrow test, social recognition, and
interactions (APA, 1994; Lord et al., 2000; social preference tests.
Piven et al., 1997; Volkmar & Pauls, 2003). The automated three-chambered social
These impairments have been characterized as approach apparatus, developed by Nadler, Moy,
a lack of interest in others, unusual and inappro- Crawley, and colleagues (2004), compares time
priate social approach behaviors, lack of social that a subject mouse spends with a novel mouse
reciprocity, and failure to develop peer relation- versus time that a subject mouse spends with a
ships appropriate to developmental ages (Kanner, novel object (Brodkin et al., 2004; DeLorey et al.,
1943; Lord et al., 2000; Piven et al., 1997; 2008; Hines et al., 2008; McFarlane et al., 2008;
A 164 Animal Models
Animal Models, Table 3 Selected examples of mouse

and rat models used to test hypotheses about environmen-
tal factors implicated in autism
Autism-relevant
Rodent model behavioral phenotypes
Mice with a heterozygous Low sociabilitya
mutation in the murine tuberous Reduced reciprocal
sclerosis 2 (Tsc2) gene exposed social interactionsb
to an immunostimulant Reduced ultrasonic
compound during gestation vocalizationsb
Offspring of rats and mice
Increased motor
subjected to immune system
stereotypiesb
challenges during pregnancy
Rats and mice prenatally exposed Reduced reciprocal
to the antiepileptic drug valproic social interactionsc
acid Increased motor Animal Models, Fig. 1 Three-chambered social
stereotypiesc approach apparatus used to evaluate sociability and pref-
a
Ehninger et al. (2010) erence for social novelty in mice (Photograph contributed
b
Patterson (2009) by Dr. Mu Yang, Laboratory of Behavioral Neuroscience,
c
Dufour-Rainfray et al. (2011) NIMH)
Moy et al., 2004, 2009; Nadler et al., 2004; conspecifics by sniffing. Thus, to determine
Nakatani et al., 2009; Ryan, Young, Crawley, whether time spent in the chamber containing the
Bodfish, & Moy, 2010). Detailed procedures for novel mouse reflects true social interactions versus
conducting this task are available (Yang, nonsocial exploration of the chamber, a human
Silverman, & Crawley, 2011). The subject observer scores, from videotapes of the test ses-
mouse is first placed in the empty center chamber sion, the amount of time the subject mouse spends
to habituate to the novelty of the environment sniffing the wire cup containing the novel mouse.
(shown in Fig. 1). After the 10-min habituation Investigating the novel object instead of the novel
session, the subject mouse is returned to the center mouse may be analogous to the tendency of autis-
chamber, while the targets are placed in the left tic individuals to engage in nonsocial activities
and right side chambers. A novel object is placed such as playing with one toy for an extended
in one side chamber. The novel object is usually an period of time or to spend more time visually
inverted wire pencil cup that elicits considerable examining geometric patterns as compared to
exploration and sniffing by the subject mouse. social images (Frith, 2003; Pierce, Conant,
A novel mouse is placed in the other side chamber, Hazin, Stoner, & Desmond, 2011).
inside in a wire cup that permits visual, olfactory, The partition test (Spencer et al., 2011) can be
auditory, and some tactile contact while used to evaluate social interest as well as basic
preventing aggressive or sexual interactions. The social recognition. A subject mouse is placed in
number of seconds spent in each chamber, and the one side of a standard cage divided in half by
number of entries between chambers, is automat- a perforated partition made of clear plastic or
ically recorded by the software detection of pho- wire and a partner mouse in the opposite side.
tocell beam breaks in the partitions between the The subject mouse can see, hear, and smell the
compartments. Sociability in this task is defined as partner mouse, but cannot engage in physical
the subject mouse spending more time in the side interactions with the partner. Approaches to and
chamber containing the novel mouse than in the time spent at the partition by the subject mouse
side chamber containing the novel object. Equal or represent the amount of interest in the social
less time spent with the novel object as compared partner. Social preference and social memory
to the novel mouse is interpreted as the absence of can be evaluated through sequential presentation
sociability in this task. Mice investigate novel of different social partners.
Animal Models 165 A
Animal Models, Table 4 Examples of genetically homogeneous inbred mouse strains that display behavioral
phenotypes relevant to the diagnostic symptoms of autism
Inbred strain Autism-relevant behavioral phenotypes
A
A/J Low sociabilitya, b, c
Reduced reciprocal social interactionsd
Impaired reversal learningc
BALB/cJ, BALB/cByJ Low sociabilityc
Reduced reciprocal social interactionse
Reduced ultrasonic vocalizationse
BTBR T + tf/J Reduced reciprocal social interactionsd, f, g
Low sociabilityf
Increased repetitive self-groomingf
Ultrasonic vocalizations elevated in pups and reduced in adultsh, i
Unusual repertoire of ultrasonic vocalization call categories as pups and adultsh, i
Impaired social transmission of food preferencef
Impaired reversal learningc
Preference for specific unfamiliar objects and repetitive object exploration patternsj
C58/J Low sociabilityk
Impaired social transmission of food preferencek
High level of repetitive self-grooming and motor stereotypiesk
NZB/B1NJ Low sociabilityl
Impaired reversal learningl
129 S1/SvImJ Low sociabilityl
Lack of preference for social noveltyl
Impaired reversal learningk
a
Brodkin et al. (2004)
b
Moy et al. (2004)
c
Moy et al. (2007)
d
Bolivar et al. (2007)
e
Panksepp et al. (2007)
f
McFarlane et al. (2008)
g
Defensor et al. (2011)
h
Scattoni, Gandhy, Ricceri, and Crawley (2008)
i
Scattoni, Ricceri, and Crawley (2011)
j
Pearson et al. (2010)
k
Ryan, Young, Crawley, Bodfish, and Moy (2010)
l
Moy et al. (2008b)
To more fully assess the complexity and chasing, mounting, and wrestling (Bolivar et al.,
variability of social behaviors in mice, more 2007; McFarlane et al., 2008; Terranova &
fine-grained analyses of reciprocal social interac- Laviola, 2001). Nonsocial behaviors such as
tions can be conducted in freely moving dyads of self-grooming, repetitive digging in the bedding,
mice. Behaviors exhibited by two unfamiliar and arena exploration are simultaneously scored.
age-matched rats or mice can be detected with Subject animals can be tested at different ages
automated video-tracking equipment or scored and over repeated test sessions to evaluate trajec-
by a human observer. A variety of parameters tories of complex social behaviors across differ-
can be scored depending on the age and sex of ent neurodevelopmental stages. A juvenile play
the animals, including nose-to-nose sniffing, apparatus for scoring reciprocal social interac-
nose-to-anogenital sniffing, body sniffing, fol- tions in 21-day-old mice is shown in Fig. 2.
lowing, pushing past each other with physical The visible burrow system can be used to
contact, crawling over and under each other, evaluate social interactions among adult mice in
A 166 Animal Models
Animal Models, Fig. 2 (a) Noldus PhenoTyper 3000 juvenile C57BL6/J mice engaged in nose-to-nose sniffing
apparatus for scoring reciprocal social interactions (Photographs contributed by Dr. Mu Yang, Laboratory of
between pairs of age-matched unfamiliar mice. (b) Two Behavioral Neuroscience, NIMH)
a context that provides many features of rodents’ evaluated, or has their ability to capture the
natural habitats, including multiple burrows subtleties inherent to the rodent social behavior
connected via tunnels to a larger open area repertoire. If their accuracy can be verified, use
(Arakawa, Blanchard, & Blanchard, 2007). of automated software programs with standard-
Behaviors displayed in the visible burrow system ized quantification methods may allow higher-
can be videotaped and scored later by a human throughput scoring of rodent social behaviors
observer. Social behaviors such as huddling, while improving the chances of reproducibility
chasing, following, and mounting can be scored of results across labs.
along with nonsocial behaviors such as self- Social preference tests can be used to evaluate
grooming and fleeing from another animal components of social affiliation, social recogni-
(Arakawa et al., 2007; Pobbe et al., 2010). Food tion, and social memory in rodents. In these tests,
and water can be provided in the visible burrow the subject animal is offered a choice between
system to allow observation of social behaviors at partners, and time spent with each partner is
different times of day over several consecutive measured. In partner preference tests, two stimu-
days or weeks. lus animals with different characteristics (e.g.,
Manual scoring of rodent social behaviors different strain, familiar versus unfamiliar) are
requires highly trained human observers, is presented simultaneously. The time spent with
often time-consuming and is subject to observer and number of approaches to each stimulus ani-
bias. A growing number of video-tracking soft- mal can then be recorded and used to calculate
ware systems are becoming available to automate a preference score (Williams, Catania, & Carter,
scoring of social behaviors in rodents. Several 1992). Partner preference tests are often
different software programs have been shown to conducted in a Y-maze apparatus where freely
be reasonably accurate for quantifying social moving subject mice spend time with tethered
approach behaviors in mouse models of autism target mice in three cages connected by tunnels
using the three-chambered apparatus (e.g., (e.g., Lim et al., 2004; Winslow, Hastings, Carter,
Nadler et al., 2004; Page, Kuti, & Sur, 2009). Harbaugh, & Insel, 1993). The three-chambered
Use of more sophisticated software packages to social approach apparatus (shown in Fig. 1) has
automatically score reciprocal social interactions been used to investigate preference for social
between pairs of animals is also on the rise novelty in mice (DeLorey et al., 2008; Moy
(Ahern, Modi, Burkett, & Young, 2009; et al., 2004; 2009). Preference for social novelty
Scearce-Levie et al., 2008). However, the degree is defined as the subject mouse spending more
to which these programs accurately track multi- time in a chamber or in physical contact with
ple animals has not yet been systematically a novel mouse in one side chamber than with
Animal Models 167 A
a familiar mouse in the other side chamber. Mice
usually habituate quickly to the presence of
a novel conspecific and will move on to approach A
and investigate another novel conspecific when it
is presented. During social approach testing as
described above, the subject mouse becomes
habituated to the novel mouse. The subject
mouse can then be provided access to a second
unfamiliar novel mouse, and time spent with the
Animal Models, Fig. 3 Olfactory habituation/
first versus second novel mouse can then be dishabituation test, showing a mouse sniffing a cotton
recorded. Partners can also be presented sequen- swab saturated with odors from an unfamiliar mouse
tially, with time delays between presentations, to (Photograph contributed by the authors)
evaluate social recognition memory (Winslow &
Insel, 2002). A lack of normal preference for The social transmission of food preference test is
a novel social partner or deficits in social recog- a three-stage process. First, a “demonstrator” ani-
nition may be analogous to the tendency of autis- mal is allowed to eat a novel-flavored food. After
tic individuals to avoid unfamiliar individuals or consuming the novel food, the demonstrator
to indiscriminately approach strangers (Ameri- interacts with an “observer” animal. During this
can Psychiatric Association, 1994). time, the observer animal acquires familiarity
with the novel flavor, presumably by sniffing
Communication the face, breath, and whiskers of the demonstrator
The second DSM-IV criterion for autism, quali- animal. In the final phase, the observer is given
tative impairments in communication (American a choice between the flavor of the food eaten by
Psychiatric Association, 1994; Frith, 2003; Lord the demonstrator and some other novel flavor.
et al., 2000), is perhaps the most challenging to The observer animal will express a preference
model in rodents. The nature of mouse commu- for the now-familiar food as indicated by eating
nication is not yet well understood, although more of it. Normal performance on this task is
considerable interest has recently focused on thought to depend on the observer animal
ultrasonic vocalizations (Lahvis, Alleva, & detecting olfactory cues on the breath of the
Scattoni, 2011; Scattoni et al., 2009). Olfaction demonstrator, which requires social interactions,
is the primary sense used by rats and mice for particularly nose-to-nose sniffing (Galef &
individual recognition and is likely of central Wigmore, 1983; Wrenn, 2004).
importance in rodent communication (Brennan The olfactory habituation/dishabituation task
& Kendrick, 2006). Information between (shown in Fig. 3) measures the ability to detect
members of the same species is conveyed using and discriminate between different odors. When
chemical signals commonly termed pheromones. mice are presented with a cotton swab containing
In addition to pheromonal communication, rats a novel odor, they will investigate it by sniffing.
and mice emit ultrasonic vocalizations in differ- Upon repeated presentations of the same odor,
ent social contexts throughout the lifespan a progressive decrease in sniffing (olfactory
(Lahvis et al., 2011; Scattoni et al., 2009). Several habituation), will be seen. Reinstatement of high
behavioral tasks involving the evaluation of sniffing levels (dishabituation) will be seen when
responses to olfactory and auditory cues can be a novel odor stimulus is subsequently introduced
used to assay possible communication deficits in (Ryan et al., 2010; Yang & Crawley, 2009). Fresh
rodents. urine or swipes from the bottom of a soiled cage
Tasks designed to assay olfactory communi- of unfamiliar mice can be used as social odors.
cation in rodents include social transmission of The shapes of the habituation and dishabituation
food preference, olfactory habituation/ curves reflect the ability to discriminate between
dishabituation to social odors, and scent marking. same and different odors. The peaks of the curves
A 168 Animal Models
reflect the level of interest in each odor stimulus. and recorded using specialized software. Quanti-
Social odors elicit considerably higher levels of tative and qualitative analysis of USVs emitted
sniffing as compared to nonsocial odors, such as by mice have been used to examine possible
almond and banana extracts (Yang & autism-relevant communication deficits in both
Crawley, 2009). inbred strains and various genetic mutant mouse
Olfactory cues influence a variety of social lines. When separated from the nest, mouse pups
behaviors in rodents, such as kin and individual emit calls that parents use to locate and retrieve
recognition, bond formation, mate attraction the pup (Nakatani et al., 2009; Scattoni, Gandhy,
and selection, and communication of danger Ricceri, & Crawley, 2008; Shu et al., 2005; Wins-
(Arakawa et al., 2008; Brennan & Kendrick, low & Insel, 2002). USVs are also emitted during
2006; Hurst, 1990). Scent-marking tasks are juvenile interactions, by resident females in
widely used in mice (Arakawa et al., 2008; a resident-intruder task and by males exposed to
Wöhr, Roullet, & Crawley, 2011). Mice deposit a female in estrus or their urine (Bozdagi et al.,
urinary steroidal pheromones that serve as 2010; Panksepp et al., 2007; Wöhr et al., 2011).
territorial scent marks and are distinct among Analysis of USV spectrograms (shown in Fig. 4)
genetically diverse individuals (Brennan & has allowed researchers to identify discrete cate-
Kendrick, 2006). High levels of interest in uri- gories of ultrasonic calls in mice (e.g.,
nary scents from other mice are indicated by the Panksepp et al., 2007; Scattoni et al., 2008;
tendency of a subject mouse to explore the Scattoni, Ricceri, & Crawley, 2011). Simulta-
anogenital area of a novel mouse, investigate neous recording of social interactions and USVs
urinary scent marks in a cage, and sniff a cotton have revealed correlations between call emission
swab soaked in urine from another mouse. When rates, types of calls emitted, and various social
a male mouse encounters a scent mark deposited behaviors, suggesting that USVs might convey
by another male in its territory, it tends to communicative information during social situa-
countermark in response. Countermarking is tions (Panksepp et al., 2007; Scattoni et al.,
gradually reduced when a male mouse is repeat- 2011). However, much work remains to be done
edly exposed to scent marks from the same mouse in order to determine the potential communica-
and is increased again when the subject mouse tive value of rodent USVs and their relevance to
encounters scent marks from a novel, genetically the types of communication impairments seen in
different mouse (Arakawa et al., 2008). Thus, autistic individuals.
countermarking behavior might be useful for
studying the ability to discriminate between dif- Repetitive Behaviors and Resistance to Change in
ferent individuals based on olfactory cues. Male Routine
mice also deposit scent marks when exposed to Several assays are available to investigate behav-
urine from a female mouse (Wöhr et al., 2011). ioral phenotypes in rodents relevant to the third
Female urine-elicited scent marking is thought to DSM-IV diagnostic criterion of autism, stereo-
play a role in mate attraction and could serve as typed, repetitive behaviors, and patterns with
a measure of social motivation (Hurst, 1990; restricted interests or activities (American Psy-
Wöhr et al., 2011). The importance of olfactory chiatric Association, 1994; Lord et al., 2000).
cues across many social contexts suggests that Rats and mice display spontaneous motor stereo-
rodent models of autism displaying olfactory typies that appear to have no specific function,
communication deficits might be useful for including circling, back flipping, jumping, and
understanding aspects of impaired social commu- cage bar biting (DeLorey et al., 2008; Hines
nication in autism. et al., 2008; Lewis, Tanimura, Lee, & Bodfish,
Emission of ultrasonic vocalizations (USVs) 2007; Ryan et al., 2010). Repetitive behaviors in
in social situations is a consistent and robust rodents, which may appear as normal patterns but
phenomenon in rodents. These USVs can be persist for unusually long periods of time, include
detected using sensitive ultrasonic microphones self-grooming (shown in Fig. 5a) and marble
Animal Models 169 A
Animal Models, a
Fig. 4 Spectrograms of
ultrasonic vocalizations kHz
emitted by (a) a C57BL/6 J 100 A
mouse pup separated from
the nest and (b) an adult 75
C57BL/6 J male mouse
interacting with an 50
unfamiliar C57BL/6 J
female mouse in estrus 25
(Spectrograms contributed
by the authors)
0.1 0.2 0.3 8
b
kHz
100
75
50
25
0.1 0.2 0.3 8
Animal Models, Fig. 5 (a) A BTBR T + tf/J mouse reversal learning, which evaluates resistance to change
engaged in repetitive self-grooming. Photograph contrib- an established position habit (Photograph contributed by
uted by Dr. Mu Yang, Laboratory of Behavioral Neuro- the authors)
science, NIMH. (b) Morris water maze for measuring
burying (McFarlane et al., 2008; Ryan et al., for example, by placing a food reward in the left
2010; Spencer et al., 2011). Resistance to change arm of a standard T-maze or by placing the
has been modeled in rodents using reversal learn- escape platform into one quadrant of the Morris
ing tasks, which measure perseverative behavior water maze (shown in Fig. 5b). The location of
patterns (Moy et al., 2007; 2008b; Nakatani et al., the food reward or escape platform is then
2009). Reversal learning tasks measure the changed, requiring the development of a new
flexibility of the animal to switch from an position habit. Successful acquisition of the ini-
established habit to a new habit. Animals are tial position habit but failure to develop the new
first well-trained to form a spatial position habit, one might be analogous to insistence on sameness
A 170 Animal Models
and inflexibility in routines that is characteristic phenotypes directly relevant to a diagnostic

of autism (Moy et al., 2008b; Nakatani et al., symptom. For example, a mutant mouse
2009). Tasks relevant to restricted interests or line with high-anxiety-like behavior would
activities are still under development. One likely display low levels of exploratory activity
approach measures restricted exploration of in the three-chambered social approach task,
only one of the available holes in a hole board confounding interpretation of their social
(Moy et al., 2008a) or only one of several novel approach behavior. This issue requires careful
objects in an open field (Pearson et al., 2010). consideration for each animal model in which
autism-relevant behavioral phenotypes have
Associated Symptoms been detected.
Additional associated symptoms, which occur in
some cases of autism, include intellectual impair- Control Parameters
ments, anxiety, sleep disturbances, aggression, When investigating autism-relevant behavioral
clumsiness, idiosyncratic responses to sensory phenotypes in animal models of ASDs, it is
stimuli, and seizures (Dawson et al., 2002; Lord essential to control for physical disabilities that
et al., 2000; Piven et al., 1997). In order to more could produce false positives in many of the
fully characterize a proposed animal model of behavioral tasks described here (Crawley,
autism, it is useful to include behavioral tasks 2007a). For example, a mutant mouse line with
which address phenotypes relevant to these asso- a gene mutation affecting olfactory functions
ciated symptoms (reviewed in Crawley, 2007a, could show deficits on social tasks based on suc-
2007b). Standard tasks available for rats and mice cessful detection of conspecific odors. Similarly,
are well-characterized in the behavioral neurosci- rats or mice treated with a drug that produces
ence literature. Learning and memory tasks (e.g., sedation will likely show impairments in social,
Morris water maze, contextual and cued fear con- cognitive, or motor tasks that are attributable to
ditioning, novel object recognition) can be used low overall activity as opposed to a reduction in
to detect cognitive deficits that may be relevant to reciprocal social interactions or a learning deficit.
the symptom of mental retardation. Tasks used to To rule out these types of artifacts, potential
assay anxiety-related behaviors (e.g., elevated rodent models of autism must be evaluated on
plus maze, light ↔ dark exploration) can be a series of tasks measuring general health, neuro-
used to detect high or low levels of anxiety in logical reflexes, sensory abilities, motor
an animal model. Disturbances in sleep patterns functions, and home cage behaviors (Crawley,
can be evaluated using electroencephalography 2007b).
(EEG) recordings, circadian running wheels, and
home cage monitoring systems. Resident-
intruder tasks can be used to measure aggressive Future Directions
behavior in males. Motor clumsiness can be
tested using the balance beam, rotarod, and foot- Autism is a complex disorder with variable symp-
print tests. Sensory hypersensitivity or toms, some of which may be uniquely human. For
hyposensitivity can be detected through the example, deficits in theory of mind, or the ability
acoustic and tactile startle tests, as well as tests to intuit what another person is thinking or
that measure pain sensitivity (e.g., hot plate, tail feeling, may be difficult to model in nonhuman
flick). Spontaneous seizures, audiogenic seizures animals. However, recent reports suggest that
induced by loud tones, or drug-induced seizures mice display empathy-like behaviors following
induced by administration of convulsants can be exposure to cagemates who have experienced
measured using observer scoring or EEG record- a painful stimulus (e.g., Chen, Panksepp, &
ings. A potential pitfall of detecting phenotypes Lahvis, 2009). Subtle language and communica-
relevant to the associated symptoms of autism is tion deficits, such as the inability to understand
that they may complicate interpretation of humor or sarcasm, are unlikely to be successfully
Animal Models 171 A
modeled in animals. However, detailed analysis Both pharmacological and behavioral interven-
of rodent ultrasonic vocalizations may provide tion strategies have been tested in mouse models
information about their communicative value such as the BTBR T + tf/J strain, which displays A
(Lahvis et al., 2011). Modeling complex cogni- behavioral phenotypes relevant to all three diag-
tive abilities, such as executive functions and nostic symptoms of autism (Bolivar et al., 2007;
joint attention, is also a challenge. Researchers McFarlane et al., 2008; Pearson et al., 2010;
are starting to develop cognitive tasks that eval- Scattoni et al., 2008; Scattoni et al., 2011).
uate sustained attention and attentional set- A single injection of the drug 2-methyl-6-
shifting abilities in rodents similar to those used (phenylethynyl)pyridine (MPEP), a potent antag-
to evaluate cognitive abilities in autistic individ- onist at mGluR5 subtype glutamate receptors,
uals (Brigman, Bussey, Saksida, & Rothblat, significantly reduced repetitive self-grooming in
2005). BTBR mice (Silverman, Tolu, Barkan, &
The occurrence of autism is significantly Crawley, 2010). Rearing BTBR mice with social
higher in males than in females, with a male to C57BL6/J mice as cagemates after weaning sig-
female ratio of 4:1 (Volkmar & Pauls, 2003). nificantly improved their sociability in the three-
Thus, an animal model that displays relevant chambered social approach task as adults (Yang,
phenotypes in males but not females could be Perry, Weber, Katz, & Crawley, 2011). Several
considered to have face validity with regard to potential drug candidates, such as other mGluR5
the prevalence of ASDs. Due to the higher prev- antagonists, rapamycin, brain-derived neuro-
alence of autism in males, many studies have only trophic factor (BDNF), and oxytocin, have been
tested male animals (e.g., Bolivar et al., 2007; shown to prevent or reverse aberrant phenotypes
Hines et al., 2008; McFarlane et al., 2008; Moy in a variety of mouse models of ASDs (reviewed
et al., 2007, 2008b; Nakatani et al., 2009; Pearson in Silverman et al., 2010). Animal models
et al., 2010; Peca et al., 2011), precluding detec- with robust and well-replicated behavioral pheno-
tion of possible sex differences. However, sex types will be powerful tools for developing
differences have been reported for a few animal pharmacological and behavioral treatments for
models of autism. For example, social deficits autism.
have been detected in male but not female mice
of the inbred C58/J strain (Ryan et al., 2010) and
in male but not female rats exposed prenatally to Acknowledgements
valproic acid (Dufour-Rainfray et al., 2011).
Other studies have tested both males and females We thank Dr. Mu Yang, NIMH, for contributing
and detected autism-relevant behavioral pheno- the photographs of mouse behavioral tasks shown
types in both sexes (e.g., Brodkin et al., 2004; in Figs. 1, 2, and 5a. This work was supported by
Cheh et al., 2006; Etherton et al., 2009; Moy the National Institute of Mental Health Intramu-
et al., 2004; Scattoni et al., 2011). Systematic ral Research Program.
investigations of sex differences in potential ani-
mal models of autism will likely lead to a better
understanding of the etiology of ASDs. See Also
Despite these challenges, animal models of
autism have been useful for evaluating potential ▶ Broader Autism Phenotype
treatments. Early behavioral interventions ▶ Copy Number Variation
have been the most effective treatments for ▶ Genetics
the symptoms of autism (Rogers & Vismara, ▶ Neuroscience
2008). Medications have been reported to ▶ Social Behaviors and Social Impairment
improve associated symptoms of autism such as ▶ Social Communication
hyperactivity or mood, but have not been shown ▶ Stereotypic Behavior
to affect the diagnostic features of autism. ▶ Synaptic Proteins
A 172 Animal Models
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ogy. Nature Reviews Genetics, 9(5), 341–355. Friedman, S., Aylward, E., et al. (2002). Defining the
Ahern, T. H., Modi, M. E., Burkett, J. P., & Young, L. J. broader phenotype of autism: Genetic, brain, and
(2009). Evaluation of two automated metrics for behavioral perspectives. Developmental Psychopa-
analyzing partner preference tests. Journal of Neuro- thology, 14(3), 581–611.
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Antecedent-Behavior-Consequence (A-B-C) Analysis 175 A
and types of support for the child to meet IEP functional behavior assessment. The goal of this
goals, and considering and explaining placement analysis is to develop hypothesis regarding the
options. function that a problem behavior serves for an A
individual with ASD. A-B-C analysis views
behavior (B) as a function of the antecedents
See Also (A) that precede it and the consequences (C) that
follow it. Typically, an A-B-C chart is used over an
▶ Free Appropriate Public Education extended time period to record events that occur
▶ Individual Education Plan naturally rather than being systematically arranged.
▶ Individualized Plan for Employment (IPE) These events occur in the natural environment,
▶ Individualized Transition Plan (ITP) with the observer recording the environmental
▶ Individuals with Disabilities Education Act events that occur immediately before the behavior
(IDEA) in the (A) section, the specific behavior observed
in the (B) section, and the events occurring
immediately after the behavior in the (C) section.
Bateman, B. D., & Herr, C. (2006). Writing measurable Historical Background

IEP goals and objectives. Verona, WI: Attainment
Publications.
Boutot, E. A., & Myles, B. S. (2011). Autism spectrum A-B-C analysis began in the 1960s with the
disorders. Pearson, NJ: Upper Saddle River. beginnings of applied behavior analysis, with
Hall, L. J. (2007). Autism spectrum disorders: From the- Sidney Bijou and colleagues asserting the impor-
ory to practice. Pearson, NJ: Upper Saddle River.
tance of collecting direct and repeated data on the
Ruble, L. A., McGrew, J., Dalrymple, N., & Jung, L. A.
(2010). Examining the quality of IEPs for young chil- observable interactions between the behavior
dren with autism. Journal of Autism and Developmen- exhibited by the organism and the events in
tal Disorders, 20, 1459–1470. naturally occurring conditions. Interrelationships
between the behavior and past and future events
were the primary data of interest. The first step of
the analysis was a narrative recording, which was
Anorexia a running description of occurrences during an
observational period, with no specific behavior
▶ Eating Disorders targeted for observation. These descriptions were
the first step in identifying a targeted behavior
that would be measured formally in further
analysis. These temporally sequenced events
Antecedent-Behavior-Consequence were translated into A-B-C forms that specified
(A-B-C) Analysis each behavior of interest and the events
that occurred immediately before and after
Kathleen Dyer the behavior.
River Street Autism Program at Coltsville, In the 1970s, research conducted by Edward
Capitol Region Education Council/Elms College, Carr and colleagues found that many
Hartford, CT, USA problem behaviors were logically linked to
a small set of antecedents and consequences.
Specifically, these researchers stated than
Definition an individual with ASD usually exhibited
problem behavior to either gain access to
An A-B-C analysis is a descriptive assessment that attention or a desired item or to escape an
is conducted as an initial part of a complete undesired event. With the growing body of
A 176 Antecedent-Behavior-Consequence (A-B-C) Analysis
research studies that supported these falling on the ground; and third, throwing
findings, the focus of A-B-C analysis narrowed. large objects at adults.
Currently, many A-B-C analyses focus on more 2. Antecedent events (A’s) that immediately
severe problem behavior, such as self-injury, precede the behavior.
aggression, tantrums, and pica. Antecedent 3. Consequent events (C’s) that immediately
conditions usually consist of (1) demands, follow the behavior. The consequent events
(2) attention removed, (3) preferred activity customarily recorded are the social behavior
removed, and (4) alone. Similarly, consequence of the adult that is interacting with the individ-
events that follow the problem behavior are ual and include behaviors such as providing
often restricted in focus to (1) attention provided attention, feedback, reprimands, access to
in the form of reprimands or soothing state- preferred items/events, and ignoring.
ments, (2) removal of demands, (3) access to It is also important to include information
preferred items, or (4) problem behavior is regarding the setting, other persons present, and
ignored or neutrally redirected. In addition, ini- materials available and include any other infor-
tiation of the A-B-C analysis is triggered by mation that may be relevant, such as time of day,
concerns regarding the problem behavior voiced day of week, and any unusual events that may
by clinical or educational team. effect behavior.
Information gathered from A-B-C analysis is
used to develop hypothesis regarding the function
Current Knowledge (motivation) of the problem behavior and
then develop subsequent treatment plans based
The customary usage of the A-B-C form is as one on this information.
component of a complete functional behavior Use of A-B-C forms requires training of
assessment of a problem behavior exhibited by observers to limit their recordings to observable
the individual with ASD. However, these forms and measurable behaviors, as untrained observers
can be used for any socially significant behavior of have been reported to include subjective
interest. A-B-C forms can be open-ended, where impressions of thoughts and feelings of the
the observer fills in any event that occurs before or person observed. This might lead to instances of
after the behavior. Some A-B-C analyses specify recording impressions such as “frustrated,”
time frames and define “immediately” specifically “mad,” “agitated,” or “sad.” In addition, sensitiv-
(e.g., as 20 s before or after the behavior occurs). ity to the types of environmental events needs to
The categories to be completed in the be trained. It is not uncommon for an untrained
observation are: observer to record “nothing” as an event, and
1. The observable behaviors (B) exhibited training on specificity of events to include aspects
by the individual with ASD. When defining such as physical environment, persons present,
behavior, it is important to provide clear and materials available is necessary.
criteria of the behavior. (e.g., tantrums might
be distinguished from whining or crying Narrative Recordings
by being described with an intensity and These recordings included a description of the
duration measure, such as screaming setting, time, people present, and materials
and loud crying, that lasts more than 30 s. available. The evaluator begins with a running
In addition, tantrums co-occur with one of narrative description of the individual’s behavior,
the following behaviors: lying on the floor, such as “Ed is playing alone in the block
kicking legs, and/or swiping materials off center.” When the teacher says “Time to come
desk). It is also important to record the extent to circle,” Ed continues to play with the blocks,
to which the behavior co-occurs with other and the teacher starts the circle without him.
behaviors in a sequence. Such a sequence When the Aide taps Ed on the shoulder and says
might be, for example, first, crying; second, “Ed, it’s time to go to circle,” Ed throws the block
at the aide. The aide then leaves Ed to play with Antecedent-Behavior-Consequence (A-B-C) Analy-
the blocks, and the teacher conducts circle time sis, Table 1 Open-ended A-B-C form
with the other children. Here is sample sequence Antecedent
(what
Behavior
(record
Consequence
(what happened
Comments
A
analysis of this recording into a three-column
happened right the right after the
form of antecedents (A), behaviors (B), and before the behavior behavior
consequences (C). behavior here) occurred?)
occurred?)
Antecedent (what Behavior Consequence (what Ex. Teacher Ex. Ex. Teacher
happened right (record the happened right after said “Time for Kicked says “It looks
before the behavior behavior the behavior math” while teacher like you’re not
occurred?) here) occurred?) placing ready for work”
Ed is playing worksheet and takes
in the block before student worksheet and
center walks back to
Teacher says “It’s Ed continues Aide taps Ed and desk
time for circle” to play with asks him to join the
blocks circle
Aide taps Ed and Ed throws Aide leaves Ed
asks him to join the block at aide alone Specific A-B-C Recording
circle In this type of A-B-C analysis, the observer is
Aide leaves Ed Ed plays with Teacher and aide provided with a specific checklist of A-B-C
alone blocks conduct circle
without Ed events to record in a specific ongoing time period.
For example, the time period might consist of a
The analysis is restricted to describing the 1-h block in the morning, and the observer would
participant’s behavior and excludes conjecture record specified behaviors that occurred during
regarding the participant’s thoughts and that time. In addition, the specified antecedents
feelings. For example, “He hits other children are recorded whether or not they were followed
because he does not understand the situation” by problem behavior. This is distinguished from
would not be included in the analysis, as the open-ended recording described above that is
understanding is not observable or measurable only used when the targeted behavior occurs.
behavior. Finally, in A-B-C analysis, general- This type of recording allows a more fine-tuned
izations are not made about the environment analysis of the relationship between the anteced-
and behavior, such as “He is a trouble maker ent and behavior, as it would detect conditions
who always gives the teacher a hard time.” where the antecedent occurred and the behavior
Finally, in this analysis, consequent events did not follow, ruling out faulty correlations
for one behavior can turn into antecedent between antecedents and consequences.
events for the following behavior. The specific events recorded can be developed
from preliminary information gathered from inter-
Open-Ended A-B-C Recording views and/or narrative recordings (see above). The
In this type of analysis, the narrative record- following are possible specific antecedents, behav-
ing is omitted. The observer uses the A-B-C iors, and consequences used on these forms:
form when the specific targeted behavior Antecedents
occurs and records the antecedents and conse- • Demand
quences that come before and after the • Request
targeted behavior. It is recommended that • Feedback
observers include the time the behavior • Denial
started and ended, the intensity of the behav- • Reprimand
ior, and any other important characteristics of • Transition
the setting. An example of a form for this type • Alone
of recording is in Table 1. • Removal or diversion of adult attention
A 178 Antecedent-Behavior-Consequence (A-B-C) Analysis
Antecedent-Behavior-Consequence (A-B-C) Analysis, Table 2 Specific A-B-C recording form

Antecedent (circle antecedent) Behavior (circle behavior) Consequence (circle consequence)
Demand/instruction Self-injury Provide adult attention
Transition Aggression Give preferred item or activity
Playing alone Tantrums Remove adult demand
Adult attention removed Provide adult attention
Restrict access to preferred item/activity Adult reprimand
Other:_____________________ Other:_____________________
Demand/instruction Self-injury Provide adult attention
Transition Aggression Give preferred item or activity
Playing alone Tantrums Remove adult demand
Adult attention removed Provide adult attention
Restrict access to preferred item/activity Adult reprimand
Other:____________________ Other:_____________________
Repeat above
After the data are collected, summary statements are developed for each major antecedent or consequence of the
behavior and hypotheses are generated regarding the function of the problem behavior.
• One-to-one instruction – Response cost

• Group instruction – Contingent exercise
• Physical contact While the above list provides broad categories
• Social interaction of environmental conditions to be analyzed, more
• Engaged in preferred activity fine-grained analysis is often warranted. For
Behaviors example, “task demand” can be specified further
• Aggression as follows:
• Tantrums • Task demand
• Self-injury – Instruction provided with only auditory
• Bolting cues
• Pica – Instruction with auditory and visual cues
• Loud vocalizations – Instruction with only visual cues
• Stereotyped behavior – Instruction with auditory, visual, and tactile
• Noncompliance cues
• Throwing Or
• Property destruction • Task demand
Consequences – Math task
• Attention – Art task
• Corrective feedback – Writing task
• Access to preferred item – Expressive speech task
• Ignoring or redirecting behavior The important point to remember is that the
• Task demand A-B-C analysis should be provided with enough
• Task removed specificity to identify the relevant variables that
• Physical contact trigger and maintain the problem behavior.
• Soothing If a student will play with all toys with the excep-
• Automatic reinforcement (self-stimulation) tion of puzzles, this should be specified in the
• Reactive behavior management procedure analysis.
– Time out The sample form in Table 2 lists specific
– Overcorrection categories of antecedents, behaviors, and
consequences for the observer to check off. Using predictors of behavior. These can include
this form, the observer records the antecedent deficiencies such the ability to process complex
events as they occur, even if the problem behav- auditory information, cognitive limitations, and A
ior does not occur after the antecedent. difficulty with abstract reasoning. In addition, the
effects of anxiety and mood disorders could be
considered as contributing factors to behavior.
Future Directions
While there is a growing body of peer-reviewed See Also

research studies that shows that while the data
collected from A-B-C observations is useful, ▶ Analog Condition Functional Analysis
additional studies have asserted that functional ▶ Applied Behavior Analysis
analysis is a more reliable method of identifying ▶ Functional Behavior Assessment
variables that control the behavior, and therefore,
manipulating these variables lead to more suc-
cessful treatments. It is therefore recommended
that information gathered from the descriptive
A-B-C analysis be used as an initial
Bijou, S. W., Peterson, R. F., & Ault, M. H. (1968).
information-gathering step that precedes A method to integrate descriptive and experimental
a formal functional (experimental) analysis. field studies at the level of data and empirical concepts.
There is controversy regarding this recommenda- Journal of Applied Behavior Analysis, 1, 175–191.
Carr, E. G. (1977). The motivation of self-injurious behav-
tion, as it is argued by some that the information
ior: A review of some hypotheses. Psychological
from the A-B-C analysis is sufficient to form Bulletin, 84, 800–816.
hypothesis regarding the motivation of problem Feldman, M. A., & Griffiths, D. (1997). Comprehensive
behavior that can lead to effective treatments. assessment of severe behavior problems. In N. N.
Singh (Ed.), Prevention and treatment of severe
The time, cost, and controlled clinical settings
behavior problems: Models and methods in develop-
required to conduct a thorough functional mental disabilities. Pacific Grove, CA: Brookes
analysis is often not available in customary Publishing Company.
educational and clinic settings where treatment Lerman, D. C., & Iwata, B. A. (1993). Descriptive
and experimental analysis of variables maintaining
is provided.
self-injurious behavior. Journal of Applied Behavior
Current A-B-C analyses are restricted to Analysis, 26, 293–319.
recording observable events in the environment Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2011).
that may predict the occurrence of problem Behavior analysis for lasting change (2nd ed.).
New York: Sloane Publishing.
behavior. These events are restricted to imme-
Neef, N., & Peterson, S. (2007). Functional behavior
diate antecedents and consequences, which assessment. In J. O. Cooper, T. E. Heron, &
have been referred to as near triggers. Future W. L. Heward (Eds.), Applied behavior analysis
analysis are taking into account far triggers (2nd ed., pp. 500–524). Upper Saddle River, NJ:
Pearson Education.
such as lack of sleep, a death in the family,
O’Neill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R.,
moving residences, or other changes in events Storey, K., & Newton, J. S. (1997). Functional
that may not be immediately apparent in the assessment for problem behavior: A practical
A-B-C setting. It is recommended to use equip- handbook (2nd ed.). Pacific Grove, CA: Brooks/Cole.
Pyles, D. A. M., & Baily, J. S. (1990). Diagnosing severe
ment to measure biological variables, such as
behavior problems. In A. C. Repp & N. N. Singh
increased or decreased heart rate, the need to (Eds.), Perspectives on the use of aversive
urinate, physical pain, and low blood sugar and nonaversive interventions for persons with
when identifying predictors of problem behav- developmental disabilities (pp. 381–401). Sycamore,
IL: Sycamore Publishing.
ior in the future.
Romamczyk, R. G. (1996). Behavioral analysis and
It is argued that underlying characteristics of assessment: The cornerstone to effectiveness. In
the individual with ASD can also be strong C. Maurice, G. Green, & S. C. Luce (Eds.), Behavioral
A 180 Anterior Cingulate
intervention for young children with autism provided a coordinate-based meta-analysis of

(pp. 195–217). Austin, TX: PRO-ED. neuroimaging studies suggesting the cognitive-
Sulzer-Azaroff, B., Dyer, K., Soucy, D., & Dupont, S.
(2012). Applying behavior analysis across the autism affective demarcation of the ACC is less clear-
spectrum: A field guide for practitioners (2nd ed.). cut than was originally assumed.
Cornwall-on-Hudson, NY: The Cambridge Center
(Sloan Century Series in Behavior Analysis).
Function
The anterior cingulate’s functions are diverse,

Anterior Cingulate including the cognitive control of motor behavior
in response monitoring (Botvinick, Braver, Barch,
Michael J. Crowley Carter, & Cohen, 2001; Devinsky, Morrell, &
Developmental Electrophysiology Laboratory, Vogt, 1995; Holroyd & Coles, 2002), reward-
Yale Child Study Center, New Haven, CT, USA based learning (Holroyd & Coles), registering
physical (Craig, Reiman, Evans, & Bushnell,
1996) and social pain (Eisenberger & Lieberman,
Synonyms 2004), empathy, consciousness, and autonomic
functions.
ACC The ACC is implicated in the related processes
of conflict monitoring, response inhibition, and
error detection. On simple behavioral paradigms
Structure such as the Stroop color word interference task,
the individual is charged with responding to the
The anterior cingulate cortex (ACC) is in the color of a word when the word color differs from
frontal portion of the cingulate cortex, situated the written word (e.g., the word blue written in
medially just above the corpus callosum. The yellow text). In this task conflict is engaged
ACC consists of Brodmann areas 24, 25, 32, because the automaticity involved in reading
and 33. Vogt and colleagues (Vogt, 2009) defined the word conflicts with the different color of the
four major subdivisions of the rostral ACC. These printed word. However, the ACC has been shown
include a supracallosal portion (above the corpus to be activated independently of the presence
callosum), designated “midcingulate cortex,” of response alternatives on a Stroop-like task
which is divided into an anterior and a posterior suggesting a role as a top-down regulator increas-
portion. The aspect of the cingulate lying anterior ing the amount of “top-down” regulation required
and ventral to the corpus callosum is designated to meet the task demands (Roelofs, van
“anterior cingulate.” This region is further Turennout, & Coles, 2006). In doing so, the
divided into a pregenual region (more anterior) ACC would selectively enhance the activation
and subgenual region (more ventral). Based on of a correct response pending some selection
observed functional differences (Bush, Luu, & threshold to be exceeded (Roelofs et al., 2006).
Posner, 2000), neuroscientists often distinguish The incorrect response must be inhibited in favor
between a “cognitive” dorsal portion of the of the correct response. If an incorrect response is
ACC and an affective ventral portion of the executed, it needs to be detected to adjust perfor-
ACC. The dorsal ACC is connected to the pre- mance accordingly. In this process, the ACC
frontal, parietal and motor cortices, and motor appears to be involved in error detection, regard-
and frontal eye fields whereas the ventral ACC less of whether or not errors are consciously
is connected to the more traditional limbic perceived, and in the perception of errors com-
regions including the amygdala, nucleus mitted by others (Gentsch, Ullsperger, &
accumbens, anterior insula, and hypothalamus. Ullsperger, 2009; Hester, Foxe, Molholm,
More recently, Shackman and colleagues (2011) Shpaner, & Garavan, 2005; Holroyd et al., 2004;
Anterior Cingulate 181 A
Klein et al., 2007; Ullsperger & von Cramon, Shackman et al., 2011). The ventral ACC has
2001; Ullsperger, Nittono, & von Cramon, 2007). been shown to be engaged in modulation of the
The role of the ACC in response monitoring sympathetic as well as the parasympathetic A
and reward processing has been linked in a general aspects of the autonomic nervous system
reinforcement model that attempts to account for (Critchley, Mathias, & Dolan, 2001b; Matthews,
error processing, feedback processing, and rein- Paulus, Simmons, Nelesen, & Dimsdale, 2004).
forcement learning more generally. Here, the dor- As part of a network of higher cortical structures
sal ACC is thought to use reward prediction error including the insula, amygdala, and hippocam-
signals, conveyed via the mesencephalic dopa- pus, the ventral ACC is connected to lower struc-
mine system, to reinforce adaptive behavioral tures that have been dubbed the central
responses (Holroyd & Coles, 2002). As noted by autonomic network (Benarroch, 1993).
Holroyd and Coles (2008), two general types of
theories have been proposed to describe the role of
the dorsal ACC in response monitoring processes. Pathophysiology
Some theories propose the ACC serves an evalu-
ative role to detect errors or conflict. The response Emerging evidence at the levels of cell micro-
selection perspective suggests ACC is directly structure, neuronal connectivity, and brain vol-
involved in the decision making process ume suggest abnormalities in the ACC of people
(Holroyd & Coles). Other neuroimaging work with an autism spectrum disorder (ASD). In post-
implicates the ACC, but not specifically the dorsal mortem work, Simms and colleagues (Simms,
ACC in outcome anticipation, uncertainty of out- Kemper, Timbie, Bauman, & Blatt, 2009)
come (Critchley, Mathias, & Dolan, 2001a), sub- observed that individuals with autism had smaller
jective value of potential rewards (Kable & neurons and reduced neuronal density in the
Glimcher, 2007), and imagined or “fictive” ACC. They specifically examined von Economo
rewards (Hayden, Pearson, & Platt, 2009). neurons (VENs). Interest in VENs in ASD has
A growing body of work implicates the ACC burgeoned recently given their putative role in
in physical pain, social pain, and empathy-related emotional regulation and social interaction
processes. In terms of physical pain, recent neu- (Allman, Watson, Tetreault, & Hakeem, 2005;
roimaging work indicates the ACC is associated Allman et al., 2010). Simms et al. (2009) found
with the unpleasantness aspect of physical pain that while VENs did not differ from control
(Rainville, Duncan, Price, Carrier, & Bushnell, brains overall, a subset of (n ¼ 3) ASD individ-
1997). Studies of social exclusion, a socially uals had significantly increased VEN density
painful experience, indicate that some of the whereas the remaining six individuals had
same neural circuitry, including the ACC, is reduced VEN density compared to controls.
involved in the distressing aspect of being Suda et al. (2011) recently documented the
excluded by others in a group (Eisenberger & expression of axon guidance proteins were sig-
Lieberman, 2004). Among typically developing nificantly lower in the ACC region among autistic
adolescents, neural response to social rejection individuals compared to controls (Suda et al.).
engages brain regions involved in affective dis- Similarly, in an examination of ACC single cell
tress (subgenual anterior cingulate, anterior axons in brain white matter, Zikopoulos and
insula) and affect regulation (ventrolateral PFC, Barbas (2010) found evidence for a decrease in
ventral striatum) (e.g., Masten et al., 2011a; long axons that communicate over long distances
Sebastian et al., 2011). Interestingly, the anterior and an excessive number of thin axons linking the
cingulate cortex is part of a network consistently ACC to neighboring areas. Other work points to
engaged in studies of empathy for others’ pain the role of GABAergic (gamma-aminobutyric
(Krach et al., 2011). acid) function in the ACC in ASD (Zikopoulos
The ventral ACC has been implicated in emo- and Barbas). GABAergic neurons have chiefly
tion processing (for reviews see Bush et al., 2000; inhibitory action at receptors in the brain.
GABA is important for normal cortical function- group in the right frontal lobe, left parietal lobe,
ing, information processing, and cytoarchitecture and right anterior cingulate and increased white
during brain development (Di Cristo, 2007). For matter density in the right frontal lobe, left parietal
instance, in a pair of studies Oblak, Gibbs, and lobe, and left cingulate gyrus compared to control
Blatt (2009, 2010) observed reductions in children (Ke et al.). Lastly, in terms of grey matter,
GABAA and GABAB receptor densities in the Waiter et al. (2004) documented an increase in
ACC (Oblak et al. 2009, 2010). Lastly, Nakamura grey matter volume in the ACC among male ado-
et al. (2011) conducted a postmortem study lescent ASD subjects (Waiter et al.).
implicating the serotonin (5-HT) system in the A growing number of studies find individuals
ACC to ASD. In the brain, serotonin plays an with ASD have deficits in response monitoring.
important role in mood regulation sleep and Response monitoring is an executive task
appetite. Nakamura et al. (2011) observed that subserved by the ACC. Response monitoring spe-
the expression of a protein that regulates the cifically refers to evaluating whether one’s
serotonin transporter (5-HTT), STX1A, was sig- actions are consistent with one’s goals and mod-
nificantly lower in the ACC region in an autism ifying behavior accordingly to optimize out-
group compared to controls (Nakamura et al., comes. In a recent fMRI study, Thakkar et al.
2011). (2008) used a performance monitoring task find-
In vivo research documents altered ACC cell ing that individuals with ASD had increased ros-
membrane metabolism (Levitt et al., 2003). tral ACC activation which was related to
Employing positron emission tomography repetitive behaviors (Thakkar et al.). In terms of
(PET), Ohnishi et al. (2000) found decreased behavioral responses, Russell and Jarrold (1998)
left ACC cerebral blood flow (Ohnishi et al.). reported reduced error self-correction among
Similarly, Haznedar et al. (1997) observed adults with ASD (Russell and Jarrold). Bogte,
reduced glucose metabolism throughout the cin- Flamma, van der Meere, and van Engeland
gulate gyrus and reduced right ACC volume (2007) observed reduced post-error slowing in
(Haznedar et al.). Moreover, in the ASD group, ASD, an index of behavioral correction to
glucose metabolism was positively associated improve performance on a subsequent trial
with social interaction, verbal communication, (Bogte et al., 2007). In one of the first ERP studies
and nonverbal communication scores. suggesting abnormal response monitoring in
In terms of connectivity with other brain high-functioning ASD, Henderson et al. (2006)
regions, Welchew et al. (2005) observed atypical observed increased latency in the ERN event-
connectivity of the ACC with inferior occipital related potential response, and poorer behavioral
and inferior frontal cortices (Welchew et al.). performance overall. ASD children did not differ
In the first study using diffusion tensor imaging from comparison children in terms of ERN
in ASD, Barnea-Goraly et al. (2004) observed amplitude, but ASD probands with higher IQs
that ASD children had reduced ACC fractional showed significantly larger ERN responses,
anisotropy (FA), a measure thought to reflect fiber suggesting hypersensitivity to errors among this
density, axonal diameter, and myelination in white group. In a second study with ASD children,
matter, extending to adjacent regions including the Vlamings, Jonkman, Hoeksma, van Engeland,
ventromedial frontal area and subgenual prefron- and Kemner (2008) observed smaller ERNs and
tal region, bilateral temporoparietal junctions, and a lack of post-error slowing behaviorally
adjacent superior temporal gyrus (Barnea-Goraly (Vlamings et al., 2008). The authors observe
et al.). Similarly, Noriuchi et al. (2010) observed this finding, coupled with a comparable correct
that FA was significantly lower in a child ASD trial negativity (CRN) for ASD and typical chil-
group in the mid and right ACC among other dren is consistent with perseverative behavior
regions (Noriuchi et al.). Using diffusion tensor seen in ASD children (for a similar finding in
imaging, Ke et al. (2009) observed decreased adults see Santesso et al. (2010)). Interestingly,
white matter density in a high-functioning autism a recent study employing a reward-loss feedback
task did not find differences in a related brain themselves (“self” condition) or a close other
response thought to be subserved by the ACC, person (“other” condition) and related to psycho-
the feedback-related negativity (FRN) (Larson, logical personality traits (“internal”) or observ- A
South, Krauskopf, Clawson, & Crowley, 2011). able characteristics/behaviors (“external”).
These data suggest that individuals with ASD Within the ventral medial prefrontal cortex and
process external, concrete feedback similarly to ventral anterior cingulate cortex, activity was
typically developing individuals. reduced for the ASD group across all conditions
Not surprisingly, anterior cingulate dysfunc- and also during a rest condition, suggesting task-
tion also continues to emerge when the experi- independent dysfunction in this region (Kennedy
mental paradigm involves social functioning. A and Courchesne).
meta-analytic examination of 24 studies on social While clearly a large amount of data supports
information processing and 15 nonsocial studies ACC involvement in the autism phenotype, the
by Di Martino et al. (2009) suggests that ACC should not be considered the only neural
a distributed system involving the ACC and the structure relevant to autism pathophysiology.
anterior insula was hypoactive for individuals First, the ACC is connected to multiple brain
with autism – in nonsocial studies the ASD indi- and body systems that may be more or less
viduals were more likely to show activation in the affected in the disorder (see above). Second, and
rostral ACC, which is typically suppressed in relatedly, functioning in the ACC contributes to
attention-demanding tasks. Importantly, we see self-regulatory and social cognitive abilities, but
deficits in the functioning of this specific circuitry in concert with other brain and body systems.
in social challenge tasks such as social rejection/ Third, functioning in the ACC cannot account
exclusion paradigms. Compared to controls, chil- for all aspects of the autism phenotype more
dren and adolescents with ASD showed generally (e.g., language delays). Thus, future
hypoactivation in the ventral ACC and right work examining ACC function in autism will
insula when they were excluded from a simple need to incorporate new developments in our
computer game by same-aged peers (Bolling understanding of ACC anatomy and function
et al., 2011; Masten et al., 2011b). (Shackman et al., 2011; Vogt, 2009) coupled
Other recent social-cognitive work employing with nuanced and yoked paradigms that can be
experimental paradigms seems to tap monitoring used to parse ACC-relevant functions (Bolling
processes as described above, but social monitor- et al., 2011; Chiu et al., 2008) explicit examination
ing in particular. Recently, Chiu et al. (2008) of individual differences (Henderson et al., 2006)
provided evidence that atypical neural self- and a neural systems perspective (Mundy,
representation in ASD involves the cingulate Gwaltney, & Henderson, 2010). There again,
cortex. In typical adolescents and young adults, autism emerges in a developing organism necessi-
self-referential compared with other-referential tating developmental studies tracking the course of
processing preferentially recruited the middle ACC development against the backdrop of typical
cingulate cortex and ventromedial prefrontal ACC development (Pelphrey, Shultz, Hudac, &
cortex-ASD individuals did not show this self- Vander Wyk, 2011). As of yet, we do not know
referential preference. Instead, ventromedial pre- whether or not the ACC dysfunction plays a causal
frontal cortex responded equally to self and other, role in the emergence of the disorder or is second-
while middle cingulate cortex responded more ary to having the condition.
to other-mentalizing than self-mentalizing (Chiu
et al.). Importantly, the lack of cingulate “self”
response pattern in the ASD group related para- See Also
metrically to ASD symptom severity. In another
important study, Kennedy and Courchesne ▶ ERN
(2008) had autism and control participants make ▶ Error-Related Negativity
true/false judgments for statements about ▶ Feedback-Related Negativity
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A 186 Antianxiety Medication
with autistic spectrum disorder. NeuroImage, 22(2), The anticholinergic drugs can also have
619–625. adverse effects. In the low doses used to
Welchew, D. E., Ashwin, C., Berkouk, K., Salvador, R.,
Suckling, J., Baron-Cohen, S., et al. (2005). Functional treat neurological side effects of antipsychotic
disconnectivity of the medial temporal lobe in medications, adverse effects are not common.
Asperger’s syndrome. Biological Psychiatry, 57(9), At higher doses, adverse effects can include con-
991–998. fusion and memory problems, and hallucinations
Zikopoulos, B., & Barbas, H. (2010). Changes in prefron-
tal axons may disrupt the network in autism. The can occur.
Journal of Neuroscience, 30(44), 14595–14609.
See Also
Antianxiety Medication ▶ Neurotransmitter
▶ Anxiolytics
Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric

Anticholinergic psychopharmacology: Principles and practice

Nursing & Child Psychiatry, Yale University
New Haven, CT, USA Anticipated Regression
Fred R. Volkmar
Definition Director – Child Study Center, Irving B. Harris
Acetylcholine is a chemical that transmits Psychology, School of Medicine,
messages between nerve cells in the brain. Yale University, New Haven, CT, USA
Centrally acting anticholinergic drugs block the
effect of acetylcholine in the brain. These drugs
are used to counteract adverse effects of antipsy- Definition
chotic medications. Acetylcholine is a major neu-
rotransmitter in the brain. Acetylcholine and Under current federal law, and as clarified in
dopamine are in a dynamic balance in the brain. several court cases and policy explanations,
Because many antipsychotic medications block services for the extended school year (ESY)
dopamine receptors in motor regions of the brain, for children with disabilities (either because
there is a relative excess of acetylcholine. This they have an IEP or 504 plan) can be provided
gives rise to the commonly observed neurological in some contexts. Historically, the potential for
side effects of antipsychotic medications such as the child to regress (anticipated regression) has
tremor, dyskinesia, and dystonia. These adverse been regarded as one of the most relevant of
effects typically occur early in treatment, are these; even here, however, multiple factors
unpleasant, and may pose a serious threat to med- should be taken into account. This regression
ication adherence. Anticholinergic medications would typically be defined by a loss of knowl-
such as benztropine are often useful in reducing edge or skills that reflects an interruption of
these neurological effects of antipsychotic medi- educational programming, placing the gains
cations (link to “Psychopharmacology” section the child has made at risk. Among the factors
of this encyclopedia). considered by the IEP team have to do with
Antidepressant Medications 187 A
maintenance of skills as well as the nature and used to treat depressive disorders, conditions
severity of the disability. characterized by depressed mood often along
with other symptoms including the following: A
changes in appetite, changes in sleep habits, low
See Also energy, low self-esteem, poor concentration, and
feelings of hopelessness.
▶ 504 Plan
▶ Individuals with Disabilities Education Act
(IDEA) Historical Background
▶ Regression
The first types of antidepressants to be developed,
sometimes referred to as the first-generation
References and Readings antidepressants, include the MAOIs and TCAs.
The first of the MAOIs to be developed was ipro-
Mandlawitz, M. R. (2005). Educating children with niazid, a drug initially marketed in 1952 for the
autism: Current legal issues. In F. R. Volkmar,
treatment of tuberculosis. When it was shown that
A. Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of
autism and pervasive developmental disorders iproniazid appeared to induce euphoria in patients
(3rd ed., Vol. 2, pp. 1161–1173). Hoboken, NJ: Wiley. and reversed the effects of reserpine, a known
Volkmar, F., & Wiesner, L. (2009). A practical guide to depressant, Saunders and Kline began using ipro-
autism. Hoboken, NJ: John Wiley.
niazid to treat clinical depression. Kline published
an article on its clinical use for the treatment of
depression in 1958. Although its adverse effects
caused its use to be discontinued, iproniazid was
Anticonvulsants replaced by other compounds that inhibit mono-
amine oxidase. However, the MAOIs were found
▶ Antiepileptic Drugs (AEDs) to exhibit adverse reactions with other drugs and
amines. The development of the TCAs began at
the same time as that of the MAOIs. The first TCA
to be developed, imipramine, was tested as
Antidepressant Medications a neuroleptic agent when it was found to relieve
depressive symptoms. Comparing the mecha-
Maureen Early1, Logan Wink1,2, nisms of action of the MAOIs and the TCAs
Craig Erickson1,2 and Christopher J. McDougle3 caused investigators to recognize that increasing
1
Christian Sarkine Autism Treatment Center, the amount of synaptic neurotransmitter was
Indianapolis, IN, USA important for the treatment of depression.
2
Department of Psychiatry, Indiana University SSRIs, considered to be second-generation
School of Medicine, Indianapolis, IN, USA antidepressants, were developed to have the spe-
3
Lurie Center for Autism/Harvard Medical cific mechanism of action of the inhibition of the
School, Lexington, MA, USA reuptake of serotonin (5-HT) which resulted in
similar treatment effectiveness compared to the
TCAs, with decreased side effect profiles in all of
Definition the SSRIs besides zimelidine. Zimelidine was the
first SSRI to be developed, but its production was
Medications, including monoamine oxidase discontinued due to its toxicity. Fluoxetine, the
inhibitors (MAOIs), tricyclic and tetracyclic first SSRI to be marketed that is still in use, was
antidepressants (TCAs), selective serotonin first marketed by Eli Lilly and Co. in 1987.
reuptake inhibitors (SSRIs), and serotonin- Another antidepressant medication first marketed
norepinephrine reuptake inhibitors (SNRIs), in the 1980s is bupropion, an antidepressant with
A 188 Antidepressant Medications
the brand name Wellbutrin which is not the reuptake of 5-HT. This action of SSRIs in the
a serotonin reuptake inhibitor (SRI) but instead CNS causes an increase in the amount of synaptic
may facilitate dopamine (DA) neurotransmission 5-HT. Before the neurons are desensitized to
and may affect norepinephrine (NE). drug, this increase in synaptic 5-HT is
Development of the third-generation antide- counteracted by the stimulation of the presynap-
pressants began with the goal of obtaining tic 5-HT1A autoreceptor which inhibits the fur-
compounds which expand upon the functionality ther release of 5-HT into the synapse. After about
of the SSRIs to include other pharmacological 10–14 days of drug treatment, this autoreceptor
effects thought to affect depressive symptoms is desensitized, and the amount of synaptic 5-HT
while maintaining low side effect profiles. increases. The five SSRIs currently FDA-
The development of SNRIs as antidepressants approved to treat major depressive disorder
followed the development of SSRIs starting in (MDD) and marketed in the United States are
the 1980s, although testing for the appropriate fluoxetine, sertraline, paroxetine, citalopram,
approval for clinical use for the first SNRI and escitalopram. Fluoxetine, with the brand
marketed was not completed until 1993. names Prozac and Sarafem, is also marketed for
Nefazodone is a third-generation antidepressant the treatment of obsessive-compulsive disorder
first marketed in the United States in 1994 which (OCD). Sertraline, with the brand name Zoloft,
inhibits the reuptake of 5-HT and NE, as well is also marketed for the treatment of OCD, panic
as acting as an antagonist at the 5-HT2A and disorder, posttraumatic stress disorder (PTSD),
a1-adrenergic receptors. Another third- premenstrual dysphoric disorder (PMDD), and
generation antidepressant, mirtazapine, was first social anxiety disorder. Paroxetine, with the
marketed in the United States in 1996 and inhibits brand names Paxil, Paxil CR, and Pexeva, is
the reuptake of 5-HT and NE, as well as acting also marketed for the treatment of OCD, panic
as a noradrenergic a2-autoreceptor blocker and disorder, social anxiety disorder, generalized
a 5-HT2 and 5-HT3 antagonist. anxiety disorder (GAD), and PTSD. Citalopram,
with the brand name Celexa, is only marketed for
the treatment of MDD. Escitalopram, with the
Current Knowledge brand name Lexapro, is also marketed for the
treatment of GAD. Additionally, fluvoxamine,
Research has suggested that 5-HT, NE, and DA with the brand names Luvox and Luvox CR,
are involved in the pathophysiology of depres- although only marketed for the treatment of
sion. Each of the antidepressants developed to OCD in the United States, is often prescribed
date affects one to all three of these neurotrans- for the treatment of depression.
mitters in the central nervous system (CNS). The SNRIs relieve symptoms of depression by
Although many different antidepressant drugs blocking the reuptake of 5-HT and NE. These
and families of antidepressant drugs with different drugs are similar in clinical use to the SSRIs,
functionalities exist, including the SSRIs, SNRIs, but two have the additional effects of treating
TCAs, and MAOIs, currently these drugs do not pain and physical symptoms, such as those of
differ much from one another in efficacy. How- fibromyalgia (FM). The three SNRIs currently
ever, different individuals may have a greater marketed in the United States for the treatment
treatment response to one antidepressant medica- of depression are duloxetine, venlafaxine, and
tion than to another. Family history of clinical desvenlafaxine. Duloxetine, with the brand
response to a specific antidepressant medication name Cymbalta, is also marketed for the treat-
may be a predictor for the response of an individ- ment of GAD, diabetic peripheral neuropathy,
ual to that drug in some cases. FM, and chronic musculoskeletal pain.
The SSRIs are a commonly prescribed group Venlafaxine, with the brand names Effexor and
of antidepressant medications which relieve Effexor XR, is also marketed for the treatment of
symptoms of depression by selectively blocking GAD, social anxiety disorder, and panic disorder.
Antidepressant Medications 189 A
Desvenlafaxine, with the brand name Pristiq, is comorbid depression, anxiety, or both, and for
only marketed for the treatment of MDD. Addi- individuals with psychotic depressive disorders
tionally, milnacipran, with the brand name with anxiety. A formulation of doxepin is also A
Savella, is marketed for the treatment of MDD marketed with the brand name Silenor to treat
in Japan, although it is only marketed for the insomnia, and a cream with doxepin hydrochloride
treatment of FM in the United States. as its active ingredient is marketed with the brand
Other antidepressants with different mecha- name Zonalon for the short-term treatment of pru-
nisms of action than the SSRIs and SNRIs are ritus in adults with atopic dermatitis or lichen
bupropion, nefazodone, and mirtazapine. simplex chronicus. Trimipramine, with the brand
Bupropion, with the brand name Wellbutrin, is name Surmontil; amoxapine, formerly with the
not an SRI but instead may potentiate DA activity brand name Asendin; maprotiline, with the brand
and may affect NE. Nefazodone inhibits the reup- name Ludiomil; imipramine, with the brand
take of 5-HT and NE, as well as acting as an name Tofranil; a formulation combining amitrip-
antagonist at the 5-HT2A and a1-adrenergic tyline hydrochloride with perphenazine, with the
receptors. Mirtazapine, with the brand names brand names Triavil 2-10, Triavil 2-25, Triavil
Remeron and Remeron SolTab, inhibits the reup- 4-10, Triavil 4-25, and Triavil 4-50; nortriptyline,
take of 5-HT and NE, as well as acting as with the brand name Pamelor; protriptyline, with
a noradrenergic a2-autoreceptor blocker and the brand name Vivactil; and desipramine, with
a 5-HT2 and 5-HT3 antagonist. the brand name Norpramin, are marketed only for
The TCAs are a family of compounds which the treatment of depression. Additionally,
affect 5-HT and NE, as well as acting as anticho- a formulation combining amitriptyline hydrochlo-
linergic or antimuscarinic agents, alpha- ride with chlordiazepoxide, with the brand name
adrenergic antagonists, and antihistamines. Limbitrol, is marketed as a treatment for depres-
Although these drugs seem to have similar effi- sion associated with anxiety. In addition to these
cacy to the SSRIs and SNRIs and may be more nine TCAs, clomipramine, with the brand name
effective than those drugs, the TCAs are not as Anafranil, is marketed only for the treatment of
well tolerated and have more side effects than the OCD in the United States but is marketed for the
SSRIs and the SNRIs. Clinically, the TCAs are treatment of MDD in Europe.
rarely used due to their side effects. Although Many MAOIs exist for the treatment of
these compounds are named for their chemical various pathologies. MAOIs act by inhibiting
rings, their side chains are believed to be more monoamine oxidase (MAO) enzymes in the ner-
important to their functions. The TCAs with ter- vous system. Since MAO is located on the outer
tiary amine groups on their side chains tend not to surface of mitochondria, it can only deaminate
be tolerated as well as the TCAs with secondary species in the cytoplasm and not species inside
amine groups on their side chains. The TCAs organelles, thereby keeping the concentration of
with tertiary amine groups block the reuptake of amines in the cytoplasm low unless inhibited.
5-HT more strongly than they do NE, whereas the The inhibition of the MAO enzymes by the
TCAs with secondary amine groups block MAOIs is not thought to be the direct cause of
the reuptake of NE more strongly than they do the alleviation of the symptoms of depression as
5-HT. The nine TCAs currently marketed for the has been observed from treatment with MAOIs.
treatment of depression in the United States are Secondary effects of these drugs are thought to be
doxepin, trimipramine, amoxapine, maprotiline, important for their use for the treatment of
imipramine, amitriptyline, nortriptyline, depression. The MAOIs are not widely used to
protriptyline, and desipramine. treat depression due to their risks, including the
Doxepin, marketed under the brand name risk of hypertensive crisis.
Sinequan, is labeled for use as a treatment for The four MAOIs currently marketed in the
psychoneurotic individuals, alcoholic individuals, United States for the treatment of depression are
and individuals with an organic disease with phenelzine, isocarboxazid, tranylcypromine, and
A 190 Antidepressant Medications
selegiline. Phenelzine, with the brand name Future Directions

Nardil, is marketed for the treatment of atypical,
nonendogenous, or neurotic individuals with In recent years, the development of new, more
depression. Isocarboxazid, with the brand name efficacious antidepressants has been attempted by
Marplan, is marketed for the treatment of depres- combining the effects of SRIs with other pharma-
sion. Tranylcypromine, with the brand name cological effects. Other antidepressant drugs simi-
Parnate, is marketed for the treatment of major lar to the third-generation antidepressants are being
depressive episodes without melancholia. developed with novel mechanisms of action. For
Selegiline, with the brand name Emsam, is example, a group of compounds known as seroto-
marketed for the treatment of MDD. nin-norepinephrine-dopamine reuptake inhibitors
Important safety issues must be noted with the (SNDRIs) are being developed for potential clini-
use of antidepressant medications. The use of anti- cal use in the treatment of depressive disorders. At
depressants in children and adolescents may least five SNDRI compounds have been developed.
increase depressive symptoms or cause the onset Other compounds being developed and investi-
of suicidal ideation; therefore, appropriate discre- gated are SRIs and 5-HT2A antagonists; at least
tion must be used when prescribing SRIs in chil- 27 of these compounds have been developed to
dren, adolescents, or young adults with depression. date. The treatment of depression with
Also, the concomitant use of SRIs and MAOIs is a combination of SRIs with atypical antipsychotics
a known cause of serotonin syndrome which is is another approach being investigated. Other com-
potentially lethal; therefore, these drugs should pounds with SRI activity have reportedly been
not be prescribed concomitantly, and time should developed, but these compounds require further
be allowed between discontinuation of one of testing to determine their viability as medications.
these types of drugs and the initiation of treatment
with a drug of the other type. At least 2 weeks must
be allowed before beginning an MAOI after See Also
discontinuing most SSRIs, although at least 5
weeks must be allowed before beginning an ▶ Serotonin Reuptake Inhibitors (SRIs)
MAOI after discontinuing fluoxetine. At least ▶ Serotonin Syndrome
a few days must be allowed before beginning an
MAOI after discontinuing a TCA.
MAOIs have adverse drug interactions with References and Readings
various drugs including the SRIs, serotonin ago-
nists, stimulants, direct sympathomimetics, indi- Andreasen, N. C., & Black, D. W. (2001). Introductory
textbook of psychiatry (3rd ed.). Washington, DC:
rect sympathomimetics, and antidiabetic agents.
American Psychiatric Publishing.
Also, MAOIs have adverse interaction with some Boland, R. J., & Keller, M. B. (2006). Treatment of
foods which is thought to be due to increased depression. In A. F. Schatzberg & C. B. Nemeroff
tyramine levels. Important safety precautions (Eds.), Essentials of clinical psychopharmacology
(2nd ed., pp. 465–478). Washington, DC: American
must be taken during the use of MAOIs including
the avoidance of certain foods: cheese, overripe Gillman, P. K. (2005). Monoamine oxidase inhibitors,
fruit, fava beans, sausage, salami, sherry, opioid analgesics and serotonin toxicity. British
liqueurs, sauerkraut, monosodium glutamate, Journal of Anaesthesia, 95, 434–441.
Greden, J. F. (2006). Duloxetine and milnacipran. In A. F.
pickled fish, brewer’s yeast, beef liver, chicken
Schatzberg & C. B. Nemeroff (Eds.), Essentials of
liver, fermented products, and red wine. Addi- clinical psychopharmacology (2nd ed., pp. 171–180).
tionally, the following foods should be used in Washington, DC: American Psychiatric Publishing.
moderation during the use of MAOIs: coffee, Jacobsen, E. (1986). The early history of psychotherapeu-
tic drugs. Psychopharmacology, 89, 138–144.
chocolate, colas, tea, soy sauce, beer, and wines
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J.
other than those previously listed which should (2001). Treatment with antidepressants. In Princi-
be avoided during the use of MAOIs. ples and practice of psychopharmacotherapy
Antidepressants 191 A
(3rd ed., pp. 215–325). Philadelphia: Lippincott Wil- Definition
liams & Wilkins.
Kline, N. (1958). Clinical experience with iproniazid.
Journal of Clinical and Experimental Psychopathol- Antidepressants are a broad group of medications A
ogy, 19, 72–78. with various mechanisms of action. Until the early
Krishnan, K. R. R. (2006). Monoamine oxidase inhibitors. 1990s, the most commonly used antidepressants
In A. F. Schatzberg & C. B. Nemeroff (Eds.), were the so-called tricyclic antidepressants
Essentials of clinical psychopharmacology (2nd ed.,
pp. 113–125). Washington, DC: American Psychiatric (TCAs). More recently, the most commonly
Publishing. used antidepressants are the selective serotonin
Moltzen, E. K., & Bang-Andersen, B. (2006). Serotonin reuptake inhibitors (SSRIs). The SSRIs is
reuptake inhibitors: The corner stone in treatment of a class of medications that includes fluoxetine,
depression for half a century-a medicinal chemistry
survey. Current Topics in Medicinal Chemistry, 6, fluvoxamine, paroxetine, sertraline, citalopram,
1801–1823. and escitalopram. As the name suggests, the
Nelson, J. C. (2006). Tricyclic and tetracyclic drugs. In SSRIs block the reuptake of released serotonin at
A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials the presynaptic serotonin transporter. This action
of clinical psychopharmacology (2nd ed., pp. 5–29).
Washington, DC: American Psychiatric Publishing. prolongs the presence of serotonin in the synapse,
Sadock, B. J., & Sadock, V. A. (2003). Kaplan which is a major neurotransmitter in the brain.
and Sadock’s synopsis of psychiatry: Behavioral Neurotransmitters are used to communicate
sciences/clinical psychiatry. Philadelphia: Lippincott messages from one nerve to the next nerve.
Williams & Wilkins.
Sadock, B. J., & Sadock, V. A. (2005). Kaplan Unlike conventional electrical wiring, which
and Sadock’s pocket handbook of clinical psychiatry. requires wire-to-wire contact to move the electri-
Philadelphia: Lippincott Williams & Wilkins. cal signal onward, nerve endings do not make
Stahl, S. M. (2000). Classical antidepressants, serotonin physical contact with one another. The transmit-
selective reuptake inhibitors, and noradrenergic reup-
take inhibitors. In H. Meltzer (Ed.), Essential psycho- ting nerve ending comes near, but does not touch,
pharmacology: Neuroscientific basis and clinical the neighboring nerve ending. The message is
applications (pp. 199–243). Cambridge: Cambridge carried by a neurotransmitter such as serotonin,
University Press. dopamine, norepinephrine, or acetylcholine.
Thase, M. E., & Sloan, D. M. E. (2006). Venlafaxine.
In A. F. Schatzberg & C. B. Nemeroff (Eds.), Once the neurotransmitter, such as seroto-
Essentials of clinical psychopharmacology (2nd ed., nin, is released to carry the message to the
pp. 465–478). Washington, DC: American Psychiatric neighboring neuron, there is a series of regula-
Publishing. tory steps designed to return the system to the
U.S. Food and Drug Administration. (2011).
Drugs@FDA. Retrieved on June 28, 2012 from resting state. Reuptake, which is an important
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/ regulatory mechanism, is an active process of
index.cfm recovering released neurotransmitter back into
the transmitting nerve ending. If a drug blocks
serotonin reuptake, it permits the neurotrans-
mitter to remain in the synaptic space longer.
Antidepressants Although this is a known effect of the SSRIs,
there is often a delay between starting the
Lawrence David Scahill medication and achievement of beneficial
Nursing & Child Psychiatry, Yale University effects. This suggests that the blockade of
School of Nursing, Yale Child Study Center, serotonin reuptake, which occurs with the
New Haven, CT, USA first dose of medication, is not a complete
explanation for the therapeutic effect of these
medications.
Synonyms Tricyclic Antidepressants: The tricyclic
antidepressants (abbreviated TCAs) are an
Selective serotonin reuptake inhibitors (SSRIs); older class of antidepressants that include
Tricyclic antidepressants (TCAs) imipramine, desipramine, clomipramine,
A 192 Antidepressants
amitriptyline, and nortriptyline. The term tricy- to toxic effects. The tricyclic medications
clic refers to the three-ring structure of this class have not been well studied in children or
of antidepressant medications. These medica- adults with autism.
tions are not used as commonly as in the past Doxepin: Doxepin is a tricyclic antidepressant
as they have been largely replaced by the SSRIs. medication that has largely fallen out of use as an
Imipramine has been used to treat both depres- antidepressant. It is approved for the treatment of
sion and anxiety. Desipramine has been used to adults with insomnia – especially midsleep awak-
treat depression and attention deficit/hyperactiv- ening. It is associated with multiple adverse
ity disorder. Clomipramine is often considered effects including poor coordination, confusion,
a breakthrough because it was the first medica- and increased heart rate and also has a potential
tion shown to be effective for the treatment of for cardiac arrhythmia. Other adverse effects
obsessive-compulsive disorder. These three include dry mouth, urinary retention, and consti-
compounds, imipramine, desipramine, and clo- pation. There are no studies of the use of doxepin
mipramine, represent three distinct modes of in children or adults with autism spectrum
action for drugs in the same class. For example, disorders.
desipramine has highly selective norepinephrine Clomipramine: As noted above, clomipramine
reuptake inhibitor properties. By contrast, clo- has serotonin reuptake inhibiting properties.
mipramine is well known for its more selective Because of its apparent effectiveness in obses-
serotonin reuptake inhibiting properties. Indeed, sive-compulsive disorder, it was studied for the
clomipramine served as a model for the next treatment of repetitive behavior in adults with
generation of selective serotonin reuptake inhib- autism. The result of these studies is somewhat
itors (see below). Imipramine is intermediate equivocal. Given the complexities of the tricyclic
with both norepinephrine and serotonin reuptake antidepressants (need for electrocardiographic
inhibiting properties. Other members of the and blood-level monitoring as well as potential
class, such as nortriptyline and protriptyline, for adverse effects), the tricyclic antidepressants
are predominately norepinephrine reuptake are not commonly used in treating the patients
inhibitors. with autism.
The tricyclic antidepressants have several
adverse effects in common including dry
mouth, urinary retention, constipation, nausea, See Also
increased heart rate, dizziness, and, at higher
doses, confusion. The tricyclic antidepressants ▶ Citalopram
also carry some risk of altering the electrical ▶ Clomipramine
conduction in the heart. They are well known ▶ Escitalopram
to be fatal on overdose due to their potential ▶ Fluoxetine
for causing cardiac arrhythmia. Because of ▶ Fluvoxamine
their known toxicity at higher doses, treatment ▶ Paroxetine
with tricyclic antidepressants requires blood- ▶ Sertraline
level monitoring and electrocardiogram moni-
toring as well. Finally, the tricyclic antide-
pressants are also vulnerable to drug-drug
interaction. For example, some medications
such as SSRIs or certain antibiotics may inter- Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric
fere with the breakdown of tricyclic antide- psychopharmacology: Principles and practice
pressant medications. The interference of (2nd ed.). New York: Oxford University Press.
McDougle, C. J., Naylor, S. T., Cohen, D. J., Volkmar,
metabolism of the tricyclic can cause a sharp
F. R., Heninger, G. R., & Price, L. H. (1996).
increase in the blood levels of the tricyclic A double-blind, placebo-controlled study of
antidepressants and increase the vulnerability fluvoxamine in adults with autistic disorder
Antiepileptic Drugs (AEDs) 193 A
[comment]. Archives of General Psychiatry, 53(11), Specific Compounds and Properties
1001–1008.
McDougle, C. J., Price, L. H., & Goodman, W. K. (1990).
Fluvoxamine treatment of coincident autistic disorder Phenobarbital A
and obsessive compulsive disorder: A case report. Phenobarbital (PB) is classified as a barbiturate
Journal of Autism and Developmental Disorders, 20, and displays a broad spectrum of anticonvulsant
537–543. activity. It was first introduced in 1912. It remains
McDougle, C. J., Price, L. H., Volkmar, F. R., Goodman,
W. K., Ward-O’Brien, D., Nielsen, J., et al. (1992). the oldest anticonvulsant commonly used and the
Clomipramine in autism: Preliminary evidence of effi- most widely used around the world.
cacy. Journal of the American Academy of Child and Indications: Phenobarbital is effective for gen-
Adolescent Psychiatry, 31(4), 746–750. eralized tonic-clonic seizures as well as partial
seizures. PB is also effective for status epilepticus.
It is usually the drug of choice for neonatal sei-
zures. It is not effective for absence seizures.
Antiepileptic Drugs (AEDs) Mechanism of action/metabolism: PB works
by enhancing gamma-aminobutyric acid
Reet Sidhu1, Gregory Barnes2 and (GABA) inhibition. It is extensively metabolized
Roberto Tuchman3 in the liver. PB undergoes autoinduction whereby
1
Department of Pediatric Neurology, Columbia clearance may be increased requiring increasing
University, New York, NY, USA dose adjustment when used as monotherapy.
2
Department of Neurology, School of Medicine, Adverse effects: The most common adverse
Vanderbilt University, Nashville, effect is sedation; however, tolerance to sedation
TN, USA usually develops with continued use of the drug.
3
Department of Neurology, Miami Children’s Other common side effects include irritability,
Hospital, Weston, FL, USA hyperactivity, ataxia, and cognitive impairment.
Decreased bone mineral density may occur. Rash
occurs as an idiosyncratic reaction with very rare
Synonyms occurrence of Stevens-Johnson syndrome and
toxic epidermal necrolysis. Other rare adverse
Anticonvulsants; Antiseizure medications effects include megaloblastic anemia and respi-
ratory depression. Weight change is not common.
Dosing: PB is available in the following for-
Indications mulations: liquid (20 mg/5 ml), tablets (15 mg,
30 mg, 60 mg, 100 mg). Intravenous preparation
The decision about which antiepileptic drug is available. Average daily dosing is in the range
(AED) to use is based on both the seizure type of 4–11 mg/kg/day in children less than 1 year,
and the epilepsy syndrome along with the effi- 2–7 mg/kg/day for children over 1 year, and
cacy and toxicity profile of the AEDs for the 1.5–4 mg/kg/day for children over age 12 and
various types of seizures. A list of the most com- adults. Loading doses are effective ways of rap-
mon AEDs used in autism spectrum disorders is idly achieving a therapeutic level. PB should be
described below. Each drug is listed with the gradually tapered after chronic use to avoid with-
following categories: indications, mechanism of drawal seizures, usually over 3–6 months.
action/metabolism, adverse effects, and dosing.
Phenytoin (Dilantin)
Phenytoin (PHT) was introduced in 1938 as being
Mechanisms of Action useful in controlling seizures without sedative
effects as seen in phenobarbital. In addition to
Mechanisms of action (provided under each entry its use as an antiepileptic drug, it is also used in
below) treatment of trigeminal neuralgia.
A 194 Antiepileptic Drugs (AEDs)
Indications: Phenytoin is effective for partial Indications: Carbamazepine is effective in

seizures as well as generalized tonic-clonic sei- simple and complex partial seizures as well as
zures. PHT is also highly effective for status generalized tonic-clonic seizures. It is not indi-
epilepticus. It is useful in the treatment of neona- cated for use in neonatal or febrile seizures. It is
tal seizures. It is not effective for absence and contraindicated in the treatment of generalized
myoclonic seizures. seizures seen in idiopathic generalized epilepsy,
Mechanism of action/metabolism: PHT acts as as well as absence seizures. It is not used the
a use-dependent blocker of voltage-sensitive treatment of epileptic encephalopathies.
sodium channels. It inhibits calcium channels Mechanism of action/metabolism: Carbamaz-
and calcium sequestration. PHT is extensively epine acts a use-dependent blocker of voltage-
metabolized in the liver. It undergoes sensitive sodium channels. It inhibits the release
autoinduction whereby clearance may be of glutamate. CBZ is extensively metabolized in
increased requiring increasing dose adjustment the liver. Carbamazepine exhibits autoinduction
when used as monotherapy. whereby clearance may be increased requiring
Adverse effects: Common adverse effects are increased dose adjustment when used as
cosmetic including acne, gingival hyperplasia, monotherapy.
and hirsutism. Nausea, vomiting, nystagmus, ver- Adverse effects: Common adverse effects
tigo, ataxia, and lethargy may occur with toxicity. include gastrointestinal distress, drowsiness, con-
Rare adverse effects include hyperglycemia, fusion, headaches, dizziness, ataxia, and blurred
movement disorders, and confusional states. or double vision. Aplastic anemia, agranulocyto-
More serious side effects include rare hepatotox- sis, and liver toxicity are rare but nonetheless
icity and hematological abnormalities, including serious potential reactions that can occur with
thrombocytopenia, anemia, leukopenia, and carbamazepine use. Therefore, hematologic and
agranulocytosis. Other rare life-threatening hepatic parameters should be monitored, espe-
effects include lymphadenopathy and serious cially in the first 6 months of therapy. Rare occur-
rash including Stevens-Johnson syndrome and rence of severe rash, including Stevens-Johnson
toxic epidermal necrolysis. Effect on weight is syndrome, and cardiac arrhythmias has been
not common. seen. CBZ may cause syndrome of inappropriate
Dosing: PHT is available in the following antidiuretic hormone (SIADH) with
formulations: chewable tablets (50 mg), capsules hyponatremia since it both increases the release
(30 mg, 100 mg). An oral suspension is available and potentiates the action of ADH (vasopressin).
but discouraged from use as it is unstable. Intra- Weight change is not typical.
venous preparation is available. Average daily Dosing: CBZ is available in the following
dosing is in the range of 4–10 mg/kg/day for formulations: liquid (100 mg/5 mL), chewable
children and 300–400 mg/day for adults. Neo- tablets (100 mg), tablets (200 mg), extended
nates may require more than 10 mg/kg/day. As release sprinkle capsule (Carbatrol) in 100 mg,
with most AEDs, discontinuation should be done 200 mg, 300 mg, and extended release tablets
with gradual dose reduction over several weeks, (Tegretol-XR) in 100 mg, 200 mg, 400 mg.
unless there is concern for serious adverse effect. Average daily dosing is in the range of
10–30 mg/kg/day for children and
Carbamazepine (Tegretol) 600–1,200 mg/day for adults.
Carbamazepine (CBZ) was initially marketed in
1962 for the treatment of trigeminal neuralgia Valproic Acid (Depakote)
and shortly after for the treatment of epilepsy. It Valproic acid (VPA) is often referred to as
is particularly effective in the treatment of focal valproate. Its anticonvulsant properties were
epilepsies. In addition to its use as an anticonvul- first discovered in the early 1960’s and since
sant, it is beneficial for neuropathic pain and then has become one of the most commonly
affective disorders including bipolar disorder. prescribed anticonvulsants worldwide. It is
a broad-spectrum AED, effective against all capsules (125 mg), tablets (125 mg, 250 mg,
types of seizures and epilepsies. In addition to 500 mg), and extended release tablet (250 mg,
its use as an AED, it is also used frequently for 500 mg). It is also available intravenously. A
migraine prophylaxis and treatment of manic Average daily doses are 30–60 mg/kg/day in
episodes of bipolar disorder. children and 1,000–3,000 mg/day in adults.
Indications: VPA is highly effective in treat- L-carnitine supplementation is suggested in cer-
ment of generalized epilepsies. It is effective for tain individuals, especially in young children. As
all types of generalized seizures including myo- with most AEDs, discontinuation should be done
clonic and absence seizures. It is also used in the with gradual dose reduction over several weeks,
treatment of partial seizures. Febrile seizures, unless concern for serious adverse effect.
refractory status epilepticus, and epileptic
encephalopathies, including Lennox-Gastaut Oxcarbazepine (Trileptal)
syndrome, may be treated with VPA. Oxcarbazepine (OXC) is an analogue of carba-
Mechanism of action/metabolism: The pri- mazepine (CBZ) with a keto group at the ten
mary mechanism of action of VPA is not clear carbon position. It is rapidly metabolized to
but may act by any one of the following: increas- a 10-monohydroxy metabolite, which is primar-
ing levels of GABA by decreasing its metabo- ily responsible for its anticonvulsant effects. Its
lism, blocking voltage-gated sodium channels anticonvulsant profile is nearly identical to CBZ,
and T-type calcium channels, or decreasing but it is better tolerated.
levels of excitatory amino acid aspartate. VPA Indications: Oxcarbazepine is similar to car-
is extensively metabolized in the liver. bamazepine in its antiepileptic efficacy. It is
Adverse effects: Common adverse effects effective for simple and complex partial seizures
include mild sedation, nausea, vomiting, and as well as generalized tonic-clonic seizures. It
anorexia. These side effects commonly occur may be particularly useful in individuals who do
during initiation of therapy and are usually tran- not tolerate CBZ but respond to CBZ. It is not
sient. Alopecia and tremor may occur, but effects indicated for use in neonatal or febrile seizures. It
on cognition are minimal. The major serious is contraindicated in the treatment of generalized
adverse side effects relate to hepatic dysfunction. seizures seen in idiopathic generalized epilepsy,
Fatal hepatotoxicity is considered to be an idio- as well as absence seizures. It is not used in the
syncratic reaction rather than a dose-related phe- treatment of epileptic encephalopathies.
nomenon. Children younger than 2 years old are Mechanism of action/metabolism:
at higher risk. Therefore, serum transaminases Oxcarbazepine acts a use-dependent blocker of
(AST, ALT) should be obtained prior to initiation voltage-sensitive sodium channels. It inhibits
of therapy and periodically during treatment. the release of glutamate. Oxcarbazepine is
Thrombocytopenia more than leukopenia can rapidly metabolized in the liver to
occur and appears to be a dose-related phenome- 10-hydroxycarbazepine, its pharmacologically
non. Routine monitoring of CBC and platelets is active metabolite. Compared with CBZ, OXC
usually recommended. Fatal pancreatitis has has less prominent actions on CYP 450 enzyme
been reported, albeit rare. If clinically indicated, systems and therefore, fewer pharmacokinetic
serum amylase and lipase should be obtained. interactions. It does not exhibit autoinduction,
Hyperammonemia may occur and is often binds less to serum proteins, has fewer drug inter-
asymptomatic. Usual treatment is L-carnitine actions, and thus, a lower incidence of side
but exclusion of urea cycle disorders may be effects than CBZ.
warranted. VPA should not be used in patients Adverse effects: Common adverse effects
with suspected mitochondrial disorders. Weight include somnolence, headache, dizziness,
gain is common. blurred/double vision, nausea, and vomiting.
Dosing: VPA is available in the following There is risk of rash, including Stevens-Johnson
formulations: liquid (250 mg/5 mL), sprinkle syndrome and toxic epidermal necrolysis, but the
risk is lower with OXC as compared with CBZ. vomiting, diplopia, ataxia, and insomnia, espe-
There is a 25–30% incidence of cross-reactive cially when combined with carbamazepine.
rash with CBZ. As with CBZ, hyponatremia Hematologic and hepatic effects are rare. Weight
may occur. Hematologic effects, including agran- gain is not common.
ulocytosis and aplastic anemia, are very rare. Dosing: LTG is available in the following
Hepatotoxicity is not a side effect, as in CBZ. formulations: chewable tablets (2 mg, 5 mg,
Weight gain is not common. 25 mg), orally disintegrating tablets (25 mg,
Dosing: OXC is available in the following 50 mg, 100 mg, 200 mg), tablets (25 mg,
formulations: liquid (300 mg/5 ml), tablets 100 mg, 150 mg, 200 mg), and extended release
(150 mg, 300 mg, 600 mg). Average daily doses tablets (25 mg, 50 mg, 100 mg, 200 mg). Average
are 600–1,200 mg/day for children less than daily doses vary depending on whether LTG is
30 kg and 900–1,800 mg/day for children used as monotherapy or with Valproic Acid
30–60 kg. Average doses for adults are (VPA) or other enzyme-inducing AEDs.
600–2,400 mg/day. Enzyme-inhibiting drugs such as VPA increase
LTG levels, whereas enzyme-inducing drugs
Lamotrigine (Lamictal) such as PB, PHT, and CBZ decrease LTG levels.
Lamotrigine (LTG) is a broad-spectrum Therefore, initial and maintenance doses need to
antiepileptic drug that is used for all seizure be adjusted accordingly. Slow dosage titration is
types with the exception of epilepsies with prom- recommended to reduce the risk of potential
inent myoclonic jerks. In addition to its use as an severe reactions, especially skin rash.
AED, it is also used for treatment of bipolar
disorder, migraines, and other headaches, along Levetiracetam (Keppra)
with trigeminal neuralgia and other neuropathic Levetiracetam is a broad-spectrum antiepileptic
pain disorders. drug. It is widely used due to its low propensity
Indications: Lamotrigine is effective for the for drug interactions, relatively benign side-
treatment of both partial and generalized sei- effect profile, and effectiveness for nearly all
zures, including absence seizures. It is also used types of epilepsies. It is also used for treatment
in treating Lennox-Gastaut syndrome. of neuropathic or chronic pain.
Mechanism of action/metabolism: Lamotrigine Indications: Keppra is effective in the treat-
acts a use-dependent blocker of voltage-sensitive ment of both partial and generalized seizures. It is
sodium channels. It inhibits the release of the not contraindicated for any seizure type, although
excitatory amino acid, glutamate. LTG is exten- experience in neonates and use for febrile sei-
sively metabolized in the liver. zures is limited. It is used in treatment of status
Adverse effects: Common adverse effects epilepticus.
include rash. Nonspecific rashes occur in approx- Mechanism of action/metabolism: The precise
imately 10% of patients and the vast majority of mechanism of action of levetiracetam has not yet
these are benign. However, rare cases of Stevens- been established. Levetiracetam is not metabo-
Johnson syndrome (SJS) and toxic epidermal lized in the liver, and thus, its metabolism does
necrolysis (TEN) have been reported. The inci- not depend on the hepatic cytochrome P450
dence of SJS and TEN is higher in individuals enzymes. Therefore, doses do not need to be
younger than 16 years of age. Concurrent use of adjusted in those with hepatic impairment.
valproic acid and rapid escalation of LTG doses Adverse effects: Common adverse effects
are both thought to be risk factors for the devel- include somnolence, ataxia, and dizziness.
opment of these rashes. The risk of rash is thought Behavioral symptoms including irritability, agi-
to be higher in the first 6–8 weeks of therapy. tation, aggression, emotional lability, anxiety,
However, SJS has developed in LTG and depression may occur and are thought to be
monotherapy and after several months of therapy. more common in children than adults. These
Other common risks include headache, nausea, symptoms are more common at initiation of the
drug and often subside within the first few months risk for hypohidrosis and resultant hyperther-
of use. Use of pyridoxine (vitamin B6) has been mia. Weight loss is common.
suggested to decrease the occurrence of behav- Dosing: ZNM is available in the following A
ioral side effects, but this has not been proven in formulations: capsules (25 mg, 50 mg, 100 mg).
controlled data. Behavioral symptoms that persist Average daily dosing for monotherapy in
often require discontinuation of the drug. children is 8 mg/kg/day and 12 mg/kg/day when
Levetiracetam has no organ toxicity, and there- used with enzyme-inducing AEDs. Average daily
fore, serious or life-threatening side effects are doses range between 100–400mg/day for adults.
exceedingly rare. Weight gain is not common.
Dosing: Levetiracetam is available in the fol- Vigabatrin
lowing formulations: 100 mg/ml (liquid), tablets Vigabatrin (VGB) is primarily used in the treat-
(250 mg, 500 mg, 750 mg, 1,000 mg), and ment of infantile spasms but is also effective in
extended release tablets (500 mg). Intravenous partial epilepsies. Due to its serious potential
solution is available. Average daily doses range effects on vision, it had not been approved for
between 30 and 60 mg/kg/day for children and use in the United States until 2009. It is now
1,000–3,000 mg/day for adults. available for use as monotherapy for children
ages 1 month to 2 years with infantile spasms
Zonisamide (Zonegran) and adjunctive therapy for adults with refractory
Zonisamide is a broad-spectrum antiepileptic complex partial seizures in whom the potential
drug. It is not contraindicated for any particular benefits outweigh the risks for vision loss.
type of epilepsy. In addition to its use as an Indications: Vigabatrin is effective against
anticonvulsant, it is used in treatment of infantile spasms, especially if spasms are due to
migraines, obesity, and bipolar disorder. tuberous sclerosis. It is also used in the treatment
Indications: Zonisamide is effective in the of partial seizures. It is contraindicated in
treatment of both partial and generalized sei- absence seizures and may provoke absence status
zures. It is the drug of choice for myoclonic epilepticus.
seizures. It is useful in the management of epi- Mechanism of action/metabolism: Vigabatrin
leptic encephalopathies along with Lennox- irreversibly inhibits GABA transaminase, the
Gastaut syndrome and infantile spasms. enzyme that breaks down GABA, effectively
Mechanism of action/metabolism: The exact increasing GABA levels. Vigabatrin is not
mechanism of action is not known. Although it metabolized in the liver.
may be a carbonic anhydrase inhibitor, this is not Adverse effects: The potential for visual field
how it exerts its antiepileptic effects. It seems to defects may be idiosyncratic, but dose- and dura-
block sodium and T-type calcium channels along tion-dependent toxicity has been reported. It has
with inhibiting the uptake of GABA and enhanc- been reported in approximately 30% of patients.
ing the uptake of glutamate. The onset usually occurs between 6 months and
Adverse effects: Common adverse effects 2 years but is not typically reversible. Therefore,
include drowsiness, dizziness, ataxia, fatigue, treatment with vigabatrin should not be continued
nausea, vomiting, decreased appetite, and if there is no response to treatment within
headache. Metabolic acidosis, hypohidrosis, 3 months. Other common adverse effects include
and cognitive/behavioral changes occur more somnolence, dizziness, headache, and ataxia.
commonly in children. Paresthesias and kidney Behavioral, mood, and cognitive changes are
stones are reported but uncommon. Life- also reported. Life-threatening side effects are
threatening side effects such as Stevens- rare, including encephalopathic syndromes.
Johnson syndrome, blood dyscrasias, and Angioedema, hallucinations, and rash are rare.
hyperthermia are extremely rare. Use with cau- Weight gain is common.
tion when combining with other carbonic Dosing: Vigabatrin is available in the follow-
anhydrase inhibitors or anticholinergics due to ing formulations: sachet, i.e., powder (500 mg),
tablets (500 mg). Average daily doses for infants or cluster seizures. They are commonly used as
with infantile spasms are 100–200 mg/kg/day. adjunctive agents or as temporary drugs while
Average doses for children are 2,000–3,000 mg/ waiting to achieve therapeutic concentrations of
day and 1,000–3,000 mg/day for adults. mainstay therapy. Diazepam, lorazepam, and
midazolam are used for status epilepticus while
Topiramate (Topamax) clonazepam, clorazepate, and clobazam are used
Topiramate (TPX) is a broad-spectrum for chronic anticonvulsant therapy. Clobazam is
antiepileptic drug that is used for all seizure not available in the USA.
types. In addition to its use as an AED, it is com- Major side effects include sedation, ataxia,
monly used for migraine prophylaxis. It is also and behavioral problems such as hyperactivity,
used in treatment of bipolar disorder and obesity. irritability, moodiness, restlessness, and aggres-
Indications: Topiramate is effective for both sion. Disinhibition is common. Tolerance to ben-
partial and generalized seizures. It is also used in zodiazepines occurs frequently.
the treatment of infantile spasms, Lennox- Diastat is the rectal gel preparation of diaze-
Gastaut syndrome, and progressive and idio- pam that has been approved for use with acute
pathic myoclonic epilepsies. It is not repetitive seizures and cluster seizures.
contraindicated for any type of seizures. Although not approved for use in status
Mechanism of action/metabolism: The exact epilepticus, it is used for treatment of prolonged
mechanism of action is not known, but TPX seizures at home. It is usually recommended for
appears to act by inhibiting voltage-dependent seizures lasting greater than 5 min in duration.
sodium channels, enhancing GABA-mediated inhi- This is very useful as it allows caregivers to
bition, and decreasing glutamate-mediated excit- intervene early on and potentially avoid the
atory neurotransmission. It also inhibits carbonic need for emergency room care. It is supplied in
anhydrase, but this is not how it exerts its doses of 2.5 mg, 5 mg, 10 mg, 15 mg, and 20 mg
antiepileptic effects. It is metabolized in the liver, that is dosed by weight (0.5–0.3 mg/kg). Serious
especially when used with enzyme-inducing AEDs. side effects are rare, including respiratory
Adverse effects: Common adverse effects depression.
include somnolence, mental slowing, impaired
concentration or confusion, and word-finding dif- ACTH and Steroids
ficulties. Paresthesias occur frequently with ACTH (adrenocorticotropic hormone) is used in
monotherapy, more frequently in adults than chil- the treatment of infantile spasms. It is also used in
dren. Other side effects include dizziness, weight other epileptic encephalopathies, such as
loss, metabolic acidosis, and hypohidrosis. Rare Lennox-Gastaut syndrome, Landau-Kleffner
side effects include nephrolithiasis and glaucoma. syndrome, and Dravet syndrome. As such,
Serious side effects are related to metabolic acido- ACTH is used almost exclusively in children.
sis and oligohidrosis that leads to hyperthermia. Steroids, especially prednisone, have been
The risk of these is higher in children than in used to treat acquired epileptic aphasia of child-
adults. Hepatotoxicity and bone marrow depres- hood (Landau-Kleffner syndrome) and electri-
sion do not occur. Weight loss is common. cal status epilepticus of sleep (ESES). In these
Dosing: TPX is available in the following disorders, oral prednisone is most commonly
formulations: sprinkle capsules (15 mg, 25 mg) used.
and tablets (25 mg, 50 mg, 100 mg, 200 mg). Common side effects include irritability,
Average daily doses for children are 5–10 mg/ weight gain, hypertension, and hyperglycemia.
kg/day and 200–400 mg/day for adults. Serious side effects include peptic ulcers,
cataracts/glaucoma, cardiomyopathy, and brain
Benzodiazepines atrophy. Life-threatening adverse effects include
Benzodiazepines have been used especially for immunosuppression, sepsis, and congestive heart
the treatment of status epilepticus and repetitive failure.
Antigluten Therapy 199 A
Clinical Use (Including Side Effects) Pellock, J., Bourgeois, B., Dodson, E., Nordli, D., &
Sankar, R. (2008). Pediatric epilepsy: Diagnosis and
therapy (3rd ed.). New York: Demos Medical
AEDs are commonly administered to children Publishing. A
and adolescents with ASD, both with and with- Wyllie, E. (Ed.). (2011). The treatment of epilepsy: Prin-
out epilepsy. Two of the most widely used ciples and practice (5th ed.). Philadelphia: Lippincott
AEDs in the ASD population include valproic Williams & Wilkins.
acid and lamotrigine. As described herein, many
AEDs have a psychotropic effect and are used in
treating psychiatric symptoms and disorders,
such as bipolar disorder, obsessive-compulsive Antigluten Therapy
disorder, mood lability, irritability, and aggres-
sive behaviors. As many children with ASD Madison Pilato
have coexisting affective disorders, AEDs are Neurodevelopmental and Behavioral Pediatrics,
an attractive drug of choice for targeting both University of Rochester Medical Center,
mood disturbances as well as epilepsy. There Rochester, NY, USA
are reports of behavioral improvements for
children with ASD and epileptiform EEG
abnormalities without clinical seizures; how- Definition
ever, at present time, there are no data to support
the use of antiepileptic drugs in the treatment of Antigluten therapy is the elimination of gluten
these abnormalities in the absence of clinical from the body by dieting and/or supplemental
seizures. Whether these AEDs have a positive enzymes. This entry will examine enzyme sup-
psychotropic effect on children with ASD, with plements that break down gluten. For elimination
and without epilepsy, is not currently known. diets, see “▶ Gluten-Free Diet.”
There is a need for large randomized control
trials in this area in order to determine the effi-
cacy of these AEDs in treating the core symp- Historical Background
toms of autism.
In 1979, Jaak Panksepp hypothesized that the
symptoms of autism may be caused by an opiate
See Also excess, although he was unsure how such an excess
might come about. Starting in the 1980s, some
▶ Depressive Disorder investigators reported abnormal peptide concentra-
▶ Epilepsy tions in the urine of children with autism and
▶ Mania proposed that enzyme deficiencies caused this
▶ Mood Disorders abnormality (Trygstad et al., 1980; Reichelt et al.,
▶ Seizures 1981; Reichelt, Ekrem, & Scott, 1990). Addition-
ally, these investigators speculated that the abnor-
mal peptide concentrations reflected abnormal
References and Readings levels of opioid peptides in the brain (Trygstad
et al., 1980; Reichelt et al., 1981). More recently,
Browne, T., & Holmes, G. (2008). Handbook of epilepsy
Andrew Wakefield (Wakefield et al., 1998)
(4th ed.). Philadelphia: Lippincott Williams &
Wilkins. described intestinal abnormalities in several chil-
Di Martino, A., & Tuchman, R. (2001). Antiepileptic dren with autism and hypothesized that this abnor-
drugs: Affective use in autism spectrum disorders. mality could provide another explanation for the
Pediatric Neurology, 25(3), 199–207.
Patsalos, P., & Bourgeois, B. (2010). The epilepsy pre-
opiate-excess theory. More specifically, he hypoth-
scriber’s guide to antiepileptic drugs. Cambridge: esized that children with autism have a leaky gut
Cambridge University Press. that results in the release of opioids that enter blood
A 200 Antigluten Therapy
vessels and circulate into the brain. However, Efficacy Information

Wakefield’s study has since been retracted by
The Lancet and is considered to be unreliable. For information on the efficacy of gluten-free
diets, see “▶ Gluten-Free Diet.”
To date, there are only two empirical studies
Rationale or Underlying Theory examining the efficacy of enzyme supplements to
break down gluten for individuals with autism.
Antigluten therapy is based on the opioid-excess, (Brudnack et al., 2002) placed 46 patients on
enzyme deficiency, and leaky gut theories. a combination of several enzymes for 12 weeks.
According to the opioid-excess theory, the core Several behavioral parameters were measured
symptoms of autism may be explained by disrupted every two weeks for the entire 12 weeks. The
opiate activity in the brain (Panksepp, 1979). One authors report improvement on every measure
proposed explanation for this theory is that children including core symptoms. However, there was
with autism have deficient peptidase enzymes no control group, the baseline measures were
(Trygstad et al., 1980; Reichelt et al., 1981). How- assumed to be zero rather than measured directly,
ever, Hunter, O’Hare, Herron, Fisher, & Jones and behavioral evaluators were aware that the
(2003) did not find dipeptidyl peptidase IV to be children had received a supplement. Addition-
defective in children with autism. A “leaky gut” or ally, behavioral measurements were collected
increased intestinal permeability has also been the- from an “SOS” form (not shown or explained in
orized to cause an opioid excess and to be associ- the manuscript) in addition to scoring by an
ated with autism. The theory suggests that observer, and it is not clear whether the observer
undigested proteins and peptides leak into the was distinct from a teacher, parent, or guardian
bloodstream through the intestines, eventually who completed the SOS form. No standardized
causing damage and/or disrupted opioid receptor instruments (i.e., ADOS, Vineland, Mullen, etc.)
activity in the brain. However, this theory lacks were used. Despite the reported improvements,
empirical support as it is based on a discredited the numerous methodological weaknesses in the
study (Wakefield et al., 1998) that found intestinal study make the results unreliable.
abnormalities in several children with autism and Munasinghe, Oliff, Finn, & Wray (2010)
that has not been replicated by other investigators conducted a more scientifically rigorous study
(Buie et al., 2010; Fernell, Fagerberg, & Hellstrom, that incorporated a randomized, double-blind,
2007; Sandhu, Steer, Golding, & Emond, 2009). crossover design. Only food selection improved
Another uncorroborated theory that has been significantly at the month two measurements.
adduced to support antigluten therapy is that chil- Improvements were not sustained at three
dren with autism have a wheat allergy and other months. Thus, the two available studies provide
symptoms similar to celiac disease (Lucarelli insufficient information to recommend antigluten
et al., 1995). However, there is no evidence for therapy in the form of enzymatic supplements at
increased co-occurrence of wheat allergies or this time.
celiac disease and autism spectrum disorders
(Fitzgerald, Woods, & Matthews, 1999;
McCarthy & Coleman, 1979). Outcome Measurement
Antigluten treatment is intended to reduce

Goals and Objectives autism symptoms and improve adaptive func-
tioning. Therefore, if clinical trials of
The goals of antigluten therapy include adminis- antigluten therapy are undertaken, outcome
tering digestive enzymes to assist in the break- measures should include measures of autism
down of gluten and preventing undigested gluten symptoms such as the ADOS and measures of
and gluten derivatives from affecting the body. adaptive behaviour such as the Vineland. Also,
Antipsychotics: Drugs 201 A
because digestive enzymes are administered, spectrum disorders: A double-blind randomized con-
measures of nutrition and vital signs should be trolled trial. Journal of Autism and Developmental
Disorders, 40(9), 1131–1138.
included. Panksepp, J. (1979). A neurochemical theory of autism. A
Trends in Neuroscience, 2, 174–177.
Reichelt, K. L., Ekrem, J., & Scott, H. (1990). Gluten,
Qualifications of Treatment Providers milk proteins and autism: Dietary intervention effects
on behaviour and peptide secretion. Journal of Applied
Nutrition, 42, 1–11.
Caregivers should consult a board-certified Reichelt, K. L., Hole, K., Hamberger, A., Saelid, G.,
physician before beginning antigluten therapy. Edminson, P. D., Braestrup, C. B., et al. (1981). Bio-
Additionally, the use of enzyme supplements logically active peptide-containing fractions in schizo-
phrenia and childhood autism. Advances in
should be supervised by a physician. Biochemical Psychopharmacology, 28, 627–643.
Sandhu, B., Steer, C., Golding, J., & Emond, A. (2009).
The early stool patterns of young children with autistic
See Also spectrum disorder. Archives of Disease in Childhood,
94, 497–500.
Trygstad, O. E., Reichelt, K. L., Foss, I., Edminson, P. D.,
▶ Food Intolerance Selid, G., Bremer, J., et al. (1980). Patterns of peptides
▶ Gastrointestinal Disorders and Autism and protein-associated-peptide complexes in psychiat-
▶ Gluten-Free Diet ric disorders. British Journal of Psychiatry, 136,
59–72.
▶ Leaky Gut Syndrome Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J.,
▶ Nutritional interventions Casson, D. M., Malik, M., et al. (1998). Illeal-
lymphoid-nodular hyperplasia, non-specific colitis,
and pervasive developmental disorder in children.
The Lancet, 351, 637–641.
Brudnack, M. A., Rimland, B., Kerry, R. E., Dailey, M.,

Taylor, R., Stayton, B., et al. (2002). Enzyme-based
therapy for autism spectrum disorders - Is it worth
another look? Medical Hypotheses, 58, 422–428. Anti-Hist [OTC]
Buie, T., Campbell, D. B., Fuchs, G. J., III, Furuta, G. T.,
Levy, J., Van de Water, J., et al. (2010). Evaluation, ▶ Diphenhydramine
diagnosis, and treatment of gastrointestinal disorders
in individuals with ASDs: A consensus report. Pediat-
rics, 125, S1–S18.
Fernell, E., Fagerberg, U. L., & Hellstrom, P. M. (2007).
No evidence for a clear link between active intestinal Antipsychotic-Induced Dyskinesia
inflammation and autism based on analyses of faecal
calprotectin and rectal nitric oxide. Acta Paediatrica,
96, 1076–1079. ▶ Tardive Dyskinesia
Fitzgerald, M., Woods, M., & Matthews, P. (1999). Inves-
tigation of possible links between autism and celiac
disease. Autism, 3, 193–195.
Hunter, L. C., O’Hare, A., Herron, W. J., Fisher, L. A., &
Jones, G. E. (2003). Opioid peptides and dipeptidyl Antipsychotics: Drugs
peptidase in autism. Developmental Medicine and
Child Neurology, 45, 121–128. Susan Boorin
Lucarelli, S., Frediani, T., Zingoni, A. M., Ferruzzi, F.,
Giardini, O., Quinteri, F., et al. (1995). Food allergy
School of Nursing Yale University, New Haven,
and infantile autism. Panminerva Medica, 37, CT, USA
137–141.
McCarthy, D. M., & Coleman, M. (1979). Response of
intestinal mucosa to gluten challenge in autistic sub-
jects. The Lancet, 314, 877–878.
Synonyms
Munasinghe, S. A., Oliff, C., Finn, J., & Wray, J. A.
(2010). Digestive enzyme supplementation for autism Neuroleptics
A 202 Antiseizure Medications
Indications looked for new compounds that would maintain

the antipsychotic benefits with decreased risk of
Schizophrenia neurological side effects. This led to the introduc-
tion of the so-called atypical antipsychotics. These
medications include clozapine, risperidone,
Mechanisms of Action olanzapine, quetiapine, ziprasidone, aripiprazole,
asenapine, iloperidone, and lurasidone. As a class,
There has been considerable debate about the dif- these atypical antipsychotics, also called second-
ference between the traditional antipsychotics and generation antipsychotics, do indeed reduce the
the so-called atypicals. Indeed, the matter is not risk of neurological adverse effects. However,
completely settled. It is generally agreed that the depending on the actual drug discussed, they have
traditional antipsychotics exert their beneficial and varying degrees of risk for other adverse effects.
adverse effects through dopamine blockade at the
dopamine D2 receptor. The traditional antipsy-
chotic, haloperidol, is a potent blocker of dopa- See Also
mine. Its capacity to bind to D2 receptors is strong,
and it is not easily displaced by dopamine in the ▶ Chlorpromazine
brain. This affinity and persistent binding to D2 ▶ Loxitane
receptors in the basal ganglia probably accounts ▶ Molindone
for the motor side effects described above. By ▶ Perphenazine
contrast, clozapine (often considered the prototype ▶ Phenothiazine
atypical) has much lower affinity for D2 receptors.
Across the current list of atypical antipsychotics, References and Readings
the affinity for D2 receptors varies. For example,
risperidone has strong affinity for D2 receptors – Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric
but it does not appear to have the same firm hold psychopharmacology: Principles and practice
on these receptors as haloperidol does. Because (2nd ed.). New York: Oxford.
the hold on the D2 receptors is not firm, endoge-
nous dopamine is more able to bind to the recep-
tors and we are less likely to see the motor side Antiseizure Medications
effects associated with haloperidol.
▶ Antiepileptic Drugs (AEDs)
Specific Compounds and Properties
Antipsychotics Antiyeast Therapy

Antipsychotic medications are a large group of
medications developed primarily for the treat- Madison Pilato
ment of schizophrenia. The antipsychotic medi- Neurodevelopmental and Behavioral Pediatrics,
cations were introduced in the 1950s with University of Rochester Medical Center,
so-called second-generation antipsychotics Rochester, NY, USA
appearing in the 1990s. These newer medications
have properties in common with the older anti-
psychotics but also important differences. Definition
Atypical Antipsychotics Antiyeast therapy includes diets that restrict

Because of the adverse neurological effects of the intake of sugar and yeast as well as supplements
traditional antipsychotic medications, chemists and drugs to eliminate yeast from the body.
Antiyeast Therapy 203 A
Historical Background probiotics, antiyeast diet, and antifungal products
as antiyeast therapies.
Candida albicans is a form of yeast and is known A
to cause human infections. In works published from
1978 to 1981, C. Orian Truss was the first to pro- Treatment Procedures
pose the idea that the natural yeasts in the gastroin-
testinal tract can cause a variety of symptoms Shaw (2008) offers tests for yeast overgrowth
(Edwards, 1988). In 1983, William Crook popular- through his Great Plains Laboratory and recom-
ized this idea with his book, The Yeast Connection, mends probiotics, antiyeast diet, and antifungal
in which he coined the term “Candida syndrome” to products as antiyeast therapies. Probiotics can be
explain a host of psychological and neurological found in yogurt or purchased as supplements from
syndromes, including learning disabilities. He pharmacies or health food stores. An antiyeast diet
offered anecdotes as evidence for this syndrome, is a low-sugar diet with the simple mantra: “If it’s
notably an account of “Candida drunken syn- sweet, don’t eat.” Nonprescription antifungal sup-
drome” that involved a boy with autism who was plements include garlic, oregano, caprylic acid,
said to improve after antiyeast interventions. The MCT oil, colloidal silver (although Shaw acknowl-
popularity of antiyeast therapies for the treatment of edges that this may be dangerous), lactoferrin, and
autism increased after Shaw, Kassen, and Chaves biotin. Prescription antifungal drugs that are con-
(1995) reported abnormal metabolites in the urine sidered safe because they are poorly absorbed from
of two brothers with autism. the intestines include nystatin and amphotericin B.
Other prescription antifungals which Shaw does
not consider to be as safe are Sporanox
Rationale or Underlying Theory (itraconazole) and Lamisil (terbinafine). Use of
any prescription drug should be closely supervised
Current antiyeast therapy was developed by by a board-certified physician.
Shaw et al. (1995) based on a report of abnormally
high levels of metabolites in the urine of two siblings
with autism, compared to typically developing chil- Efficacy Information
dren. These metabolites included citramalic acid,
a citric acid analog, tartaric acid, and a compound Dr. Shaw reports that combining diet and anti-
assumed to be arabinose. From their case report, fungals “double[s] the effectiveness of diet alone
Shaw et al. made three assumptions: (1) The metab- in eliminating yeast overgrowth.” However, he
olites are produced by an overgrowth of a fungus or does not cite any evidence for a link between
fermenting yeast such as Candida albicans. (2) The autism and yeast and does not report on the valid-
overgrowth of fungus or yeast in individuals with ity of his lab tests. Furthermore, he concedes that
autism occurs in the gastrointestinal system rather no “formal assessments” are available to address
than the urinary tract. (3) The growth interferes with the effects of the diet and antifungals on the core
normal metabolism and produces symptoms of symptoms of autism (2008). At this time, no
autism. None of these hypotheses have been con- clinical trials have been performed and only
firmed by independent investigators in peer- anecdotal evidence supports the application of
reviewed studies, and some are considered biologi- antiyeast diets or medications. Levy and Hyman
cally implausible (Lord, 2003). (2008) have categorized antifungal therapy as a
Grade C treatment for autism, supported only by
low-quality evidence. According to a consensus
Goals and Objectives statement from an expert panel of clinicians,
antiyeast therapy is not recommended for patients
The goal of antiyeast therapy is to rid the body of with autism spectrum disorders at this time (Buie
yeast. William Shaw (2008) recommends et al., 2010).
A 204 Anxiety
Outcome Measurement
Anxiety
Antiyeast treatment is intended to reduce autism
symptoms and improve adaptive functioning. C. Enjey Lin
Therefore, if clinical trials of antiyeast therapy Departments of Education and Psychiatry,
are undertaken, outcome measures should University of California, Los Angeles,
include measures of autism symptoms such as Los Angeles, CA, USA
the ADOS and measures of adaptive behavior
such as the Vineland. Also, because the mecha-
nism by which the treatment is postulated to work Synonyms
is to reduce intestinal yeast overgrowth, well-
validated measures of intestinal yeast should be Fear; Worry
included.
Definition
Qualifications of Treatment Providers
Anxiety is a psychological and physiological
A physician should be contacted before begin- state characterized by cognitive (e.g., recurrent
ning an antiyeast therapy. The use of antifungal or obsessive thoughts), somatic (e.g., headache,
medications should have ongoing supervision dizziness, nausea), affective (e.g., dysphoria or
from a board-certified physician. negative mood), and behavioral (e.g., trembling,
pacing, or restlessness) responses that arise as
a result of a perceived threat to the individual.
See Also Evolutionarily, these responses are adaptive in
allowing individuals to prepare themselves to
▶ Gastrointestinal Disorders and Autism either flee or fight when faced with a threat,
▶ Yeast Infection increasing the likelihood of survival. Although
periodic anxiety experienced at moderate levels
is common to most individuals and can be adap-
References and Readings tive, irrational or extreme anxiety over an
extended length of time may be indicative of an
Buie, T., Campbell, D. B., Fuchs, G. J., III, Furuta, G. T., anxiety disorder. Several studies have shown that
Levy, J., Van de Water, J., et al. (2010). Evaluation, children with a pervasive developmental disorder
(PDD) exhibit rates of anxiety disorders signifi-
in individuals with ASDs: A consensus report. Pediat-
rics, 125, S1–S18. cantly higher than typically developing children.
Edwards, J. E. (1988). Systemic symptoms of candida in In addition, it has been speculated that some core
the gut: Real or imaginary? Bulletin of the New York autism symptoms may be driven or exacerbated
Academy of Medicine, 64, 544–549.
by anxiety and that some anxiety disorder symp-
Levy, S. E., & Hyman, S. L. (2008). Complementary and
alternative medicine treatments for children with toms overlap with PDD features such as persev-
autism spectrum disorders. Child and Adolescent erative thought and speech.
Psychiatric Clinics of North America, 17, 1–15.
Lord, R. S. (2003). Urinary markers of intestinal yeast.
Townsend Letter for Doctors and Patients, 245, 96–97.
Shaw, W., Kassen, E., & Chaves, E. (1995). Increased See Also
urinary excretion of analogs of Krebs cycle metabo-
lites and arabinose in two brothers with autistic ▶ Amygdala
features. Clinical Chemistry, 41, 1094–1104.
▶ Anxiety Disorders
Shaw, W. (2008). Biological treatments for autism and
PDD (3rd ed.). United States of America: William ▶ Cognitive Behavioral Therapy (CBT)
Shaw, Ph.D. ▶ General Anxiety
Anxiety Disorders 205 A
▶ Obsessive-Compulsive Disorder (OCD) orbitofrontal cortex, anterior cingulated gyrus,
▶ Separation Anxiety Disorder hippocampus and amygdala limbic circuits.
▶ Social Anxiety Disorder When the fear occurs in the absence of a threat A
▶ Social Phobia is called anxiety. Both fear and anxiety are nor-
mal reactions to danger. The physiologic normal
response of fear and anxiety triggers a “fight,
References and Readings freeze, or flight response” that has been preserved
throughout evolution. If anxiety is triggered by
American Psychiatric Association. (2000). Diagnostic a non-dangerous stimuli, or it is too intense or
and statistical manual (4th ed., Text Rev.). Washing-
persistent, or it creates impairment, it can be
ton, DC: APA Press.
Gillott, A., Furniss, F., & Walter, A. (2001). Anxiety in high- considered as an anxiety disorder. Symptoms
functioning children with Autism. Autism, 5(3), 277–286. are of a cognitive (e.g., worry thoughts), physio-
Kanner, L. (1943). Autistic disturbances of affective con- logical (e.g., tachycardia), or behavioral (e.g.,
tact. Nervous Child, 2, 217–250.
avoidance) nature. Anxiety disorders and mood
Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L., &
Wilson, F. J. (2000). The prevalence of anxiety and disorder form the category of affective disorders
mood problems among children with autism and (Revised in Soutullo & Figueroa, 2010).
Aspergers syndrome. Autism, 4(2), 117–132.
McPheeters, M. L., Davis, A., Navarre II, J. R., &
Scott, T. A. (2010). Family report of ASD concomitant
with depression or anxiety among US children. Journal Categorization
of Autism and Developmental Disorders. Retrieved
from http://www.springerlink.com/content/00477205 There are several types of anxiety disorders,
pj2p2383/fulltext.pdf
depending on the stimuli that trigger the anxiety:
• Separation anxiety disorder (SAD)
• Panic disorder
• Agoraphobia
Anxiety Disorders • Generalized anxiety disorder (GAD)
• Simple Phobia that has five subtypes:
César Soutullo Animal
Child & Adolescent Psuychiatry Unit, Environmental (heights, storms, etc.)
Department of Psychiatry and Medical Pain (injections, blood, injuries, surgeries)
Psychology, University of Navarra Clinic, Situational (flights, elevators, closed environ-
Pamplona, Spain ments, tunnels)
“Other types” (choking, vomiting, having an
illness)
Synonyms • Social phobia
• Obsessive-compulsive disorder (OCD)
Affective disorders (includes mood and anxiety • Posttraumatic stress disorder (PTSD)
disorders); Neurotic disorders (DSM-II
terminology)
Epidemiology
Short Description or Definition Anxiety disorders as a group are the most

frequent psychiatric disorders in children and
Fear is a normal brain state, a physiologic adolescents. The epidemiology varies across
response in response to a threat, or a dangerous development. Usually simple phobias and sepa-
or unexpected stimuli that serves as a warning ration anxiety appear first, and then social phobia,
system to maintain the individual and/or group GAD, and panic disorder. Some authors suggest
safety. It is mediated by the activation of that the different anxiety disorders across
A 206 Anxiety Disorders
childhood and adolescence represent only Anxiety Disorders, Table 1 Content of anxious
a developmental variation of the disorder. Avail- thoughts for specific anxiety disorders
able data suggests that 2.8–27% of children and Anxiety disorder: worries, anticipated harm
adolescents may have some form of anxiety SAD: Being separated from caretaker, harm to self or
disorder (Krain et al., 2007). Anxiety disorders caretaker
are usually more frequent in females, and inter- PD: Being unable to escape the current situation, dying,
losing control, going crazy
estingly, female preponderance emerges before
Social phobia: Negative social judgment embarrassment,
puberty, except in GAD, that only becomes more negative evaluation, or rejection
frequent in females after adolescence (Krain PTSD: Posttraumatic event, reexperiencing traumatic
et al., 2007). event
Prevalence of GAD is 6.5% in preschoolers, OCD: Contamination, contracting a disease, doubt,
3.8% in children, and 6.6% in adolescents; of catastrophic outcome
social phobia 3.4% in preschoolers, 1.3% in GAD: Routine life issues such as academic performance
or social interactions, wide range of possible negative
children, and 1.1% in adolescents; of separation outcomes (e.g., failure, rejection)
anxiety disorder is 2.4% in preschoolers, 4.1% in
children, and 1.4% in adolescents; of simple
phobia 1.9% in preschoolers, 5.8% in children,
and 4.1% in adolescents; and of panic disorder symptoms, school avoidance and worries
0.8% in children, and 2.7% in adolescents. The about the loved ones, or about getting lost.
lifetime prevalence rate of OCD is between 1% 2. Social phobia: Fear on social situations that
and 4% (Keeley & Storch, 2009). The mean age are avoided or endured.
of onset is 4.1 years for simple phobia, 4.3 for 3. GAD: Excessive uncontrollable worries about
separation anxiety, 5.3 for agoraphobia, 6 for multiple issues during most of the time.
social phobia, 6.3 for GAD, 6.5 for PTSD, and 4. Specific phobia: Extreme fear and avoidance
8.5 for panic disorder. of specific situations or objects.
5. Panic disorder: Unexpected panic attacks,
brief in time, with associated physical and
Natural History, Prognostic Factors, psychological symptoms, and fear of having
Outcomes another attack in the future.
6. PTSD: Anxiety symptoms after a traumatic
There is a statistically robust, but modest in effect event, with associated autonomic
size (Odds Ratio: 2.0:4.0), association between hyperarousal, avoidance of the situation, and
pediatric anxiety disorders and a range of adult intrusive memories.
psychiatric disorders, such as mood and anxiety 7. OCD: Obsessions (intrusive ego-dystonic
disorders. The most robust association appears to thoughts) and associated compulsions (behav-
be between GAD and major depression, and anx- iors) aimed to reduce anxiety.
iety disorder, especially panic disorder (Krain Anxiety-related disorders are among the most
et al., 2007). frequent presenting problems in the clinical set-
ting in children with ASD (Tables 1, 2).
The etiology and pathophysiology of anxiety
Clinical Expression and is still under study, but we know that there are
Pathophysiology four factors involved in the development of an
anxiety disorder: (1) genetic and environmental
The key characteristics of the different anxiety influences, (2) the neural circuits underlying
disorders are (Tables 1, 2): emotion process, (3) core psychological pro-
1. Separation anxiety disorder: Excessive cesses, and (4) broad behavioral tendencies,
worries concerning separation from loved including temperament. There are important
one, frequently associated with physical genetic components in various forms of
Anxiety Disorders, Table 2 Somatic symptoms of anx- Fear is regulated by connections between pre-
iety included in the DSM-IV-TR (Keeley & Storch, 2009) frontal cortex (PFC) and the amygdala. When
System & symptoms these circuits are altered (by a genetic or by an A
Cardiac environmental overactivation), the child per-
Tachycardia ceives a neutral stimuli as dangerous. In PFC
Palpitations/Heart pounding
Chest pain
the two areas involved in anxiety and fear are
Shortness of breath the orbitofrontal cortex (OFC) that makes
Gastrointestinal (GI) a representation of both negative and positive
Dry mouth reinforcers, and the anterior cingulated cortex
Difficulty swallowing (ACC), that regulates the emotional response. In
Nausea/vomiting, diarrhea
GI discomfort addition to these responses, an activation of the
Urogenital amygdala activates:
Frequent urination, tenesmus • The HPA axis, and the hypothalamus secretes
Respiratory CRF (corticotrophin releasing factor), induces
Shortness of breath the secretion of ACTH, that will induce the
Smothering sensation
secretion of cortisol and adrenaline in the
Choking sensation
Neurologica
adrenal gland, and causes hyperglycemia and
Numbness/tingling tachycardia, needed for the brain and muscles
Tremor/shaking to respond to danger.
Syncopal episodes/fainting • The parabrachial nuclei that increases respira-
Sleep tory frequency and may cause a sensation of
Insomnia
Reluctance/refusal to sleep alone shortness of breath similar to an asthma attack.
Nightmares • The locus coeruleus, that also releases adren-
Sleeptalking/sleepwalking aline, that raises blood pressure, pulse, acti-
Excessive tiredness vates sweating, and induces tremor (Revised
Dermatological/temperature regulation
in Soutullo & Figueroa, 2010).
Sweating
Hot flashes
Chills
Cold, clammy hands Evaluation and Differential Diagnosis
ENT
Dizziness
Lightheadedness
Evidence-based methods of evaluation include
Feeling unsteady diagnostic interview schedules, rating scales,
Others observations, and self-monitoring forms.
Increased startle response
Muscle tension Diagnostic Interviews
Diagnostic interviews are reliable and valid
instruments to facilitate diagnostic decisions con-
anxiety. Genetic and environmental influences sistent with DSM-IV-TR criteria. These clini-
are likely to shape more basic psychological cian-administered structured diagnostic
processes which in turn influence risk for anx- interviews assess for anxiety disorders and for
iety. Despite the evidence for genetic contribu- the presence of other psychiatric disorders. How-
tion, anxiety disorders involve a large ever, these interviews require trained clinicians,
environmental component. Parents with anxi- and can be time-consuming and expensive (last-
ety may have distinctive child rearing or paring 60–120 min). The most common diagnostic
enting practices, and may encourage or train interviews used in the diagnosis of anxiety disor-
their children to maladaptive patterns of ders include:
responding to ambiguous situations (Keeley & 1. The Anxiety Disorders Interview Schedule for
Storch, 2009). DSM-IV: Child and Parent Versions
2. K-SADS-PL: Kiddie Schedule for Affective 2. Behavioral avoidance tasks: In which a child’s
Disorders and Schizophrenia-Present and response to being exposed to a fear or anxiety-
Lifetime Version provoking stimuli is observed
3. SCID: Structured Clinical Interview for 3. Parent–child interaction tasks: In which parent
DSM-IV and child are observed in a problem-solving
Rating scales: Self-report or parent-report rat- task
ing scales require minimal training, are easy to
administer, can be completed and scored quickly, Self-monitoring Procedures This is a method
are useful screening devices, and are easily to identify and quantify symptoms and behaviors
readministered to capture clinical change over time. using self-rated via diary-like entries.
General Anxiety Rating Scales

1. The SCARED (Screen for Child Anxiety Treatment
Related Emotional Disorders-Revised) has
five subscales (Panic/Somatic, Separation Practice parameters for the treatment of children
Anxiety, Social Phobia, General Anxiety, with anxiety disorders recommend a multimodal
and School Phobia) that help to identify spe- approach to treatment, and comprehensive care
cific anxiety symptoms. should include consideration of:
2. The MASC (Multidimensional Anxiety Scale • Psychoeducation
for Children) is another commonly used rat- • Cognitive-behavioral psychotherapy (CBT)
ing scale of general anxiety symptoms with • School consultation
four subscales (Physical Symptoms, Harm • Family therapy
Avoidance, Social Anxiety, and Separation/ • Psychodynamic psychotherapy
Panic) and an Anxiety Disorders Index, • Pharmacotherapy (AACAP, 2007)
which includes items found to differentiate The psychological interventions that have the
children with and without an anxiety most empirical support for childhood anxiety to
disorder. date are behavioral and cognitive-behavioral
3. The Fear Survey Schedule for Children- interventions and pharmacotherapy with selec-
Revised is a commonly used measure to assess tive serotonin reuptake inhibitors (SSRIs) in the
childhood fears, with five subscales: Fear of short-term treatment of childhood anxiety
Failure/Criticism, of the Unknown, of Injury (AACAP, 2007).
and Small Animals, of Danger/Death, and
Fear of Medical Situations. Behavioral and Cognitive-Behavioral
Psychotherapy (CBT)
Syndrome-Specific Anxiety Measures Cognitive-behavioral therapy (CBT) has proven
1. The Social Anxiety Scale for Children- to be effective in treating children and adoles-
Revised cents with anxiety disorders. CBT includes:
2. The Children’s Yale-Brown Obsessive- 1. A cognitive-restructuring component
Compulsive Scale-Child Report and Parent 2. Modeling
Report 3. Relaxation skills training
3. Trauma Symptom Checklist for Children to 4. Homework
assess PTSD Symptoms 5. Contingency management
6. Most importantly, exposure to feared
Observational and Self-monitoring Methods situations
Direct Observation The exposure (imagined, virtual, or real) is an
1. Social evaluative tasks: In which a child is opportunity for the patient to practice newly
observed performing in a social situation learned coping skills in a safe and controlled
(e.g., public speaking) environment. The cognitive part helps children
to change the thinking patterns that support their • Social phobia (Birmaher et al., 2003; RUPP,
fears, and the behavioral part helps them to 2001; Wagner et al., 2004)
change the way they react to anxiety-provoking • SAD (Birmaher et al., 2003; RUPP, 2001) A
situations. • OCD (POTS, 2004)
Despite some methodological limitations, No randomized, placebo-controlled trials of
mainly the use of a waiting list as a control SSRIs exist for pediatric Panic Disorder (PD) or
group, CBT has demonstrated efficacy in the PTSD. Uncontrolled trials of SSRIs for pediatric
treatment of children with social phobia, GAD, PD suggest that SSRI treatment results in clini-
and SAD, in two 16-week randomized controlled cally significant reductions in symptoms (Keeley
trials (Kendall et al., 1997). CBT with a family- & Storch, 2009).
based component was also effective, and had
added benefits, particularly for younger female Pharmacotherapy of Anxiety in Children with
children, and treatment gains were maintained at Autistic Spectrum Disorders (ASD)
6-year follow-up (Barrett et al., 2001). There is some very preliminary evidence for the
Exposure-based behavioral therapy has been efficacy of sertraline, fluvoxamine, fluoxetine,
used to treat specific phobias and OCD exposing buspirone, and dextromethorphan. None of
the child gradually to the object or situation that is these reports included a control group or placebo
feared, perhaps at first only through pictures or arm, and the largest sample size was 22 (White
tapes, then later face-to-face. Often the therapist et al., 2009).
will accompany the person to a feared situation to
provide support and guidance. CBT is undertaken SSRIs
when the child decides he is ready for it and with Two children ages 6 and 13 with DSM-IV ASD
his permission and cooperation. To be effective, and co-occurring anxiety symptoms, treated with
the therapy must be directed at the person’s spe- sertraline (25–50 mg/day) improved in symptoms
cific anxieties and must be tailored to his or her of anxiety (Ozbayrak, 1997).
needs. There are no side effects other than the An 11-year-old girl with ASD and separation
discomfort of temporarily increased anxiety. anxiety disorder improved after 8-week treatment
CBT or behavioral therapy often lasts about with sertraline (150 mg/day) (Bhardwaj et al.,
12 weeks. It may be conducted individually or 2005).
with a group of people who have similar prob- A 7-year-old girl with PDD-NOS and intellec-
lems. Group therapy is particularly effective for tual disability treated with fluvoxamine had
social phobia. Often “homework” is assigned for a 15.5 point decrease in the parent-reported
participants to complete between sessions. There CARS (Childhood Autism Rating Scale), and
is some evidence that the benefits of CBT last also fewer aggressive behaviors, less nervous-
longer than those of medication for people with ness, but no reduction of repetitive behaviors or
panic disorder, and the same may be true for anxiety. The child’s parents and teachers
OCD, PTSD, and social phobia. If a disorder received concurrent training and behavior inter-
recurs at a later date, the same therapy can be ventions, which may have contributed to behav-
used to treat it successfully a second time. ior changes (Kauffmann et al., 2001).
A retrospective chart review of 15 outpatients
Pharmacotherapy with SSRIs with ASD treated with citalopram (5–40 mg/day
Several recent randomized, placebo-controlled for 14–621 days), found improvements in symp-
trials of SSRIs have shown evidence for the toms of anxiety in 10 of the 15 youth (Namerow
short-term efficacy of these medications in the et al., 2003).
treatment of children with anxiety disorders, Silveira et al. (2004) treated with fluoxetine
including: (20 mg daily) a 6-year-old girl with ASD who
• GAD (Birmaher et al., 2003; RUPP, 2001; was also diagnosed with selective mutism and
Rynn et al., 2001) social anxiety. After 8 weeks, her parents
reported improvements in symptoms of anxiety Barrett, P. A., Duffy, A. L., Dadds, M. R., & Rapee, R. M.
and selective mutism. (2001). Cognitive-behavioral treatment of anxiety dis-
orders in children: Long term (6-year follow-up). Jour-
A retrospective chart review of the effective- nal of Consulting and Clinical Psychology, 69,
ness of citalopram reported that 10 of 17 children 135–141.
with ASD who were treated with the SSRI Bhardwaj, A., Agarwal, V., & Sitholey, P. (2005).
(5–40 mg/day) showed improvement in target Asperger’s disorder with co-morbid separation anxiety
disorder: A case report. Journal of Autism Develop-
symptoms (Couturier & Nicolson, 2002). mental Disorders, 35, 135–136.
Birmaher, B., Axelson, D. A., Monk, K., Kalas, C., Clark,
Buspirone D. B., Ehmann, M., et al. (2003). Fluoxetine for the
Buitelaar, et al. (1998) conducted an open trial of treatment of childhood anxiety disorders. Journal of
the American Academy of Child and Adolescent Psy-
buspirone to treat anxiety and irritability in chil- chiatry, 42, 415–423.
dren with ASD. All 22 youth exhibited chronic Buitelaar, J. K., van der Gaag, J., & van der Hoeven, J.
problems with anxiety, irritability, and/or affec- (1998). Buspirone in the management of anxiety and
tive dysregulation. After 6–8 weeks of buspirone irritability in children with pervasive developmental
disorders: Results of an open-label study. Journal of
treatment (15–45 mg/day), 16 of the 21 patients Clinical Psychiatry, 59, 56–59.
who completed the trial showed a positive Couturier, J. L., & Nicolson, R. (2002). A retrospective
response: nine had marked improvement and assessment of citalopram in children and adolescents
seven had moderate improvement on the Clinical with pervasive developmental disorders. Journal of
Child and Adolescent Psychopharmacology, 12,
Global Impressions-Improvement scale (CGI-I). 243–248.
Kauffmann, C., Vance, H., Pumariega, A. J., & Miller, B.
Dextromethorphan (2001). Fluvoxamine treatment of a child with severe
Another case study of a 10-year-old boy diagnosed PDD: A single case study. Psychiatry: Interpersonal
and Biological Processes, 64, 268–277.
with autistic disorder and GAD reported improve- Keeley, M. L., & Storch, E. A. (2009). Anxiety in youth.
ments in target behaviors, leaving the classroom Journal of Pediatric Nursing, 24(1), 26–40.
and aggressive tantrums, following treatment with Kendall, P. C., Flannery-Schroeder, E., Panicchelli-
dextromethorphan 30 mg/day (Woodard et al., Mindel, S. M., Southam-Gerow, M., Henn, A., &
Warman, M. (1997). Therapy for youths with anxiety
2005). Dextromethorphan may have relieved dis- disorders: A second randomized clinical trial.
comfort associated with other illnesses, may have Journal of Consulting and Clinical Psychology, 65,
had secondary sedative effects, or may have 366–380.
helped via its glutamate receptor antagonism. Krain, A. L., Ghaffari, M. Y., Freeman, J., Garcı́a, A.,
Leonard, H., & Pine, D. (2007). Anxiety disorder. In
A. Martin & F. R. Volkmar (Eds.), Lewis’s child and
adolescent psychiatry: A comprehensive textbook.
See Also Philadelphia, PA: Williams & Wilkins/Wolters Kluver
Business.
Namerow, L. B., Thomas, P., Bostic, J. Q., Prince, J., &
▶ Generalized Anxiety Disorder Monuteaux, M. C. (2003). Use of citalopram in perva-
▶ Obsessive-Compulsive Disorder (OCD) sive developmental disorders. Journal of Developmen-
▶ Phobia tal and Behavioral Pediatrics, 24, 104–108.
▶ Posttraumatic Stress Disorder Ozbayrak, K. R. (1997). Sertraline in PDD. Journal of the
American Academy of Child and Adolescent Psychia-
▶ Separation Anxiety Disorder try, 36, 7–8.
▶ Social Phobia Pediatric OCD Treatment Study (POTS) Team. (2004).
Cognitive-behavior therapy, sertraline, and their com-
bination for children and adolescents with obsessive-
References and Readings compulsive disorder. JAMA: The Journal of the Amer-
ican Medical Association, 292, 1969–1976.
American Academy of Child and Adolescent Psychiatry. Research Units on Pediatric Psychopharmacology Anxi-
(2007). Practice parameter for the assessment and ety Study Group (RUPP). (2001). Fluvoxamine for the
treatment of children and adolescents with anxiety treatment of anxiety disorders in children and adoles-
disorders. Journal of the American Academy of Child cents. New England Journal of Medicine, 344,
and Adolescent Psychiatry, 46, 267–283. 1279–1285.
Anxiolytic Drugs 211 A
Rynn, M. A., Siqueland, L., & Rickels, K. (2001). Placebo Historical Background
controlled trial of sertraline in the treatment of children
with generalized anxiety disorder. American Journal
of Psychiatry, 158, 2008–2014. There is accumulating evidence to suggest that A
Silveira, R., Jainer, A. K., & Bates, G. (2004). Fluoxetine children and adolescents with ASD have
treatment of selective mutism in pervasive develop- increased comorbidity with anxiety disorders,
mental disorder. International Journal of Psychiatry in although there exists controversy on how the
Clinical Practice, 8, 179–180.
Soutullo, C., & Figueroa, A. (2010). Convivir con niños diagnosis of anxiety is made in ASD and what
y adolescentes con ansiedad (Living with children and specific anxiety disorders are prevalent in this
adolescents with anxiety). Madrid, Spain: Editorial population. In fact, there has been some discus-
Médica Panamericana. sion that certain types of anxiety symptoms may
Wagner, K. D., Berard, R., Stein, M. B., Wetherhold, E.,
Carpenter, D. J., & Perera, P. (2004). A multicenter, be on a continuum or difficult to differentiate
randomized, double-blind, placebo-controlled trial of from core symptom domains (e.g., social anxiety
paroxetine in children and adolescents with social anx- and social deficits associated with ASD).
iety disorder. Archives of General Psychiatry, 61,
1153–1162.
White, S. W., Oswald, D., Ollendick, T., & Scahill, L.
(2009). Anxiety in children and adolescents with Current Knowledge
autism spectrum disorders. Clinical Psychology
Review, 29(3), 216–229. There are limited randomized, placebo-
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., &
Langer, D. A. (2009). Cognitive behavioral therapy for controlled trials of anxiolytic drugs for the
anxiety in children with autism spectrum disorders: purposes of reducing anxiety in ASD. Prelimi-
A randomized, controlled trial. Journal of Child Psy- nary efficacy for SSRIs/SNRIs, buspirone,
chology and Psychiatry, and Allied Disciplines, 50(3), dextromethorphan, risperidone, and alpha-
224–234.
Woodard, C., Groden, J., Goodwin, M., Shanower, C., & adrenergic antagonists exists in this area. Only
Bianco, J. (2005). The treatment of the behavioral two of these studies included a control group, and
sequelae of autism with dextromethorphan: A case the largest sample size was 31.
report. Journal of Autism and Developmental Disor- SSRIs: There are three children with ASD
ders, 35, 515–518.
and comorbid anxiety that have responded to
sertraline based on clinician ratings on case
reports (Bhardwaj, Agarwal, & Sitholey, 2005;
Ozbayrak, 1997). Improvements in “nervous-
Anxiolytic Drugs ness” with fluvoxamine were reported in
a single case by Kauffmann, Vance,
Evdokia Anagnostou1 and Deepali Mankad2 Pumariega, & Miller, 2001. Silveira, Jainer, and
1
Department of Peadiatrics, University of Bates (2004) reported on a single case of a 6-
Toronto Clinician Scientist, Bloorview Research year-old girl with ASD, selective mutism, and
Institute, Toronto, ON, Canada social anxiety who responded to fluoxetine. Two
2
Holland Bloorview Kids Rehabilitation retrospective case series of citalopram in children
Hospital, Toronto, ON, Canada with ASD and anxiety symptoms reported
improvements in anxiety in response to
citalopram (Couturier & Nicolson, 2002,
Definition Namerow, Thomas, Bostic, Prince, &
Monuteaux, 2003). Of note, there is a debate in
Anxiolytic medications are used to treat anxiety the literature about whether repetitive behaviors
symptoms. The most common categories involve seen in autism are related to anxiety disorders.
SSRIS, serotonin agonists, and benzodiazepines. Two large, randomized trial studies to date have
Other medications of interest but with minimal pre- shown that SSRIs (citalopram and fluoxetine) are
liminary data include anticonvulsants, glutamate not effective in reducing repetitive behavior in
antagonists, and alpha-2 adrenergic antagonists. youth with ASD.
A 212 Anxiolytic Drugs
Buspirone: There is an open-label trial of Future Directions

buspirone, a serotonin agonist, in 22 children
with ASD with comorbid anxiety, irritability, There is also a clear lack of randomized, con-
and affective dysregulation (Buitelaar, van der trolled trials of anxiolytic medications for the
Gaag, & van der Hoeven, 1998). Sixteen of the treatment of anxiety in ASD. In addition, there
22 children were rated as responders at the end of is accumulating data to support the use of
the 8-week study. CBT-based programs for anxiety in this popula-
Alpha-adrenergic agonists: A small double- tion. There seems an urgent need to identify
blind, placebo-controlled, crossover study of effective medications, and even more impor-
transdermal clonidine in seven children and two tantly, there is need to examine how medication
adults with ASD and “hyperarousal” reported may facilitate the ability psychoeducational
improvements on the CGI scale (Fankhauser, programs to teach new skills and ultimately
Karumanchi, German, Yates, & Karumanchi, change the trajectory of anxiety symptoms in
1992). An open-label study (Ming, Gordon, this population.
Kang, & Wagner, 2008) also showed improve-
ments in sleep latency and night awakenings.
Glutamatergic agents: A case report See Also
suggested improvements in anxiety with dextro-
methorphan, a weak NMDA inhibitor (Woodard, ▶ Anxiety
Groden, Goodwin, Shanower, & Bianco, 2005). ▶ Anxiolytics
SNRIs: An open-label study of mirtazapine in ▶ Benzodiazepines
26 children and young adults with ASD ▶ Clonidine
suggested clinically meaningful improvements ▶ Diazepam
in 9/26 participants based on improvements in ▶ Fluoxetine
a variety of symptoms including anxiety. ▶ Fluvoxamine
Atypical antipsychotics: In a double-blind, ▶ Risperidone
placebo-controlled trial of risperidone in adults ▶ Selective Serotonin Reuptake Inhibitors
with ASD, significant improvements were noted (SSRIs)
in anxiety in the risperidone group over ▶ Sertraline
a 12-week period versus the placebo group
(McDougle et al., 1998).
There has been almost no data that examines
the role of benzodiazepines in ASD. Oswal and
Sonenklar (2007) reported that in 2002, less than Bhardwaj, A., Agarwal, V., & Sitholey, P. (2005).
5% of ASD patients were prescribed Asperger’s disorder with co-morbid separation anxiety
a benzodiazepine, suggesting that this class of disorder: A case report. Journal of Autism and Devel-
opmental Disorders, 35(1), 135–136.
medications is not widely used in ASD, despite
Buitelaar, J. K., van der Gaag, R. J., & van der Hoeven, J.
their known effectiveness for anxiety disorders. (1998). Buspirone in the management of anxiety and
Other than being habit forming, there are also irritability in children with pervasive developmental
reports of paradoxical reactions with the use of disorders: Results of an open-label study. The Journal
of Clinical Psychiatry, 59(2), 56–59.
benzodiazepines in this population. For example,
Couturier, J. L., & Nicolson, R. (2002). A retrospective
Marrosu, Marrosu, Rachel, and Biggio (1987) assessment of citalopram in children and adolescents
published a case series of anxiogenic and aggres- with pervasive developmental disorders. Journal of
sive responses to diazepam in seven children with Child and Adolescent Psychopharmacology, 12(3),
243–248.
ASD. Overall, this class of medication is less
Fankhauser, M. P., Karumanchi, V. C., German, M. L.,
attractive for use in pediatrics and especially in Yates, A., & Karumanchi, S. D. (1992). A double-
children with ASD. blind, placebo-controlled study of the efficacy of
Anxiolytics 213 A
transdermal clonidine in autism. The Journal of Clin-
ical Psychiatry, 53(3), 77–82. Anxiolytics
Gibbs, T. T. (2010). Pharmacological treatment of autism.
In G. J. Blatt (Ed.), The neurochemical basis of autism A
(pp. 245–267). New York: Springer Science and Lawrence David Scahill
Business media. Nursing & Child Psychiatry, Yale University
Kauffmann, C., Vance, H., Pumariega, A. J., & Miller, B. School of Nursing, Yale Child Study Center,
(2001). Fluvoxamine treatment of a child with
severe PDD: A single case study. Psychiatry, 64(3), New Haven, CT, USA
268–277.
Marrosu, F., Marrosu, G., Rachel, M. G., & Biggio, G.
(1987). Paradoxical reactions elicited by diazepam in Synonyms
children with classic autism. Functional Neurology,
2(3), 355–361.
McDougle, C. J., Holmes, J. P., Carlson, D. C., Pelton, Antianxiety medication
G. H., Cohen, D. J., & Price, L. H. (1998). A double-
blind, placebo-controlled study of risperidone in adults
with autistic disorder and other pervasive developmen-
tal disorders. Archives of General Psychiatry, 55(7), Indications
633–641.
Ming, X., Gordon, E., Kang, N., & Wagner, G. C. (2008). ANXIOLYTIC: Anxiolytic is a broad term meant
Use of clonidine in children with autism spectrum to describe medications that are used to reduce
disorders. Brain & Development, 30(7), 454–460.
Namerow, L. B., Thomas, P., Bostic, J. Q., Prince, J., & anxiety. Most commonly, these include benzodi-
Monuteaux, M. C. (2003). Use of citalopram in azepines and SSRIs.
pervasive developmental disorders. Journal of BENZODIAZEPINES: Benzodiazepines are
Developmental and Behavioral Pediatrics, 24(2), a class of medications containing several drugs
104–108.
Oswald, D. P., & Sonenklar, N. A. (2007). Medication use used in the treatment of insomnia, anxiety, and
among children with autism spectrum disorders. for the treatment of seizures. The benzodiaze-
Journal of Child and Adolescent Psychopharmacol- pines represent a major advance in psychophar-
ogy, 17(3), 348–355. macology with their introduction in 1950s. These
Ozbayrak, K. R. (1997). Sertraline in PDD. Journal of the
American Academy of Child and Adolescent Psychia- medications have been commonly used, but these
try, 36(1), 7–8. medications are habit-forming.
Posey, D. J., Guenin, K. D., Kohn, A. E., Swiezy, N. B., & SSRI: SSRIs are approved for the treatment of
McDougle, C. J. (2001). A naturalistic open-label adults with generalized anxiety disorder, social
study of mirtazapine in autistic and other pervasive
developmental disorders. Journal of Child and anxiety disorder, and obsessive-compulsive
Adolescent Psychopharmacology, 11(3), 267–277. disorder. But few trials with any medications
Silveira, R., Jainer, A. K., & Bates, G. (2004). Fluoxetine focused on anxiety symptoms have been
treatment for selective mutism in pervasive develop- conducted in subjects with autism spectrum
mental disorder. International Journal of Psychiatry in
Clinical Practice, 8, 179–180. disorders.
van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). More recently, other medications have been
Anxiety disorders in children and adolescents added to a list of anxiolytics such as buspirone
with autistic spectrum disorders: A meta-analysis. and mirtazapine, SSRIs, and specific anticonvul-
Clinical Child and Family Psychology Review, 14(3),
302–317. sants (e.g., gabapentin and pregabalin).
White, S. W., Oswald, D., Ollendick, T., & Scahill, L.
(2009). Anxiety in children and adolescents with
autism spectrum disorders. Clinical Psychology Benzodiazepine
Review, 29(3), 216–229.
Woodard, C., Groden, J., Goodwin, M., Shanower, C., &
Bianco, J. (2005). The treatment of the behavioral The benzodiazepines have not been well
sequelae of autism with dextromethorphan: A case studied in children or adults with autism. The
report. Journal of Autism and Developmental Disor- short-acting benzodiazepines (lorazepam and
ders, 35(4), 515–518.
alprazolam) are sometimes used to decrease
A 214 Anxiolytics
anxiety prior to medical or dental procedures in Alprazolam is used to treat anxiety disorders
children with ASDs. The right dose given at the in adults.
right time prior to the procedure can be helpful. Lorazepam is used in adults to treat anxiety
However, adverse effects of the benzodiaze- or acute agitation.
pines may include disinhibition (increased
impulsiveness) and poor coordination. The dis-
inhibition can be extreme. Rather than exerting Clinical Use (including Side Effects)
a calming effect, some children have paradox-
ical activation. It is usually advisable to try SSRIs: Currently, the SSRIs are likely the
a test dose before the actual day of the proce- most commonly used medications for
dure to estimate the dose and the child’s the treatment of anxiety. Indeed, several of
response (Scahill, Poncin, & Westphal, 2010). the SSRIs are approved for the treatment of
These adverse effects in the short run and the adults with generalized anxiety disorder,
possibility of habit formation suggest that this social anxiety disorder, and obsessive-
class of medications does not have an important compulsive disorder. But few trials with any
role to play in the treatment of adults or chil- medications focused on anxiety symptoms
dren with autism. have been conducted in subjects with autism
In the treatment of anxiety disorders, effec- spectrum disorders.
tive treatment usually combines cognitive
behavior therapy with medication. The optimal
treatment plan involves discontinuation of See Also
the benzodiazepine after 2–3 months. Long-
term use of benzodiazepines can present ▶ Alprazolam
a significant difficulty in getting the patient off ▶ Benzodiazepines
the medication. ▶ Diazepam
The mechanism of action is complicated, but it ▶ Gabapentin
has been shown that the benzodiazepines enhance ▶ Oxazepam
GABA function in the brain. The benzodiaze- ▶ Selective Serotonin Reuptake Inhibitors
pines bind to specific GABA receptors in the (SSRIs)
brain and enhance a GABA function. GABA is
a primary inhibitory neurotransmitter in the
brain. The effect of the benzodiazepines is to References and Readings
promote the influx of chloride ions in specific
brain areas. This is the mechanism by which Marrosu, F., Marrosu, G., Rachel, M. G., & Biggio, G.
it enhances the inhibitory effects of GABA. (1987). Paradoxical reactions elicited by diazepam in
The commonly used benzodiazepines include children with classic autism. Functional Neurology,
2(3), 355–361.
diazepam, clonazepam, oxazepam, lorazepam, Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric
and alprazolam. psychopharmacology: Principles and practice
Diazepam is used to treat acute agitation and (2nd ed.). New York: Oxford University Press.
anxiety. It is also used in the emergency room to Scahill, L. (2009). Antipsychotic medications. In M. K.
Dulcan (Ed.), Dulcan’s textbook of child and adoles-
manage severe seizures. cent psychiatry (pp. 775–778). Arlington, VA:
Clonazepam is a long-acting benzodiazepine American Psychiatric Publishing.
that is used for the treatment of anxiety and for Scahill, L., Poncin, Y., & Westphal, A. (2010). Alpha-
treating seizures. adrenergics, betas-blockers, benzodiazepines,
buspirone and desmopressin. In M. K. Dulcan (Ed.),
Oxazepam is primarily used to treat anxiety Dulcan’s textbook of child and adolescent psychiatry
disorders in adults but may also be used as a sleep (pp. 775–786). Arlington, VA: American Psychiatric
medication. Association.
APA Division 33 Intellectual and Developmental Disabilities 215 A
• To convey to the public the importance of
Anxiset E (India) psychological, behavioral, and social factors
in the lives of persons with intellectual and A
▶ Escitalopram developmental disabilities.
• To inform legislative and administrative bod-
ies of the importance of psychological, behav-
ioral, and social factors in intellectual and
APA Division 33 Intellectual and developmental disability services and the
Developmental Disabilities value of psychology in contributing to the
solution of problems in this service sector.
Stanley E. Lunde1 and James Anton Mulick2 • To strengthen the practice of psychology in
1
Psychology, UCLA-MRRC Laboratories, intellectual and developmental disabilities as
Lanterman Developmental Center, Pomona, a distinct professional and scientific entity.
CA, USA • To pursue the creation of standards for train-
2
Child Development Center Columbus ing, practice, and research for psychologists in
Children’s Hospital, Columbus, OH, USA intellectual and developmental disabilities.
Definition Historical Background
Mission Statement Division History

The Division on Intellectual and Developmental Prior to the formation of Division 33 in
Disabilities (Division 33) of the American Psy- 1973, psychologists in the mental retardation
chological Association (APA) is an organization field associated with other divisions in APA
of psychologists concerned with research prac- including Clinical Psychology, Developmental
tice and policy in the field of intellectual and Psychology, School Psychology, Rehabilitation
developmental disabilities. Psychology, and Experimental Analysis of
The purpose of the division is to unite in Behavior and also the oldest organization
a single professional organization all members devoted to intellectual and developmental dis-
of the American Psychological Association who abilities, the American Association on Mental
are interested in the psychological and social Deficiency (AAMD), recently renamed the Asso-
aspects of intellectual and developmental disabil- ciation on Intellectual and Developmental
ities and their amelioration: Disabilities (AAIDD). Edgar A. Doll served
• To expand and exchange knowledge and 1932–1933 with Frederick Kuhlman as presiding
information related to intellectual and devel- officers of the Clinical Section of APA and as
opmental disabilities through research, educa- president of AAMD 1934–1935 as he was devel-
tion, and professional communication. oping the Vineland Social Maturity Scale (Doll,
• To enhance professional development and the 1935). He also served 1945–1946 as president of
quality of professional services. the Division of Clinical and Abnormal Psychol-
• To develop partnerships with persons with ogy (Division 12) after it was formed as
intellectual and developmental disabilities a division of APA (Routh, 1997).
and with organizations that represent them in A number of these psychologists wished that
order to incorporate their perspectives in the APA had a division devoted to mental retarda-
division’s efforts. tion, and during the 1970 meeting of the AAMD
• To collaborate with professional organizations Region X in Provincetown, Massachusetts, they
concerned about persons with intellectual and formed a steering committee to create the divi-
developmental disabilities. sion. The members were Allan G. Barclay,
A 216 APA Division 33 Intellectual and Developmental Disabilities
Alfred A. Baumeister, Leonard S. Blackman, neurodevelopmental aspects of intellectual and

Lloyd M. Dunn, Norman R. Ellis, Mortimer developmental disabilities. During the early
Garrison, Olivia J. Hooker, Harris Kahn, 2000s, members were discussing the need to
Henry Leland, Harold Michal-Smith, Murry emphasize neurodevelopmental disorders such
Morgenstern, William Sloan, and Sue A. Warren. as autism in the division programming. Division
The purpose would be to promote psychology as President Sara Sparrow of the Yale Child Study
the “scientist-practitioner” model in the field of Center at Yale University was acutely aware of
mental retardation. The Division on Mental the lack of representation of autism researchers
Retardation (Division 33) was officially founded and practitioners in APA and Division 33 in par-
in January 1973 by a vote of the APA Council of ticular. At the annual meeting in 2004, a decision
Representatives at the annual meeting in 1972. was made to emphasize autistic spectrum disor-
Marie Skodak Crissey was the first president, and der as one major focus and to reach out to psy-
she was followed by Norman R. Ellis and then chologists, graduate students, and to other
Henry Leland (Routh, 1999). organizations interested in autism. The outreach
The Gatlinburg Conference on Theory and has been successful. The number of presentations
Research in Mental Retardation was first held in pertaining to autism during the division’s allotted
1968 as a forum for the presentation of experi- programming hours at the annual APA meetings
mental research as well as for informal interac- has increased as has the number of awards for
tions among participants. For many of these research related to autism.
years, it was held annually in Gatlinburg,
Tennessee, but recently it has alternated among
eastern, western, and southern cities. After the Current Knowledge
founding of Division 33, the Gatlinburg confer-
ence served as an important scientific forum of Landmark Contributions: Autism Spectrum
the division. The Division 33 executive council Disorder
often holds its semiannual meeting at the confer- There was little empirical evidence that a person
ence. An important resource to both the division with autism could learn or become a productive
and the conference was Theodore Tjossem, the member of society until 1987 when a multiyear
chief of the mental retardation and behavioral study based on what is now called applied behav-
disabilities branch of the National Institute of ior analysis (ABA) was published by O. Ivar
Child Health and Human Development, which Lovaas. The study demonstrated that early inten-
supported the institute’s Mental Retardation sive behavioral intervention (<4 years old, 40 h/
Research Centers program (Routh, 1999). week, including all significant people in all sig-
The field of developmental disabilities was char- nificant environments) for 2 and up to 6 years can
acterized by rapid changes in technologies and produce large gains in most children. Children
advances in research during the 1970s and 1980s. were able to pass first grade in either a normal
In recognition of the breadth of conditions that were or “aphasia classes” (Lovaas, 1987). Follow-up at
recognized to constitute intellectual and develop- mean age of 13 years showed that 42% were
mental disabilities, the division changed its name indistinguishable from average children in terms
from the Division on Mental Retardation to the of IQ and adaptive behavior (McEachin, Smith,
Division on Mental Retardation and Developmen- & Lovaas, 1993). Lovaas helped create the field
tal Disabilities in 1988 and to Division on Intellec- of applied behavior analysis (ABA). In 1994, he
tual and Developmental Disabilities in 2007. As of received the division’s highest award, the Edgar
December 31, 2010, there were 545 members A. Doll Award, for revolutionizing the treatment
across the six types of membership including fel- of autism.
low, member, associate, life, affiliate, and student. Claims of “recovery” for some participants
The decade of the brain, 1990–1999, ushered were greeted skeptically. A number of replica-
in a wealth of new findings on the tions showing strong gains have occurred.
However, none of these found as large a gain, the best overall measure to gauge the baseline
though none provided the intensity and duration level of a person’s functioning and subsequently
of the original study (Thompson, 2007a). An the person’s response to intervention(s). Division A
overview of five meta-analyses of early intensive 33 members have been active in extending the
behavioral intervention (EIBI) studies (Reichow, work of Doll (1935, 1936) to develop the Vine-
2011) concluded that EIBI can produce “large land Adaptive Behavior Scales (Sparrow, Balla,
gains in IQ and/or adaptive behavior” for many & Cicchetti, 1984) and the Vineland Adaptive
children and that “the current evidence on effec- Scales-II (Sparrow, Cicchetti, & Balla, 2005,
tiveness of EIBI meets the threshold and criteria 2008), which has become the most widely used
for the highest level of evidence-based treat- measure of adaptive behavior for persons on the
ments.” EIBI strategies have been evolving autistic spectrum. The 2008 version includes sup-
from highly structured programs in one-to-one plemental norms for autism (Carter et al., 1998).
settings to more naturalistic strategies. Pivotal Sara S. Sparrow (1933–2010) received many
response training, developed by former students awards, including the Edgar A. Doll Award in
of Lovaas, is a naturalistic extension of ABA that 2009, for her contributions to measuring adaptive
emphasizes self-initiation, self-management, and behavior and to conceptualizing developmental
responsivity to multiple cues (Schreibman & disability as a holistic understanding of a person’s
Koegel, 2005). self-sufficiencies in everyday life.
Recently, there has been an increasing
emphasis on gene-brain-behavior relationships Landmark Contributions: Death Penalty
to provide a more complete understanding of The Supreme Court agreed in March 2001 to
problem behavior (Schroeder, Oster-Granite, & address the issue, for the third time, of whether
Thompson, 2002). Travis Thompson, past presi- the Eighth Amendment’s prohibition against
dent of Division 33 and recipient of the division’s cruel and unusual punishment prohibits the exe-
Edgar A. Doll Award in 2002, proposed that one cution of an individual with mental retardation. In
of the primary tools of ABA, functional analysis mid-2001, division officers William MacLean,
of problem behavior, be extended to include Laraine Glidden, and Philip Davidson assisted
biological measures functionally related to the the APA Office of General Counsel in preparing
problem behavior (Thompson, 2007b). He also an amicus brief for a North Carolina death
addressed the question of why only approxi- penalty case. Before that case reached the docket,
mately half of the children treated by EIBI the North Carolina legislature passed a law
respond well, by pointing to neurophysiological prohibiting execution of a person with mental
evidence suggesting that practice enhances syn- retardation. The Atkins case from Virginia then
aptic growth, which enables communication both emerged. APA revised the brief and joined the
within and among brain networks. If individuals American Association on Mental Retardation and
lack sufficient neuroplasticity in critical areas, other amici to refile the brief. APA took the
then new synapses may not be formed. He position that execution of a person with mental
suggested that children with autism who were retardation violated the constitutional prohibition
responsive to EIBI may have been able to on cruel and unusual punishment.
develop synapses in critical brain areas during The Supreme Court, in a 6–3 decision
treatment, whereas those unresponsive were (Atkins v. Virginia, 536 U.S. 304, 2002), ruled
unable to develop synapses in these areas that executions of mentally retarded criminals are
(Thompson, 2005, 2007b). “cruel and unusual punishments” prohibited by
Accurate diagnosis of individuals with ASD is the Eighth Amendment. The opinion followed
necessary both for research purposes and for the line of arguments presented in APA’s amicus
determining effective treatment(s). Adaptive brief and specifically cited the brief. This deci-
behavior represents what a person typically does sion effectively banned capital punishment for all
rather than the person’s potential and is perhaps persons diagnosed with mental retardation, now
termed “intellectual disability” (ID). A critical devoted to early intervention and especially
issue remaining was, and is, the appropriate eval- early intensive behavioral intervention for
uation methodology and expertise required young children with autism. The issue of facili-
for assessing such an individual. The division tated communication was also addressed several
Committee on Intellectual Disability and the times in the newsletter, as well as by other actions
Death Penalty has been active in writing articles, taken by the division (details later). Finally, the
making presentations at meetings of attorneys behavior modification interest group column also
and psychologists specializing in ID, and considered problems associated with the use of
testifying in court. Committee members are also aversive motivation in behavior modification.
collaborating with American Association on Newsletters from 2000 to the present are avail-
Intellectual and Developmental Disabilities to able on the division website (http://www.apa.org/
work toward evidence-based standards with divisions/div33/homepage.html).
regard to the assessment of intellectual and adap- Division 33 published its own Manual of
tive behavior deficits for expert witnesses in Diagnosis and Professional Practice in Mental
death penalty cases (Olley, Greenspan, & Retardation in 1996, edited by Jacobson and
Switzky, 2006). Mulick. The peer-reviewed volume was
published by APA Books and went on to become
Division Publications a bestseller for APA. Revenue from the book
Division 33 has one regular publication, the peri- augmented the division treasury and led to
odic newsletter Psychology in Intellectual and a long period of financial solvency for Division
Developmental Disabilities. The first issue was 33. Currently, Division 33 is organizing an
in the winter of 1974. The publication appeared updated and revised manual as a priority project.
irregularly until 1981 when Robert A. Fox began
his term as newsletter editor. Subsequently, the Major Activities
newsletter appeared three times per year. Con- The division sponsors a series of programs at the
tents included division business, articles based on annual meeting of the American Psychological
invited addresses, and talks by Division 33 award Association each year in August. The 2010 APA
winners. annual meeting featured 6 h or 30% of the divi-
Beginning in the early 1990s, officers of sion programming devoted to autism.
Division 33 hoped to generate greater member Division 33 members have always been
interest in participating in the affairs of the divi- involved in advocacy on behalf of people with
sion by offering space in the newsletters to spe- developmental disabilities. At the same time,
cial interest groups. Regular contributors to they have been wary of fads and ephemeral fash-
subsequent newsletters included an interest ions in advocacy that have arisen from time to
group on aging in mental retardation and one time in the general community. Many members
related to behavior modification. For a period of worked actively in the deinstitutionalization
time, the newsletter flourished with these addi- efforts of the 1970s and 1980s. In doing so, they
tional contributions and considerable reader emphasized improvements in treatment
interest was generated by the newsletter. John approaches including behavioral intervention
W. Jacobson and James A. Mulick collaborated and assessment. The treatment of severe behavior
on frequent columns for the behavior modifica- disorders, in part a result of the deplorable con-
tion interest group. These columns gradually ditions inside institutions and of the absence of
evolved into pointedly humorous critiques and services in community settings, led to widespread
expositions of important issues in developmental application of behavioral treatments to normalize
disabilities. Several columns were devoted to their behavior. As treatment procedure evolved,
problems with various definitions and criteria some in the wider field of developmental disabil-
for diagnosing intellectual disability. Beginning ities began to grow concerned about the possible
in the late 1990s, quite a few columns were detrimental or inappropriate use of behavioral
procedures. Pressure to ready former institutional of letters. As asserted by Syracuse Professor,
residents for community life was sometimes Douglas Biklen (1990), the manual support pro-
associated with an emphasis on quick success cedure was known as “facilitated communica- A
and less than thoughtful use of powerful, and tion,” and credulous teachers, classroom aides,
sometimes aversive and restrictive procedures and hopeful parents have been trained in this
with little concern about alternative approaches. technique. Unfortunately, a large body of con-
Then too, many in the broad community could trolled research has established that facilitated
imagine that the labor intensive and sometimes communication was, whenever subjected to
complicated treatment strategies would lead to empirical evaluation, not the product of the per-
a loss of autonomy or even mind control over son with a disability, but rather the often
a vulnerable population. This led advocacy “nonconscious” result of influence by the facili-
groups to criticize the use of “aversive proce- tator (Spitz, 1997). Members of Division 33 con-
dures” and to attempts to use regulations and tributed a critique of facilitated communication
guidelines to control the treatment options that which was published in the American Psycholo-
could be used. Division 33 acted to assert a set of gist (Jacobson, Mulick, & Schwartz, 1995), and
guidelines for the limited, appropriate use of lobbied in APA for the passage of resolution
aversive and restrictive procedures that were con- discouraging the use of facilitated communica-
sistent with the scientific literature on behavior tion by psychologists for any purpose, and cau-
change and the need to control severe aggression, tioning specifically against relying on it as
self-injury, and destructive behavior that would a means of practical communication in any
otherwise deny people with developmental dis- important context. The resolution was adopted
abilities the ability to live in the community. as policy of APA by the Council of Representa-
These guidelines were published in the newsletter tives in 1994. The full text of the resolution was
and included in the division’s Manual of Diagno- included in the Manual of Diagnosis and Profes-
sis and Professional Practice in Mental Retarda- sional Practice in Mental Retardation.
tion (Jacobson & Mulick, 1996), although they The division recently established an Ad Hoc
were not adopted as official policy of the division Committee on Evidence-Based Practice that is
or of the American Psychological Association. chaired by Ann Kaiser. The committee encour-
The pressure for universal education and nor- ages research on empirically based treatment for
malization of conditions in society for people individuals with intellectual and developmental
with developmental disabilities was very intense disabilities and has promoted symposia and pre-
throughout the last quarter of the twentieth cen- sentation at recent APA meetings.
tury and remains so at this writing. Inevitably, the
extravagant desire for universal inclusion some- Division Awards
times clashes with the reality of disability in the Two Student Research Excellence Awards
context of education. Some students have been (annual) are available for students, for proposals
found to be unable to benefit from all but the most submitted for a presentation at the APA annual
systematic and individualized behavioral educa- meeting. During each of the years 2007–2010,
tional services and not to be able to participate in one of these awards went for a study on autism.
traditional teaching approaches in any practical The Edgar A. Doll Award (annual) is named in
sense. Usually, this is the result of a lack of any honor of Edgar A. Doll, the research director of
viable communication ability on the part of the the Vineland Training School from 1925 to 1945
person with the disability. Into this vacuum of where he made profound contributions in the
social and family disappointment, outrageous areas of brain injury, electroencephalography
claims were made for the existence of “hidden (EEG), and adaptive behavior. He is perhaps
literacy” that nevertheless could be induced to best known for developing the Vineland Social
emerge with mere manual support of the disabled Maturity Scale (1935), the revised versions of
person’s hand or arm over a keyboard or array which are generally considered to provide the
most useful measure of the impact of intellectual professional meetings. They also advocate for
and developmental disabilities (see above). The treatment services for individuals with intellec-
Doll award is the division’s highest recognition tual and developmental disabilities.
of outstanding scientific contributions to the field The recently established Ad Hoc Committee
of intellectual and developmental disabilities and on Evidence-Based Practice encourages
was first given in 1981 to Samuel A. Kirk. research and dissemination of findings on
The John W. Jacobson Award (biannual) empirically based treatment for individuals
acknowledges John W. Jacobson’s dedication to with intellectual and developmental disabil-
critical thinking in the field (see contributions ities. Committee members conduct research on
above). The Jacobson award recognizes merito- empirically based treatments and also organize
rious contributions to the field of intellectual and symposia and promote presentations at profes-
developmental disabilities in an area directly sional meetings.
related to behavioral psychology, evidence- The 2010 health-care legislation requires reg-
based practice, dual diagnosis, or public policy ulations for implementation. The US Department
and was first given in 2007 to Richard Foxx. of Health and Human Services (HHS) and state
The Sara S. Sparrow Early Career Research governments are developing the details of how
Award (see her contributions above) of Division the health-care legislation will work. The execu-
33, alternating biannually with the Jacobson tive council of the division will be closely mon-
Award, honors an early career individual who itoring the development of regulations that
has made substantial contributions to the under- pertain to psychological services for individuals
standing of intellectual or developmental disabil- with intellectual and developmental disabilities,
ities as reflected in his or her published and especially ASD. Division members are preparing
presented works. The award was first given in work with the central APA office to inform
2008 to Luc Lecavalier. HHS and state agencies of best practices for the
treatment of an individual with ASD and of
the qualifications needed for those providing
Future Directions treatment services.
The division will continue to emphasize autistic

spectrum disorder (ASD) as one major focus and See Also
to reach out to psychologists, graduate students,
and to other organizations interested in autism. ▶ American Psychological Association
Programming at the annual meeting will include ▶ Early Intensive Behavioral Intervention (EIBI)
research aimed toward a better understanding of ▶ Pivotal Response Training
the genetic, neurophysiological, psychological, ▶ UCLA Young Autism Project
and social factors and their interactions that ▶ Vineland Adaptive Behavior Scales
underlie ASD and other intellectual and develop-
mental disabilities.
The division has five special interest groups: References and Readings
behavior modification and technology, dual diag-
nosis, early intervention, aging and adult devel- Biklen, D. (1990). Communication unbound: Autism and
praxis. Harvard Educational Review, 60, 291–314.
opment, and making the transition into Carter, A., Volkmar, F., Sparrow, S., Wang, J., Lord, C.,
adulthood. Division members involved pursue Dawson, G., et al. (1998). The vineland adaptive
research in these areas and contribute to the sci- behavior scales: Supplementary norms for individuals
entific and professional literature. They partici- with autism. Journal of Autism and Developmental
Disorders, 28, 287–302.
pate in forums at professional meetings to present
Doll, E. A. (1935). The vineland social maturity scale:
and discuss the latest findings. In particular, Manual of directions. The Training School Bulletin,
members promote and organize symposia at 32, 1–3.
Apgar Score 221 A
Doll, E. A. (1936). The Vineland social maturity scale: Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005).
Revised condensed manual of directions. Vineland: Vineland adaptive behavior scales: Second edition
The Training School. (Vineland II), survey interview form/caregiver rating
Jacobson, J. W., & Mulick, J. A. (Eds.). (1996). Manual of form. Livonia, MN: Pearson Assessments. A
diagnosis and professional practice in mental retarda- Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2008).
tion. Washington, DC: American Psychological Vineland adaptive behavior scales: Second edition
Association. (Vineland II), The expanded interview form. Livonia,
Jacobson, J. W., Mulick, J. A., & Schwartz, A. A. (1995). MN: Pearson Assessments.
A history of facilitated communication: Science, pseu- Spitz H. (1997). Nonconscious movements: from mystical
doscience, and antiscience. American Psychologist, messages to facilitated communication. Manwah, NJ:
50, 750–765. Lawrence Erlbaum.
Lovaas, O. I. (1987). Behavioral treatment and normal Thompson, T. (2005). Paul E. Meehl & B. F. Skinner:
educational and intellectual functioning in young Autitaxia, autitypy and autism. Behavior and Philoso-
autistic children. Journal of Consulting and Clinical phy, 33, 101–131.
Psychology, 55, 3–9. Thompson, T. (2007a). Making sense of autism.
McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long- Baltimore: Paul H. Brooks Publishing.
term outcome for children with autism who received Thompson, T. (2007b). Relations among functional sys-
early intensive behavioral treatment. American tems in behavior analysis. Journal of the Experimental
Journal of Mental Retardation, 97, 359–372. Analysis of Behavior, 87, 423–440.
Olley, J. G., Greenspan, S., & Switzky, H. (2006). Divi-
sion 33 ad hoc committee on mental retardation and
the death penalty. Psychology in Mental Retardation
and Developmental Disabilities, 31(2), 11–13.
Reichow, B. (2011). Overview of meta-analyses on early Apgar Score
intensive behavioral intervention for young children with
autism spectrum disorders. Journal of Autism and Devel-
opmental Disorders. doi: 10.1007/s10803-011-1218-9.
Susan Hyman
Reichow, B., & Wolery, M. (2009). Comprehensive Division of Neurodevelopmental and Behavioral
synthesis of early intensive behavioral interventions Pediatrics, University of Rochester Golisano
for young children with autism based on the UCLA Children’s Hospital, Rochester, NY, USA
Young Autism Project model. Journal of Autism and
Developmental Disorders, 39, 23–41.
Routh, D. K. (1997). A history of Division 12 (Clinical
Psychology): Fourscore years. In D. Dewsbury (Ed.), Definition
Unification through division: Histories of the divisions
of the American Psychological Association (Vol. 2,
pp. 55–82). Washington, DC: American Psychological
The Apgar score is a numerical score developed
Association. by Virginia Apgar, MD, an American anesthe-
Routh, D. K. (1999). A history of Division 33 (Psychology siologist, in 1952 to standardize the description
in Mental Retardation and Developmental Disabilities). of newborn infant medical stability in the deliv-
In D. Dewsbury (Ed.), Unification through division:
Histories of the divisions of the American Psychological
ery room. A scale from 0 (worst) to 2 (normal)
Association (Vol. 3, pp. 117–142). Washington, DC: is assigned to the following parameters: heart
American Psychological Association. rate (no heart rate to normal >100 beats per
Schreibman, L., & Koegel, R. L. (2005). Training for minute), respiratory effort (no respiratory
parents of children with autism: Pivotal responses,
generalization, and individualization of interventions.
effort to cries and has regular breathing), mus-
In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial cle tone (flaccid to active motion), reflex irrita-
treatments for child and adolescent disorders: bility (no response to grimace and cry), and
Empirically based strategies for clinical practice skin color (dusky blue to pink). The scores are
(pp. 605–631). Washington, DC: American Psycho-
logical Association.
added up to quantify the infant’s status at 1 and
Schroeder, S. R., Oster-Granite, M. L., & Thompson, T. 5 min. Infants rarely receive perfect scores of
(Eds.). (2002). Self-injurious behavior: Gene-brain- 10 because they typically have bluish-colored
behavior relationships. Washington, DC: American fingertips even if they are otherwise pink (1 for
Psychological Association.
Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984).
color). Lower Apgar scores may reflect neona-
Vineland adaptive behavior scales: Survey form man- tal stress, use of maternal anesthetic, and imma-
ual. Circle Pines, MN: American Guidance Service. turity or prematurity. Apgar scores were
A 222 Aphasia
designed for use with term infants. Scores of 0– can include both the spoken and written
3 at 1 and 5 min indicate neonatal depression modalities. Aphasia most commonly occurs
and suggest the need for medical attention to secondary to stroke in which brain cells are
help the baby adjust to postnatal conditions. deprived of oxygen, resulting in tissue death,
A lower Apgar score at 1 min with a normal but it can also be the result of degenerative
range score at 5 min is not typically of concern. disorders or traumatic brain injury. Aphasia
Apgar scores are not measures of neonatal can co-occur with other conditions including
asphyxia or necessarily predictive of later neu- apraxia and dysarthria which are neurologi-
rologic impairment. cally based motor disorders that can affect
speech output.

Categorization
American Academy of Pediatrics, Committee on Fetus
and Newborn and Committee on Obstetric Practice,
Historically, aphasia has been classified
American College of Obstetrics and Gynecology.
(1996). Use and abuse of the Apgar score. Pediatrics, according to the region of the brain that is
98, 141–142. affected and the symptoms that are displayed.
Health children, American Academy of Pediatrics. http:// For example, damage to what is considered
www.healthychildren.org/English/ages-stages/prenatal/
“Broca’s area,” the region anterior to the
delivery-beyond/pages/Apgar-Scores.aspx?nfstatus¼
401&nftoken¼00000000-0000-0000-0000-00000000 rolandic fissure, often results in a nonfluent
0000&nfstatusdescription¼ERROR%3a+No+local+ form of aphasia in which comprehension is
token. Accessed May 23, 2012. intact, but articulation and speech output,
National Library of Medicine and National Institutes
including syntax, is impaired. A disorder in
of Health. http://www.nlm.nih.gov/medlineplus/ency/
article/003402.htm. Accessed May 23, 2012. which syntax and language output are preserved,
while comprehension is impaired, is often
referred to Wernicke’s aphasia, due to the fre-
quent damage that is observed in Wernicke’s
area within the temporal lobe of the brain. How-
Aphasia ever, as research continues to indicate that there
is not necessarily a one-to-one correspondence
Elizabeth R. Eernisse between region in which brain damage is
Department of Language and Literacy, Cardinal displayed and the type of symptoms that are
Stritch University, Milwaukee, WI, USA experienced, other classification systems have
developed.
More recently, types of aphasia have been
Synonyms divided into two categories: fluent and nonfluent
aphasias. Fluent aphasias include Wernicke’s
Dysphasia aphasia (above) and are characterized by individ-
uals speaking in long sentences that often contain
unnecessary words and are devoid of meaning.
Short Description or Definition Comprehension in Wernicke’s aphasia is often
impaired as well.
Aphasia, from the Greek term “aphatos” Nonfluent aphasias include Broca’s aphasia
meaning “without language,” is a disorder (above). In addition, global aphasia is another
caused by damage to the language areas of nonfluent aphasia that is characterized by exten-
the brain. Depending on the type and severity sive brain damage and severe communication
of the damage, deficits may be noted in lan- deficits in both receptive and expressive
guage comprehension and/or production and language.
Aphasia 223 A
Epidemiology follows. Evaluation includes the use of language
in both comprehension and production contexts,
The incidence of aphasia is largely unknown, including reading and writing. Evaluations typ- A
given that it occurs in many types of disorders ically include taking a comprehensive case his-
including cerebrovascular, traumatic, and degen- tory, observation of the patient in daily contexts,
erative disorders. In general, it is estimated that and formal evaluations of language skills,
about one million individuals in the USA demon- including naming of objects. Standardized eval-
strate aphasia with approximately 80,000 indi- uation tools that often are used include the
viduals acquiring this disorder every year Boston Diagnostic Aphasia Examination
(ASHA, 2008). (Goodglass, Kaplan, & Barresi, 2000), the Bos-
ton Naming Test (Kaplan, Goodglass, &
Weintraub, 1983), and the Western Aphasia Bat-
Natural History, Prognostic Factors, and tery (Kertesz, 2006). Once the individual’s pro-
Outcomes file of language strengths and needs is
determined, treatment is initiated.
Outcomes for patients with aphasia vary greatly
depending on the type and location of brain dam-
age and level of severity of the disorder. Recov- Treatment
ery is often more favorable for younger
individuals or individuals with less extensive Treatment for aphasia is often multifaceted and is
brain damage. In addition, language comprehen- typically individualized based on the patient’s
sion skills are often recovered more completely profile of strengths and needs. Individuals with
than language production skills. Factors includ- aphasia often enroll in formal speech-language
ing age of onset, health, education level, and how therapy to address functional communication in a
soon treatment takes place after brain damage variety of settings in which they are expected to
have been shown to be predictive of recovery in communicate. Therapy goals are focused
aphasia. on maximizing the individual’s ability to com-
municate effectively with peers and family mem-
bers, given residual strengths. In addition,
Clinical Expression and computer-assisted treatments are beginning to
Pathophysiology show promise as supports for individuals with
aphasia.
Aphasia typically manifests itself as a difficulty Although some individuals recover
in language comprehension, production, or both completely, individuals with aphasia often expe-
depending on the type and severity of the condi- rience lifelong deficits. In these cases, family
tion. Aphasia most commonly occurs secondary member and patient support groups are often
to stroke, but it can also be the result of degener- a critical piece of the therapeutic process as the
ative disorders or traumatic brain injury. patient and family learn to manage their new
situation. The National Institute on Deafness
and other Communication Disorders (NIDCD,
Evaluation and Differential Diagnosis 2011) recommends the use of the following care-
giver support strategies:
Aphasia is typically initially diagnosed by a • Simplify language by using short, uncompli-
neurologist or other physician who is responsi- cated sentences.
ble for the treatment of the patient’s physical • Repeat the content words or write down key-
and neurological symptoms utilizing case his- words to clarify meaning as needed.
tory and observation. Further evaluation by • Maintain a natural conversational manner
a licensed speech-language pathologist often appropriate for an adult.
A 224 Aphonia
• Minimize distractions, such as a loud radio or

TV, whenever possible. Aphonia
• Include the person with aphasia in
conversations. Elizabeth R. Eernisse
• Ask for and value the opinion of the person Department of Language and Literacy, Cardinal
with aphasia, especially regarding family Stritch University, Milwaukee, WI, USA
matters.
• Encourage any type of communication, whether
it is speech, gesture, pointing, or drawing. Synonyms
• Avoid correcting the person’s speech.
• Allow the person plenty of time to talk. Loss of voice
• Help the person become involved outside the
home. Seek out support groups such as stroke
clubs. Short Description or Definition
Aphonia is the complete loss of voice, typically

See Also due to an acquired cause such as vocal cord
paralysis or damage to the recurrent laryngeal
▶ Broca’s Aphasia nerve. In aphonia, phonation (i.e., the process
▶ Global Aphasia by which sounds are produced through the
▶ Wernicke’s Aphasia vibration of the vocal folds) is completely
impaired, in contrast to dysphonia in which
sound production is limited but not completely
References and Readings absent. Individuals with aphonia are only able to
whisper when attempting to speak.
American Speech-Language-Hearing Association
(ASHA) (2008). Incidence and prevalence of speech,
voice, and language disorders in adults in the United
States. Retrieved May 1, 2011, from www.asha.org/ Epidemiology
research/reports/speech_voice_language.htm
Barresi, B., Goodglass, H., & Kaplan, E. (2001).
While specific epidemiologic estimates of the
The assessment of aphasia and related disorders.
Hagerstown, MD: Lippincott, Williams & Wilkins. incidence of aphonia are rare, generally speaking,
Chapey, R. (2008). Language intervention strategies in approximately 7.5 million people in the United
aphasia and related neurogenic communication disor- States demonstrate difficulty with vocal use.
ders. Philadelphia: Wolters Kluwer/Lippincott,
Voice disorders are more prevalent in individuals
Williams & Wilkins.
Goodglass, H., Kaplan, E., & Barresi, B. (2000). Boston working in occupations that are characterized by
diagnostic aphasia examination (BDAE-3) (3rd ed.). frequent or intense vocal use.
Austin, TX: Pro-Ed.
Kaplan, E., Goodglass, H., & Weintraub, S. (1983). The
Boston naming test. Philadelphia: Lea and Febiger.
Kent, R. D. (1994). Reference manual for communicative Natural History, Prognostic Factors, and
sciences and disorders: Speech and language. Austin, Outcomes
TX: Pro-Ed.
Kertesz, A. (2006). Western aphasia battery-revised
Some of the known causes of aphonia include
(WAB-R). Austin, TX: Pro-Ed.
Lapointe, L. L. (2004). Aphasia and related neurogenic laryngeal or thyroid cancer, vocal fold paralysis,
language disorders. New York: Thieme Medical nodules or polyps on the vocal folds, vocal abuse,
Publishers. respiratory problems, injury to the laryngeal
National Institute on Deafness and Other Communication
nerve, surgical removal of the larynx, vocal fold
Disorders (NIDCD) (2011). Aphasia. Retrieved
May 1, 2011, from http://www.nidcd.nih.gov/health/ thickening, or, in rare cases, psychogenic causes.
voice/aphasia.htm Risk for aphonia increases when an individual is
Applied Behavior Analysis 225 A
exposed to surgery involving the larynx, when an See Also
individual engages in vocally abusive behaviors
such as smoking or vocal overuse, or when an ▶ Speech Impairment A
individual experiences anxiety. Prognosis for
recovery largely depends upon the cause, sever-
ity, and nature of the disorder. References and Readings
Aronson, A. E., & Bless, D. M. (2009). Clinical voice

disorders (4th ed.). New York: Thieme.
Clinical Expression and ASHA (2008) Incidence and prevalence of speech,
Pathophysiology voice, and language disorders in adults in the United
States: 2008 edition: Retrieved from 1 May 2011.
Aphonia manifests itself as a complete loss of www.asha.org/research/reports/speech_voice_language.
htm
voice. Some individuals are able to whisper,
Boone, D. R., McFarlane, S. C., Von Berg, S. L., &
while others demonstrate total vocal loss. Zraick, R. I. (2009). The voice and voice therapy
(8th ed.). Boston, MA: Allyn & Bacon.
Johnson, A. F., & Holcomb Jacobson, B. (2007). Medical
speech-language pathology: A practitioner’s guide.
Evaluation and Differential Diagnosis Michigan: Thieme.
NIDCD (2010). Statistics on Voice, Speech Language
Aphonia is typically diagnosed by medical from NIDCD: Retrieved from 1 May 2011. www.
professionals who specialize in voice disorders nidcd.nih.gov/health/statistics/vsl.asp
Rammage, L., Morrison, M., & Nichol, H. (2001).
such as physicians who specialize in Ear, Nose,
Management of the voice and its disorders (2nd ed.).
& Throat conditions (ENTs), or medically San Diego, CA: Singular.
trained speech-language pathologist. Diagnos- Stemple, J., Glaze, L., & Gerdeman Klaben, B. (2000).
tic procedures typically involve thorough case Clinical voice pathology - Theory and management
(3rd ed.). San Diego: Singular.
histories as well as physical examination to
Verdolini, K., Rosen, C. A., Branski, R. C., & Andrews,
determine possible causes. Diagnostic proce- M. L. (2006). Classification manual for voice
dures include analyses of vocal fold function disorders I. Mahwah, NJ: Lawrence Erlbaum.
including laryngoscopy and videostroboscopy.
In the case of the absence of a clear physical
cause, psychological evaluations are often
recommended. Apo-Haloperidol
▶ Haloperidol
Treatment
Treatment of aphonia depends upon the nature

and severity of the disorder. Treatments can Applied Behavior Analysis
include surgery, counseling for anxiety and
related issues that appear to be causing tension Kathleen Dyer
that limits vocal fold function, lifestyle changes River Street Autism Program at Coltsville,
such as vocal rest, change of occupation, Capitol Region Education Council/Elms College,
increased hydration, and relaxation techniques, Hartford, CT, USA
and formal voice therapy. Often therapy with a
licensed speech-language pathologist is
recommended, especially in cases where specific Definition
counseling and treatment techniques appear to be
beneficial to the patient in terms of recovery of Applied behavior analysis (ABA) is a science that
vocal function. identifies variables that meaningfully and
A 226 Applied Behavior Analysis
lawfully influence socially significant behavior in autism, data collection, and early single-subject
real-world settings. This is done by using princi- methodology became the foundations of a new
ples of behavior to successfully teach and support science for behavior change called applied
the learning of adaptive, constructive behavior behavior analysis.
and by reducing excessive problem behavior. Excitement from these early studies also led to
Within ABA, the behaviors to be changed and the development of research laboratories that
descriptions of interventions responsible for focused solely on the comprehensive treatment
changes are explicitly defined and technologi- of children with autism, with the most notable
cally exact, allowing replication of procedures being Behavioral Intervention Clinic at the
by others. This technological precision allows University of California, Los Angeles (UCLA).
analysis and establishment of functional relation- Under the direction of O.I. Lovaas, the behavioral
ships between interventions and behavior change. model focused on treating observable behavioral
It is these interventions that have been come to deficits and excesses exhibited by the children
known in the public vernacular as ABA. and rejected the earlier popular notion that autism
was a psychopathology caused by poor mother-
ing. The original findings from the University of
Historical Background Washington were thus replicated with larger
numbers of children and a broader range of
Applied behavior analysis had its origins at the behavioral targets, with more carefully controlled
University of Washington in the early 1960s, studies. These early studies also revealed the
when Montrose Wolf, Todd Risley, and col- deleterious effects of institutional environments
leagues conducted a series of studies designed to and the positive effects of intensive, early, com-
change behavior using principles of operant con- prehensive treatments that included parent train-
ditioning delineated by B.F. Skinner. These ing in community settings.
researchers were asked to help a 3-year-old child The results of a 1987 study published by
with autism who was living in a psychiatric facil- Lovass, showing that 47% of 19 children
ity. Having received cataract surgery, he was at achieved normal intellectual functioning, as
risk for permanently losing vision, as he would not well as successful inclusion in school, resulted
wear his glasses. He displayed self-destructive in controversy regarding the methods employed
tantrums, had sleeping problems, eating problems, in the study and the dramatic results that were
and severe deficits in functional communication. gained. This treatment was named the Lovaas
Attempts to treat these problems with sedatives, approach or early intensive behavioral interven-
tranquilizers, and restraints were unsuccessful. tion (EIBI), and many replication studies were
Behavioral intervention consisted of shaping conducted following this historical work. While
of behavior by reinforcing successively longer the results of the subsequent studies did not reveal
periods of glasses wearing with small bits of the extent of improvement in the Lovaas, 1987
preferred food and of removal of social attention study, positive effects of EIBI were still
for tantrums. Gains in appropriate speech evidenced, with children showing socially mean-
resulted from presenting clear cues to verbalize ingful improvements as a result of behavioral
and reinforcement of correct responses with intervention. Researchers and scholars in the sci-
small bites of food. What is now known as dis- entific community responded to findings with
crete-trial training was pioneered in this original questions regarding the effectiveness of this
effort. Additional hallmarks of this study were intervention with children of varying severity
staff and parent training, early intervention, and levels and with comorbid diagnosis. Many
systematic follow-up to ensure maintenance of scholars cautioned against a “one-size-fits-all”
treatment gains, as well as teaching of new, philosophy when considering EIBI interventions.
socially appropriate behavior. In addition, the A change in terminology occurred when the,
natural setting intervention for children with and the interventions designed from the science
of applied behavior analysis, began to be com- vantage point. This model sees specific
monly referred to as “ABA.” Common use of the responses as those selected for survival by the
term in the public vernacular referred to one-to- function they perform. Behavior is examined A
one discrete-trial interventions in low distraction objectively and viewed as evolving from peo-
environments, where individual skills were ple’s histories of interactions with their environ-
taught using in a massed-trial approach using ments. Scientific investigation is conducted in
high rates of positive reinforcement. the real-world laboratory, and behavior is ana-
However, scholars and researchers continued to lyzed to determine systematic relationships
use the science of applied behavioral analysis between conditions of the environment and
research, including single-subject designs and resultant behavior.
socially valid treatments and outcomes, to expand
the intervention strategies. Interventions were
developed to increase the amount of child control Goals and Objectives
in the intervention by incorporating children’s
choices and preferences and following the child’s In applied behavior analytic interventions,
lead in language intervention. In addition, Edward socially valid behavior change goals that are ben-
Carr and V. Mark Durand discovered that many eficial to the student and those in his or her
problem behaviors served a communicative func- environment are of primary importance. In
tion for valid needs including the need for atten- autism intervention, goals focus on behavior
tion, the need for assistance, and the need to say change in areas of behavioral deficits, including
“no” to unpleasant things. This evolved into func- communication, social, play behavior, and areas
tional communication training as a major focus of of behavioral excess, including repetitive behav-
behavioral intervention, where students were ior patterns and problem behaviors such as self-
taught appropriate communication to replace injury, aggression, property destruction, and
severe problem behavior. tantrums. Overall goals focus on building age
In addition to an expansion of treatments, and developmentally appropriate skills to
applied behavior analysis treatments expanded improve independent functioning in home,
to include interventions with older children, ado- school, and community settings, answering the
lescents, and adults, with emphasis on appropri- following questions:
ate academic skills in the classroom, vocational • What skills are interfering with the learning
skills, and peer socialization. Settings expanded process, and how can we decrease them?
to include entire day and residential treatment • What skills are necessary for the student to
facilities devoted to behavioral intervention function within school settings?
with students with autism, inclusion models, • What skills are necessary for the student to be
applications in public schools, home programs, able to transition to a less restrictive setting or
community settings, and adult education pro- classroom?
grams. Today, ABA procedures are now being • What skills are appropriate to the student’s
implemented with individuals with ASD interna- developmental level?
tionally, in countries including Norway, Spain, • What appropriate skills are needed to serve the
Australia, China, Japan, France, Scotland, function of problem behavior?
Canada, Germany, Greece, the United Arab • What skills are needed to develop independent
Emirates, Ireland, and England. functioning in home, vocational, and commu-
nity settings?
• What skills are needed to increase the ability
Rationale or Underlying Theory for the student to make informed choices,
becoming their own advocates, and control-
The ABA model addresses behavior scientifi- ling their environment in an effort to improve
cally and views behavior from a functional overall quality of life?
Treatment Participants cue) to the student who is attending to the

instructor or task at hand.
Treatment procedures developed from the sci- – The stimulus may be followed by a prompt
ence of ABA have been used with individuals to evoke the desired response.
with ASD across the age range. The majority of – The student responds correctly or
research studies, particularly discrete-trial inter- incorrectly.
ventions, have been conducted with younger – The teacher provides a consequence that is
children diagnosed as having autistic disorder immediate, easily discriminable, contin-
and PDD-NOS. Fewer studies have been gent, and consistent.
conducted with adolescents and even fewer with – There is a brief 1–3-s intertrial interval
adults. In addition, procedures documented with before the next trial begins.
individuals with Asperger’s disorder are limited • Extinction: When using this strategy, rein-
to social narratives, video modeling, and self- forcers maintaining problem behavior are
management packages (see below). Finally, at first identified, and treatment then involves
least one study has found negligible effects of removing those reinforcers to decrease the
intensive ABA interventions for children with problem behavior. For example, if a student
Rett syndrome. were engaging in a tantrum to gain access to
a desired toy, the toy would not be provided
when tantrum behavior was displayed. The
Treatment Procedures most common reinforcers that are removed
are access to tangible items, escape from
Treatment procedures developed from the sci- nonpreferred task demands, and attention.
ence of ABA, heretofore referred to as ABA Removal of access to sensory reinforcers that
interventions, have a behavioral emphasis as would be provided for individuals who engage
their foundation. The cornerstone of this founda- in self-stimulatory behavior is known as sen-
tion is differential reinforcement, where desired sory extinction. When implementing extinc-
behaviors are reinforced, and undesired behav- tion, it is common to see an increase in the
ioral excesses are not reinforced. By reinforcing increase and intensity of the problem behav-
behaviors that are more functional than the prob- ior, known as an extinction burst, before the
lem behavior, inappropriate behaviors are behavior decreases. This procedure is com-
thereby replaced with appropriate behavior. For monly used in conjunction with differential
students with ASD, ABA interventions are com- reinforcement.
monly on a continuum of instructor-directed • Antecedent-based interventions: These
activities in low distraction isolated environ- involve the modification of environmental
ments to interventions that have a higher degree events that occur before a target behavior is
of shared control between the instructor and produced, with the aim of preventing problem
student, with more peers, in naturalistic school, target behaviors and setting the occasion for
home, and community environments. Descrip- competing, appropriate behaviors. Providing
tions of these interventions are as follows: a fast instructional pace, known as using
• Discrete-trial intervention: Initial treatment short 1–2-s intertrial intervals, prevents the
often focuses on intense training of small, occurrence of competing self-stimulatory
discrete skills through repeated opportunities behavior, and providing choices of tasks and
to respond to trials, and this is referred to as preferred materials increases interest level
discrete-trial instruction. This helps present and reduces competing problem behaviors.
instruction in a clear manner with the general Other antecedent interventions include
format for a training trial as follows: (1) changing the schedule, (2) providing cues
– The instructor presents a clear stimulus about schedule changes, (3) providing mate-
(instruction, question, or environmental rials that the student can engage with to
compete with interfering behavior (such as prompts and provides the student an oppor-
using a squeeze ball while walking to reduce tunity to perform the response on each trial.
hand flapping), (4) stimulus variation, If the student does not respond correctly A
(5) errorless learning, (6) priming, (7) seating after presenting the instructional cue, the
arrangements, and (8) interspersing mastered teacher provides more assistance (e.g.,
tasks. a verbal prompt). If, after a short latency,
Natural language interventions: Hallmarks of the student fails to make the correct
natural language interventions are following the response, the instructor provides even more
student’s communicative initiations for access assistance (e.g., a model). This is followed
preferred items and activities. The instructor by even more intrusive prompting (e.g.,
sets up the environment with multiple preferred a physical prompt) until a correct response
items and activities, and after the student indi- is achieved.
cates a desire for the item, the instructor prompts • Graduated guidance: This employs prompts
the student to use an elaborated form of commu- of decreasing intrusiveness and is typically
nication. For example, in a play interaction, if used to ensure errorless responding. For exam-
a child indicated a desire for a hammer by ple, an instructor teaching a student to ride
reaching for it, the instructor would block access a bicycle would begin with full physical
to the hammer and prompt the child to request the prompting and gradually fade to partial phys-
hammer using communicative form that has been ical prompting and then to shadow prompting
targeted by the team as developmentally and by keeping his hands close to the student, as
socially appropriate. Prompts to communicate the student gradually gained physical control
are faded over repeated opportunities to commu- over the response.
nicate requests for the items, such that the pre- • Time delay: When using a time delay
ferred item becomes the cue for appropriate prompting strategy, the instruction is pro-
communication rather than reliance on external vided, and after a brief delay, the prompt is
instructor prompts. These interventions have provided. This strategy was initially used to
been referred to as incidental teaching, the natu- increase student requesting of desired items in
ral language paradigm, and one aspect of pivotal the presence of the items, rather than being
response training (see below). dependent on adult’s telling them to ask for
Functional communication training: When what they want, or on answering questions
children are using problem behavior to commu- such as “What do you want?” Time delay
nicate valid needs to gain something desired or strategies have been expanded across a wider
avoid/escape something undesired, appropriate range of skills including skills that require
communicative behaviors are taught to replace responding to environmental rather than
these problem behaviors. Widely targeted com- adult cues.
municative responses include requesting pre- Shaping: New responses that are not yet in the
ferred items, attention, or a break, or protesting student’s repertoire are shaped through reinforce-
nondesired activities or items. ment of successive approximations to the
Prompts and prompt fading: Prompts are extra targeted response. For example, if a student
cues used to effectively guide the student’s were learning to request a preferred toy by
response and are faded during the course of treat- pointing, the teacher would first reinforce the
ment. Prompting strategies include: child if they reached for the object, and then
• Fading prompt intensity: This is done gradu- over successive trials, the child would be required
ally, over a series of successive trials where to make more specific finger pointing responses
progressively less intensive stimuli are used to to gain access to the toy.
guide the student to make a correct response. Task analysis/chaining: This involves task
• Least-to-most prompting hierarchies: This is analyzing complex skills that have many steps
also referred to as a system of least intrusive into their component parts such as multistep
vocational, self-care, leisure, and independent words, objects, labels, scripts, and visual bound-
academic behaviors. Examples of behaviors that aries. Widely used visual supports include (1) pic-
are task analyzed and taught through chaining are ture activity schedules, which provide the steps to
shoe tying, bed making, bowling, operating engage in a sequence of independent play, voca-
a computer, following a recipe, and object assem- tional, or self-care activities; (2) visual schedules
bly. These task-analyzed sequences can be taught which provide the student with support to inde-
through one of the following strategies: pendently transition across activities through the
• Backward chaining: This begins by prompting day; and (3) scripts, which can assist individuals
the student through all the steps of the chain during social exchanges.
except the last and requiring the student to Picture exchange communication system
complete the last step correctly and indepen- (PECS): Students are provided with visual sup-
dently to gain reinforcement. For example, if ports in the form of pictures that are exchanged
a student were learning how to tie their shoe, with a listener during communicative interac-
the trainer would require the student to com- tions. Communicative skills in the PECS system
plete the final step, which would be pulling the include (1) spontaneous requesting of items,
laces tight, before obtaining reinforcement. activities, assistance, and breaks;
After the student mastered the last step, the (2) commenting; (3) building sentence structure;
trainer would require the last two steps of the and (4) responding to “What do you want?”
chain performed correctly before providing Pivotal response training: Pivotal skills
reinforcement and so on. known to affect large areas of learning are the
• Forward chaining: This begins by requiring focus of this intervention. Attention, motivation,
the student to perform the first response in responding to multiple cues, self-management,
a chain to gain reinforcement. For example, and self-initiation are skills that provide the foun-
if a student was learning how to tie their shoe, dation upon which widespread generalization of
the trainer might prompt the student to cross learning can occur. Characteristics of pivotal
the first lace and then provide reinforcement. response training include using student interests
After the student mastered this first step, in the context of play, varied materials, and
instruction would require two steps of the responses; reinforcement of attempts to commu-
chain performed correctly before providing nicate; shared control, and using natural and
reinforcement and so on. direct reinforcers.
• Whole-task training: The student is allowed to Self-management: The individual with ASD is
complete all steps of the chain, and the instruc- taught to independently regulate their own behav-
tor either uses least-to-most or graduated iors by setting their own goals, accurately record-
guidance prompting strategies on each step ing and monitoring their own behavior, and
of the chain. rewarding themselves for engaging in desired
Video modeling: Students watch a video targets.
recording of the targeted appropriate behavior Peer- and sibling-based interventions: Same-
as a preliminary step in teaching. Models can be aged peers or siblings can support the learning
adults, peers, and/or experts performing the skill. of the individual with ASD using behavioral
When self-modeling is used, the interventionist strategies. While these have customarily
films the student, edits out any undesired behav- involved social skills training, additional areas
ior, and shows the student a film engaging in only of training have involved the implementation of
the desired behavior. This technique is com- natural language training, discrete trial inter-
monly used to teach social skills, appropriate vention, and picture exchange communication
academic behavior, and play skills. systems.
Visual supports: Visual stimuli are used to aid Parent-implemented interventions: Parents
the individual with ASD to engage in appropriate have been successfully trained to use behavioral
behavior. These stimuli can include pictures, intervention strategies to build appropriate skills
and reduce problem behaviors using all the ABA • American Psychological Association
based-procedures delineated in this section. • American Speech-Language-Hearing
Social narratives: These describe situations Association A
with examples of desired responding and relevant • Society for Developmental and Behavioral
cues to display those behaviors and are often Pediatrics
presented in a short-story format with salient • Autism Society of America
pictures. They are used as a precursor to an • National Institute of Child Health and Human
upcoming event and are often used to teach Development
appropriate social skills and address problem • National Institute of Mental Health
behaviors.
Programming for generalization: Skills are
taught using the above-described strategies Outcome Measurement
across persons, places, language cues, and set-
tings. An essential component of ABA interven- Target behaviors are measured on a regular
tion is family involvement, where parent training basis, with 10–40 trials a day as a standard in
and sibling training are conducted. In addition, many ABA programs. Data is collected on the
same-aged peers can be recruited to implement frequency, intensity, duration, and accuracy of
peer-mediated instruction or interventions. targeted behaviors. Criterion is established at
Finally, to increase generalization of responding the beginning of treatment to provide clear indi-
in environments without adult direction, self- cators of mastery of the target behavior. Suc-
management strategies are taught. cessful outcomes are those where the targeted
behavior change has been achieved, and that the
change has maintained in the presence of natu-
Efficacy Information ral contingencies, as well as generalized across
persons, settings, and other relevant situations
Expert panels and task forces have reviewed where the behavior occurs. In addition to data
ABA interventions for individuals with ASD. on observable and measurable behaviors, social
Criteria for an evidenced-based practice included validity data is collected to ensure treatment
multiple publication of peer-reviewed, experi- outcomes are socially significant and
mentally controlled research in scientific journals appropriate.
with individuals with ASD, across different
investigators or research groups. ABA practices
have been determined as meeting the stringent Qualifications of Treatment Providers
criteria developed by the National Professional
Development Center on Autism Spectrum Disor- It is recommended that ABA programs are super-
ders and the National Autism Center’s Standards vised by individuals who have certification by the
Project. In addition, ABA practices are endorsed Behavior Analyst Certification Board ® (BACB ®)
by the US Surgeon General and in reports of the as a Board Certified Behavior Analyst ®
New York Department of Health Early Interven- (BCBA ®). Standards for certification as
tion program, as well as the Maine Administra- a BCBA ® can be found in the Consumer Infor-
tors of Services for Children with Disabilities. mation section of www.BACB.com. BCBA cer-
Additional organizations that endorse ABA as tification does not guarantee experience in
a scientifically proven approach include: delivering ABA services to persons with ASD.
• Autism Speaks Thus, additional expertise in delivering ABA ser-
• American Academy of Neurology vices to persons with autism is advised. Addi-
• American Academy of Pediatrics tional training in areas including causes and
• American Academy of Occupational Therapy characteristics of autism, curriculum, assess-
Association ments, autism-specific intervention, and family
concerns is recommended. Please refer to The Cooper, J. O., Heron, T. E., & Heward, W. L. (2006).
Autism Special Interest Group of the Association Applied behavior analysis (2nd ed.). Upper Saddle
River, NJ: Prentice Hall.
for Behavior Analysis recommendations for Green, G. (1996). Evaluating claims about treatments for
recommended training. To download the com- autism. In C. Maurice (Ed.), G. Green, & S. C. Luce
plete text, please go to http://www.abainter- (Co-Eds.), Behavioral intervention for young children
national.org/Special_Interests/AutGuidelines.pdf. with autism: A manual for parents and professionals
(pp. 15–28). Austin, TX: PRO-ED.
Persons who deliver treatments that are developed Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G.,
and supervised by a BACB®-approved provider & Stanislaw, H. (2005). A comparison of intensive
must have demonstrated competency in following behavior analytic and eclectic treatments for young
written lesson plans, data collection, and behavior children with autism. Research in Developmental Dis-
abilities, 26, 359–383.
reduction plans using ABA procures described Jacobson, J. W., Foxx, R., & Mulick, J. A. (2005). Con-
above. troversial therapies for developmental disabilities.
Mahwah, NJ: Lawrence Erlbaum Associates.
Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter,
C. M. (1999). Pivotal response intervention I: Over-
See Also view of approach. Journal of the Association for
Persons with Severe Handicaps, 24, 174–185.
▶ Behavior Analysis Lovaas, O. I. (1977). The autistic child: Language devel-
▶ Behavior Modification opment through behavior modification. New York:
Irvington.
▶ Early Intensive Behavioral Intervention (EIBI) Lovaas, O. I. (1987). Behavioral treatment and normal
▶ Lovaas Approach educational and intellectual functioning in young
▶ Lovaas, O. Ivar autistic children. Journal of Consulting and Clinical
▶ UCLA Young Autism Project Psychology, 55, 3–9.
MADSEC Autism Taskforce. (1999). Executive summary.
The following websites contain further Portland, ME: Department of Education, State of
information that may be useful to consumers: Maine.
• The Association for Behavior Analysis – Matson, J. L., Benavidez, D. A., Compton, L. S.,
www.abainternational.org Paclawskyj, T., & Baglio, C. (1996). Behavioral treat-
ment of autistic persons: A review of research from
• The Association for Science in Autism Treat- 1980 to the present. Research in Developmental Dis-
ment – www.asatonline.org abilities, 17, 433–465.
• The ABA Autism Special Interest Group – Mayer, R. G., Sulzer-Azaroff, B., & Wallace, M. Behavior
www.autismsig.org (or www.abainter- analysis for lasting change (2nd ed.) Sloane
Publishing.
national.org/Special_Interests/autism.asp) New York State Department of Health Early Intervention
• The Behavior Analyst Certification Board – Program. (1999). Clinical practice guideline quick
www.BACB.com reference guide: Autism/pervasive developmental dis-
• The Cambridge Center for Behavioral Studies orders – Assessment and intervention for young
children (age 0-3 years). Albany, NY: Health Educa-
– www.behavior.org tion Services (1999 Publication No. 4216).
• The National Standards Report – www. Sallows, G. O., & Graupner, T. D. (2005). Intensive
nationalautismcenter.org behavioral treatment for children with autism: Four-
• The National Professional Development Cen- year outcome and predictors. American Journal on
Mental Retardation, 110, 417–438.
ter on Autism Spectrum Disorders-http:// U.S. Department of Health and Human Services. (1999).
autism.fpg.unc.edu Mental health: A report of the surgeon general. Rock-
ville, MD: U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Ser-
vices Administration, Center for Mental Health
References and Readings Services, National Institutes of Health, National Insti-
tute of Mental Health.
Carr, E. G., & Durand, V. M. (1985). Reducing behavior Wolf, M. M., Rislay, T. R., & Mees, H. L. (1964). Appli-
problems through functional communication train- cation of operant conditioning procedures to improve
ing. Journal of Applied Behavior Analysis, 18, behavior problems of an autistic child. Behavior
111–126. Research and Therapy, 1, 305–312.
Apraxia 233 A
Apprenticeships Appropriate Adaptation
A
Richard B. Graff ▶ Reasonable Accommodation
The New England Center for Children, Inc,
Southborough, MA, USA
Appropriate Educational Placement

Synonyms
▶ Least Restrictive Environment (LRE)
Vocational training
Definition Apraxia
One method to include individuals with autism in Allison Bean

the workplace is through the use of apprenticeships. Speech and Hearing Science,
An apprenticeship involves direct on-the-job The Ohio State University, Columbus, OH, USA
training by a qualified individual. This structured
training may be supplemented by classroom-based
training. Apprenticeship programs typically last for Synonyms
1–5 years and are concluded based upon complet-
ing a pre-specified number of hours, meeting Dyspraxia
specific job competencies, or a combination of
both. Apprenticeships allow individuals with
autism to gain job skills in integrated settings Short Description or Definition
while earning an income, which typically increases
over time. Apraxia is a neurological motor disorder that
impairs an individual’s ability to perform volun-
tary movements in the absence of weakness,
See Also paralysis, or neuromuscular slowness (Duffy,
1995; Freed, 2000; Vinson, 2007). Apraxia is
▶ Supported Employment subtyped according to the area of impairment
▶ Vocational Training and ranges in severity from mild to severe
(NINDS, n.d.).

Categorization
Lynn, I., & Mack, D. (2008). Multiple Strategies
for Improving Transition. Outcomes of Youth with Apraxia is a neurological motor disorder that is
Disabilities: Issue Paper on Increasing Access to subtyped according to the area of impairment.
Apprenticeship Opportunities. Washington, DC: Insti-
Some apraxias affect general motor movements,
tute for Educational Leadership and HeiTech Services,
Inc. doi: http://www.dol.gov/odep/categories/youth/ while others affect the speech mechanism.
apprenticeship/ApprenticeshipIssuePaper.pdf. Apraxias that affect general motor movements
Scholl, L., & Mooney, M. (2003, 2004). Youth with include limb-kinetic apraxia (impairment in the
disabilities in work-based learning programs:
ability to make fine precise movements with an
Factors that influence success. The Journal for
Vocational Special Needs Education, 26 (1, 2), arm or leg), ideomotor apraxia (impairment in the
4–16. ability to make appropriate movements in
A 234 Apraxia
response to a command), and ideational apraxia examining population estimates of childhood

(impairment in the ability to coordinate activities apraxia of speech are based on clinical referral.
with sequential movements, such as dressing). Population estimates range from one to two chil-
Apraxias specific to the speech mechanism are dren per thousand to 2.4–4.3 % of children
nonverbal oral apraxia (impairment in the ability referred with speech delay of unknown origin,
to carry out facial movements on command) and with a 3:1 male to female ratio (Delaney &
apraxia of speech (impairment in coordinating Kent, 2004 as cited by ASHA, 2007; Shriberg,
mouth and speech movements to produce Aram, & Kwiatkowski, 1997).
speech), also known as verbal apraxia or
dyspraxia. Different types of apraxia may occur
alone or together (Freed, 2000; NINDS, n.d.). Natural History, Prognostic Factors,
There are two types of apraxia of speech, and Outcomes
acquired and developmental. Acquired apraxia
of speech, or adult apraxia of speech, occurs The developmental course of childhood apraxia
after neurological insult, such as a stroke (e.g., of speech is not well documented (Shriberg et al.,
ASHA, 2007; Freed, 2000). Developmental 1997). The signs and symptoms of childhood
apraxia of speech, also known as childhood apraxia of speech may vary across children and
apraxia of speech, is a developmental motor within the same child over time (ASHA, 2007).
speech disorder. Both acquired and developmen- This is further complicated by the finding that
tal apraxias of speech are characterized by children appear to move in and out of the child-
impaired volitional movements of the speech hood apraxia of speech diagnostic category at
structures. The core features of acquired apraxia different points in development. For example,
of speech and childhood apraxia of speech over- children initially diagnosed with an articulation
lap. However, because of the significant differ- disorder may go on to receive a diagnosis of
ence in the time in development at which the childhood apraxia of speech and vice versa
disorders manifest themselves, there may be (Hall, 1989). Research suggests that children
important differences in associated features with apraxia of speech make improvements
(Massen, 2002; ASHA, 2007). This encyclopedia between preschool and school-age in articulating
entry focuses mainly on childhood apraxia of single words and in their overall intelligibility.
speech, also known as developmental apraxia. However, these children continue to have diffi-
culty sequencing multisyllabic words and persis-
tent concomitant language impairments (Lewis,
Epidemiology Freebairn, Hansen, Iyengar, & Taylor, 2004).
Acquired apraxia of speech arises from neurolog-

ical insult such as stroke, degenerative disease, Clinical Expression and
trauma, or tumor (Freed, 2000). Stoke is the lead- Pathophysiology
ing cause of apraxia of speech in adults followed
by degenerative diseases (Duffy, 1995). In con- Children suspected of having apraxia of speech
trast, childhood apraxia of speech may occur as typically demonstrate deficits in at least one of
the result of unknown causes or in association the following domains: nonspeech motor behav-
with complex neurobehavioral disorders iors, motor speech behaviors, speech sounds and
of known or unknown origins (e.g., fragile structures, prosody, language, metalinguistic/
X syndrome). Recent research suggests that phonemic awareness, and literacy. Nonspeech
childhood apraxia of speech may have a genetic motor behavior deficits are characterized by gen-
basis (for a review, see ASHA, 2007). Little data eral awkwardness or clumsiness, impaired voli-
is available on the prevalence of acquired apraxia tional oral movements, mild delays in oral motor
of speech or childhood apraxia of speech. Studies development, mildly low muscle tone, hyper- or
Apraxia 235 A
hyposensitivity in the oral area, and oral apraxia. Evaluation and Differential Diagnosis
Motor speech deficits are characterized by slow
development of speech, reduced phonetic inven- There is currently no definitive diagnostic marker A
tory, multiple speech sound errors, reduced perfor childhood apraxia of speech, and many of the
centage of consonants correct, and characteristics of childhood apraxia of speech
unintelligibility. Both the nonspeech and motor overlap with other speech sound disorders.
speech deficits observed in apraxia are also found Thus, the challenge for both researchers and cli-
in other speech sound disorders such as speech nicians is to differentiate childhood apraxia of
delay and dysarthria. Characteristics that appear speech from other speech sound disorders. The
to be distinctive of childhood apraxia of speech characteristics that appear to be distinctive to
include reduced vowel inventory, vowel errors, childhood apraxia of speech include reduced
inconsistency of articulation errors, increased vowel inventory, vowel errors, inconsistency of
errors in longer or more complex syllable and errors, increased errors in longer or more com-
word shapes, groping, unusual errors, persistent plex syllable and word shapes, groping, unusual
or frequent regression, differences in perfor- errors, regression, differences in performance of
mance of automatic versus volitional activities automatic versus volitional activities (with voli-
(with volitional activities being more affected), tional activities being more affected), and errors
and errors in the ordering of sounds, syllables, in sequencing. However, these patterns may also
morphemes, or even words (for a review, see be found in children who do not fit the overall
ASHA, 2007). pattern of apraxia of speech. Because apraxia
Syllable and prosody production are also impairs motor coordination, clinicians must first
affected in children with apraxia of speech. The rule out muscle weakness, sensory loss, a com-
atypical prosody observed in individuals with prehension deficit, or incoordination as the
suspected childhood apraxia of speech may be underlying cause of the impairment. Currently,
attributed to prolonged sound production and the minimum age of diagnosis of childhood
prolonged pauses between sounds, syllables, or apraxia of speech ranges from under 2 years of
words. As a result of these prolongations, the age to under 4 years of age (for a review, see
sounds, syllables, and/or words are produced as ASHA, 2007).
separate entities. This gives the listener the Standardized tests that focus on nonverbal oral
impression of staccato speech. Other prosodic motor and/or motor speech performance that may
deficits include reduced variability in pitch or be used to diagnose apraxia include the Apraxia
loudness, which result in excessive-equal stress Profile Preschool and School-Age Versions
(i.e., all or most syllables in a word receiving (Hickman, 1997), the Kaufman Speech Praxis
prominent stress) during speech production (for Test for Children (Kaufman, 1995), the Oral
a review, see ASHA, 2007). Speech Mechanism Screening Examination,
Most children suspected of having apraxia of Third Edition (St. Louis & Ruscello, 2000),
speech have significant concomitant language Screening Test for Developmental Apraxia of
deficits. These impairments are often more sig- Speech – Second Edition (Blakely, 2001), the
nificant and more persistent than in children Verbal Dyspraxia Profile (Jelm, 2001), and the
with other speech sound disorders (Lewis et al., Verbal Motor Production Assessment for Chil-
2004). Language difficulties include poor pho- dren (Hayden & Square, 1999). While these tests
nological awareness (a skill that lies at the foun- may assist in diagnosis, they lack normative data
dation of literacy development), difficulty and behavioral standards to use in test interpreta-
perceiving and producing rhymes, and counting tion and clear behavioral standards on which
syllables. Other areas of difficulty include defi- to base treatment decisions (McCauley &
cits in word identification and spelling (Lewis Strand, 2008).
et al., 2004; Marquardt, Sussman, Snow, & Differential diagnosis of childhood apraxia of
Jacks, 2002). speech may also include examination of
A 236 Apraxia
nonspeech motor behaviors. Children with with specific sensory and gestural cueing tech-
apraxia of speech are more likely to demonstrate niques. Linguistic approaches focus on teaching
general awkwardness or clumsiness, impaired the child the sounds and the rules regarding sound
volitional oral movements, mild delays in oral sequences and sound use. Motor-programming
motor development, mildly low muscle tone, techniques use principles of motor learning to
hyper- or hyposensitivity in the oral area, and teach children to acquire the skills needed to
oral apraxia (Davis, Jakieslski, & Marquardt, make sounds and sequences of sounds accurately
1998; McCabe, Rosenthal, & McLedo, 1998; and consistently. Other approaches combine
Shriberg et al., 1997). However, many of these linguistic and motor-programming intervention
motor behaviors are characteristic of dysarthria. strategies. Finally, there are programs that
In addition, clinicians may use the sequential involve the child’s senses such as vision, touch,
motion rate task, conversational speech and read- as well as being touched, to help cue the child
ing, and repeating words of increasing length to about some aspect of the speech sound he or she
examine motor speech behaviors during diagnosis attempting to make (Hall, 2000; ASHA, 2007).
tic evaluations (Freed, 2000). The sequential For children with significantly reduced intelligi-
motion rate task is one of the most sensitive bility, treatment goals may focus on facilitating
assessments for differentiating apraxia of speech overall communication through the use of
from other motor disorders (e.g., Davis et al., Augmentative and Alternative Communication
1998; Freed, 2000; Nijland, Maassen, van der (ASHA, 2007).
Meulen, Gabreels, Kraaimaat, & Schreuder,
2002).
Although there is not currently a validated list See Also
of diagnostic features that may be used to differ-
entiate apraxia of speech from other speech sound ▶ Ataxia
disorders, three features are consistent with a ▶ Developmental Apraxia
deficit in the planning and execution of motor ▶ Dyspraxia
movements. These features are (1) inconsistent ▶ Motor Planning
errors on consonants and vowels in repeated ▶ Nonverbal Oral Apraxia
production of syllables or words, (2) lengthened ▶ Praxis
and disrupted coarticulatory transitions between ▶ Verbal Apraxia
sounds and syllables, and (3) inappropriate
prosody (ASHA, 2007).
Treatment American Speech-Language-Hearing-Association.
(2007). Childhood apraxia of speech [Technical
There have been few treatment studies of apraxia Report]. Retrieved 25 January, 2011. Available from
www.asha.org/policy.
of speech. Of the treatment studies conducted,
Blakely, R. W. (2001). Screening test for developmental
none met the highest level of evidence for treat- apraxia of speech-second edition. Austin, TX: Pro-Ed.
ment efficacy (ASHA, 2007; Pannbacker, 1998). Davis, B., Jakieslski, K., & Marquardt, T. (1998). Develop-
To date, management of childhood apraxia of mental apraxia of speech: Determiners of differential
diagnosis. Clinical Linguistics and Phonetics, 12, 25–45.
speech is similar to that of dysarthria and other Delaney, A. L., & Kent, R. D. (2004). Developmental
articulation disorders. Treatment is most often profiles of children diagnosed with apraxia of speech.
focused on improving speech production. In Poster session presented at the annual convention of
Basic approaches to treating apraxia of speech the American-Speech-Language-Hearing Association,
Philadelphia.
include (1) linguistic approaches, (2) motor-
Duffy, J. R. (1995). Motor speech disorders: Substrates,
programming approaches, (3) linguistic-motor differential diagnosis, and management. St. Louis,
programming combinations, and (4) treatments MO: Mosby.
Aripiprazole 237 A
Freed, D. (2000). Motor speech disorders: Diagnosis and
treatment. San Diego, CA: Singular. Apraxia of Speech (AOS)
Hall, P. K. (1989). The occurrence of developmental
apraxia of speech in a mild articulation disorder: A
A childhood apraxia of speech study. Journal of ▶ Verbal Apraxia
Communication Disorders, 22, 265–276.
Hall, P. (2000). Part 1: Speech Characteristics of the
disorder. Language, Speech, and Hearing Services in
Schools, 31, 169–172.
Hayden, D., & Square, P. (1999). Verbal motor production Arciform Rhythm
assessment for children. San Antonio, TX: The
Psychological Corporation. ▶ Mu Rhythm
Hickman, L. (1997). Apraxia profile. San Antonio, TX:
The Psychological Corporation.
Jelm, J. M. (2001). Verbal dyspraxia profile. DeKalb, IL:
Janelle.
Kaufman, N. (1995). Kaufman Speech Praxis Test for ARD Committee
Children. Detriot, MI: Wayne State University Press.
Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar,
S. K., & Taylor, G. H. (2004). School-age follow-up of ▶ Admission, Review, and Dismissal Committee
children with apraxia of speech. Language, Speech (ARD Committee)
and Hearing Services in Schools, 35, 122–140.
Marquardt, T., Sussman, H. M., Snow, T., & Jacks, A.
(2002). The integrity of the syllable in developmental
apraxia of speech. Journal of Communication Disor- Aripiprazole
ders, 26, 129–160.
Massen, B. (2002). Issues contrasting adult acquired ver-
sus developmental apraxia of speech. Seminars in Maureen Early1, Logan Wink1,2,
Speech and Language, 23, 257–266. Craig Erickson1,2 and Christopher J. McDougle3
McCabe, P., Rosenthal, J. B., & McLedo, S. (1998). Fea- 1
Christian Sarkine Autism Treatment Center,
tures of developmental dyspraxia in the general speech
impaired population? Clinical Linguistics and Phonet- Indianapolis, IN, USA
2
ics, 12, 105–126. Department of Psychiatry, Indiana University
McCauley, R. J., & Strand, E. A. (2008). A review of School of Medicine, Indianapolis, IN, USA
standardized tests of nonverbal oral speech motor 3
performance in children. American Journal of
Speech-Language Pathology. 17, 81–91. School, Lexington, MA, USA
National Institute of Neurological Disorders and
Stroke (n.d.). Apraxia information page. Retrieved
25 January, 2011. Available from www.ninds.hih. Synonyms
gov/disorders/apraxia/apraxia.htm?css¼print
Nijland, L., Maassen, B., van der Meulen, S., Gabreels, F.,
Kraaimaat, F. W., & Schreuder, R. (2002). 7-[4-[4-(2,3-Dichlorophenyl)-1-piperazinyl]but-
Coarticulation patterns in children with developmental oxy]-3,4-dihydro-2(1H)-quinolinone; Abilify
apraxia of speech. Clinical and Linguistic Phonetics,
16, 461–483.
Pannbacker, M. (1998). Management strategies for develop-
mental apraxia of speech: A review of teh literature. Definition
Journal of Communication Disorders, 21, 363–371.
Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997).
Developmental apraxia of speech: I. Descriptive and
theoretical perspectives. Journal of Speech, Language,
Cl N
and Hearing Research, 40, 273–285.
St. Louis, K. O., & Ruscello, D. (2000). Oral speech Cl N
O N O
mechanism screening examination (3rd ed.). Austin, H
TX: Pro-Ed.
Vinson, B. (2007). Language disorders across the lifespan
(2nd ed.). Clifton Park, NY: Thomson Delmar Aripiprazole is a prescription drug in the family
Learning. of atypical antipsychotics initially FDA-
A 238 Aristaless-Related Homeobox Gene
approved for medical use in the year 2002 with U.S. Food and Drug Administration. (2010). Atypical anti-
the chemical formula C23H27Cl2N3O2. This psychotics drug information. Retrieved from http://
www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafety
compound is a partial agonist of the dopamine2 InformationforPatientsandProviders/ucm094303.htm
(D2) receptor and the serotonin type 1A (5-
HT1A) receptor and is an antagonist of the sero-
tonin type 2A (5-HT2A) receptor. This drug is
mostly metabolized by the enzymes CYP2D6 Aristaless-Related Homeobox Gene
and CYP3A4 of cytochrome P450. Oral formu-
lations in solution and tablet forms are FDA- Kimberly Aldinger
approved for the treatment of schizophrenia in Department of Cell and Neurobiology, Keck
adolescents and adults, the acute treatment of School of Medicine, University of Southern
manic and mixed episodes in pediatric patients California, Los Angeles, CA, USA
ages 10 years and older and adults with bipolar
I disorder, as an adjunct to lithium or valproate;
for the treatment of major depressive disorder in Synonyms
adults as an adjunctive treatment; and for the
treatment of irritability in pediatric patients ARX
ages 6–17 years with autistic disorder. The
injectable form is FDA-approved for the acute
treatment of agitation in adults with schizophre- Definition
nia or bipolar I disorder. Observed side effects
include nausea, akathisia, headache, insomnia, The Aristaless-related homeobox gene on the
agitation, anxiety, and mild transient X chromosome produces a homeodomain tran-
somnolence. scription factor that, by regulating numerous
genes, is crucial for many processes during embry-
onic development, especially the proliferation and
See Also migration of neurons. ARX is expressed in fore-
brain interneurons that release the inhibitory neu-
▶ Atypical Antipsychotics rotransmitter gamma-aminobutyric acid (GABA).
Mutations in ARX can run in families or occur
sporadically. These mutations cause a range of
X-linked developmental disorders that include
References and Readings lissencephaly (“smooth brain”), agenesis of the
Aripiprazole (n.d.). Retrieved from the ChemSpider Wiki:
corpus callosum, abnormal genitalia, seizures,
http://www.chemspider.com/RecordView.aspx?rid¼365 ataxia and dystonia, and syndromic and
ceb61-2923-4e82-bd96-e849caa18b11 nonsyndromic intellectual disability. Some people
Lauriello, J., Biehl, T. K., Bustillo, J. R., & Jenkusky, with ARX mutations with intellectual disability but
S. M. (2009). Schizophrenia and other psychotic dis-
without structural brain malformations show fea-
orders. In L. W. Roberts (Ed.), Clinical psychiatry
essentials (pp.163–180). Philadelphia, PA: Lippincott tures of autism including speech delay, impaired
Williams & Wilkins. social interactions, and stereotyped repetitive
Printz, D. J., & Lieberman, J. A. (2006). Aripiprazole. In behaviors. However, mutations in this gene are
A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials
of clinical psychopharmacology (2nd ed., pp. 277–
not typically found in individuals with autism.
283). Washington, DC: American Psychiatric
Publishing.
Smith, B. D., & Richards, M. P. (2010). Therapeutic See Also
response to psychiatric emergencies. In L. W.
Roberts (Ed.), Clinical psychiatry essentials
(pp. 481–497). Philadelphia: Lippincott Williams ▶ Epilepsy
& Wilkins. ▶ X-Linked Traits
Arlington Central School District v. Murphy 2006 (IDEA not Authorizing Expert Evaluations) 239 A
References and Readings a local or state educational agency under fee-
shifting provisions in the Individuals with Dis-
Chaste, P., Nygren, G., Anckarsater, H., Rastam, M.,
Coleman, M., Leboyer, M., Gillberg, C., & Betancur, C.
abilities Act (IDEA). The United States Supreme A
Court held that expert witness fees were not
(2007). Mutation screening of the ARX gene in patients
with autism. American Journal of Medical Genetics “costs” as provided for in the act.
Part B Neuropsychiatric Genetics, 114B(2), 228–230. Implications for Parents and Professionals
Friocourt, G., & Parnavelas, J. G. (2010). Mutations in Involved in IDEA Actions
ARX result in several defects involving GABAergic
The IDEA provides a fee-shifting provision to
neurons. Frontiers in Cellular Neuroscience, 4(4),
1–11. allow parents prevailing in actions under the Act
Fulp, C. T., Cho, G., Marsh, E. D., Nasrallah, I. M., to recover their costs associated with the litiga-
Labosky, P. A., & Golden, J. A. (2008). Identification tion. Following ACSD v. Murphy, expenses asso-
of Arx transcriptional targets in the developing basal
ciated with services provided by experts do not
forebrain. Human Molecular Genetics, 17(23),
3740–3760. fall within the provisions of the act and thus were
Kato, M., Das, S., Petras, K., Kitamura, K., Morohashi, K., not recoverable by parents. Allowable costs iden-
Abuelo, D. N., Barr, M., Bonneau, D., Brady, A. F., tified by the Supreme Court as being provided for
Carpenter, N. J., Cipero, K. L., Frisone, F., Fukuda, T.,
in IDEA are shown below.
Guerrini, R., Iida, E., Itoh, M., Lewanda, A. F.,
Nanba, Y., Oka, A., Proud, V. K., Saugier-Veber, P.,
Schelley, S. L., Selicorni, A., Shaner, R., Silengo, M., Authorized by
Stewart, F., Sugiyama, N., Toyama, J., Toutain, A., 20 U.S.C.
Varags, A. L., Yanazawa, M., Zackai, E. H., & 1415(i)(3)(B)
Dobyns, W. B. (2004). Mutations of ARX are associ- (IDEA)
ated with striking pleiotropy and consistent genotype- Attorney’s fees
phenotype correlation. Human Mutation, 23(2), Authorized by
147–159. 28 U.S.C. 1920
Stromme, P., Mangelsdorf, M. E., Shaw, M. A., Fees of the clerk and marshal
Lower, K. M., Lewis, S. M., Bruyere, H., Fees of the court reporter for all or any
Lutcherath, V., Gedeon, A. K., Wallace, R. H., Scheffer, part of the stenographic transcript
I. E., Turner, G., Partington, M., Frints, S. G., Fryns, necessarily obtained for use in the case
J. P., Sutherland, G. R., Mulley, J. C., & Gecz, J. (2002).
Fees and disbursements for printing
Mutations in the human ortholog of Aristaless cause X-
and witnesses
linked mental retardation and epilepsy. Nature Genet-
ics, 30(4), 441–445. Docket fees under section 1923 of
title 28
Compensation of court-appointed
experts (limited to $40 per diem plus
travel expenses under 28 U.S.C. 1821),
compensation of interpreters, and
Arlington Central School District v. salaries, fees, expenses, and costs of
Murphy 2006 (IDEA not Authorizing special interpretation services under
Expert Evaluations) section 1828 of title 28
Fees for exemplification and copies of
papers necessarily obtained for use in
Jonathan Sliva the case
Quinnipiac University School of Law, Hamden,
CT, USA Current and Future
On March 17, 2011, in direct response to the

Definition Supreme Court’s ruling in ACSD v. Murphy,
Senator Tom Harkin (D-IA), the Chairman of
Arlington Central School District v. Murphy the Health, Education, Labor, and Pensions Com-
Arlington Central School District (ACSD) v. mittee; Senator Barbara Mikulski (D-MD); and
Murphy concerned parents’ ability to recover Senator Bernie Sanders (I-VT) introduced to the
costs associated with a successful claim against Senate the IDEA Fairness Restoration Act, and
A 240 Arousal
Congressmen Chris Van Hollen (D-MD 8) and dilation of the pupils (Romanczyk & Gillis,
Pete Sessions (R-TX 32) introduced an identical 2006), and can be indicative of a variety of emo-
bill in the House of Representatives. This act tions such as fear, anxiety, excitement, or feelings
would amend IDEA’s fee-shifting provision so of competitiveness (Romanczyk & Gillis, 2006).
that “the term ‘attorneys’ fees’ shall include the Typically, a moderate amount of arousal is opti-
fees of expert witnesses, including the reasonable mal for learning (Baron, Groden, Groden, &
costs of any test or evaluation necessary for the Lipsitt, 2006).
preparation of the parent or guardian’s case in the
action or proceeding.” The bill is similar to ones
that have been introduced in the past two Con- Historical Background
gresses but which never made it out of committee.
As of May, 2011, the bill remains in committee in An individual’s state of arousal can provide valu-
both the Senate and House of Representatives. able insight about a variety of socially significant
indicators such as anxiety levels, ability to recog-
nize and react to fearful or stressful situations,
See Also and the ability to identify and regulate emotions.
Each of these skills is crucial to social function-
▶ Eligibility (for Services Under IDEA/ADA, etc.) ing and to forming meaningful relationships
throughout life. A more in-depth understanding
of the history and current state of the arousal
References and Readings literature, as well as a review of typical and
atypical demonstrations of arousal, will illustrate
Arlington Central School District v. Murphy, 548 U.S. 291 the critical role it plays in autism research and the
(2006).
important contributions it can make to interven-
Council of Parent Attorneys and Advocates. (2011). Rein-
state Parents’ Right to Expert Witness Fees. Retrieved tions. Since the 1960s, numerous studies have
July 5, 2012, from http://www.copaa.org/public-pol- measured arousal in individuals with autism
icy/copaas-major-legislative-priorities/reinstate-par- using a variety of different measures. Initially,
ents-right-to-expert-witness-fees/
three main hypotheses explaining arousal
IDEA Fairness Restoration Act, S.613 HR.1208, 112th
Cong., 1st Sess. (2011). dysfunction were studied: hyperarousal,
hypoarousal, and difficulties with arousal modu-
lation. Hutt and colleagues (1965, 1966, 1968)
found evidence of hyperarousal which contrib-
Arousal uted to the hypothesis that individuals with
autism are chronically overly aroused and that
Shantel E. Meek and Laudan B. Jahromi they regulate their arousal through stereotypical,
School of Social & Family Dynamics, Arizona repetitive motor behaviors. Other studies simi-
State University, Tempe, AZ, USA larly found that individuals with autism are
overly aroused in response to social and nonso-
cial stimuli and, especially, in response to novel
Definition stimuli when compared with typical individuals
and individuals with other developmental disabil-
Arousal is defined as a physiological prepared- ities (Hermelin & O’Connor, 1968; James &
ness to perceive and react to environmental stim- Barry, 1980). In contrast to the hyperarousal
uli and is produced by the activation of the hypothesis, other early investigators found
sympathetic branch of the autonomic nervous evidence of hypoarousal, that is, chronic
system. An arousal response may be identified underarousal in individuals with autism when
through increased heart rate, increased blood compared to typically developing individuals
pressure, increased sweat gland activity, and (DesLauriers & Carlson, 1969). Early proponents
Arousal 241 A
of this hypothesis suggested that individuals with nearly 50% less variance in heart rate between
autism engage in stereotypical, repetitive motor baseline and stressful situations when compared
behaviors to increase sensory stimulation. Still, to the control group (Goodwin et al.). Other stud- A
others found evidence of fluctuations between ies have found that individuals with autism expe-
both hyper- and hypoarousal dependent on the rienced less arousal than typical individuals when
environment, stimuli, and developmental level viewing sad or fearful stimuli but more arousal
of the individuals (Hermelin & O’Connor, 1970; when viewing neutral stimuli (Bolte, Feineis-
Ornitz & Ritvo, 1968), thereby forming the Matthews, & Poustka, 2008). Combined, this
hypothesis that individuals with autism experi- research may indicate that individuals with
ence difficulties in modulating arousal in general, autism are chronically hyperaroused or that they
whether hypo or hyper. The varied results noted experience more arousal than typical individuals
are likely due to a host of limitations including in testing situations but demonstrate less arousal
inconsistencies with terminology and diagnosis during stressful, sad, or fearful situations. Still,
identification; most early studies were published other recent work has found no significant group
prior to the publication of the DSM III-R which differences in arousal levels between individuals
more clearly outlined the criterion for an autism with autism and typical individuals (Ceponiene
diagnosis. This limitation causes uncertainty in et al., 2003; Kemner, Oranje, Verbaten, & van
the actual diagnosis of participants studied. In Engeland, 2002). Inconsistent results may be due
addition, the early measurement tools used to to the developmental level of the individuals
measure physiological functioning were likely studied (Dawson & Lewy, 1989) and the variabil-
uncomfortable and may have caused heightened ity seen within individuals with autism (Zahn,
anxiety and arousal for participants. Finally, 1986), in combination with differences in the
many studies did not collect baseline data making measures of arousal (e.g., heart rate, skin
it difficult to determine resting states of arousal conductance).
and actual fluctuation, hyper, or hypo states While much of the discussion in early arousal
(Goodwin et al., 2006). research was focused on the relations between
arousal and stereotypical repetitive motor
behaviors, recently, there has been increased
Current Knowledge discourse regarding the relation between
arousal, social anxiety, and social functioning
Technological advances and continued research in individuals with autism. Bellini (2006)
have provided investigators with the tools to recently proposed the developmental pathways
study arousal more uniformly. Currently, heart model to explain the role of arousal in social
rate, blood pressure, and skin conductance tests anxiety in individuals with autism. Specifically,
are the most common types of physiological the model suggests that social anxiety is indi-
arousal tests studied. Despite the use of more rectly the product of temperament, of which
uniform measures, discrepancies in results physiological hyperarousal is intricately
remain, even within tests. As with early research, related. Individuals with a temperament marked
more recent studies continue to find that individ- by increased physiological arousal may with-
uals with autism demonstrate elevated levels of draw socially in order to prevent overarousal;
physiological arousal (Bellini, 2006; Goodwin this social withdrawal may then lead to social
et al., 2006). One important study found that skills deficits. Bellini’s work is founded in previ-
while individuals with autism were less reactive ous work that indicates that individuals that dem-
(i.e., hypoaroused) to environmental stressors onstrate hyperarousal levels may be more likely to
than typically developing controls, on average, develop social anxiety in response to negative
the autism group demonstrated higher heart rate peer interactions when compared to individuals
during baseline and in stressful situations. Inter- with chronically lower arousal levels (Biederman,
estingly, however, the autism group displayed Rosenbaum, Chaloff, & Kagan, 1995).
A 242 Arousal
In support of this theoretical perspective, other Ozonoff, 2005). Baseline data should be taken
investigators have recently found that individuals on every individual studied, including control
with autism are more aroused by social stimuli subjects, to determine a range of normal and
than typically developing individuals and, as maladaptive arousal levels, and studies should
a result, may avoid them in order to prevent look at within- and between-group variability
hyperarousal. This avoidance, in turn, may signif- as Goodwin and colleagues (2006) have done.
icantly contribute to social functioning deficits Moreover, future researchers should conduct
(Corden, Chilvers, & Skuse, 2008; Nacewicz longitudinal studies in order to better under-
et al., 2006; Schultz, 2005). While more research stand the developmental course of arousal.
is needed to confidently draw the link between Studying patterns and trends within groups
arousal, social withdrawal, and social compe- over time may also identify individuals at
tency, recent studies have shown preliminary but higher risks for social anxiety and other inter-
promising leads in the field. nalizing or externalizing mental health issues.
Finally, the recent push for incorporating bio-
logical, neurological, and physiological mea-
Future Directions sures in psychological studies will also
undoubtedly bring forth large gains in the field
Technological advances in data collection will be of arousal, social anxiety, and social function-
imperative to the future study of arousal. In the ing. Similarly, applied research on this topic has
past, intrusive data collection techniques may the potential to advance clinical work in the
have skewed results in that individuals studied field of behavior and emotion regulation, social
may have experienced elevated levels of arousal anxiety, and social functioning.
solely based on the testing situation. If this is the
case, these results may only reflect arousal con-
ditions during intrusive testing rather than on See Also
arousal states in general. Thus, it is critical to
develop the least intrusive measures possible in ▶ Hypo-arousal
order to accurately and confidently draw conclu- ▶ Sensation Avoiding
sions about true arousal levels that mirror condi- ▶ Sensation-Seeking
tions in the natural environment. Similarly, in ▶ Sensory Experiences Questionnaire
order to answer questions about neutral arousal ▶ Sensory Processing
levels and about how individuals with and with-
out autism will react to real-life stressors, future
studies should attempt to naturalize the testing
setting as much as possible and even aim to References and Readings
collect data in the individual’s natural
environment. Baron, M. G., Groden, J., Groden, G., & Lipsitt, L. P.
(2006). Stress and coping in autism. New York:
Other considerations that should be made
Oxford University Press.
include providing detailed information about Bellini, S. (2006). The development of social anxiety in
the participants studied. Individuals with adolescents with autism spectrum disorders. Focus on
autism demonstrate a wide range of functioning Autism and Other Developmental Disabilities, 21,
138–145.
levels, and results based on the average of high- Bernal, M. E., & Miller, W. H. (1970). Electrodermal and
and low-functioning individuals are difficult to cardiac responses of schizophrenic children to sensory
generalize to any particular subset of the disor- stimuli. Psychophysiology, 7, 155–168.
der. Further, the use of a developmentally Biederman, J., Rosenbaum, J. F., Chaloff, J., & Kagan, J.
(1995). Behavioral inhibition as a risk factor for anx-
matched control group is crucial in order to
iety disorders. In J. S. March (Ed.), Anxiety in children
control for the effects of general maturation and adolescents (pp. 61–81). New York: Guilford
delays (James & Barry, 1981; Rogers & Press.
Articulation 243 A
Bolte, S., Feineis-Matthews, S., & Poustka, F. (2008). impairment in adolescent and adult males with autism.
Brief report: Emotional processing in high functioning Archives of General Psychiatry, 63(12), 1417–1428.
autism- physiological reactivity and affective report. doi:10.1001/archpsyc.63.12.1417.
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776–781. doi:10.1007/s10803-007-0443-8. stancy in early infantile autism. Archives of General
Ceponiene, R., Lepisto, T., Shestakova, A., Vanhala, R., Psychiatry, 18, 76–98.
Alku, P., Naatanen, R., et al. (2003). Speech-sound- Rogers, S., & Ozonoff, S. (2005). Annotation: What do we
selective auditory impairment in children with autism: know about sensory dysfunction in autism? A critical
They can perceive but do not attend. Proceedings of review of the empirical evidence. Journal of Child
the National Academy of Sciences, 100, 5567–5572. Psychology and Psychiatry, 46, 1255–1268.
doi:10.1073/pnas.0835631100. doi:10.1111/j.1469-7610.2005.01431.x.
Corden, B., Chilvers, R., & Skuse, D. (2008). Avoidance Romanczyk, R. G., & Gillis, J. M. (2006). Autism and the
of emotionally arousing stimuli predicts social- physiology of stress and anxiety. In M. G. Baron,
perceptual impairment in Asperger’s syndrome. J. Groden, G. Groden, & L. P. Lipsitt (Eds.), Stress
Neuropsychologia, 46, 137–147. doi:10.1016/j. and coping in Autism (pp. 183–204). New York:
neuropsychologia.2007.08.005. Oxford University Press.
Dawson, G., & Lewy, A. (1989). In Dawson G. (Ed.), Schultz, R. (2005). Developmental deficits in social
Arousal, attention, and the socioemotional impair- perception in autism: The role of the amygdala and
ments of individuals with autism. New York, NY, fusiform face area. International Journal of Develop-
US: Guilford Press. mental Neuroscience, 23, 125–141. doi:10.1016/j.
DesLauriers, A. M., & Carlson, C. F. (1969). Your child is ijdevneu.2004.12.012.
asleep: Early infantile autism. Homewood, IL: Dorsey Zahn, T. P. (1986). Psychophysiological approaches
Press. to psychopathology. In M. Coles, E. Donchin, &
Goodwin, M., Groden, J., Velicer, W., Lipsitt, L., Baron, S. Porges (Eds.), Psychophysiology: Systems, pro-
G., Hofmann, S., et al. (2006). Cardiovascular arousal cesses, and applications (pp. 508–610). New York:
in individuals with autism. Focus on Autism and Other Guilford Press.
Developmental Disabilities, 21, 100–123.
Hermelin, B., & O’Connor, N. (1968). Measures of the
occipital alpha rhythm in normal, subnormal, and
autistic children. The British Journal of Psychiatry,
114, 603–610.
Articulation
Hermelin, B., & O’Connor, N. (1970). Psychological
experiments with autistic children. Oxford: Pergamon. Elizabeth R. Eernisse
Hutt, S. J., & Hutt, C. (1968). Stereotypy, arousal Department of Language and Literacy, Cardinal
and autism. Human Development, 11, 277–286. Stritch University, Milwaukee, WI, USA
doi:10.1159/000270612.
Hutt, S. J., Hutt, C., Lee, D., & Ounsted, C. (1965).
A behavioral and electroencephalographic study of
autistic children. Journal of Psychiatric Research, 3, Synonyms
181–197. doi:10.1016/0022-3956(65)90028-2.
Hutt, C., & Ounsted, C. (1966). The biological signifi-
cance of gaze aversion with particular reference to Pronunciation; Speech sound production
the syndrome of infantile autism. Behavioral Science,
11, 346–356. doi:10.1002/bs.3830110504.
James, A. L., & Barry, R. J. (1980). Respiratory and Definition
vascular responses to simple visual stimuli in autistics,
retardates, and normals. Psychophysiology, 17,
541–547. Articulation is a general term that refers to the
James, A. L., & Barry, R. J. (1981). General maturational act of producing speech sounds in the vocal tract
lag as an essential correlate of early onset psychosis. (i.e., the movement and sequencing of physical
Journal of Autism and Developmental Disorders, 11,
271–283. structures including the lips, tongue, teeth, jaw,
Kemner, C., Oranje, B., Verbaten, M. N., & van etc.). Speech sounds are often classified based
Engeland, H. (2002). Normal P50 gating in children on either the place of articulation (i.e., the phys-
with autism. The Journal of Clinical Psychiatry, 63, ical structures that are involved and where the
214–217.
Nacewicz, B. M., Dalton, K. M., Johnstone, T., point of contact occurs between structures) or
Long, M. T., McAuliff, E. M., Oakes, T. R., et al. manner of articulation (i.e., the amount/type of
(2006). Amygdala volume and nonverbal social restriction of airflow involved).
A 244 Articulation Disorders
See Also Categorization
▶ Phonetics Articulation disorders often are classified in

▶ Phonology terms of severity (e.g., mild, moderate, severe).
▶ Speech This rating is typically based on the type/number
of errors the individual produces relative to age/
developmental norms, as well as a measure of
References and Readings overall intelligibility.
Bowen, C. (1998). Children’s speech sound disorders:

Questions and answers. Retrieved April 25, 2011,
http://www.speech-language-therapy.com/phonol-and-
Epidemiology
artic.htm
Crystal, D. (1991). A dictionary of linguistics and phonet- Shriberg, Tomblin, and McSweeny (1999)
ics (3rd ed.). Cambridge, MA: Basil Blackwell. reported the prevalence of speech delay in
Ladefoged, P., & Maddieson, I. (1996). The sounds of the
a large sample of 6-year-olds to be 3.8% with
world’s languages. Oxford: Blackwell.
What is Language? What is speech? (n.d.). In American- a male-to-female ratio of 1.5:1. The comorbidity
Speech-Language-Hearing-Association Typical Speech of speech delay and language impairment was
and Language development. Retrieved April 25, 2011, reported to be 1.3%. However, estimates of the
from http://www.asha.org/public/speech/development/
prevalence of speech sound disorders within the
language_speech.htm
Zemlin, W. R. (1998). Speech and hearing science: general population have been reported to be as
Anatomy and physiology (4th ed.). Boston: Allyn and high as 10%.
Bacon.
Natural History, Prognostic Factors,

Outcomes
Articulation Disorders
Within the pediatric population, outcomes for
Elizabeth R. Eernisse individuals with articulation disorders range con-
Department of Language and Literacy, Cardinal siderably depending on the severity of the disorder
Stritch University, Milwaukee, WI, USA and the presence of other co-occurring conditions.
For children who have been diagnosed with
strictly articulation disorders, evidence suggests
Synonyms that with research-supported intervention, many
speech sound disorders can be remediated.
Phonological disorders; Speech delay; Speech
disorder; Speech sound disorder
Clinical Expression and
Pathophysiology
Short Description or Definition
Articulation disorders are typically characterized
Articulation disorders involve difficulty with the by the atypical development or production of
correct production of speech sounds. Within the a speech sound or group of speech sounds that
literature, articulation disorders are often differ- results in a reduction in intelligibility. An articu-
entiated from phonological disorders in that artic- lation disorder is not the result of a cultural or
ulation disorders involve motor movements, dialectal difference. Disorders may include
while phonological disorders refer to the under- sound substitutions, distortions, additions, or
lying rules/patterns of sound production within omissions that impact an individual’s ability to
a language. be understood in conversation. Speech sounds
Articulation Disorders 245 A
may be incorrectly produced due to incorrect disorders. Once an individual’s specific areas
placement of articulators, imprecise voicing, of deficit have been determined, best practice
and/or structural deficits of the larynx, lips, would target the area of need that would most A
tongue, palate, teeth, and/or jaw. benefit the individual’s intelligibility (i.e., how
easily his or her speech is understood).
Depending on the nature of the problem, treat-
Evaluation and Differential Diagnosis ment may involve individualized speech ther-
apy in which the individual is taught how to
Articulation disorders are assessed using standard- produce the sound correctly through demonstra-
ized tests as well as observational measures. tion and repeated practice, learning specific
Examples of formal assessments of articulation techniques to shape how the speech mechanism
abilities include the Arizona Articulation Profi- is used. Additional techniques that are often
ciency Scale, Third Revision (Fudala, 2000), Clin- used include training in recognizing correct
ical Assessment of Articulation and Phonology and incorrect productions so that the individual
(Secord, Donohue, & Johnson, 2002), and the can monitor how his or her speech sounds and
Goldman-Fristoe Test of Articulation-Second Edi- practicing in contexts that increase in
tion (Goldman & Fristoe, 2000). In addition to complexity.
standardized measures, samples of speech taken
in single-word and conversational contexts can be
used to determine the type of speech sound errors See Also
that are present. Speech sampling procedures may
include the assessment of a child’s overall pho- ▶ Phonological Disorders
netic inventory (i.e., the number and variety of ▶ Speech Delay
sounds he or she is able to produce), an analysis
of syllable shapes and phonetic complexity, and an
analysis of error patterns. Stimulability measures References and Readings
(i.e., gradually prompting and shaping sounds
using cues and feedback from the clinician) often American Speech-Language-Hearing Association,
are used to determine if the individual is able to ASHA. (1993). Definitions of communication disor-
ders and variations. ASHA, 35(Suppl. 10), 40–41.
produce the sound given maximal support. In addi-
Bleile, K. (1995). Manual of articulation and phonologi-
tion to these procedures, best practice suggests that cal disorders: Infancy through adulthood. San Diego:
a complete oral-motor examination of the individ- Singular.
ual be completed to determine if there are any Fudala, J. B. (2000). Arizona articulation proficiency
scale (3rd rev.). Los Angeles, CA: Western Psycho-
structural or motor function deficits that are
logical Services.
impeding correct speech sound production. Gierut, J. (2008). Treatment efficacy summary: Phonolog-
In addition, articulation disorders typically are ical disorders in children. Available from http://www.
differentiated from phonological disorders. Care- asha.org/public/EfficacySummaries.htm
Goldman, R., & Fristoe, M. (2000). The Goldman-Fristoe
ful assessment of a child’s speech patterns may
test of articulation (2nd ed.). Circle Pines, MN: Amer-
reveal not only a difficulty with speech sound ican Guidance Service.
production (i.e., a phonetic disorder) but also dif- Secord, W., Boyce, S., Donahue, J., Fox, R., & Shine, R.
ficulties with the patterns of use of sounds within (2007). Eliciting sounds: Techniques and strategies
for clinicians (2nd ed.). Albany, NY: Thomson Delmar
the language (see ▶ Phonological Disorders). Learning.
Secord, W., Donohue, J., & Johnson, C. (2002). Clinical
assessment of articulation and phonology. Greenville,
Treatment SC: Super Duper Publications.
Shriberg, L. D., Tomblin, J. B., & McSweeny, J. L. (1999).
Prevalence of speech delay in 6-year-old children and
There are a variety of treatment approaches that comorbidity with language impairment. Journal of
are used for the management of articulation Speech and Hearing Research, 42, 1461–1481.
A 246 Articulatory Apraxia (or Dyspraxia)
Articulatory Apraxia (or Dyspraxia) Asperger Syndrome
▶ Verbal Apraxia Marc Woodbury-Smith

Department of Psychiatry and Behavioural
Neuroscience, McMaster University, Hamilton,
ON, Canada
ARX
Synonyms
▶ Aristaless-Related Homeobox Gene
Asperger’s disorder; Autism spectrum disorder
(ASD); PDD
ASAS
▶ Australian Scale for Asperger’s Syndrome
Asperger syndrome (AS) is a developmental dis-
order characterized by qualitative impairments in
social interaction in association with repetitive and
ritualistic patterns of behavior. By definition, there
ASAS-R: Australian Scale for is no clinically significant delay in (1) general
Asperger’s Syndrome – Revised cognitive development, as evidenced by IQ in the
normal range (i.e., greater than 69), (2) adaptive
▶ Australian Scale for Asperger’s Syndrome behaviors, including self-help skills and curiosity
about the environment, and (3) expressive lan-
guage, broadly defined by the use of words by
the age of 2 years and phrases by 3 years.
Asperger syndrome, or Asperger’s disorder,
ASDI came to prominence in the 1980s, following the
publication of Wing’s seminal paper describing 34
▶ Asperger Syndrome Diagnostic Interview young adults with impairments of social interac-
tion and aspects of everyday communication and
associated adherence to routine and circumscribed
patters of interest (Wing, 1981). The children and
ASHA FACS young adults described in her paper all exhibited
difficulties forming and maintaining relationships
▶ American Speech-Language-Hearing Associa- with others, with some presenting as aloof and
tion Functional Assessment of Communication passive, while others actively tried to engage
Skills socially, but their communicative exchanges
were odd: Unfortunately, therefore, despite their
social motivation, their clumsy posture, poor eye
contact, and poor vocal intonation denied them the
friendships they desired. The majority of the cases
ASIEP-2 Wing described pursued circumscribed, solitary
interests with enthusiasm with the result that
▶ Autism Screening Instrument for Educational many acquired a significant knowledgebase on
Planning (ASIEP-2) particular subjects.
Asperger Syndrome 247 A
Wing used the term “Asperger syndrome” to and the World Health Organization’s (WHO)
draw attention to the paper first published in 1944 International Classification of Diseases (ICD-
by Hans Asperger, in which four boys with 10), Asperger syndrome is categorized along A
sociocommunicative impairments and repetitive with autistic disorder, Rett’s syndrome, child-
patterns of behavior, including the pursuit of hood disintegrative disorder, and pervasive
circumscribed interests, were described developmental disorder not otherwise specified
(Asperger, 1944, translated in Frith, 1991). She (PDDNOS). Much has been written about the
also drew comparisons with the syndrome first relationship between Asperger syndrome and the
described by Kanner in 1943 (Kanner, 1943) and, other PDDs. It is certainly true that the syn-
in doing so, brought Asperger and Kanner’s syndromes first described by Kanner and Asperger
dromes together for the first time and in what has share many features, and therefore in clinical
subsequently become known as the “autism spec- terms, it is understandable that they have been
trum disorders” (ASDs), a tridimensional group brought together under the same spectral
of disorders characterized by impairments of umbrella. However, what is also apparent is
social interaction communication and repetitive that in bringing these conditions together,
and ritualistic patterns of behavior. many of the features described by Asperger
Since the publication of Wing’s paper, there have been subsequently de-emphasized.
has been considerable interest in Asperger syn- For example, Asperger focused on the abnor-
drome, as evidenced by the large body of scientific mal patterns of communication that characterized
literature devoted to understanding its epidemiol- the boys he described. These included abnormal-
ogy, etiology, and management. There has also ities of social pragmatics, i.e., the everyday
been significant interest in its conceptual relation- aspects of communication, despite normal formal
ship to the other “autism spectrum disorders,” with language skills (such as semantics and syntax). In
much of this research failing to find any evidence particular, posture, facial expression, gaze, and
of a distinction, thereby supporting the spectral other nonverbal communicative gestures were
representation (Volkmar & Klin, 2005). Indeed, described as notably peculiar. In addition,
as discussed subsequently, so strong is the evi- Asperger commented that language itself, i.e.,
dence that the validity of maintaining Asperger’s verbal communication, was of diagnostic impor-
as a distinct disorder vis-à-vis autistic disorder has tance in view of its peculiarities, which varied
been brought into question, and it is quite possible from case to case. This included abnormalities
that the term “Asperger’s” will not find a place in with volume of speech (too loud or too quiet),
the subsequent revisions of the World Health intonation of speech (e.g., talking in a monotone
Organization’s (WHO) International Classifica- or talking in an overmodulated way resembling
tion of Diseases eleventh revision (ICD-11) or exaggerated verse speaking), and in choice of
the American Psychiatric Association’s (APA) works for communication, which may be formal,
Diagnostic and Statistical Manual fifth edition pedantic, or otherwise quirky. The importance of
(DSM). Nonetheless, as will become apparent, the pragmatic aspects of communication is that
there are a number of reasons for its retention, they do offer some differentiation from the pat-
and even if removed, it is a term that will continue terns of communication seen in other ASDs, but
to be used clinically, and therefore it is important unfortunately, they are not included in either the
for clinicians and health-care workers to have an DSM-IV or ICD-10.
understanding of its characteristics. In addition to this “feature de-emphasis,” the
other aspect of our current classification systems
that is potentially problematic for the concept of
Categorization AS is the rule of diagnostic hierarchy. That is, the
diagnosis of “autistic disorder” takes precedence
In both the American Psychiatric Association’s over Asperger syndrome, such that if an individ-
(APA) Diagnostic and Statistical Manual (DSM-IV) ual meets the diagnostic criteria for both (and this
A 248 Asperger Syndrome
scenario is not uncommon), then the autistic dis- Epidemiology

order diagnosis takes priority and the individual
is assigned that diagnosis. The result of this is that The prevalence of a disorder may vary if
individuals who may be deemed clinically to researchers use different syndrome defining
have AS are “sucked” into the autistic disorder criteria, and this issue is of crucial significance
category. for AS. For example, before AS was described in
Although hierarchical diagnosis and symptom the most recent versions of the ICD and DSM,
de-emphasis may be useful if the spectral concep- clinicians, eager to diagnose, developed their
tualization is correct, as they allow the syndromes own criteria. These included those of Ehlers and
of Kanner and Asperger to be more closely Gillberg, who subsequently carried out a robust
aligned, it may be problematic if there is a true epidemiological study of the prevalence of
difference between the disorders. While it is fair to Asperger syndrome using these criteria (Ehlers
say that most of the research examining the exter- & Gillberg, 1993). Their criteria were certainly in
nal validity of differentiating between the two keeping with characteristics described by
disorders has failed to find any strong evidence Asperger and included the communication items
for a distinction (discussed in Klin, McPartland, & described above, although were fundamentally
Volkmar, 2005a), much of this research has relied limited by being very broadly defined. Their
on either the ICD-10 or DSM-IV conceptualiza- study found a point prevalence of 28.5/10,000
tions, and therefore the results come as no great (95% CI 0.6–56.5/10,000).
surprise as they are confounded by tautology. In Fombonne (2009), in his overview of ASD
particular, if the two disorders are defined epidemiology, took into consideration six more
according to the same set of criteria, and if there recent surveys of autism prevalence and found
is a hierarchical system of diagnosis in place, then that the rates of AS were consistently lower than
the two syndromes may only differ in name. autism, with an average ratio of 5:1 for rates of
The only way to overcome this tautological autism versus AS. This translates into a median
confound will be to re-examine for external prevalence estimate of 2.6/10,000 for AS along-
validity for groups described according to more side 13/10,000 for autism, and 60/10,000 when
robust criteria that offer some possibility of more broadly defined cases are included
symptom separation (as, it can be argued, would (Fombonne, 2009).
be the case if Kanner’s and Asperger’s original In terms of sex ratios, males are more often
criteria are applied) and if the hierarchical system affected than females, with ratios varying
is removed. One study has explored the external according to diagnostic subtype and level of
validity of AS in a more objective manner, by intellectual ability. In particular, among lower
comparing features according to three different functioning groups, the sex ratio approaches
diagnostic systems, including (1) current DSM- unity, whereas among those who are higher func-
IV criteria, (2) division of the spectrum according tioning, males are affected more frequently than
to onset of language, and (3) criteria more closely females. The exact ratio is unclear, with variation
aligned with Asperger’s case studies, which they between 4:1 and 9:1 being demonstrated between
termed the “new system” (Klin et al., 2005a). different studies (ibid.).
This study found that, on balance, their “new
system” differentiated greatest between autism,
PDDNOS, and Asperger syndrome. Interestingly, Natural History, Prognostic Factors,
while it has also been suggested that IQ profiles Outcomes
differentiate Asperger’s (verbal performance dis-
crepancy favoring the former) from autism (ver- Comorbidities
bal performance discrepancy favoring the latter), Along with the other ASDs, there are high rates of
no such differences were found for any of the additional neuropsychiatric disorders among
systems used. children and adults with AS. Conditions such as
epilepsy, tic disorders, and disorders of attention number is poor (Barnard, Harvey, Prior, & Potter,
and motor control are known to occur with 2001). This is particularly true of those who are
increased frequency in the ASDs, although no higher functioning, who have the added problem A
robust data are available for AS. Certainly it is of being excluded from support services because
true that for seizure disorders, the highest rates of their normal intellectual function. It is crucial,
(approaching 20%) are seen among those who are therefore, that services are developed to meet the
lower functioning, and this is probably true of the needs of this population that will facilitate their
attentional and motor disorders too. social inclusion and thereby improve their quality
In terms of mental health problems, mood and of life.
anxiety disorders are particularly common, It is also apparent that the higher functioning
although due to an absence of epidemiological population with ASDs may be at risk of unlawful
data, it is not possible to give a true prevalence behavior and contact with the criminal justice
figure (Woodbury-Smith & Volkmar, 2009). In system, as discussed elsewhere in this volume.
Wing’s case series (1981), 8 of the 36 individuals While this may only be true for a small minority,
described had “probable depression,” and in there is some evidence that the core autism phe-
Tantam’s study of 85 individuals with primary notype mediates this relationship. In particular,
social relationship difficulties (1988), many of impairment of emotional processing and the pur-
whom fulfilled the criteria for AS, 11% had clin- suit of circumscribed interests may both play
ical depression, this being the most common a role.
mental health problem reported (Tantam, 1988).
It is certainly true that prevalence estimates for
comorbid depression vary widely, but taken Clinical Expression and
together, they suggest that clinical depression is Pathophysiology
a significant problem in this population. Simi-
larly, anxiety disorders are also commonly Clinical Expression
reported among individuals with Asperger syn- All descriptions of Asperger’s have highlighted
drome. Once again, however, no truly epidemio- its core impairment in relating to others. Fairly
logical study has been carried out, and figures are consistent has also been the descriptions of com-
based on administrative samples. The prevalence munication impairments. Finally, most descrip-
of psychotic disorders among AS is less clear, tions highlight the restricted pattern of behaviors,
with schizophrenia occurring in three of usually taking the form of circumscribed patterns
Tantam’s cases (3.5%) and approximately 4% of interest, often solitary, and generally pursued
of the “loners” described by Wolff (Wolff, in preference to other activities.
2000), but none of a clinic-based sample The social impairment is, arguably, the sine
(Ghaziuddin, Weidmer-Mikhail, & Ghaziuddin, qua non of Asperger syndrome and all other
1998). ASDs. It is characterized by difficulty relating
to others. As a result, children with AS are often
Outcome rejected by, and thereby isolated from, their
There is now evidence that as many as 20% will peers, and as adults may live a fairly solitary
no longer meet the criteria for an ASD as they existence. In describing Asperger syndrome,
transition though their adolescent and early adult Wing highlighted two forms of social impair-
years, and many others show a significant ment, namely, the “aloof” and “active but odd”
improvement in their symptoms (Seltzer et al., types, binary categories that have some clinical
2003). Unfortunately, however, studies investi- validation. It is certainly true that most individ-
gating outcome more generally, including param- uals with AS probably fall into the “active but
eters of social inclusion and quality of life such as odd type,” with only a minority failing to form
employment, independent living, and relation- social relationships because of aloofness and lack
ships, suggest that the outcome for a significant of interest. Instead, many go out of their way to
A 250 Asperger Syndrome
try and form friends, but their approach may be available, the studies more specifically pertaining
clumsy, with limited use of eye contact, social to AS will be highlighted.
smiling, or socially recognized greetings. They There is now little doubt that genetic mecha-
may dress peculiarly or at least in an unfashion- nisms play an important role in the etiology of
able way. They sometimes fail to appreciate the ASDs. Although these same genetic risk factors
impact of poor self care on acceptance by others may be relevant specifically for AS (Rutter, 2005),
and may stand too close to, or far away from, their there is a paucity of linkage and association studies
interlocutor. specifically examining probands with AS. One
Their communicative exchanges are often for- study has investigated genetic linkage in AS
mal, particularly noticeable among children who (Ylisaukko-oja et al., 2004) and observed linkage
resemble adults in their use of words and formal- at 1q21–22, 3p14–24, and 13q31–33 in 17 multiplex
isms. They may talk in a monotone or families with 119 affected probands, 72 of whom
overintonated voice, failing to appreciate the fulfilled the ICD-10 criteria for AS. Interestingly,
point of “social chit chat,” and may instead chose the loci on chromosomes 1 and 3 overlap with
to present an in-depth monologue about a topic of previously identified autism susceptibility loci, and
interest, failing to appreciate whether their listener on 1 and 13, with schizophrenia susceptibility loci.
is interested or bored or, indeed, understands the Other research on etiology has focused on
topic at all. Unfortunately, many people with AS looking at neuropsychological mediators of
are not interested in the same things as their peers. ASDs. This represents a vast literature, although
Among children, for example, an interest in sports, the impairments identified fall into the domains
music, and/or fashion is more accepted than cos- of (1) theory of mind, (2) executive dysfunction,
mology or license plate collecting. and (3) central coherence (discussed in Klin et al.,
The circumscribed interests are a prominent 2005b). Research using MRI has also identified
feature of the disorder, and it is important that both structural and functional abnormalities in
they are differentiated from normal patterns of regions including the fusiform face area, amyg-
hobbies that many people engage in. Differentia- dala, and regions of the dorsolateral and
tion is unfortunately somewhat arbitrary and orbitofrontal prefrontal cortices (Schultz,
based on interpretation of their intensity and/or Romanski, & Tsatsanis, 2000).
focus. To all intents and purpose, an interest is Unifying all this research into a model of the
intense to a significant degree if it impinges on pathogenesis of autism is difficult. Certainly, the
other day-to-day activities (such as eating, different genes identified all seem to converge on
sleeping, paying bills, and so forth), and is odd the synapse, and the neuropsychological and neu-
in focus if it is not clearly functional (e.g., roimaging research all indicates neural pathways
collecting tin cans). Importantly, it is not unusual involved in the processing of social and emotional
for interests to change over time. information and mental flexibility. A different per-
spective aligns the impairments seen in AS with an
Etiology extreme form of the male brain, with some support
Much of the literature concerned with the etiol- for this model existing in the form of the in utero
ogy of the ASDs has investigated the spectrum in hormonal environment (Baron-Cohen, 2005).
broad terms, on the assumption that all ASDs
share the same causal mechanisms. As indicated
previously, there has been research examining Evaluation and Differential Diagnosis
the differences between AS and other autistic
disorders from a biological (primarily neuropsy- Evaluation
chological) perspective, but much of this research The diagnosis of Asperger syndrome is based
has failed to differentiate between the disorders. upon a detailed clinical assessment, which
In the discussion that follows, this broader etio- includes history from an informant who knew the
logical literature will be summarized, but where person during their formative years and a direct
observation of the person themselves. The autism Social anxiety disorder is differentiated by the
diagnostic interview (ADI-R) can be used to struc- fairly circumscribed nature of the situations that
ture the history, and the autism diagnostic obser- provoke symptoms of anxiety (such as public A
vation schedule (ADOS) can be used to structure speaking) and the onset usually in adolescence
the direct observation component. While neither and beyond. Obsessive-compulsive disorder is
of these contain algorithms specific to the diagno- differentiated on the basis of the egodystonicity
sis of AS, extrapolating from the algorithms that that characterizes the thinking and ritualistic
do exist is relatively straightforward. Importantly, behaviors and the absence of major qualitative
these instruments are intended to approximate social impairments.
rather than replace expert clinical opinion. Several
other diagnostic instruments have also been devel- Treatment
oped, including the Australian Scale for Asperger There is much overlap in the interventions used
Syndrome (ASAS) and the Gilliam Autism Rating for AS and other ASDs. In particular, these
Scale (GARS), and screening instruments specifi- include those strategies aimed at the core features
cally for AS are also available (e.g., the autism of the disorder and those aimed at managing
spectrum quotient (AQ). Most of these have data comorbidities (Woodbury-Smith & Volkmar,
on validity and reliability and are commercially 2009). A number of behavioral and educational
available (references available in Woodbury- interventions have been developed aimed at
Smith & Volkmar, 2009). engendering sociocommunicative skills and
adaptive functioning and overcoming some of
Differential Diagnosis the weaknesses in problem solving and judgment
There are several other disorders that exist at the that occur as a result of executive dysfunction.
boundary of the ASDs and which may be confused The evidence base for these interventions is lim-
with them, particularly among those with ASDs ited and often based on single-case studies or
who are higher functioning. This includes schizoid small-case series. Nevertheless, all approaches
and schizotypal personality disorders, social anxi- share a core set of “ingredients,” which include
ety disorder, and obsessive-compulsive disorder. making the treatment individualized, using
The two personality disorders may represent the a “parts to whole” approach, augmented with
most diagnostic confusion because of the overlap visual strategies where appropriate, and using
in clinical symptomatology. Current diagnostic explicit, rote verbal learning. Executive dysfunc-
wisdom would argue that the personality disorders tion can be overcome using scheduling, scripts, or
develop in late adolescence and early adulthood, lists, and adaptive skills can be taught through
which therefore provides a fundamental distinc- practice, rehearsal, and reinforcement. It is also
tion from ASDs because the latter are of early important to recognize that a person with AS can
developmental onset. This is perhaps less helpful learn though social exposure, either in the form of
than it first appears, however, because in reality, “buddying” or “circle of friends,” social groups
PDs are often symptomatic in earlier adolescence, or explicit social skills training. The comorbid
and the higher functioning ASDs are often char- mental health problems may also require specific
acterized by relatively subtle abnormalities during management, through either psychopharmacol-
the early years, such that diagnosis is often delayed ogy or different psychotherapies (as discussed
until the adolescent period and sometimes even elsewhere in this volume) or a combination of
adulthood. In all likelihood, the two disorders the two.
may represent slightly different manifestations of
the same underlying pathological process. Cer-
tainly the relationship between Asperger syn- See Also
drome and the “schizophrenia spectrum” requires
further investigation, particularly in light of the ▶ Autistic Disorder
genetic evidence discussed above. ▶ Noradrenergic System
A 252 Asperger Syndrome Diagnostic Interview
References and Readings Wing, L. (1981). Asperger’s syndrome: A clinical

account. Psychological Medicine, 11(1), 115–129.
Asperger, H. (1944). Die “autistichen Psychopathen” im Wolff, S. (2000). Schizoid personality in childhood and
Kindersalter. Archive fur psychiatrie und Asperger syndrome. In A. Klin & F. R. Volkmar
Nervenkrankheiten. (U. Frith, Trans.)(Ed.) (1991). (Eds.), Asperger syndrome (pp. 278–305). New York:
Autism and Asperger’s syndrome (Vol. 117, The Guilford Press.
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Barnard, J., Harvey, V., Prior, A., & Potter, D. (2001). Asperger syndrome. European Child & Adolescent
Ignored or ineligible? The reality for adults with autis- Psychiatry, 18(1), 2–11.
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Society. Varilo, T., von Wendt, L., et al. (2004). Genome-wide
Baron-Cohen, S. (2005). Testing the extreme male brain scan for loci of Asperger syndrome. Molecular
(EMB) theory of autism: Let the data speak for them- Psychiatry, 9(2), 161–168.
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Asperger syndrome. A total population study. Journal
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1327–1350. Interview
Fombonne, E. (2009). Epidemiology of pervasive devel-
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591–598. Michaela Viktorinova1 and
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(1998). Comorbidity of Asperger syndrome: 1
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Klin, A., McPartland, J., & Volkmar, F. R. (2005a).
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Three diagnostic approaches to Asperger syndrome:
interview
Implications for research. Journal of Autism and
Rutter, M. (2005). Genetic influences and autism. In F. R.
Volkmar, A. Klin, R. Paul, & D. J. Cohen (Eds.), Description
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Wiley. The Asperger Syndrome Diagnostic Interview
Schultz, R. T., Romanski, L. M., & Tsatsanis, K. D. (ASDI) is a diagnostic instrument developed spe-
(2000). Neurofunctional models of autistic disorder cifically for the assessment of Asperger syn-
and Asperger syndrome: Clues from neuroimaging.
drome (AS) in children and adults. This brief
In A. Klin & F. R. Volkmar (Eds.), Asperger syndrome
(pp. 172–209). New York: The Guilford Press. structured interview consists of 20 items divided
Seltzer, M. M., Krauss, M. W., Shattuck, P. T., Orsmond, into six broader areas of behavior that may be
G., Swe, A., & Lord, C. (2003). The symptoms of indicative of AS. ASDI is an investigator-based
autism spectrum disorders in adolescence and adult-
interview in which each item is an open-ended
hood. Journal of Autism and Developmental Disor-
ders, 33(6), 565–581. question corresponding to a specific part of autis-
Tantam, D. (1988). Lifelong eccentricity and social isola- tic symptomatology. It is therefore essential that
tion. I. Psychiatric, social, and forensic aspects. The the examiner acquire a sufficient level of clinical
British Journal of Psychiatry, 153, 777–782.
material first so that correct assessment of
Volkmar, F. R., & Klin, A. (2005). Issues in the classifica-
tion of autism and related conditions. In F. R. Volkmar, presented behavior can be made. The evaluation
A. Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of is carried out by scoring each item on the inter-
autism and pervasive developmental disorders (3rd ed., view as either 0 (does not apply) or 1 (applies to
Vol. 1, pp. 5–41). Hoboken, NJ: Wiley.
some degree or very much). Total scores are
Asperger Syndrome Diagnostic Interview 253 A
obtained within six different areas. Each area
(Scoring: Three or more scores of
may require a different number of items met to
1 ¼ criterion met)
fulfill the diagnostic criteria. ASDI is based on
Area 5 (5 Items): Nonverbal Communication A
Gillberg and Gillberg’s (1989) definition of AS
Problems
and is congruent with Hans Asperger’s original Individuals with AS may display a range of
clinical account. Parents, siblings, primary care- marked nonverbal behaviors such as clumsy
givers, or any person well acquainted with the gestures, inadequate body language, limited
individual’s developmental history can also be repertoire of facial expressions, or disrupted
reporters on the ASDI. Although the ASDI gaze patterns. Such nonverbal communication
addresses major domains that tend to be problem- impairments are the focus of the Area 5.
atic in individuals with AS, it can only be con- (Scoring: One or more scores of 1 ¼ criterion
sidered as one of several steps in the diagnostic met)
process and should not be presented as the only Area 6 (1 Item): Motor Clumsiness
source of inquiry. The final domain examines difficulties related
Area 1 (4 Items): Severe Impairments in Recipro- to motor coordination in everyday functioning
cal Social Interaction (Extreme Egocentricity) and also inquires about the history of gross and
Items in this area map onto the nature of peer fine motor skill development.
interaction, interest in close relationships, abil- (Scoring: Score of 1 ¼ criterion met)
ity to follow social rules, appreciate social com-
munication cues, and the presence of socially
and emotionally appropriate behaviors. Historical Background
(Scoring: Two or more scores of 1 ¼ criterion
met) In 1981, Lorna Wing introduced the diagnosis
Area 2 (3 Items): All-Absorbing Narrow Interest of AS to English speakers in a case report of 34
Pattern(s) children and adults whose clinical observation
This area addresses the manifestation of closely matched Hans Asperger’s original case
restricted interests that could interfere with studies but did not overlap with Kanner’s
development in other domains of functioning. criteria for autism at that time. This report ini-
(Scoring: One or more scores of 1 ¼ criterion tiated further research, resulting in a publication
met) of the first diagnostic criteria for AS (Gillberg &
Area 3 (2 Items): Imposition of Routines, Rituals, Gillberg, 1989), which was revised in 1991. By
and Interests that time, AS was already a widely recognized
Following on the restricted interests, the third clinical diagnosis with several existing screen-
area deals with the imposition of routines on ing tools but suffered a paucity of reliable diag-
one self or others to a degree that impedes nostic instruments that could inform an in-depth
functioning. assessment. In addition, some authors argued
(Scoring: One or more scores of 1 ¼ criterion that gold standard measures such as the Autism
met) Diagnostic Interview-Revised (ADIR) and
Area 4 (5 Items): Speech and Language Autism Diagnostic Observation Schedule
Peculiarities (ADOS) were not sensitive enough to pick up
Language development is examined in Area 4. individuals with these milder yet very distinc-
Delays in language development are assessed tive difficulties (Klin, Volkmar, & Sparrow,
as well as abnormalities in the expressive 2000).
components of language such as odd articula- In 2001, Gillberg and colleagues published the
tion, verbosity, and characteristic diction. ASDI based on their own diagnostic criteria for
Appropriate language comprehension, includ- Asperger disorder (Gillberg & Gillberg, 1989;
ing the understanding of literal meaning and Gillberg, 1991). ASDI was a result of long-term
metaphors, is also evaluated. work with a large number of individuals with AS
A 254 Asperger Syndrome Diagnostic Interview
and high-functioning autism with symptomatol- of 20 individuals were interviewed by two neuro-
ogy difficult to notice through ordinary autism psychiatrists. The raters were blinded to the diag-
screening tools. Following on Hans Asperger’s nostic status of the participants. Both raters were
clinical observations, the diagnostic criteria present during the interviews, but only one of them
enlisted in ASDI were different from those in performed the interview while the other one was
DSM-IV and ICD-10. One of the important dif- observing and coding independently. Since the
ferences relates to language development. While ASDI contains 20 items, each rater had to make
DSM-IV requires no clinically significant delay 200 ratings. In 383 out of 400 ratings, the two
in early language development in individuals raters reached complete agreement (20 paired rat-
with AS, Gillberg, Gillberg, Rastam, and Wentz ings), which yielded a kappa statistic of.91 (high
(2001) argued that such a profile was not seen in level of agreement). The raters had a complete
clinical practice. Therefore, Gillberg and col- agreement across all items for 10 of 20 individuals,
leagues (2001) acknowledged early language an almost complete agreement (19 items) in six
impairments as primary characteristics of AS. In individuals, and in the remaining four subjects,
addition, other authors raised concerns about the they agreed on 17 and 18 items. Such results are
validity of DSM-IV criteria for AS by promising and provide support for a good
documenting that Hans Asperger’s original clin- interrater reliability, although it needs to be
ical cases would not meet those criteria and acknowledged that the authors used a small sam-
would instead fall into the autistic disorder cate- ple and only two raters. Further investigation is
gory (Leekam, Libby, Wing, Gould, & Gillberg, needed to replicate these findings.
2000; Miller & Ozonoff, 1997). These issues
continue to be debated as the ASDI is still used Intrarater Reliability
in clinical practice. It was not, however, designed Intrarater reliability refers to the degree of con-
in conjunction with DSM-IV and ICD-10. sistency of a measure over time. In Gillberg et al.
(2001) study, the intrarater reliability was deter-
mined by a repeated evaluation using ASDI at
Psychometric Data a 10- to 15-month period after the first assess-
ment. Twenty-four individuals participated in
Participants this study, and the examiners were still blinded
Reliability and validity of the ASDI have not to their diagnostic status. There was an agreement
been studied extensively. Gillberg and colleagues on 465 out of 480 items corresponding to a kappa
(2001) reported preliminary findings on the of .92. In 16 subjects, the examiner scored
interrater/intrarater reliability in a sample of 24 accordingly with the previous performance
individuals (aged 6–55) where 17 had a clinical (20 items out of 20), in five subjects, there was
diagnosis and 7 were healthy controls. The diag- a disagreement on one item, for two subjects on
nosed subjects consisted of 12 cases with AS, two items, and finally, in one case, the differences
2 cases with atypical autism, 2 cases with obses- in rating included seven different items. Based on
sive-compulsive disorder, and 1 person with mul- the results from this sample, the ASDI had very
tiple personality disorder. The individuals with good intrarater reliability although the same lim-
AS met some of the criteria for the disorder itations applied as mentioned in the case of
according to the DSM-IV and full criteria for interrater reliability.
AS as defined by Szatmari, Bremner and Nagy
(1989) and Gillberg and Gillberg (1989). Validity
In order to evaluate the construct validity of
Reliability ASDI, the number of correctly diagnosed indi-
Interrater Reliability viduals has been computed. The ASDI correctly
In order to determine the degree of agreement detected all of the subjects with a diagnosis of AS
among raters using the ASDI, first-degree relatives or atypical autism as they fulfilled from five or six
Asperger Syndrome Diagnostic Interview 255 A
(out of six) diagnostic areas. Of the remaining assessment of AS demands a more complex
sample, one individual also met criteria for approach. An individual’s medical, developmen-
autism despite having a different diagnosis – tal, and family history needs to be acquired in A
multiple personality disorder. Based on this sam- addition to direct observations of social behavior,
ple, ASDI was able to discriminate with high psychological evaluation of cognitive functioning,
accuracy between individuals with AS and other coping mechanisms, and communication skills
clinical diagnosis. However, the sample did not (Klin et al., 2000). Although ASDI can be used
include individuals with high-functioning autism, for preliminary diagnostic decisions where AS or
and thus, there is no evidence to conclude that high-functioning autism symptoms are suspected,
this measure could differentiate between those a multidisciplinary assessment guided by an expe-
two categories. rienced clinical judgment will have the best results
Although the psychometric characteristics of for informing the subsequent intervention and
ASDI have shown that this measure has good deciding whether the diagnostic category matches
intrarater reliability, interrater reliability, and the clinical presentation and the needs of the
validity, all of these reported findings are prelim- individual.
inary and have not been replicated with large
samples nor has this diagnostic interview been
used in conjunction with other AS measures. See Also
▶ Asperger Syndrome
Clinical Uses ▶ Asperger Syndrome Epidemiology
▶ Asperger Syndrome Follow-Up Studies
The ASDI has been used in AS assessment ▶ Asperger, Hans
research, although not extensively. Cederlund, ▶ Autism Diagnostic Interview-Revised
Hagberg, and Gillberg (2010) used the ASDI in ▶ Autism Diagnostic Observation Schedule
their follow-up study in a sample of 100 males ▶ Diagnostic Instruments in Autistic Spectrum
with AS who were diagnosed in childhood. The Disorders
aim of the study was to assess the awareness that ▶ Diagnostic Interviews
individuals with AS had of their emotional and ▶ Diagnostic Process
cognitive difficulties and to determine to what ▶ DISCO
extent their view was congruent with their parents’
opinion. Seven items of ASDI were administered
to both the individuals and their parents. The References and Readings
results showed significant differences between
the adults and their parents’ scores in three out of Books
these seven items (social ability, social cues, and Attwood, T. (2007). The complete guide to Asperger’s
narrow interests) with parents scoring higher than syndrome (1st ed.). London: Jessica Kingsley.
Gillberg, C. (1991). Clinical and neurobiological aspects
the individuals with AS. The authors emphasized
of Asperger syndrome in six family studies. In U. Frith
that these items possibly reflected the core deficits (Ed.), Autism and asperger syndrome. Cambridge:
of the social impairments seen in AS and therefore Cambridge University Press.
may have been the most difficult ones to be Klin, A., Volkmar, F., & Sparrow, S. S. (Eds.). (2000).
Asperger syndrome. New York/London: The Guilford
assessed accurately by individuals with AS. Such Press.
findings also underscore the extent to which diag- Ozonoff, S., Dawson, G., & McPartland, J. (2002). A
nostic interviews rely on the insight and honesty of parent’s guide to Asperger syndrome and high-
the interviewed person; yet the population with functioning autism: How to meet the challenges and
help your child thrive. New York: The Guilford Press.
AS may not be fully aware of their emotional
Szatmari, P. (2005). A mind apart: Understanding chil-
impairments or camouflage them by active learn- dren with autism and Asperger syndrome. New York:
ing of socially appropriate scripts. Naturally, the The Guilford Press.
A 256 Asperger Syndrome Epidemiology
Journal Articles may vary if researchers use different syndrome-

Cederlund, M., Hagberg, B., & Gillberg, C. (2010). defining criteria. This is relevant when
Asperger syndrome in adolescent and young adult
discussing the epidemiology of Asperger syn-
males. Interview, self- and parent assessment of social,
emotional, and cognitive problems. Research in drome (AS) for several reasons. First, even
Developmental Disabilities, 31(2), 287–298. before AS was included in the most recent ver-
Gillberg, C., & Gillberg, C. (1989). Asperger syndrome – sions of the International Classification of Dis-
Some epidemiological considerations: A research
eases (ICD, 10th edition, World Health
note. Journal of Child Psychology and Psychiatry,
30(4), 631–638. Organization [WHO], 1993) and Diagnostic
Gillberg, C., Gillberg, C., Rastam, M., & Wentz, E. and Statistical Manual of Mental Disorders
(2001). The Asperger syndrome (and high-functioning (DSM, Volume IV, American Psychiatric Asso-
autism) diagnostic interview (ASDI): A preliminary
ciation [APA], 1994), clinicians, eager to diag-
study of a new structured clinical interview. Autism,
5(1), 57–66. nose this disorder, developed their own sets of
Leekam, S., Libby, S., Wing, L., Gould, J., & Gillberg, C. criteria (Klin, McPartland, & Volkmar, 2005).
(2000). Comparison of ICD-10 and Gillberg’s criteria Notably, the first two epidemiological surveys
for Asperger syndrome. Autism, 4(1), 11–28.
of Asperger syndrome, discussed later, both
Miller, J. N., & Ozonoff, S. (1997). Did Asperger’s cases
have Asperger disorder? A research note. Journal of used such “clinician-driven” criteria. The rela-
Child Psychology and Psychiatry, and Allied Disci- tively high-prevalence figure they calculated
plines, 38(2), 247–251. might reflect the broad nature of the criteria
Szatmari, P., Bremner, R., & Nagy, J. (1989). Asperger’s
they used, particularly when compared with the
syndrome: A review of clinical features. Canadian
Journal of Psychiatry, 34(6), 554–560. generally lower estimates of prevalence for AS
Wing, L. (1981). Asperger’s syndrome: A clinical subsequently obtained.
account. Psychological Medicine, 11(1), 115–129. Even since its inclusion in the ICD-10 and
DSM-IV, with their criteria for AS almost iden-
Web Pages tical, the label Asperger syndrome has often
OASIS – Online Asperger Syndrome Information and
been applied loosely in diagnostic terms, in
Support. Retrieved February 15, 2011, from http://
www.aspergersyndrome.org some cases to mean “mild autism” or “normal
IQ autism” or even in everyday parlance synon-
ymously with “loners” or “nerds.” Moreover,
even when applying the DSM-IV or ICD-10
Asperger Syndrome Epidemiology criteria, problems with interpretation due to
ambiguity of diagnostic items are likely. For
Marc Woodbury-Smith example, at what point does an interest become
Department of Psychiatry and Behavioural a “circumscribed interest” either in terms of
Neuroscience, McMaster University, Hamilton, intensity or focus? The subjective threshold of
ON, Canada diagnosing clinicians may inflate or reduce
prevalence as a result of this ambiguity. And
finally, both diagnostic systems include
Definition a hierarchy rule, whereby a diagnosis of autism
takes precedence over AS, such that if a person
The epidemiology of Asperger syndrome refers meets criteria for both, an autism diagnosis is
to what is known about its prevalence and course. given. It has been argued that this last point may
lead to a situation where an Asperger diagnosis
becomes an impossibility, as cases are “sucked
Historical Background into” the autism category. This was formally
investigated in a study that revisited the DSM
On considering the epidemiology of a disorder, field trial autism-related data. These data
consistency as regards its definition is particu- included 48 individuals with a clinical diagnosis
larly pertinent, as the prevalence of a disorder of AS, of whom 11 (23%) were reassigned
Asperger Syndrome Epidemiology 257 A
a diagnosis of autistic disorder as a result of this described. On the whole, all these studies seem to
hierarchy rule (Woodbury-Smith, Klin, & agree on a number of points. First, autism is more
Volkmar, 2005). As such, the prevalence of the common than AS. Generally, the ratio was 2:1, A
disorder is very likely to vary according to although Baird et al. (2000) found a much wider
whether a clinician applies this rule. split of 9:1. Secondly, all but one identified
prevalence figures between 3 and 10 per 10,000.
The one study that found higher figures (Latif &
Current Knowledge Williams, 2007) used Gillberg’s criteria to iden-
tify cases which might explain why their figures
Bearing in mind these caveats, it is perhaps no were closer to those quoted in the earlier studies
great surprise that the range of prevalence figures described above. All the other studies used either
quoted for AS vary widely. For example, the ICD-10 and/or DSM-IV.
study of Ehlers and Gillberg (1993), using their The lowest prevalence was 3 per 10,000,
own diagnostic criteria, found a point prevalence quoted by Baird and colleagues (2000). This
of 36/10,000 among school-aged children is the only study that specifically indicated that
(7–16 years) in a school catchment-defined area it ignored the hierarchy rule. It seems reason-
of central Sweden. This figure rose to 71/10,000 able to propose, therefore, that the other four
if suspected cases were also included. This same studies quoted in Table 1, which all used the
study also identified a male to female ratio of 4:1 same diagnostic criteria (i.e., DSM-IV or ICD-
among the definite cases. Ehlers and Gillberg also 10), similarly did not apply this rule consider-
calculated prevalence using the ICD-10 criteria, ing their higher quoted prevalence figures.
which had just been published at the time: However, why there should be differences in
a slightly lower figure of 29/10,000 was calcu- prevalence when using the same criteria (i.e.,
lated for definite cases using these criteria. One ranging from 3/10,000 to 11/10,000) and in
other study from Sweden (Kadesjo, Gillberg, & urban-based areas in the same country is not
Hagberg, 1999) diagnosed cases according to the clear and may simply be a reflection of meth-
ICD-10 criteria and found rates of 48/10,000, odological differences rather than true preva-
with a male to female ratio of 4:1. Due to the lence differences.
fact that samples in both studies originated from The studies were fairly consistent in terms of
small populations (1,401 for Ehlers and Gillberg gender split, with the majority of those being
and 826 for Kadesjo et al.), this prevalence identified with AS being males, a figure higher
estimate amounted to only a small handful of than the 4:1 suggested by Ehlers and Gillberg
cases. The Kadesjo et al. study also examined and Kadesjo and colleagues. This may reflect the
the population prevalence of other autism fact that diagnosis is more difficult among
spectrum disorders, with autism diagnosed females or that the phenotype is expressed dif-
according to DSM-IIIR and “algorithm ICD-10” ferently. Of course, the gender difference may
criteria. The prevalence of autistic disorder was be related in some way to the underlying biolog-
60/10,000, suggesting Asperger syndrome is less ical mechanisms (such as genes on the
common than its counterpart. X chromosome, or the “extreme male brain”
While the more recent figures also support phenotype).
higher rates of autism than Asperger, the exact Fombonne (2009), in his overview of ASD
prevalence of the latter is somewhat lower than epidemiology, took into consideration the six
these earlier Swedish studies. The results of more most recent surveys of autism prevalence and
recent prevalence studies (see Fombonne, 2009) found that the rates of AS were consistently
that include figures for AS are summarized in lower than autism, with an average ratio of 3.5:1
Table 1. In each of the studies quoted, fairly for rates of autism versus AS. This translates into
robust epidemiological methods have been an estimated prevalence of 6/10,000 for
employed and screening and diagnosis are clearly AS alongside 20.6/10,000 for autism and
A 258 Asperger Syndrome Epidemiology
Asperger Syndrome Epidemiology, Table 1 Summary of recent epidemiological surveys with Asperger syndrome
(AS) data
Autism
Size of Age range prevalence AS prevalence Sex ratio Autism:
Country population (years) (per 10,000) (per 10,000) (M:F) AS ratio References
Stafford, UK 15,500 2.5–6.5 16.8 (N ¼ 26) 8.4 (N ¼ 13) 5.5:1 2:1 Chakrabarti
and Fombonne
(2001)
Stafford, UK 10,903 4.0–6.0 22 (N ¼ 24) 11 (N ¼ 12) 100% M 2:1 Chakrabarti
and Fombonne
(2005)
South Wales, 39,220 Birth–17.0 61.2 (N ¼ 267) 35.4 (N ¼ 154) 6.7–10.5:1 1.7:1 Latif and
UK Williams
(2007)
Montreal, 27,749 5–17 21.6 (N ¼ 60) 10.1 (N ¼ 28) 2:1 2:1 Fombonne
Canada et al. (2006)
London, UK 16,235 7 27.7 (N ¼ 45) 3.1 (N ¼ 5) 100% M 9:1 Baird et al.
(2000)
72.6/10,000 when more broadly defined cases are References and Readings
included (Fombonne, 2009).
American Psychiatric Association. (1994). DSM-IV
diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Future Directions Baird, G., Charman, T., Baron-Cohen, S., Cox, A.,
Swettenham, J., Wheelwright, S., et al. (2000).
Therefore, in summary, there are many inconsis- A screening instrument for autism at 18 months of age:
A 6-year follow-up study. Journal of the American
tencies in the data, but there are a number of
Academy of Child and Adolescent Psychiatry, 39(6),
factors that might explain these discrepancies. 694–702.
It seems reasonable, however, to conclude that Chakrabarti, S., & Fombonne, E. (2001). Pervasive
Asperger syndrome is a disorder that predomi- developmental disorders in preschool children. Jour-
nal of the American Medical Association, 285(24),
nantly occurs in males and is significantly less
3093–3099.
common than autistic disorder. Prevalence Chakrabarti, S., & Fombonne, E. (2005). Pervasive devel-
figures range from 3 to 11 per 10,000 when opmental disorders in pre-school children: Confirma-
ICD-10 and DSM-IV criteria are used, ignoring tion of high prevalence. The American Journal of
Psychiatry, 162, 1133–1141.
the hierarchy rule, and an estimated median prev-
alence of 6/10,000 has been suggested. If the Asperger syndrome. A total population study. Journal
hierarchy rule were to be applied, then the figure of Child Psychology and Psychiatry, 34(8),
is likely to be significantly lower. It is also impor- 1327–1350.
Fombonne, E. (2009). Epidemiology of pervasive devel-
tant to recognize that all studies quoted are from
opmental disorders. Pediatric Research, 65(6),
Europe or North America, and therefore, the 591–598.
prevalence in other countries is not known. It is Fombonne, E., Zakarian, R., Bennett, A., Meng, L., &
even uncertain as to the prevalence among McLean-Heywood, D. (2006). Pervasive developmen-
tal disorders in Montreal, Quebec, Canada: Prevalence
different ethnic groups in the countries examined.
and links with immunizations. Pediatrics, 118,
e139–e150.
See Also Kadesjo, B., Gillberg, C., & Hagberg, B. (1999). Brief
report: Autism and Asperger syndrome in seven-year-
old children: Total population study. Journal of
▶ Asperger Syndrome Autism and Developmental Disorders, 29(4),
▶ Epidemiology 327–331.
Asperger Syndrome Follow-Up Studies 259 A
Klin, A., McPartland, J., & Volkmar, F. R. (2005). operationally defined using these criteria more
Asperger syndrome. In F. R. Volkmar, A. Klin, R. precisely. Several researchers have commented
Paul, & D. J. Cohen (Eds.), Handbook of autism and
pervasive developmental disorders (3rd ed., that the DSM-IV criteria (APA, 1994) are overly A
pp. 88–125). Hoboken, NJ: Wiley. restrictive and often result in an underdiagnosis
Latif, A. H., & Williams, W. R. (2007). Diagnostic trends of AS (Cederlund, Hagberg, Billstedt, Gillberg,
in autistic spectrum disorders in the South Wales & Gillberg, 2008; Howlin, 2003; Miller &
valleys. Autism, 11(6), 479–487.
Woodbury-Smith, M., Klin, A., & Volkmar, F. (2005). Ozonoff, 1997; Szatmari, Archer, Fisman,
Asperger’s syndrome: A comparison of clinical diag- Streiner, & Wilson, 1995). Several different def-
noses and those made according to the ICD-10 and initions have therefore been used in research;
DSM-IV. Journal of Autism and Developmental however, all share the common features of core
Disorders, 35(2), 235–240.
World Health Organization. (1993). International classi- ASD deficits in the absence of clinically signifi-
fication of diseases (ICD-10) (10th ed.). Geneva, cant language or general cognitive delay.
Switzerland: Author. Follow-up studies comprise a set of study
designs that have the following features in com-
mon. The designs are (1) observational, that is,
they involve studying individuals that have been
Asperger Syndrome Follow-Up naturally selected to a particular group or expo-
Studies sure as compared to random assignment by
researchers to a particular group as in experimen-
Peter Szatmari1 and Terry Bennett2 tal designs; (2) generally prospective, that is, the
1
Department of Psychiatry and Behavioural individuals of interest are followed chronologi-
Neurosciences, McMaster University Hamilton cally and reassessed at one or more later time
Health Sciences Corporation, Hamilton, points; and (3) used to examine predictors and
ON, Canada outcomes. Predictors are early factors or charac-
2
Department of Psychiatry and Behavioural teristics of the individual or his/her environment
Neurosciences, McMaster University, Hamilton, that are associated with variation in later occur-
ON, Canada ring outcomes. Outcomes may be consequences
of a diagnosis or of early predictors of interest.
Follow-up studies are important for several
Definition reasons. First, they help to clarify the diagnosis
of Asperger syndrome and differentiate it from
Asperger syndrome (AS) is classified as one of other ASDs and developmental disabilities. As
several autism spectrum disorders (ASDs) or with many mental health and developmental dis-
pervasive developmental disorders (PDDs; orders, the validity of a diagnosis of AS may, at
American Psychiatric Association, 1994). As least in part, lie in the ability to distinguish
with other ASDs, the syndrome may be defined a developmental course with respect to symptoms
as a neurodevelopmental disability that involves and functioning over time from other disorders.
significant delays or impairment in social inter- Second, follow-up studies help individuals, fam-
action (e.g., age-appropriate friendships, sharing ilies, and clinicians understand the range of out-
interest or attention with others), communication comes that may be expected in relation to
(conversational skills, nonverbal gestures), and a diagnosis such as AS, particularly as they relate
a preference for restricted or atypical interests, to important aspects of daily life such as relation-
stereotypes, or routines. Unlike autistic disorder, ships, work, and self-sufficiency.
individuals with AS do not exhibit clinically sig- Prospective cohort studies assemble a group
nificant delays in language development, adap- of similar individuals (a “cohort”) at one time
tive functioning, or general intellectual abilities. point. These individuals are then followed up
There exists considerable variation within over one or more time points to determine
clinical work and research as to how AS can be whether and how variation in certain baseline
A 260 Asperger Syndrome Follow-Up Studies
factors relates to variation in outcomes of interest. risk of bias due to recall effects (e.g., parents of adult
If the cohort is followed over three or more time children recalling early developmental milestones)
points (including baseline), trajectories and sampling issues (e.g., missing individuals who
or pathways of particular symptoms, abilities, or do not present to a given clinic).
characteristics may be plotted to describe the rate
and shape of change over time. Prospective
cohorts are generally considered to produce higher Historical Background
quality evidence among observational studies than
cross-sectional or retrospective outcome studies, Case reports of children with features resembling
particularly if they are able to ascertain individuals Asperger syndrome (AS) were first mentioned in
who are at the same “early” stage of the disorder neurological and psychiatric literature in the 1920s
(e.g., an “inception cohort”). Such designs also (Gillberg, 1998). However, Viennese pediatrician
minimize error due to recall bias. Drawbacks of Hans Asperger most thoroughly described what he
these studies include greater expense and length of believed to be a new psychiatric disorder, which he
time to complete data collection. termed “autistic psychopathy” (Asperger, 1944).
Retrospective cohort studies also involve His descriptions of children with disordered “affec-
assembling a group of similar individuals (e.g., tive contact” were developed around the same time
individuals with ASD) that nevertheless differ on as, but without consultation with, American child
some traits or factors of interest (e.g., in this case, psychiatrist Leo Kanner, who also described chil-
diagnoses of autism and Asperger syndrome), and dren with similar traits as “autistic.”
are designed to assess whether the type of ASD is The term “Asperger syndrome” gained signif-
associated with differences in outcome. The pro- icantly greater recognition and interest after it
cess of collecting data differs, however. Retro- was reintroduced by Lorna Wing in 1981, based
spective studies look back to collect data that has on her clinical observations of children and youth
already been recorded in the past to stratify the who demonstrated obvious autistic features but
individuals into subgroups (e.g., records of diag- did not have the cognitive and language delays
noses of autism or AS) as well as information on seen in autism (Wing, 1981). An increasing num-
other important predictor (sex) variables or other ber of publications began appearing to describe
associated factors. Outcome data may also have individuals with autistic traits who nevertheless
been collected in the past or concurrently, as demonstrated average or near-average intelli-
a follow-up to earlier information. Disadvantages gence and language abilities. Asperger syndrome
of retrospective cohort studies involve sample was included in ICD-10 and DSM-IV as one of
loss, potentially absent information about impor- the pervasive developmental disorders with spe-
tant confounders, and reliance on past methods of cific criteria setting it apart from autism and per-
measurement which may have changed in the vasive developmental disorder NOS. Autism and
interim. Advantages include greater expediency Asperger syndrome were defined as sharing sev-
of data collection and lower cost relative to pro- eral of the same criteria, with the latter defined as
spective cohort studies. having relatively normal cognitive functioning
Finally, case–control studies comprise another and language abilities, the absence of language
type of follow-up study, in which individuals with delay, and fewer communication impairments
AS are sampled. They are then compared to control overall. A hierarchical rule was established,
groups with respect to rate of earlier predictors or such that any individual meeting criteria for
later outcomes of interest. For example, individuals both autism and Asperger syndrome would be
with AS (the “cases”) and higher functioning autism diagnosed with the former. This rule, as pointed
(the “controls”) may be compared with respect to out by many clinical researchers, significantly
early characteristics and developmental milestones. decreases the number of individuals eligible for
These studies also have the advantage of saving cost a diagnosis of AS (Cederlund et al., 2008;
and time to collect data; however, they are at greater Howlin, 2003; Szatmari, 2000). Accordingly,
definitions of AS have varied across research society. Understanding the course of develop-
studies, in efforts to capture samples of individ- ment and outcomes in Asperger syndrome is
uals who reflect a “true” picture of the disorder. related to the predictive validity of the diagnosis: A
In spite of this growing literature, there have whether the disorder helps forecast a develop-
been relatively few prospective follow-up studies mental pathway for AS that is distinct from
of Asperger syndrome, as distinct from other that of Autistic Disorder in a measurable and
pervasive developmental disorders and, in partic- meaningful way. More importantly, it helps indi-
ular, high-functioning autism. Gillberg and col- viduals and their families understand the impli-
leagues followed up young men who had been cations of such a diagnosis and plan for their
diagnosed with Asperger syndrome 5 or more future, while aiding clinicians in service devel-
years earlier (Cederlund et al., 2008), whereas opment by anticipating their future needs.
Szatmari and colleagues followed a cohort of
children aged 4–6 recently diagnosed with Childhood
Asperger syndrome and high-functioning autism Studying the short-term outcomes of children
every 2–4 years into adolescence (Szatmari et al., with Asperger syndrome sheds light on baseline
2000). Other studies used individuals with AS variation between children with autism spectrum
and high-functioning autism who have presented disorders and the importance of early develop-
as adolescents or adults to clinical services and mental “head starts.” For example, Szatmari et al.
then examined current and retrospective features (2000, 2003) followed up 68 children aged
associated with the diagnosis (Gilchrist et al., 4–6 years old who were diagnosed with either
2001; Howlin, 2003). The differing study designs autistic disorder or Asperger syndrome and had
and definitions of AS have led to some variation IQs of at least 68 standard score points (Szatmari
in results, particularly regarding the extent to et al., 2000, 2003). Children diagnosed with
which AS is distinct from high-functioning Asperger syndrome had significantly better
autism. However, all share the common goal of socialization scores on the Vineland Adaptive
understanding how individuals with AS fare as Behavior Scales at baseline and 2 years later
they age into adulthood with respect to symp- compared to children with autistic disorder, con-
toms, adaptive functioning, and quality of life. trolling for initial language ability and nonverbal
IQ. Children with autistic disorder who gained
functional language over the course of the
Current Knowledge follow-up period achieved socialization scores
similar to the Asperger syndrome group at base-
Follow-up studies of individuals with Asperger line. These early studies indicated that children
syndrome (AS) have been few in number and with Asperger syndrome seem to embark on
have differed widely with respect to their overall parallel, but higher functioning, trajectories com-
design, the definition of Asperger syndrome used, pared to peers with autistic disorder and that the
the sampling methods for finding cases with AS, achievement of verbal fluency may act as an
the type of comparison group employed, and important early differentiating step between
how predictors and outcomes are measured developmental pathways (Szatmari et al., 2009).
(Cederlund et al., 2008; Gilchrist et al., 2001;
Howlin, 2003; Szatmari et al., 2009; Szatmari, Adolescence and Early Adulthood
Bryson, Boyle, Streiner, & Duku, 2003). Never- The evaluation of how well individuals with
theless, they share a common goal of understand- Asperger syndrome fare in adolescence and
ing how individuals with AS fare in later early adulthood understandably depends upon
childhood, adolescence, and adulthood with the group to whom individuals with AS are com-
respect to important outcomes of interest – their pared. Researchers using data from two separate
core developmental abilities and their overall prospective follow-up cohort studies (Bennett
level of adaptive functioning as individuals in et al., 2008; Cederlund et al., 2008; Szatmari
et al., 2009) found that young adults with AS GAF ¼ 22.4). However, in a study comparing
have better outcomes with respect to ASD symp- individuals with AS with high-functioning indi-
tom burden and adaptive functioning compared viduals with autistic disorder, there were no sig-
to individuals with autistic disorder (including nificant differences in ASD symptoms as
high-functioning autistic disorder with IQ > measured by the autism diagnostic interview-
70). In a prospective study of young adults with revised (ADI-R; Lord, Rutter, & Le Couteur,
AS, outcomes were classified as poor (“obvious 1994).
severe handicap, no independent social improve- Nevertheless, autistic symptoms seem to
ment”), restricted, fair, and good outcomes decrease over time in individuals with AS, as an
(engaged in IQ-appropriate work or education overall group (Szatmari et al., 2009). Researchers
and living independently if over 23 years of age examining the rate of change in core autistic
or having steady friendships/relationships if symptoms found a relatively linear rate of
younger than 23) (Cederlund et al., 2008). Only decrease from preschool to adolescent years,
26% of individuals with AS were classified as with a slightly faster rate of change between
having “poor” or “restricted” outcome, compared ages 5–10 years (Szatmari et al., 2009). This
to 64% of those with AD. Retrospective case– rate of change was similar to that for a group of
control studies have found few if any differences autistic individuals with IQ > 70; however, those
(Gilchrist et al., 2001; Howlin, 2003). A common with AS maintained a comparatively lower bur-
consensus among studies, however, is that young den of symptoms overall from childhood into late
adults with AS – despite normal-range IQ and adolescence.
absence of early language delays – have striking
difficulties across a wide range of domains com- Cognitive Profile
pared to typically developing individuals. For Cognitive abilities as measured by full-scale
example, despite a mean full-scale IQ for the performance and verbal IQ have generally been
AS group of 103.0 in Cederlund et al.’s (2008) found to be stable from childhood to adolescence/
study, 47% were classified as having “fair” and early adulthood in AS (Cederlund et al., 2008).
only 27% were deemed to have “good” There is some evidence that the relative superi-
outcomes. ority of verbal IQ over performance IQ often
described in individuals with AS compared to
Core ASD Symptoms individuals with autism is less common by ado-
A majority of individuals with AS continue to lescence/young adulthood (Cederlund, et al.).
struggle with significant social communication
deficits in early adulthood accompanied by sig- Comorbid Psychiatric Symptoms
nificant associated impairment, with the excep- Outcome studies indicate that psychiatric comor-
tion of a small number who appear to improve bidity is a common problem for individuals with
significantly into a relatively unimpaired status AS, with rates similar to those of individuals with
(Cederlund et al., 2008). One study found that the high-functioning autistic disorder and PDD-NOS
mean Global Assessment of Functioning Score but higher than those seen in the general popula-
(GAF) – a clinical measure of impairment due to tion (Hofvander et al., 2009; Howlin, 2003).
symptom burden – was 58.9, indicating moderate Mood and anxiety disorders appear more com-
symptom burden or impairment. However, 17% monly in adolescence and young adulthood
of individuals with AS in this study had GAF than childhood, occurring in 21–52% of individ-
scores greater than 70, indicating normal or uals with AS according to two case–control
near-normal functioning; 11% of all those diag- studies (Hofvander et al., 2009; Howlin, 2003).
nosed with AS and later followed up no longer Attention-deficit/hyperactivity disorder (36%),
met criteria for AS. As a group, individuals with tic disorder (21%), and obsessive-compulsive
AS demonstrated less impairment than individ- disorder (21%) have also been found to be more
uals diagnosed with autism as children (mean common than in controls (Hofvander et al., 2009).
Rates of psychotic disorders measured in clinical short-term, low-pay, or voluntary posts or struc-
and population samples of individuals with AS tured work activities in a support center
range from 4% to 15% (Cederlund et al., 2008; (Cederlund et al., 2008; Howlin, 2003). Further- A
Hofvander et al., 2009). more, despite normal IQ abilities, only 35–64%
of young adults with AS live independently, the
Adaptive Functioning majority of these requiring ongoing parent sup-
Perhaps the most striking burden of Asperger port (Cederlund et al., 2008; Howlin, 2003).
syndrome in adolescence and adulthood falls Consistent with reports of persistent social
under the domain of adaptive functioning – the disabilities related to their diagnosis, individuals
ability to support oneself in day-to-day self-care, with AS report ongoing difficulties in
independent living, and financial self-sufficiency, maintaining social and romantic relationships.
to engage in relationships and to pursue voca- Approximately 4–15% of individuals report
tional interests. Adaptive functioning is an long-term relationships such as longstanding
important measure of impairment related to AS, close friendships, romantic partnerships, or
as well as an indirect measure of burden of care marriage (Cederlund et al., 2008; Howlin,
on parents, schools, and community systems of 2003), although a larger number of individuals
care. Furthermore, adaptive functioning has been (40.5%) in one study reported having a range
found to be associated with self-reported quality of less intimate friends and acquaintances
of life among individuals with high-functioning (Howlin, 2003). Nevertheless, individuals with
ASD (Kamp-Becker, Schroder, Remshmidt, & AS remain persistently less impaired than
Bachmann, 2010). Prospective research has are individuals with autism (including high-
found that individuals with AS demonstrate functioning autism) from childhood into adult-
significant improvement in adaptive functioning hood (Szatmari et al., 2009).
throughout childhood to adulthood, with some
slowing of progress during adolescence. It must Predictors of Adolescent Outcome
be remembered, however, that individuals with IQ and language abilities have been found to be
AS remain significantly impaired compared to important predictors of improved functioning in
the general population (Szatmari, et al., 2009). adolescents and adults with AS and HFA (Ben-
Educational achievement appears to be nett et al., 2008; Cederlund et al., 2008; Szatmari
a relative strength among individuals with AS. et al., 2009). This finding is in keeping with
A greater number of individuals with AS achieve research combining ASDs of all cognitive abili-
advanced levels of schooling, compared to those ties (Baghdadli et al., 2007). Higher full-scale
with autism. In one study, twice as many individ- and verbal IQ scores are associated with
uals with AS (52%) completed advanced level improved overall outcome in adolescents and
high school courses as did those with high- young adults with AS (Cederlund et al., 2008).
functioning autism (24%) (Howlin, 2003). Because AS is defined largely by the absence of
Another study found that 11.4% of individuals clinically significant language delay in most
with AS enrolled themselves in university, and research studies, this feature has been proposed
5.6% had obtained university degrees, while 33% to account for improved outcomes compared to
completed high school studies. Among high- individuals with autism and IQ > 70 found in
school completers, over half (64%) completed prospective studies (Cederlund et al., 2008;
their studies in mainstream classrooms Szatmari et al., 2003), although not in retrospec-
(Cederlund, et al., 2008). tive investigations (Gilchrist et al., 2001; Howlin,
Such academic abilities do not seem to trans- 2003). Structural language impairment at age
late into longer term vocational success or self- 6 years, defined as significant deficits in
sufficiency, however. Only 5–10% of individuals nonpragmatic aspects of language (e.g., gram-
with AS hold permanent, well-paying jobs in mar, syntax), has been found to predict greater
adulthood, whereas a greater number work in variability in functional outcomes across social,
communication, and daily living skill domains in in adolescence and adulthood are poor relative to
adolescents in high-functioning ASD than the typically developing individuals. This consensus
presence of language delay (Bennett et al., underlines the importance of having a better
2008; Szatmari et al., 2009). This suggests that understanding of how early determinants and
structured assessments of language as well as developmental pathways lead to variation in out-
cognitive ability in preschool/early school-aged comes. While prospective studies suggest that
years are important early steps in understanding improved cognitive and early language abilities
the prognosis of children with high-functioning account for superior outcomes in Asperger syn-
ASDs. There is evidence of persistent language drome compared to autistic disorder, more work
impairment in individuals with AS compared to is needed to understand early predictors within
typically developing norms (Howlin, 2003); groups of individuals diagnosed with AS taking
however, its role in predicting outcomes more into account the considerable heterogeneity in
specifically within this group has yet to be studied outcome in this population. Future longitudinal
systematically. studies should focus on unpacking how early pre-
dictors lead to later outcomes, for example,
through mediators (individual or contextual fac-
Summary and Conclusions tors that account for the association between pre-
dictors and outcomes) or moderators (groups or
In evaluating how individuals with AS fare in ado- circumstances under which an effect occurs or
lescence and adulthood, it is important to consider not). For example, poorer mental health may
the standards against which they are being com- mediate, or explain, an association between ear-
pared. According to prospective follow-up studies, lier individual traits or cognitive abilities and
the outcomes of individuals with AS are signifi- later adaptive functioning in certain individuals.
cantly better compared to those with autistic disor- Future study designs that combine intervention
der, including high-functioning autism. This is and longitudinal follow-up will be particularly
likely a function of better cognitive and language important in both elucidating developmental path-
ability, which puts them at an early and persistent ways in Asperger syndrome and addressing the
advantage compared to lower functioning peers suboptimal outcomes that all too often occur.
with autism. However, given these cognitive capac- Hybrid studies may include intervention trials (ide-
ities, young adults with AS continue to have diffi- ally randomized and controlled) and long-term
culty living and working independently and remain measurement of outcomes. Early social communi-
significantly burdened by social impairment. Fur- cation interventions, prevention, or treatment trials
thermore, rates of early improvement in function- for depression and anxiety and more intensive
ing begin to plateau in late adolescence, which may social, communication, and vocational supports
reflect slowed learning or simply an inability for for adolescents may each demonstrate effects on
this learning to keep pace with the increasing func- more global or specific aspects of functioning and
tional demands of transition to adulthood. These quality of life in adulthood. Finally, follow-up and
findings highlight the obvious need for continued intervention studies should also follow individuals
vocational, social, and daily living supports for with Asperger syndrome farther into adulthood to
teens and adults with Asperger syndrome. continue to track their pathways in learning and
functioning and to determine how best to encour-
age their strengths and support their needs.
Future Directions
Despite a relatively small number of follow-up See Also

studies of young people with Asperger syndrome
published to date, the data clearly demonstrate ▶ Adulthood, Transition to
that as a group, their functioning and well-being ▶ Asperger Syndrome
Asperger, Hans 265 A
▶ Factors Affecting Outcomes Miller, J. N., & Ozonoff, S. (1997). Did Asperger’s cases
▶ Longitudinal Research in Autism have Asperger disorder? A research note. Journal of
▶ Outcome Studies PubMed PMID: 9232470. A
Szatmari, P., Archer, L., Fisman, S., Streiner, D. L., &
Wilson, F. (1995). Asperger’s syndrome and autism:
Differences in behavior, cognition, and adaptive func-
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Pernon, E., Berstezjn, C., & Aussiloux, C. (2007). Duku, E. (2003). Predictors of outcome among high
What happens to children with PDD when they grow functioning children with autism and Asperger syn-
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Zwaigenbaum, L., Vaccarella, L., & Boyle, M. (2009). Similar developmental trajectories in autism
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Cederlund, M., Hagberg, B., Billstedt, E., Gillberg, I. C., & Szatmari, P., Bryson, S. E., Streiner, D. L., Wilson, F.,
Gillberg, C. (2008). Asperger syndrome and autism: Archer, L., & Ryerse, C. (2000). Two-year outcome of
A comparative longitudinal follow-up study more than preschool children with autism or Asperger’s syn-
5 years after original diagnosis. Journal of Autism and drome. The American Journal of Psychiatry, 157(12),
Developmental Disorders, 38(1), 72–85. doi:10.1007/ 1980–1987.
s10803-007-0364-6. Wing, L. (1981). Asperger’s syndrome: A clinical
Gilchrist, A., Green, J., Cox, A., Burton, D., Rutter, M., & account. Psychological Medicine, 11, 15.
Le Couteur, A. (2001). Development and current func-
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Asperger, Hans
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Hofvander, B., Delorme, R., Chaste, P., Nyden, A., Adam Feinstein
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with autism with and without early language delays: Location, Dates)
Implications for the differentiation between autism
and Asperger syndrome. Journal of Autism and Devel-
opmental Disorders, 33(1), 3–13. Hans Asperger was appointed director of the
Kamp-Becker, I., Schroder, J., Remshmidt, H., & play-pedagogic station at Vienna University
Bachmann, C. J. (2010). Helath-related quality of life children’s clinic in 1935.
in adolescents and young adults with high-functioning
Appointed a lecturer at the University of Vienna,
autism spectrum disorder. GMS Psycho-Social
Medicine, 7, 10. doi:10.3205/psm000065. 1944.
Longitudinal Studies: Design and Analysis. Appointed director of the children’s clinic, 1946.
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism Named professor at the University of Innsbruck
diagnostic interview-revised: A revised version of
a diagnostic interview for caregivers of individuals
children’s clinic, 1957.
with possible pervasive developmental disorders. Jour- Named professor at the University of Vienna
nal of Autism and Developmental Disorders, 24, 26. children’s clinic, 1962.
A 266 Asperger, Hans
Landmark Clinical, Scientific, and reported that, although the former was poor the
Professional Contributions latter was very good. Asperger observed that both
were affected. Kanner believed that learning by
Dr. Asperger was working in the field of what he rote would be the best method of advancing an
called “autistic psychopathy” in Vienna from the autistic person, while Asperger suggested that his
early 1930s – several years before Leo Kanner patients were “abstract thinkers” and therefore
began working on infantile autism at Johns Hop- performed best spontaneously. Asperger said his
kins University in Baltimore. His first published patients were highly intelligent and capable of
paper in this area was not the celebrated 1944 original thought. He referred to them as “little
paper but “Das psychisch abnorme Kind,” which professors”.
appeared in the Wiener Klinischen
Wochenzeitschrift in 1938 (Asperger, 1938).
This was the transcript of a talk Asperger had Short Biography
given at Vienna University earlier that year. It is
a remarkable document: Asperger, concerned to Hans Asperger was born on a farm outside Vienna
protect the children in his charge from the eugen- on February 18, 1906. He was appointed director of
ics law which he feared would be introduced by the play-pedagogic station at Vienna University
the Nazis in the newly annexed Austria, carefully children’s clinic. He married in 1935 and had five
used terminology reminiscent of Nazi thinking children, including two daughters who themselves
while at the same time pointing out the valuable became doctors. In the later part of the Second
contributions the children could make to society. World War, Asperger served as a doctor in Croatia.
The Gestapo came to arrest him twice, but he His daughter, Dr. Maria Asperger Felder, told
received the support of his boss – Franz Adam Feinstein: “He was against war. He was
Hamburger, dean of the university – who ironi- a nature- and people-loving person, not a soldier.”
cally, unlike Asperger, was sympathetic to the In 1944, he became a lecturer at the University of
Nazis. Asperger’s 1944 paper, ‘Die Vienna and was appointed director of the children’s
autistischen Psychopathen’ im Kindesalter – clinic in 1946. In 1957, Asperger became professor
which appeared in Archiv f u€r Psychiatrie und at the University of Innsbruck children’s clinic and,
Nervenkrankheiten – provided detailed descrip- from 1962, held the same position in Vienna.
tions of four children with autistic psychopathy, Despite the fact that he traveled around the world,
or what Lorna Wing, in 1981, called “Asperger’s his writings were not mentioned at a major psychi-
syndrome” (Asperger, 1944; Wing, 1981). atry conference in Zurich in April 1957. The vet-
Unlike in classic (or “Kanner’s”) autism - where eran French autism authority, Professor Gilbert
there is language delay and IQ can be anywhere Lelord, who attended this congress, told Adam
on the scale – in Asperger’s syndrome, there is no Feinstein that this may well have been
language delay and IQ is at least average. a consequence of the Second World War: “Even
Asperger believed that his syndrome was never though Asperger was undoubtedly a victim of the
recognised in infancy and not usually before the war, German-language papers were not popular at
third year of life or later. Kanner emphasised the time.” Indeed, Asperger’s writings did not come
onset of his condition from birth or before 30 to the attention of the English-speaking world until
months. Unlike Kanner, Asperger thought of his Lorna Wing’s 1981 paper and Uta Frith’s 1991
condition as a personality disorder with organic translation into English of Asperger’s 1944 paper.
causes. While Kanner reported that three of his 11 Leo Kanner never mentioned Asperger in any of his
patients did not speak at all, and the remainder own papers, whereas Asperger often cited Kanner,
rarely used language to communicate, Asperger always insisting that his syndrome was distinct
noted that his case study patients spoke “like little from Kanner’s. Asperger’s syndrome was listed
adults”. There were also discrepancies regarding officially for the first time in ICD-10 in 1992 and in
gross co-ordination and fine motor skills. Kanner DSM-IV in 1994.
Assessment of Basic Language and Learning Skills (ABLLS) 267 A
ASQ-3 Materials Kit
Asperger, H. (1938). Das psychisch abnorme kind. Wiener
Kinischen Wochenzeitschrift, 51, 1314–1317. A
▶ Ages and Stages Questionnaire, Second
Asperger, H. (1944). Die “autistischen Psychopathen”
im Kindesalter, Archiv fur Psychiatrie und Edition
Nervenkrankheiten, 117, 76–136 [Autistic psychopa-
thy in childhood] (U. Frith (Ed.), Trans., (1991),
Autism and Asperger syndrome (pp. 37–92)).
Cambridge, England: Cambridge University Press.
Feinstein, A. (2010). A history of autism: Conversations ASQ-3™
with the pioneers. Oxford, England: Wiley-Blackwell.
Wing, L. (1981). Asperger’s syndrome: A clinical ▶ Ages and Stages Questionnaire, Second
account. Psychological Medicine, 11(1), 115–130.
Edition
Asperger’s Disorder
Assessment of Basic Language and
▶ Asperger Syndrome Learning Skills (ABLLS)
Cheryl Smith Gabig

Department of Speech-Language-Hearing
ASQ Family Access Sciences, Lehman College/The City University
of New York, Bronx, NY, USA
▶ Ages and Stages Questionnaire, Second
Edition
Synonyms
ABLLS-R; Assessment, curriculum guide, and

ASQ Hub (for Monitoring Screening skills tracking
Programs of Multiple Organizations)
▶ Ages and Stages Questionnaire, Second Description

Edition
The Assessment of Basic Language and Learning
Skills-Revised (ABLLS-R) is a criterion-
referenced assessment tool, curriculum planning
ASQ Pro (for Single-Site Programs) guide, and tracking system of requisite skills
and ASQ Enterprise (for Multisite needed for basic language and communication
Programs) development, as well as skills needed to support
learning in important academic, adaptive,
▶ Ages and Stages Questionnaire, Second and motor areas. ABLLS-R provides
Edition a comprehensive review of 544 skills from
25 skill areas. The primary purpose of the
ABLLS-R is to assess and identify skills in
language/communication and critical academic
ASQ:SE learning, self-help, and motor areas in order to
optimize communication, social interaction, and
▶ Ages and Stages Questionnaire, Second ongoing learning in everyday situations.
Edition A secondary purpose is to assist in determining
A 268 Assessment of Basic Language and Learning Skills (ABLLS)
and prioritizing educational objectives for an task item being assessed, an Examples column,
individual child. The ABLLS-R assessment can the Criteria column specifying the standards for
identify skills currently in the child’s repertoire, scoring, and a Notes column to record related
the level of skill attainment, and allows for the information about the level of performance by
ongoing tracking of progression in skill the child on the task item. For example, for
development. Task A1 under the skill area Cooperation and
The ABLLS-R is comprised of two separate Reinforcer Effectiveness, the Score column
documents: the ABLLS-R Protocol and the shows a range of scores from 0 to 2, the Task
ABLLS-R Scoring Instruction and IEP Develop- Name states: Takes reinforcer when offered, the
ment Guide. The ABLLS-R Protocol is the Task Objective states: “When offered a known
assessment document that provides a task analy- reinforcing item or activity, the students will
sis of behaviors and skills in four areas: basic take/use the item or activity,” while the Question
learner skills, academic skills, self-help skills, column provides the following question to
and motor skills. The basic learner skills assess- prompt a recall or directly observe the requisite
ment is the largest area of consideration and is behavior: “When you hold out and offer a known
comprised of 15 subcomponent skill areas includ- reinforcer, will the student take the reinforcer?”
ing aspects of language and communication, imi- The Example column provides an exemplar of
tation, visual learning ability, play and leisure, the desired behavior: “M & M taken and eaten.”
social skill interaction, group behavior, The Criteria column specifies the standard that
responding, and classroom functioning. Aca- must be met for each of the numbered scores in
demic skill assessment includes task analyses the Score column: 2 ¼ takes within 3 seconds all
for reading, math, writing, and spelling. The the time, 1 ¼ either not all the time or takes more
self-help skills assessed include dressing, eating, than 3 seconds to respond.
grooming, and toileting. The motor skills assess- For each task item in the ABLLS-R, the Score
ment addresses strengths and weaknesses in gross column has four rows of numbers. The initial
and fine motor abilities. The ABLLS-R Scoring assessment of the task item is scored in the first
Instruction and IEP Development Guide provide row; subsequent updates are scored successively
important information regarding scoring, priori- in the rows below. The numbers included in the
tizing educational objectives, and developing an Score column range from zero to the highest
Individualized Education Program (IEP). possible score, which varies by task item as 1, 2,
or 4. Therefore, depending on the task, the Score
The ABLLS-R Protocol column may have four rows, each row with the
Each language, communication, or learning area numbers 0 1; 0 1 2; or 0 1 2 3 4. A score of zero is
included in the ABLLS-R Protocol contains a list given when the skill is either absent from the
of underlying behaviors needed for potential child’s repertoire or the child does not meet the
mastery of the domain or skill area. The underly- lowest criterion indicated in the Criteria column.
ing skills for the domain are identified and num-
bered as tasks; each task has a corresponding task The ABLLS-R Scoring Instructions and IEP
objective. Individual tasks can be directly Development Guide
observed or assessed for the child, and the level The Scoring Instructions and IEP Development
of skill attainment for the task objective deter- Guide provides direction on the initial scoring,
mined by a score ranking. The numbered task how to resolve discrepancies between reports
items for each skill domain are presented in about a specific skill, how to ensure the stability
a visual grid display containing eight columns. of scores, and how to transfer the scores from the
The first column is the numbered Task, followed initial assessment (or subsequent update) to the
by the Score column, the Task Name column, the corresponding grid box on the skills tracking
Task Objective column, the Question column to system sheets. The skills tracking grid is used
prompt recall or direct observation of the specific by the educational support team, including the
Assessment of Basic Language and Learning Skills (ABLLS) 269 A
parents, teachers, and clinical staff to help deter- a variety of contexts. Additional new items for
mine the skill areas of need for each child and to specific areas were identified from the research
develop a specific individual educational plan literature on autism for inclusion in the 2006 edi- A
(IEP) for the child. The Scoring Instructions and tion, including new items added to the assessment
IEP Development Guide also provides informa- of motivation, response to complex stimuli, gen-
tion about how to prioritize the needs of the child eralization, learner readiness, social skills devel-
in order to develop an optimal IEP. opment, and imitation.
Historical Background Psychometric Data
The ABLLS-R is an assessment and intervention The ABLLS-R is a criterion-referenced assess-

planning tool based on the theory of verbal behav- ment tool. As such, the ABLLS-R is not designed
ior and learning of B.F. Skinner. Skinner proposed to compare the child’s skill or achievement to
that language or verbal behavior is a product of an a standardized peer group. No age norms, stan-
operant stimulus-response-reinforcement/punish- dardized scores, or group comparison data are
ment paradigm with additional consideration of provided. The ABLLS-R provides a skills tracking
the importance of aspects of stimulus control and system that targets the skill development in each
motivation. Skinner’s analysis of verbal behavior area of assessment. The results can be displayed on
centered on a set of functional units called verbal a grid that visually portrays the level of functioning
operants; each verbal operant consists of the in each skill area assessed. The visual grid display
response or verbal behavior and its controlling allows for the easy identification of areas of sig-
antecedents and consequences. Skinner described nificant or moderate deficit for use in identifying
four verbal operants related to vocal communica- needed areas and skills for intervention. The
tion including echoic, mand, tact, and intraverbal. ABLLS-R can be completed by a parent, educator,
Each of these functional units is included in the other professional, or a combination of these. The
basic learner skills assessment as vocal imitation, assessment can be done over a number of days or
requests, labeling, and intraverbal, respectively. In weeks, and each skill area can be revisited as the
addition to the functional verbal units, other child progresses. Each assessment area has
important areas of cognitive development and a number of task items identified to assess skill
behavior that affect verbal learning are included development and mastery of the area. The number
in the basic learner skills, including behaviors of task items varies for each area assessed. For
associated with motivation, the ability to attend example, the receptive language area contains 57
to complex stimuli, generalization, the ability to tasks associated with the domain, whereas the
use language without prompting, termed “sponta- vocal imitation domain contains 20 task items.
neity,” the ability to quickly apply a learned verbal
behavior, called fluency, joint attention, learner
readiness, and social skills development. Clinical Uses
The ABLLS-R Protocol and ABLLS-R guide
are an update to the Assessment of Basic Language The ABLLS-R is useful for parents, educators, and
and Learning Skills (ABLLS), first published in special education support staff members to assess
1998. The recent edition incorporates additional and identify specific skills needed by a child who
skills and two additional areas of importance to is nonverbal or has significant speech and lan-
verbal learning and communication for children guage delays. The ABLLS-R Protocol provides
with autism not included in the initial publication. a careful analysis of needed skills that should be
The two new areas include assessment of skill in the focus of intervention. There are limitations to
joint attention and fluency. Fluency is the ability of the ABLLS-R in that it is not an exhaustive list of
a child to quickly apply and use a learned skill in skills needed, nor does it provide instructions for
A 270 Assessment, Curriculum Guide, and Skills Tracking
teaching a desired skill. The ABLLS-R is not

standardized; therefore, a child’s performance in Assistive Device
an area cannot be compared to an age peer group.
▶ Communication Board
See Also
▶ Applied Behavior Analysis Assistive Devices

▶ Behavior Analysis
▶ Behavior Modification Vannesa T. Mueller
▶ Behavioral Objectives Speech-Language Pathology Program,
▶ Behaviorism University of Texas at El Paso College of Health
▶ Criterion-Referenced Testing Science, El Paso, TX, USA
▶ Generalization and Maintenance
▶ Imitation
▶ Motivation Synonyms
▶ Stimulus
Augmentative and alternative communication
(AAC) device
Lerman, D. C., Parten, M., Addison, L. R., Vorndran, C. M., Definition

Volkert, V. M., & Kodak, T. (2005). A methodology for
assessing the functions of emerging speech in children
with developmental disabilities. Journal of Applied Assistive devices are aided communication sys-
Behavior Analysis, 38, 303–316. tems used in the area of augmentative and alter-
Partington, J. W., & Sundberg, M. L. (1998). The assess- native communication (AAC). Aided systems are
ment of basic language and learning skills. Danville,
ones that require something other than the indi-
CA: Behavior Analysts.
Partington, J. W. (2010). The assessment of basic lan- viduals’ body to communicate. That “something”
guage and learning skills-Revised. Pleasant Hill, CA: could be picture symbols, written words, or
Behavior Analysts. a high-tech, speech-generating device. Con-
Scattone, D., & Knight, K. R. (2008). Current trends in
behavioral interventions for children with autism.
versely, unaided systems are those that do not
International Review of Neurobiology, 72, 181–193. require anything separate from one’s own body
Skinner, B. F. (1957). Verbal behavior. New York: to communicate. Essentially, gestures, body lan-
Appleton. guage, and sign language are examples of
unaided systems. Examples of assistive devices
are individual picture symbols, picture commu-
nication boards, mid-tech communication aids
Assessment, Curriculum Guide, and such as the MessageMate (sold by Words+), and
Skills Tracking high-tech communication devices such as the
VMax (sold by DynaVox). See Beukelman and
▶ Assessment of Basic Language and Learning Mirenda (2005) for a detailed description of
Skills (ABLLS) assistive devices and their implementation.
See Also
Assistant
▶ Alternative Communication
▶ Paraprofessional ▶ Augmentative and Assistive Technology
Association for Retarded Citizens (Arc) 271 A
▶ Communication Board appropriate education to children with disabil-
▶ Voice Output Communication Aids ities) and legislation to create the Supplemental
Security Income program to support persons A
with disabilities. Since that time, The Arc has
References and Readings contributed significantly to efforts to pass many
other laws contributing to increased community-
Beukelman, D. R., & Mirenda, P. (2005). Augmentative based options for living (e.g., the creation of Med-
and alternative communication: Supporting children
icaid-funded home and community-based
and adults with complex communication needs.
Baltimore: Brooks Publishing. waivers) and working (e.g., incentives for
employers who hire persons with disabilities),
other initiatives related to health (e.g., Medicaid’s
Early and Periodic Screening, Diagnosis, and
Associate Treatment program), and the landmark Americans
with Disabilities Act.
▶ Paraprofessional The Arc has also contributed to the scientific
understanding of I/DD. In the 1960s, The Arc
helped to first expose links between lead poisoning
and brain damage in children. Research and other
Association for Retarded work funded by The Arc in the 1970s helped to
Citizens (Arc) identify the treatment for phenylketonuria (PKU),
to define Fetal Alcohol Spectrum Disorder, and to
Peter Doehring first suggest infant undernutrition as a cause of
Foundations Behavioral Health, Doylestown, developmental disabilities. Since that time, The
PA, USA Arc also began to support the dissemination of
scientific findings through its sponsorship or orga-
nization of key summits and publications.
Major Areas or Mission Statement
The mission of The Arc is to “promote and pro- Major Activities

tect the human rights of people with intellectual
and developmental disabilities and actively sup- The Arc describes itself as “the largest national
ports their full inclusion and participation in the community-based organization advocating for
community throughout their lifetimes.” and serving people with intellectual and develop-
mental disabilities and their families. We encom-
pass all ages and all spectrums from autism,
Landmark Contributions Down syndrome, Fragile X and various other
developmental disabilities.” The Arc actively
The Arc was founded in 1950 as the National contributes to the development of public policies
Association of Parents and Friends of Mentally at the local, state, and federal level.
Retarded Children. It initially focused on chang- Education and Activism is a core activity of
ing perceptions about I/DD (then referred to as The Arc at the local, state, and federal level
mental retardation), from the assumption that levels, in support of legislation for civil rights,
most persons with I/DD necessitated institution- education, employment, health care, housing, and
alization, to the recognition of their potential other areas of interest. With funding from
and their rights to employment and education. Administration on Developmental Disabilities,
During the 1960s and 1970s, The Arc advocated The Arc recently established the National
for key legislation, including the passage of Autism Resource and Information Center as
Public Law 94-142 (guaranteeing a free and a “central point of access to high-quality and
A 272 Associative Learning
evidence-based resources and information for unconditioned. Associative learning, like classi-
individuals with Autism Spectrum Disorder cal conditioning, involves pairing an uncondi-
(ASD) and other developmental disabilities, tioned stimulus (which reflexively produces
their families, professionals, and other targeted a response) with another stimulus that is neutral.
key stakeholders, including underserved and Over time, the pairing results in the reliable
unserved.” emission of a response that was previously not
A broad range of supports and services are consistently emitted.
also offered by individual chapters of The Arc,
including information and referral, advocacy and
self-advocacy around a broad range of issues, See Also
residential support, family support, employment
programs, and leisure and recreational programs. ▶ Classical Conditioning
In 2011, The Arc had more than 700 state and ▶ Operant Conditioning
local chapters, and more than 140, 000 members
across the United States. Members come from all
walks of life, though most are family members or References and Readings
persons with intellectual and developmental dis-
abilities (I/DD). Moran, D., & Malott, R. (2004). Evidence based educa-
tional methods. New York: Elsevier Academic Press.
Shanks, D. (1995). The psychology of associative learning
(problems in the behavioral sciences). Cambridge:
See Also Cambridge University Press.
Whitehead, W., Lurie, E., & Blackwell, B. (1976). Clas-
sical conditioning of decreases in human systolic
▶ Advocacy
blood pressure. Journal of Applied Behavior Analysis,
▶ Disability 9, 153–157.
▶ Intellectual Disability
▶ Mental Retardation
Ataxia
Associative Learning Fred R. Volkmar

Rebecca DeAquair Professor of Child Psychiatry, Pediatrics and
The Center for Children with Special Needs, Psychology, School of Medicine,
Glastonbury, CT, USA Yale University, New Haven, CT, USA
Definition Synonyms
Associative learning refers to the process in Dystaxia

which a new response is paired with
a particular stimulus or response that already
exists within the learner’s repertoire or experi- Definition
ences; it is based on the ideas that experiences
reinforce one another and can be linked to Unsteady gait. The term ataxia refers to lack of
enhance the learning process. Associative learn- coordination of motor movements. Ataxia typi-
ing responses are “associative” in that the cally arises due to some dysfunction within the
responses being learned are associated with precentral nervous system. It has many different
vious responses or stimuli, either conditioned or causes, e.g., it can be a sign of dysfunction in
Atomoxetine 273 A
the cerebellum (where it usually would be asso-
ciated with various other difficulties). Other Atomoxetine
causes can relate to effects of drugs or other sub- A
stances, problems with the vestibular system, and Alvi Azad
other parts of the brain. Medications given to Yale Child Study Center, The Edward Zigler
control seizures are a common cause of ataxia; Center in Child Development and Social Policy,
abuse of some substances (e.g., alcohol) may also Yale University, New Haven, CT, USA
lead to ataxia.
Ataxia can also arise as a result of a deficiency
in vitamin B12, exposure to certain toxic agents, Synonyms
and so forth. Problems in the peripheral nervous
system can also be associated with ataxia. Certain Straterra (TM)
inherited (genetic) disorders can also lead to
ataxia.
In autism, problems in posture and gait are Definition
relatively common. Problems with clinically sig-
nificant ataxia often are associated with drug Atomoxetine is a drug approved for the treatment
treatments (e.g., for seizures). In Rett’s disorder, of attention-deficit hyperactivity disorder
ataxia and other movement problems are quite (ADHD). This compound is manufactured,
common and associated with the underlying path- marketed, and sold in the United States under
ophysiology of the condition. the brand name Strattera by Eli Lilly and
Treatment varies depending on the cause. Phys- Company. Generics of atomoxetine are sold in
ical therapy can be useful in some cases, and some other countries.
drug treatments have also been proposed.
Clinical Use
See Also
Atomoxetine is approved for use in children,
▶ Epilepsy adolescents, and adults; however, its efficacy
▶ Physical and Neurological Examination has not been studied in children under 6 years
▶ Rett’s Disorder old. Its advantage over stimulants for the treat-
ment of ADHD is that it has less abuse potential
than stimulants (Wee & Woolverton, 2004), is
References and Readings not scheduled as a controlled substance, and has
shown in clinical trials to offer 24-h coverage of
Rinehart, N. J., Tonge, B. J., et al. (2006). Gait function symptoms associated with ADHD in adults and
in newly diagnosed children with autism: Cerebellar children (May & Kratochvil, 2010).
and basal ganglia related motor disorder. Develop-
Therapeutic effects of atomoxetine may take
mental Medicine and Child Neurology, 48(10),
819–824. a week to be felt and an adequate trial may be up
Tachi, N., Kozuka, N., et al. (2000). Hereditary cerebellar to 8 weeks (May & Kratochvil, 2010). Many peo-
ataxia with peripheral neuropathy and mental retarda- ple respond to atomoxetine who do not respond to
tion. European Neurology, 43(2), 82–87.
VanAcker, R., Loncola, J. A., et al. (2005). Rett syndrome:
stimulants (May & Kratochvil). Atomoxetine may
A pervasive developmental disorder. In F. R. Volkmar, be preferred over amphetamine-based stimulants
A. Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of in patients with psychiatric disorders, those who
autism and pervasive developmental disorders (Vol. 1, cannot tolerate stimulants, and those with
a substance misuse recurring history. Therapy is
Volkmar, F. R., & Wiesner, L. A. (2009). A practical
guide to Autism: What every parent, teacher and fam- usually initiated by gradually increasing the dose
ily member needs to know. Hoboken, NJ: Wiley. to minimize side effects.
A 274 Atomoxetine
Arnold et al. in 2006 enrolled 16 pediatric There is a black box warning for increased risk
patients with pervasive developmental disorder of suicidality in children and adolescent with
(PDD) in a double-blind, placebo-controlled, ADHD especially during the first month of
crossover study and found that 57% of the pedi- treatment.
atric patients responded to atomoxetine (Arnold
et al., 2006).
Pharmacology
Mechanism of Action Pharmacokinetic data: bioavailability, 63–94%;

protein binding (primarily albumin), 40%;
Atomoxetine acts by selectively blocking the metabolism, hepatic, via CYP2C19 (minor),
norepinephrine transporter. The norepinephrine 2D6 (major) (Garnock-Jones & Keating, 2009)
transporter takes up norepinephrine as well as Bioavailability: 63% in extensive metabolizers;
dopamine in the prefrontal cortex, with little to 94% in poor metabolizers (Garnock-Jones &
no activity at the other neuronal reuptake pumps Keating, 2009)
or receptor sites. Blocking the norepinephrine Half-life elimination: atomoxetine: 5 h
transporter increases norepinephrine as well as (up to 24 h in poor metabolizers); active
dopamine levels; this mechanism was studies in metabolites, 4-hydroxyatomoxetine: 6–8 h;
rat prefrontal cortices (Bymaster et al., 2002). N-desmethylatomoxetine: 6–8 h (34–40 h in
Atomoxetine has been shown to improve prefron- poor metabolizers) (Chalon et al., 2003; Witcher
tal cortices in normal adults with ADHD (Cham- et al., 2003)
berlain et al., 2006, 2007). Time to peak, plasma: 1–2 h (Chamberlain
et al., 2006)
Excretion: Urine (80%, as conjugated
Dosing 4-hydroxy metabolite); feces (17%) (Chamberlain
et al., 2006)
Once- or twice-daily atomoxetine was effective
in the short-term treatment of ADHD in children
and adolescents, as observed in several placebo- See Also
controlled trials (May & Kratochvil, 2010),
0.5–1.4 mg to kilogram of body weight (May & ▶ Attention Deficit/Hyperactivity Disorder
Kratochvil).
Side Effects References and Readings
The side effects include dry mouth, tiredness, Arnold, L. E., Aman, M. G., Cook, A. M., Witwer, A. N.,
Hall, K. L., Thompson, S., et al. (2006). Atomoxetine
irritability, nausea, decreased appetite, constipa-
for hyperactivity in autism spectrum disorders: pla-
tion, dizziness, sweating, dysuria, sexual cebo-controlled crossover pilot trial. Journal of the
problems, increased obsessive behavior, weight American Academy of Child and Adolescent
changes, palpitations, and increases in heart rate Psychiatry, 45(10), 1196–1205.
Bymaster, F. P., Katner, J. S., Nelson, D. L., Hemrick-
and blood pressure (Chamberlain et al., 2006). Luecke, S. K., Threlkeld, P. G., Heiligenstein, J. H.,
Two confirmed cases of liver injury have been et al. (2002). Atomoxetine increases extracellular
reported by Eli Lilly and Company out of approx- levels of norepinephrine and dopamine in prefrontal
imately two million prescriptions written. In both cortex of rat: a potential mechanism for efficacy in
attention deficit/hyperactivity disorder. Neuropsycho-
cases, upon discontinuation of atomoxetine, pharmacology, 27(5), 699–711.
patients’ liver functions returned to normal Chalon, S. A., Desager, J. P., DeSante, K. A., et al. (2003).
(Chamberlain et al., 2006). Effect of hepatic impairment on the pharmacokinetics
Attachment 275 A
of atomoxetine and metabolites. Clinical Pharmacol- in the world, including the self (Bowlby, 1969/
ogy and Therapeutics, 73, 178–191. 1982). These models are useful in guiding
Chamberlain, S. R., Del Campo, N., Dowson, J., M€ uller,
U., Clark, L., Robbins, T. W., et al. (2007). behaviors in new situations. Furthermore, they A
Atomoxetine improved response inhibition in adults affect the quality of the child’s future relation-
with Attention Deficit/Hyperactivity Disorder. Biolog- ships throughout life (Sroufe & Fleeson, 1986).
ical Psychiatry, 62(9), 977–984. Once working models are established, they tend
Chamberlain, S. R., M€ uller, U., Blackwell, A. D., Clark, L.,
Robbins, T. W., & Sahakian, B. J. (2006). Neurochem- to remain stable. The “marker behaviors” of
ical modulation of response inhibition and probabilistic attachment can change throughout stages of
learning in humans. Science, 311(5762), 861–863. child development (e.g., physical proximity or
Garnock-Jones, K. P., & Keating, G. M. (2009). checking in with mother in the first years, ver-
Atomoxetine: a review of its use in attention-deficit
hyperactivity disorder in children and adolescents. bal negotiation at age 3 or 4). However, the
Paediatric Drugs, 11(3), 203–226. construction of the attachment patterns (secure
May, D. E., & Kratochvil, C. J. (2010). Attention-deficit or insecure) tends to remain stable (Bretherton,
hyperactivity disorder: recent advances in paediatric 1985).
pharmacotherapy. Drugs, 70(1), 15–40.
Wee, S., & Woolverton, W. L. (2004). Evaluation of the The perception of attachment as an affective
reinforcing effects of atomoxetine in monkeys: Com- bond means that the child is forming long
parison to methylphenidate and desipramine. Drug enduring ties with noninterchangeable “signifi-
and Alcohol Dependence, 75(3), 271–276. cant other/s” (Ainsworth, 1989). Thus, the
Witcher, J., Long, A., Smith, B., et al. (2003). Atomoxetine
pharmacokinetics in children and adolescents with infant’s initial ability to differentiate between
attention deficit hyperactivity disorder. Journal of people and inanimate objects and then the
Child and Adolescent Psychopharmacology, 13, 53–63. capacity to distinguish the primary caregiver
from other individuals are precursors to the
ability to form attachment. On the basis of
these differentiations, the child directs more
Attachment proximity-seeking behaviors toward the pri-
mary caregiver, shows more distress in the care-
Nirit Bauminger-Zviely giver’s absence, and calms down in the
School of Education, Bar - Illan University, caregiver’s presence. Behaviors maintaining
Ramat-Gan, Israel proximity during infancy include active efforts
to stay close to the mother (e.g., approaching,
following, clinging) and signaling behaviors
Definition (e.g., smiling, crying, calling) (Ainsworth,
Blehar, Waters, & Wall, 1978).
According to Bowlby (1969/1982), attachment A child might be able to differentiate
constitutes the first affective bond that the child between the mother and other individuals yet
forms with the primary caregiver. Bowlby, nevertheless form an insecure attachment with
drawing from object relations theory, suggested the mother. Thus, the quality of attachment also
that in the first year of life it is in the infant’s needs to be considered. The “strange situation”
interest to seek out proximity to the attachment paradigm, a series of eight episodes in which the
figure when under stress (Bretherton, 1985). infant is given the opportunity to interact with
Thus, to foster proximity, the child and mother an unfamiliar adult in the mother’s presence and
are involved in many interactions. According to absence, was developed to identify individual
Bowlby, the responsiveness of the mother to the differences in children’s quality of attachment
child’s signals will determine the nature of their (Ainsworth et al., 1978). The child’s reactions
relationship, which the child will internalize via to the separation and reunion with the mother
working models. The working model comprises during the “strange situation” episodes enable
the representation of the child’s knowledge classification of children as either securely
about the world and about significant persons attached to their mothers (e.g., showing distress
A 276 Attachment Disorder
at separation and attempting to reestablish inter-

action at reunion) or as insecurely attached. Attachment Disorder
Insecure attachment can be “avoidant” (e.g.,
showing indifference at separation and actively Tessa Chesher1 and Charles H. Zeanah2
1
avoiding parents at reunion), “resistant/ambiv- Tulane University, New Orleans, LA, USA
2
alent” (e.g., presenting high distress at separa- Department of Neurology and the Department
tion and responding to reunion with mixed of Psychiatry and Behavioral Sciences,
feelings of rejection and approaching), or as Tulane University, School of Medicine,
later identified by Main and Solomon (1986, New Orleans, LA, USA
1990), “insecure/disorganized” (e.g., lacking
observable goals, intentions, or explanations in
the parent’s presence, such as stereotypical Synonyms
movements or misdirected and incomplete
expressions). Disinhibited attachment disorder; Disinhibited
social engagement disorder; Emotionally
withdrawn/inhibited attachment disorder; Indis-
See Also criminate friendliness; Indiscriminate sociability;
Indiscriminate social behavior; Indiscriminately
▶ Reactive Attachment Disorder social/disinhibited attachment disorder; Reactive
attachment disorder

Ainsworth, M. S. D. (1989). Attachment beyond infancy.
American Psychologist, 44, 709–716. Attachment disorders describe aberrant social
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall,
behaviors in young children, particularly regard-
S. (1978). Patterns of attachment: A psychological
study of the strange situation. Hillsdale, NJ: ing how and from whom they seek comfort,
Erlbaum. support, nurturance, and protection. Two major
Bowlby, J. (1969/1982). Attachment and loss (Attach- types have been defined, an emotionally with-
ment, Vol. 1). New York, NY: Basic Books.
drawn/inhibited type, in which the child lacks
Bretherton, I. (1985). Attachment theory: Retrospective
and prospective. In I. Bretherton & E. Watres (Eds.), social and emotional responses, and an indiscrim-
Growing points of attachment theory and research inately social/disinhibited type, in which the
(Monographs of the Society for Research in Child child lacks social wariness about unfamiliar
Development, 50 (1–2, Serial No. 209)). Chicago, IL:
adults. The former includes the absence of attach-
University of Chicago Press for the Society for
Research in Child Development. ment behaviors directed at caregivers, while the
Main, M., & Solomon, J. (1986). Discovery of an latter refers to social behaviors directed at
insecure – disorganized/disoriented attachment pat- unfamiliar adults.
tern. In T. Brazelton & M. W. Yogman (Eds.), Affec-
tive development in infancy (pp. 95–124). Norwood,
NJ: Ablex.
Main, M., & Solomon, J. (1990). Procedures for identify- Categorization
ing infants as disorganized/disoriented during the
Ainsworth strange situation. In M. T. Greenberg, D.
Chicchetti, & E. M. Cummings (Eds.), Attachment in
DSM-IV-TR (American Psychiatric Association
the preschool years: Theory, research and interven- [APA], 2000) describes two subtypes of reactive
tion (pp. 134–146). Chicago, IL: University of attachment disorder, an emotionally withdrawn/
Chicago Press. inhibited type and an indiscriminately social/
Sroufe, L. A., & Fleeson, J. (1986). Attachment and the
disinhibited type, whereas ICD-10 (World Health
construction of relationships. In W. W. Hartup &
Z. Rubin (Eds.), Relationships and development Organization [WHO], 1992) defines “reactive
(pp. 51–71). Hillsdale, NJ: Erlbaum. attachment disorder” as the emotionally
Attachment Disorder 277 A
withdrawn/inhibited type and “disinhibited In a study of young children with a history of
attachment disorder” as the indiscriminately varying amounts of institutional rearing (range of
social/disinhibited type. Recent reviews have 6–54 months), only 10% had a diagnosis of RAD A
concluded that these types actually represent at 54 months of age, though a majority of children
two distinct disorders that share primarily the showed subthreshold signs of the disorder
conditions of risk in which they each occur (Gleason et al., 2011). Thus, although signs of
(Rutter, Kreppner, & Sonuga-Barke, 2009; the disorder may be evident in children with
Zeanah & Gleason, 2010). For this reason, DSM histories of maltreatment (Pears, Bruce, Fisher,
5, in keeping with ICD-10, is proposing to define & Kim, 2010; Oosterman & Schuengel 2007;
two distinct disorders. Zeanah et al., 2004) or institutional rearing
The emotionally withdrawn/inhibited type of (Chisholm, 1998; Gleason et al., 2011; Rutter
reactive attachment disorder is characterized by et al., 2007; Tizard & Rees, 1975; Zeanah,
a child who appears emotionally unresponsive Smyke, Koga, Carlson, & The BEIP Core
with limited or no positive affect. These children Group, 2005), children meeting full criteria for
do not have much of an interest in interaction the disorder are rare, especially if they are living
with any adult, and social reciprocity is minimal in families.
or absent. This overt apathy toward relationships
extends to the attachment relationship. These
children do not exhibit consistent or robustly Natural History, Prognostic Factors, and
developed attachment behaviors, that is, behav- Outcomes
iors that promote proximity to preferred adults.
Children with emotionally withdrawn/inhibited Since most children who are severely neglected
RAD fail to check in with familiar adults, and or raised in deprived institutions do not develop
they neither seek nor accept comfort from attachment disorders, there must be vulnerability
caregivers in times of emotional need. factors that predispose children to one or the
In contrast, children with the indiscriminately other types of RAD. Little progress to date in
social/disinhibited type of reactive attachment elucidating those factors has been made.
disorder are overly familiar, even with adults A related question is why children who share
they do not know. They can be intrusive and risk factors of neglect and deprivation develop
lack appropriate social and physical boundaries, such distinctively different phenotypes – one
as well as emotionally “over bright” and attention withdrawn and unresponsive and the other overly
seeking. They lack reticence around unfamiliar bright emotionally and attention seeking. Again,
adults, instead approaching and engaging with there have been no published studies to date that
anyone. In fact, they are notably willing to “go have addressed these issues. Temperamental dif-
off” with complete strangers. They may be ferences or genetic polymorphisms are potential
aggressive as well as uncomfortably “friendly.” vulnerability factors.
One of the hallmark features of attachment
disorder is that they are supposed to be responsive
Epidemiology to changes in the caregiving environment. This is
quite clear in the case of emotionally withdrawn/
These disorders are believed to be rare, even in inhibited RAD, but less clear in the case
clinic-referred children, but epidemiological data of indiscriminately social/disinhibited RAD as
are scarce. In a quasi-epidemiologic study (Egger illustrated in the following two examples.
et al., 2006), for example, 300 children were
recruited from pediatric clinics, but there were Case 1
no cases of reactive attachment disorder identi- Cade is a 30-month-old boy who spent the first
fied. A cohort study by Skovgaard showed 20 months of his life in a run-down apartment.
a prevalence of 0.9% of attachment disorders. His mother had a serious substance use disorder,
which became worse after he turned a year old. Her grandmother described her blank stare as
Only rarely did she have someone watch him. “unnerving.” Zoe was easily frustrated and diffi-
Instead, she often left him on the floor in the cult to console. At times, she smiled but her smile
kitchen, with a bowl of dry cereal, and a pet had a frozen, empty quality and did not convey
gate in place so that he would not leave the any sense of authentic positive affect. Her grand-
kitchen. A neighbor called the police, and Cade mother described Zoe as “stiff and awkward to
was taken into State’s custody. hold.” Zoe seemed to be fine as long as she was
Cade was found to be malnourished, but he left alone.
quickly recovered physically. Most striking about After a few weeks of being in her grandmother’s
his behavior in the foster home was his eagerness care, Zoe improved substantially. She began to
to be held by everyone. He immediately interact reciprocally with her grandmother, and
approached any adult, and he showed no prefer- she ran to her when she wanted comfort. She was
ences nor any reticence. He seemed starved for easily consoled, but only by her grandmother. She
attention, and his affect was overly bright. clung tightly to her grandmother when a stranger
Because his mother surrendered her rights to came into the room. Her frozen smile disappeared,
him, Cade was adopted when he was 28 months and she readily conveyed moments of genuine
old. With his adoptive parents, he continued enjoyment, though she remained irritable and
to display intrusive, affectionate behavior. easily frustrated for several more months.
They were concerned because he continued to In studies of children adopted out of institu-
go readily to any stranger. tions, there have been no children identified with
They were counseled to restrict his contact emotionally withdrawn/inhibited RAD in follow-
with adults other than the two of them for several ups months to years later (Chishom, 1998; Rutter
months. Following this, he began to seek comfort et al., 2007; Hodges & Tizard, 1989). Similarly,
preferentially from his foster parents when he in the Bucharest Early Intervention Project
was distressed and to protest when they left him. (BEIP), children removed from institutions and
They felt that he became increasingly affection- placed in foster care had a strong and early reduc-
ate with them. Despite these gains, after several tion in signs of emotionally withdrawn/inhibited
months when they began to take him into public, RAD compared to children who remained insti-
he still showed occasional lack of reticence with tutionalized (Smyke et al., 2012). In other words,
strangers, and they feared that he would be once children are removed from socially depriv-
willing to go off with one. ing environments of institutions and are placed
with families, signs of emotionally withdrawn/
Case 2 inhibited RAD disappear. On the other hand, for
Zoe was taken into State’s custody when she was children who remain in institutions, signs of emo-
13 months old because of neglect and concerns tionally withdrawn/inhibited RAD are moder-
about her safety. Zoe’s mother had been ately stable over time (Gleason et al., 2011).
displaying increasingly bizarre behavior, Thus, when being raised in environments in
according to the records, and she was later diag- which opportunities to form selective attach-
nosed with schizophrenia. She wanted to protect ments are limited, children may manifest signs
and care for Zoe, so she put her in a crib in the of emotionally withdrawn/inhibited RAD. How-
closet for hours at a time “to keep her safe.” ever, they tend to recover when placed in more
She did not like Zoe being around people because normative environments.
she was afraid of their germs. She refused to take The findings regarding the course of indis-
Zoe to the physician because of all of the “sick criminately social/disinhibited RAD are some-
people” there. Zoe was removed by Child Protec- what different. The stability of indiscriminate
tive Services and placed in her paternal grand- behavior is modest to moderate, in both institu-
mother’s care. She spent her initial days there tionalized (Gleason et al., 2011) and formerly
staring at the wall or idly touching toys. institutionalized children (Rutter et al., 2007).
Both short-term (Chishom, 1998; Gleason et al., clear, they seem to be universal. When these
2011) and long-term (Hodges & Tizard, 1989; behaviors appear, the infant is said to be attached
Rutter et al., 2007) longitudinal studies have to one or more caregivers. A
shown that indiscriminate behavior, once present, Under species typical rearing conditions,
is quite persistent in a minority of children who virtually all infants seem to become attached,
were raised in institutions, even if they are later generally to a relatively small number of caregiv-
adopted or placed with families. Indiscriminate ing adults with whom they have regular and sub-
behavior that persisted into adolescence was stantial contact. Once infants reach a cognitive
associated with peer problems. Furthermore, in age of 7–9 months, they begin to seek comfort,
the Bucharest Early Intervention Project, reduc- support, nurturance, and protection from
tion in signs of indiscriminate/disinhibited RAD a relatively small number of caregiving adults
was less powerful than the reduction in signs of whom they have learned through repeated expe-
emotionally withdrawn/inhibited RAD following riences are available to them. Research has dem-
placement in families (Gleason et al., 2011). onstrated clearly that the quality of infants’
Prognostic factors are not well delineated attachments to one or more caregivers is predic-
among children with attachment disorders. Gen- tive of subsequent psychosocial adaptation. Secu-
erally, the sooner that a young child can be placed rity of attachment has been measured
within a loving environment the better, but the categorically and continuously and predicts sub-
long-term outcomes of children diagnosed in sequent adjustment, particularly in high-risk
early childhood with attachment disorders is groups of children.
not well delineated. Signs of both emotionally In extreme rearing conditions; however, such as
withdrawn/inhibited and indiscriminately social/ social neglect or institutional care, attachment may
disinhibited RAD in children less than 30 months be seriously compromised or even absent. Attach-
of age were predictive of overall psychiatric ment disorders describe a constellation of aberrant
impairment at 54 months (Gleason et al., 2011). attachment behaviors and other behavioral anom-
Still, little is known about individual differences alies that are believed to result from social neglect
in prognosis. and deprivation. For this reason, RAD requires
a history of “pathogenic caregiving.” In response,
rather than insecure attachments, young children
Clinical Expression and with attachment disorders display absent or serious
Pathophysiology aberrations of attachment. Two clinical patterns,
described above, have been defined: an emotion-
Attachment describes a tendency for human ally withdrawn/inhibited pattern and an indiscrim-
infants to seek comfort, support, nurturance, and inately social/disinhibited pattern. In the
protection from one or more discriminated care- emotionally withdrawn/inhibited pattern, the
givers. The tendency for selective seeking of com- child exhibits limited or absent initiation or
fort is not apparent at birth, however. Following response to social interactions with caregivers
a period of interaction and comfort with adult and aberrant social behaviors, such as constricted,
caregivers during the first 6 months, two new hypervigilant, or highly ambivalent reactions. In
infant behaviors become apparent at around the indiscriminate pattern, the child exhibits lack
7–9 months of age, stranger wariness and separa- of expected selectivity in seeking comfort, sup-
tion protest. Stranger wariness describes an appar- port, and nurturance, with lack of social reticence
ent discomfort with unfamiliar adults and with unfamiliar adults and a willingness to “go
selectively turning to those the child knows and off” with strangers.
trusts. Separation protest refers to the infant’s ten- What is striking about children with the emo-
dency to protest separation from familiar care- tionally withdrawn/inhibited RAD is that they
givers. Although individual differences in the have minimal or no signs of attachment to care-
intensity and expression of these behaviors are giving adults. The lack of selective attachments
in children cognitively capable of forming attach- expressed toward caregivers. For children who
ments is the essence of the disorder. In contrast, have experienced pathogenic or grossly inade-
children may exhibit signs of indiscriminately quate care, identifying a reporter who is knowl-
social/disinhibited RAD whether or not they edgeable about the child’s behaviors may be
have formed attachments. The essence of this a challenge.
form of the disorder is socially disinhibited The evaluation of the child should include
behavior with strangers. Because it has been inquiries about the child’s behavior in different
documented in children with healthy and settings and with different caregivers to note any
unhealthy attachments, as well as in children differences. Formal observations of the child
with no attachments, some have suggested that and parent interactions are also important. Pro-
it is not actually an attachment disorder. For this cedures derived from developmental research,
reason, the current DSM 5 proposal is to define such as the Strange Situation Procedure (Ains-
it as disinhibited social engagement disorder, worth, Blehar, Waters, & Wall, 1978) or the
distinct from RAD (Zeanah & Gleason, 2010). Crowell procedure (Zeanah, Larrieu, Valliere,
& Heller, 2000), are relatively short observa-
tions of child and parent interaction which help
Evaluation and Differential Diagnosis the clinician systematically to observe the inter-
action between the child and caregiver (Zeanah,
In order to assess the presence or absence of Berlin, & Boris, 2011).
attachment in a child, it is necessary to evaluate During the assessment, there are several other
the relationship of the child with each of her diagnoses to consider since attachment disorders
caregivers. A child is able to have different may share features of some other disorders
types of attachments with each of her caregivers. (see Table 1 for details). For example, emotion-
Knowing about a child’s attachment to one care- ally withdrawn/inhibited RAD may be confused
giver does not reveal anything about the child’s with autistic spectrum disorders or global devel-
attachment to another caregiver, and not being opmental delay. The problems with emotional
attached to one caregiver does not mean that the regulation and impaired social reciprocity may
child is not attached to another caregiver. Thus, resemble the social difficulties of a child with an
the child should be seen with different caregivers autistic spectrum disorder. On the other hand,
in order to assess the lack of attachment that is there is little reason to expect restricted interests
necessary to make the diagnosis of emotionally or repetitive behaviors in children with attach-
withdrawn/inhibited RAD. ment disorders. A history of adverse caregiving
The first step in the evaluation is to gather as well as no selective impairment in language or
a thorough history of the child. This history pretend play should point toward a diagnosis of
should include information on the child’s current RAD in such children. Although children with
behaviors, past behaviors, social history, devel- RAD are likely to have cognitive delays, their
opmental history, medical history, and family impaired social responsiveness is not a symptom
history. Careful attention to the emergence and of intellectual disabilities alone. Children with
expression of selective attachment behaviors is intellectual disabilities should have social behav-
important. ior and emotional expressiveness congruent with
To guide diagnosis of attachment disorders, their cognitive ages. On the other hand, selective
use of a structured interview with the child’s reductions in social reciprocity and emotional
caregiver, such as the Disturbances of Attach- expressiveness are more indicative of emotion-
ment Interview (Gleason et al., 2011), may be ally withdrawn/inhibited RAD.
useful. This interview systematically inquires An important diagnosis to consider with indis-
about signs of emotionally withdrawn/inhibited criminately social/disinhibited RAD is attention
RAD, indiscriminately social/disinhibited RAD, deficit hyperactivity disorder (ADHD). In RAD,
and other aberrant attachment behaviors young children have social impulsivity, but this
Attachment Disorder, Table 1 Differential diagnosis of attachment disorders
Attachment Differential
disorder diagnosis Similarities Differences
A
Emotionally 1. Autistic 1. Disturbances in 1. Attachment disorder does not have selective
withdrawn/ spectrum disorder emotional regulation impairment in pretend play, repetitive preoccupation,
inhibited type or a language abnormality
2. Impaired or absent 2. Attachment disorder has a history of seriously
social and emotional adverse caregiving
reciprocity
3. May involve
cognitive delays
Emotionally 1. Intellectual 1. Cognitive delays 1. Attachment disorder does not have social/
withdrawn/ disability emotional behaviors consistent with developmental
inhibited type age
2. Attachment disorder has evidence of deviance in
social responsiveness and regulations of emotion
Indiscriminately 1. Attention deficit Social impulsivity and 1. Attachment disorder in males shows a lack of
social/disinhibited hyperactivity attention seeking selectivity in relationships with caregivers and peers
type disorder behavior
should not be confused with the broader impul- in other less rigorously designed studies that all
sivity and hyperactivity of children with ADHD. suggest that signs of emotionally withdrawn/
It is important to look in detail at how the child inhibited RAD disappear rapidly when children
interacts in social situations and especially with are placed in reasonably normative caregiving
unfamiliar adults. Children with RAD lack selec- environments. Similarly, the results in BEIP are
tivity in directing their social and sometimes compatible with studies of internationally adopted
attachment behaviors. Children with ADHD children suggesting that signs of indiscriminately
may share these features but also demonstrate social/disinhibited RAD are less responsive to
impulsivity in nonsocial situations. Children more normative caregiving environments, and
with indiscriminately social/disinhibited RAD that a minority of children have persistent signs
should show more profound misreading of social of the disorder over years (Smyke et al.).
cues and situations and engage in more social and Future research needs to better determine
physical boundary violations. recommendations for adoptive parents whose
young children exhibit signs of RAD and how
best to deal not only with the behavioral manifes-
Treatment tation but also with the social cognitive abnor-
malities that presumably underlie the disorder.
There is only one intentional treatment study of Further, although there is a clear tendency for
attachment disorders that includes pre- and post- signs of both types of disorders to diminish over
assessments and uses random assignment (Smyke time, questions about sequelae have not been
et al., in preparation). The BEIP demonstrated adequately answered at this point.
substantial treatment effects on reduction of signs
of emotionally withdrawn/inhibited RAD and
more modest treatment effects of reduction in See Also
signs of indiscriminately social/disinhibited RAD
for children placed in foster care compared to ▶ Feral Children
those who experienced continued institutional ▶ Posttraumatic Stress Disorder
care (Smyke et al.). This study bolsters confidence ▶ Romanian Adoptive Children
A 282 Attachment Disorders
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(1978). Patterns of attachment: A psychological study tional rearing on the behaviour problems and affec-
of the strange situation. Hillsdale, NJ: Lawrence tional relationships of four-year-old children. Journal
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Chaffin, M., Hanson, R., Saunders, B., et al. (2006). ment theory and research for infants and young
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Chisholm, D. (1998). A three-year follow-up of attach- disorders: A review for DSM 5. Retrieved December 29,
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Where do research findings leave the concepts? Jour- Shantel E. Meek and Laudan B. Jahromi
nal of Child Psychology and Psychiatry, 50, 529–543. School of Social & Family Dynamics, Arizona
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Landorph, S., Jørgensen, T., Olsen, E. M., et al.
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Smyke, A. T., Zeanah, C. H., Gleason, M. M., Drury, S. S.,
Fox, N. A., Nelson, C. A., et al. (2012). A randomized The ability to orient, sustain, and shift attention
controlled trial of foster care vs. institutional care for on relevant stimuli, using internal and external
Attention 283 A
cues, is a critical skill for learning about the stimulus over a prolonged period of time.
world. Prioritizing stimuli in order to process Shifting attention is the ability to effectively
pertinent, and exclude peripheral, information transfer concentration from one stimulus to A
facilitates selective learning, a skill necessary another. Encoding attention is the ability to intake
for many child development processes, including and interpret information from the environment
vocabulary development, problem solving, and (Goldstein et al., 2001). Research on these spe-
later, successful classroom learning (Frick & cific skills may be used to identify which aspects
Richards, 2001; Kannass & Colombo, 2007; of attention children with autism seem to struggle
Sillar & Sigman, 2008). Children with autism with most and, conversely, which areas of atten-
often display atypical development of attention. tion develop typically.
The processes in which these abnormalities man- A comprehensive understanding of attention
ifest, however, are yet to be determined (Ames & must include a description of environmental stim-
Fletcher-Watson, 2010). Despite the high preva- uli that help an individual to attend. Attention
lence of attentional difficulties seen in children cueing, that is, attention directed by environmen-
with autism, these difficulties are not considered tal prompts, affects what stimuli humans attend
a core characteristic of the disorder as specified to; these environmental prompts are identified as
by the fourth version of the Diagnostic and Sta- exogenous and endogenous factors. Exogenous
tistical Handbook of Mental Disorders (DSM IV, cues, those that activate “bottom-up” processes,
1994), but rather an associated symptom of ASD. are derived from stimuli properties (e.g., size,
Behavior is acted upon using visual informa- color) and evoke involuntary attention (Corbetta
tion from the environment. For example, safe & Shulman, 2002). Endogenous cues, on the
driving is largely dependent on drivers attending other hand, often characterized as activating
to stoplights, signs, pedestrians, and other cars “top-down” processes, evoke conscious and vol-
and ignoring distracting, irrelevant environmen- untary attention control through cognitive pro-
tal stimuli. The breadth of attention literature cesses, learned behavior, or past experiences
identifies several components of domain-specific (Corbetta & Shulman, 2002; Hauer & Macleod,
and domain-general attending. Visual attention, 2006). In this way, previous experiences and
in particular, plays a large role in domain-specific learned behaviors influence on what or where
attention, such as social attention. Social atten- the child attends.
tion is the preferential selection of social over The multitude of cognitive, social, and lan-
nonsocial stimuli for attention and has been the guage developmental skills learned during play
subject of much research due to its high correla- make free play an important setting in which to
tion with later social developmental processes, study attention in children. Ruff and Capozzoli
such as joint attention, theory of mind, and lan- (2003) studied the developmental trajectory of
guage development (Adamson, Bakeman, visual attention during play and identified three
Deckner, & Romski, 2009; Ames & Fletcher- types of attention. Causal attention is defined at
Watson, 2010; Mundy & Newell, 2007; Sodian looking at objects (e.g., toys), but not physically
& Thoermer, 2008). Moreover, social attention is engaging with them; settled attention is looking
of particular interest to the study of autism due to at and manipulating an object; and focused atten-
its relation to social interactions and communication is concentrating on an object intently and
tion, two core deficits of the disorder. may include facial expressions and extraneous
Attention may be subdivided into the ability to body movement in order to bring the object closer
focus, sustain, shift, and encode (Goldstein, John- to the face or body. Collectively, the study of
son, & Minshew, 2001; Zubin, 1975). Focused attention covers a wide array of specific topics,
attention is the ability to concentrate and perform all of which hold importance for a comprehensive
a task on a specific stimulus in the midst of understanding of the topic and for the develop-
distracting stimuli. Sustained attention is defined ment of interventions aimed at healthy
as the capacity to maintain attention on a target development.
A 284 Attention
Historical Background parietal lobe and the frontal lobe (Courchesne

et al., 1993, 1994; Ornitz, 1988; Pascualvaca
Attention has been a topic of study for decades by et al., 1998).
researchers and clinicians alike. Because of the
high occurrence of attention deficits in autism,
this topic has been the focus of numerous studies Current Knowledge
in autism research, in particular. The discourse of
processes and causes of this apparent attention Developmental studies on attention reveal that
deficit has evolved over time. Early researchers attention evolves over the course of childhood
hypothesized that attention difficulties in children and different patterns of attention behaviors are
with autism were due to hypo- or hyperarousal. observed over time. The duration of time infants
That is, some researchers concluded that arousal spend looking at objects or people, which
modulation in particular, was a potential cause of reflects differences in underlying attention pro-
low attention abilities (Hutt, Hutt, Lee & cesses (Kannass & Oakes, 2008), increases
Ounsted, 1964; Ornitz & Ritvo, 1968). Other from birth through 8 to 10 weeks, then
investigators attributed limited attention skills to decreases between 3 and 5 or 6 months, and
over-selectivity or what some referred to as “tun- remains stable or slightly increases thereafter
nel vision,” that is, intense attention to specific (Colombo, 2001, 2002). The initial increase of
details in combination with a lack of interpreta- look duration may be due to steady increases in
tion of outside environmental cues (Lovaas, arousal and alertness, whereas the decrease of
Koegel, & Schreibman, 1979; Rincover & look duration may be indicative of improve-
Ducharme, 1987). More recently, it has been ments in information processing. The plateau
hypothesized that attention problems may be reached near the first year is likely indicative
due to difficulties in prioritizing relevant stimuli of endogenous factors or top-down processes
and disregarding irrelevant stimuli (Bryson, manifesting (Corbetta & Shulman, 2002;
Wainwright-Sharp, & Smith, 1990; Burack, Colombo, 2001, 2002).
1994). Furthermore, Ornitz and colleagues Children with autism appear to show differ-
(1988) proposed that children with autism strug- ent patterns of attention development than their
gle in attention shifting, in particular, because typical peers. For example, the top-down
they lack an interest in people or social stimuli processing that develops around the first year
(Ornitz, 1988). Previous studies have also dichot- appears to pose difficulty for children with
omized attention in studying auditory and visual autism as compared to typically developing chil-
attention and found that children with autism dren (Ames & Fletcher-Watson, 2010; Ames &
differed from typical children in auditory atten- Jerrold, 2007; Leekam et al., 2000). Goldstein
tion (Casey, Gordon, Mannheim, & Rumsey, and colleagues (2001) also found that individ-
1993) but not in visual attention (Pascualvaca, uals with autism were different from their typi-
Fantie, Papgeorglou, & Mirsky, 1998). This find- cal counterparts in their abilities to focus and
ing, however, is inconsistent with more recent shift attention, but were not different in their
findings concerning visual attention in the litera- abilities to sustain and encode attention (Gold-
ture (Goldstein et al., 2001; Leekam, Lopez, & stein et al.). Another study found that children
Moore, 2000) and may be due to differences in with autism had more circumscribed,
measurement (Ames & Fletcher-Watson, 2010). preservative, and detail-oriented attention
With technological advances in detection tools, (Sasson, 2008).
so came a new wave of studies addressing bio- The results of studies involving eye tracking
logical hypotheses for attention deficits. and visual attention in the context of social
Throughout the past two decades, researchers stimuli have also found differences among indi-
hypothesized that inattentive behavior may be viduals with autism. One study indicated that
due to neural abnormalities in areas such as the when shown images of objects and people,
Attention 285 A
individuals with autism generally attended to See Also
the nonsocial aspects of the picture, that is,
objects rather than faces. Further, the investiga- ▶ Joint Attention A
tion found that when individuals with autism ▶ RJA/IJA (Initiating/Responding to Joint
did attend to social images, such as a human Attention)
face, they looked at noncritical social elements,
such as the nose rather than the eyes (Klin,
Jones, Schultz, Volkmar, & Cohen, 2002).
Another study found that children with autism
have difficulties processing both social and non-
Adamson, L., Bakeman, R., Deckner, D., & Romski, M.
social information (Leekam et al., 2000). Col- (2009). Joint engagement and the emergence of lan-
lectively, the literature suggests that individuals guage in children with autism and Down syndrome.
with autism lack attention to social stimuli Journal of Autism and Developmental Disorders, 39,
84–96.
which undoubtedly affects social and emotional
Allen, G., & Courchesne, E. (2001). Attention function
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Ames, C. S., & Jarrold, C. (2007). The problem with using
nitive development. Future work on attention in eye-gaze to infer desire: A deficit of cue inference in
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Bartgis, J., Thomas, D., Lefler, E., & Hartung, C. (2008).
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(2002). Visual fixation patterns during viewing of Attention Deficit/Hyperactivity
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Mundy, P., & Newell, L. C. (2007). Attention, joint atten-
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Psychological Science, 16, 269–274. Synonyms
Ornitz, E. M. (1988). Autism: A disorder of directed
attention. Brain Dysfunction, 1, 309–322. ADD; ADHD; Attention deficit disorder;
Ornitz, E. M., & Ritvo, E. R. (1968). Perceptual incon- Hyperkinetic disorders; Minimal brain damage;
stancy in early infantile autism. Archives of General
Psychiatry, 18, 76–98. Minimal brain dysfunction; Syndrome of deficits
Pascualvaca, D., Fantie, B., Papageorgiou, M., & Mirsky, in attention, motor control, and perception
A. (1998). Attentional capacities in children with (DAMP)
Attention Deficit/Hyperactivity Disorder 287 A
Short Description or Definition disorder” was introduced after the worldwide influ-
enza epidemic (Rothenberger & Neuma¨rker,
Attention deficit/hyperactivity disorder (ADHD) 2005) cited in Lange et al. (2010). The terms of A
is one of the most common psychiatric disorders “minimal brain damage” and “minimal brain dys-
in children and adolescents. It is characterized by function” were described (Hoffmann, 1948). The
inattention, impulsivity, and hyperactivity. Its name was changed to “hyperkinetic reaction of
rate decreases with the increase of age. ADHD childhood” in the second edition of the Diagnostic
usually starts in childhood and continues through and Statistical Manual of Mental Disorders (DSM-
adolescence into adulthood. The burden and psy- II) (American Psychiatric Association (APA)
chosocial functioning impairment of ADHD is (1967). Diagnostic and statistical manual for men-
farther than its inattention, impulsivity, and tal disorders). Overactivity, restlessness,
hyperactivity symptoms. There are many contro- distractibility, and short attention span were the
versies and scientific debates about ADHD characteristics of this disorder (APA (1967). Diag-
(Biederman & Faraone, 2005; Furman, 2008). nostic and statistical manual for mental disorders).
In the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III), the disor-
Categorization der was called “attention deficit disorder (ADD):
with and without hyperactivity.” In this edition, the
According to DSM-IV, there are three subtypes focus was on inattentiveness rather than hyperac-
of ADHD called “predominantly inattentive,” tivity (APA (1980). Diagnostic and statistical man-
“predominantly hyperactive-impulsive,” and ual (DSM-III)). In addition, it was stressed that
“combined.” ICD-10 lacks this categorization. hyperactivity was no more a necessary criterion
for diagnosis of this disorder. From 1987, revision
of the third edition of the Diagnostic and Statistical
Epidemiology Manual of Mental Disorders (DSM-III-R), this dis-
order was renamed “attention deficit/hyperactivity
The prevalence of ADHD in children is estimated disorder” (ADHD) (APA (1987). Diagnostic and
to be about 8–12% (Biederman & Faraone, statistical manual (DSM-III, revised)). In the DSM-
2005). The rate of ADHD in boys is three times III-R, the subtype of “ADD without hyperactivity”
more than girls, and this ratio in the clinical was replaced with the category of “undifferentiated
sample is six to nine times (Ghanizadeh, ADD” (Lange et al., 2010). From the fourth edition
Mohammadi, & Moini, 2008). of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) (APA (1994). Diagnostic and
statistical manual (DSM-IV)), the three subtypes of
Natural History, Prognostic Factors, and ADHD including “predominantly inattentive type,”
Outcomes “predominantly hyperactive-impulsive type,” and
“combined type with symptoms of both dimen-
From about two centuries ago, children with symp- sions” were presented (Lahey et al., 1994). There
toms of inattention, impulsivity, and hyperactivity was no change regarding ADHD in the text revision
have been described (Crichton, 2008; Lange, of the fourth edition of the Diagnostic and Statisti-
Reichl, Lange, Tucha, & Tucha, 2010). Heinrich cal Manual of Mental Disorders (DSM-IV-TR)
Hoffmann described some symptoms of ADHD in (APA (2000). Diagnostic and statistical manual
the story of Fidgety Phil (Hoffmann (1948) cited by (DSM-IV, Text Rev.)). It is expected that DSM-V
Lange et al. (2010)). Moral control defect was will be published in 2012.
introduced by Sir George Frederic Still ((Still, Multiple comorbid disorders and parent-
1902) cited in Lange et al. (2010)). He reports that reported ADHD severity are associated with the
these children cannot internalize rules and limits. poorer psychosocial quality of life (Klassen,
Then, the term of “postencephalitic behavior Miller, & Fine, 2004). The type of comorbidity
A 288 Attention Deficit/Hyperactivity Disorder
is also associated with the quality of life. Lower There is not enough evidence supporting that
quality of life is associated with the comorbidity ADHD is caused by foods or food additives
of oppositional defiant disorder, conduct disor- (Biederman & Faraone, 2005), while lead is
der, and learning disorder (Klassen et al., 2004). reported to be associated with ADHD
There is a positive short-term effect of medica- (Ghanizadeh, 2011). Exposure to toxins such as
tion on quality of life in children, adolescents, mercury, lead, manganese, and polychlorinated
and adults with ADHD (Coghill, 2010). Comor- biphenyls (PCBs) and pregnancy and delivery
bidity of ODD with ADHD is associated with complications (such as eclampsia, maternal age,
more severe ADHD symptoms, peer problems, prenatal alcohol exposure, maternal smoking,
and family problems (Ghanizadeh & Jafari, fetal postmaturity, duration of labor, fetal dis-
2010). tress, low birth weight, and hemorrhage) are
Children and adolescents with ADHD have other risk factors associated with ADHD
poorer social and communication skills leading (Banerjee, Middleton, & Faraone, 2007). Mean-
to more peer relationship problems. More than while, TV viewing is not a risk factor for ADHD
two-thirds of them have no close friends (Banerjee et al., 2007).
(Wehmeier, Schacht, & Barkley, 2010). So, they From the psychosocial factors, low family
are more frequently rejected by others. This cohesion, exposure to parental psychopathology
makes them more prone to join to deviant peer especially maternal psychopathology, low mater-
groups, injuries, occupational problems, educa- nal education, low social class, and single parent-
tional problems, cigarettes, and substance use hood are important risk factors for ADHD
disorders (Biederman & Faraone, 2005). (Biederman & Faraone, 2005).
The symptoms of ADHD continue from child- Brain structural studies do not report consis-
hood into adult. However, most of them will not tent findings for ADHD. However, most of imag-
meet the full diagnostic criteria in adult but they ing studies delineated overall decrease in total
will meet the diagnosis of ADHD in partial remis- brain size, the caudate nucleus, prefrontal cortex
sion (Fischer, Barkley, Smallish, & Fletcher, white matter, corpus callosum and the cerebellar
2002). vermis (Tripp & Wickens, 2009). Some of these
areas have a high density of dopamine receptors.
Neuropsychological studies show the impair-
Clinical Expression and ment of vigilance attention, executive function,
Pathophysiology working memory response, and motivation in
some children with AHD (Tripp & Wickens,
While there are many controversies about 2009). Brain maturation is delayed in ADHD
ADHD, the improvement of some symptoms (Curatolo, Paloscia, D’Agati, Moavero & Pasini,
after pharmacotherapy supports that there are 2009).
neurobiological causes for the heterogeneous Finally, children with ADHD may have diffi-
nature of ADHD. There is a large gap in our culties in social exchanges such as sharing and
knowledge and current literature regarding cooperation with peers. They are self-centered,
ADHD. However, it is clear that there is not any impulsive, and commanding (Wehmeier, Schacht
one specific brain area or genetic or neurochem- & Barkley, 2010).
ical factor as the etiology of ADHD.
The etiology of ADHD is complex
(Steinhausen, 2009). The heritability of ADHD is Evaluation and Differential Diagnosis
reported in twin and adoption studies. However,
more molecular genetic studies are necessary to In many countries, ADHD diagnoses are generally
indicate the complex genetics and the interaction made using Diagnostic and Statistical Manual,
of gene by environment in ADHD (Biederman & Fourth Edition, Text Revision (APA (2000). Diag-
Faraone, 2005; Nigg, Nikolas, & Burt, 2010). nostic and statistical manual (DSM-IV, Text Rev.)).
According to 4th Edition, Text Revision (DSM-IV- disorders are mood disorders, tic disorder, enure-
TR) criteria, there are two groups of symptoms sis, and encopresis.
including (a) attention deficit, (b) hyperactivity, It is interesting that the parent of children with A
or impulsivity. Six or more items from at least ADHD usually suffer from psychiatric disorders.
one of the groups are required for ADHD diagno- The lifetime prevalence of ADHD in fathers and
sis. In addition, functional impairments in at least mothers of children with ADHD are 45.8% and
two different settings such as at home, school, and 17.7%, respectively. Major depressive disorder is
nursery are required. very frequent in the parents. The rate in father and
In other countries, especially in Europe, Inter- mothers are 48.1% and 43.0%, respectively
national Classification of Diseases-10 (ICD-10) (Ghanizadeh et al., 2008).
is used (World Health Organization (WHO),
1992). Hyperkinetic disorder is the ICD-10
equivalent of ADHD diagnosis (WHO, 1992). Co-occurrence of ADHD and Autism
In ICD-10, several items from attention deficit,
hyperactivity, and impulsivity are required to ADHD DSM-IV-derived items do not overlap
reach diagnosis. Therefore, it is expected that with autism spectrum disorder (Ghanizadeh,
the rate of ADHD in countries using DSM-IV- 2010), and the comorbidity of ADHD and autism
TR criteria would be reported higher than that of is precluded in the DSM-IV-TR. Therefore, the
those countries using ICD-10 criteria. symptoms of inattentiveness, hyperactivity, or
ADHD diagnosis is subjective using the diag- impulsivity in individuals with autism originate
nostic systems criteria. There is not any objective from autism, not ADHD. Meanwhile, there are
diagnostic test or any biomedical laboratory test many individuals who meet diagnostic criteria for
for it. However, the ADHD diagnosis is reliable both ADHD and autism. In addition, many
when well-trained raters assess and agree the patients with Asperger’s syndrome are screened
presence of its symptoms (Biederman & Faraone, with concerns about ADHD (Murray, 2010). The
2005). children with autism my severely attend to their
There is a weak correlation between different interest and do not attend to other factors in their
informants such as parents and teachers for the environment. It can be interpreted as inattentive-
rating of ADHD symptoms. In other words, they ness. Also, sometimes, their stereotypic motor
usually do not agree on their assessment of symp- behavior can be interpreted as hyperactivity
toms in children with ADHD. The evaluation of (Murray, 2010). However, there are many
children in different situations can be an expla- published studies reported the co-occurrence of
nation for this disagreement. Teachers evaluate ADHD and autism. About 40–78% of individuals
children in school while the children are taking with autism meet diagnostic criteria for DSM-IV
medication. Sometime, parents may report some ADHD (Murray, 2010). Eighty-seven percent of
symptoms that the symptoms are not reported by children with autism spectrum disorder have at
teachers. least one of the three components of ADHD
In clinical samples, ADHD is usually comor- (Ames & White, 2011). The rate of autistic traits
bid with other psychiatric disorders. The rate of at in children with ADHD is from one-third to one-
least one comorbid psychiatric disorder in fifth (Grzadzinski et al., 2011).
children with ADHD is more than 80% In addition, the subtype of ADHD is associ-
(Ghanizadeh et al., 2008). Other disruptive ated with the severity of difficulties in autism. For
behavior disorders (oppositional defiant disorder example, language and social problems are more
(ODD) or conduct disorder (CD)) and anxiety common in those with both autism and ADHD-
disorders are the most common comorbid disor- inattentive subtype. Moreover, less symptoms of
ders in children with ADHD. The rate for ODD autism are reported in those with ADHD-
and CD is about 59.3% and 13.6% (Ghanizadeh hyperactivity subtype. While internalizing
et al., 2008). Some of the other comorbid behavior problems are usually seen in autism,
externalizing behavior problems are more com- Drug therapy with stimulant drugs (Cornforth,
mon in those with ADHD. A combination of Sonuga-Barke, & Coghill, 2010) and
externalizing and internalizing behavior prob- atomoxetine (Vaughan, Fegert, & Kratochvil,
lems are reported in those with both ADHD and 2009) is better than no drug therapy. However,
autism (Murray, 2010). Clinical profiles and out- there is not enough evidence indicating any dif-
comes of children with both ADHD and autism are ference between these medications regarding
different with that of those children with autism their efficacy or side effects (King et al., 2006).
alone. They have severe social problems and The precise mechanism of stimulants in
poorer outcomes. Furthermore, executive function ADHD is not known. Noradrenaline and dopa-
is more impaired in the individuals with both mine neurotransmitter systems are involved in
ADHD and autism than those with ADHD or ADHD. Methylphenidate and dextroamphet-
autism alone. Motor coordination abnormalities amine are stimulant medications which are effec-
are different between ADHD and autism. While tive in the management of ADHD. Atomoxetine
motor response inhibition is more common in is a nonstimulant catecholaminergic medication.
ADHD, motor planning impairment is more com- They improve ADHD symptoms through increas-
mon in autism (Murray, 2010). About two-thirds ing activation in cortical and subcortical regions
of children with the syndrome of deficits in atten- involved in attention and executive functions
tion, motor control, and perception (DAMP) meet (Curatolo et al., 2009). Meanwhile, there is
diagnostic criteria for autism spectrum disorders. a concern about the possible association of
Comorbidity with developmental coordination atomoxetine and increased suicidal behavior
problems is more likely to co-occur with autism (Garnock-Jones & Keating, 2009).
symptoms than those with ADHD alone. Autism, There are concerns about the higher rate of
ADHD, and dyslexia overlap genetically side effects of stimulants in individuals with
(Smalley, Loo, Yang, & Cantor, 2005). both autism and ADHD than those with ADHD
ADHD can be dissociated from autism spec- alone. In addition, methylphenidate efficacy in
trum disorders regarding executive dysfunction autism is less than ADHD (Stigler, Desmond,
and response inhibition. Those with autism spec- Posey, Wiegand, & McDougle, 2004). While
trum disorders are slow and accurate, while those the response rate is limited up to 25%, the rate
with ADHD are impulsive (Johnston, Madden, of side effects reaches to 60% (Stigler et al.,
Bramham, & Russell, 2011). 2004). Dexamphetamine may worsen the symp-
It is expected that the comorbidity of ADHD toms (Handen, Johnson, & Lubetsky, 2000).
and autism spectrum disorders will be allowed in Clonidine and guanfacine are a-2 agonists
DSM-V. Then, autism will not be an exclusive with promising efficacy on hyperactivity, impul-
criterion for ADHD diagnosis. sivity, irritability, explosive behaviors, stereoty-
pies, and social interaction (Scahill et al., 2006).
Atomoxetine selectively inhibits the presyn-
Treatment aptic norepinephrine transporter. There are con-
tradictory reports about the efficacy of
The educating and counseling of parents atomoxetine on ADHD symptoms in autism.
(Ghanizadeh, 2007), teachers (Ghanizadeh, While an open-label study supported its efficacy
Bahredar, & Moeini, 2006), and general physi- (Posey et al., 2006), others did not report
cians (Ghanizadeh & Zarei, 2010) about ADHD a significant effect (Charnsil, 2011).
is highly necessary and recommended. Many of Donepezil as a anticholinesterase inhibitor
parents, teachers, and medical service providers may decrease some symptoms of ADHD in chil-
have not enough and updated knowledge towards dren with autism (Yoo, Valdovinos, & Williams,
ADHD symptoms and its management. Behav- 2007). Further controlled trials are required to
ioral parent training is encouraged (van den detect the significant gains of these medications
Hoofdakker et al., 2007). on autism.
There are open-label studies promising the ▶ Pervasive Developmental Disorder
efficacy of atypical antipsychotics, such as ris- ▶ Repetitive Behavior
peridone, quetiapine, and aripiprazole, on hyper- ▶ Risperidone A
activity symptom in autism (Murray, 2010). ▶ Stereotypic Behavior
▶ Stimulant Medications
▶ Tics
See Also ▶ Treatment Effectiveness
▶ Affective Disorders (Includes Mood and

Anxiety Disorders)
▶ Antipsychotics: Drugs
▶ Aripiprazole American Psychiatric Association. (1967). Diagnostic and
▶ Asperger Syndrome statistical manual for mental disorders. Washington,
▶ Atomoxetine DC: APA Press.
▶ Attention
and statistical manual (DSM-III). Washington, DC:
▶ Atypical Antipsychotics APA Press.
▶ Autism American Psychiatric Association. (1987). Diagnostic and
▶ Autistic Disorder statistical manual (DSM-III, revised). Washington, DC:
APA Press.
▶ Behavior
▶ Behavior Modification and statistical manual (DSM-IV). Washington, DC:
▶ Behavior Rating Scale (BRS) APA Press.
▶ Cerebral Cortex American Psychiatric Association. (2000). Diagnostic
and statistical manual (DSM-IV). Washington, DC:
▶ Clonidine
APA Press.
▶ Communication Disorder/Communication Ames, C. S., & White, S. J. (2011). Brief report: are
Impairment ADHD traits dissociable from the autistic profile?
▶ Comorbidity Links between cognition and behaviour. Journal
of Autism and Developmental Disorders, 41(3),
▶ Conduct Disorder
357–363.
▶ Developmental Milestones Banerjee, T. D., Middleton, F., & Faraone, S. V. (2007).
▶ Dextroamphetamine Environmental risk factors for attention-deficit
▶ DSM-III hyperactivity disorder. Acta Paediatrica, 96(9),
1269–1274.
▶ DSM-III-R
Biederman, J., & Faraone, S. V. (2005). Attention-deficit
▶ DSM-IV hyperactivity disorder. Lancet, 366(9481), 237–248.
▶ Dyslexia Charnsil, C. (2011). Efficacy of Atomoxetine in children
▶ Education with severe autistic disorders and symptoms of
ADHD: An open-label study. Journal of Attention
▶ Educational Therapy
Disorders, 15(8), 684–689.
▶ Encopresis Coghill, D. (2010). The impact of medications on
▶ Enuresis quality of life in attention-deficit hyperactivity disor-
▶ Epidemiology der: A systematic review. CNS Drugs, 24(10),
843–866.
▶ Executive Function (EF)
Cornforth, C., Sonuga-Barke, E., & Coghill, D. (2010).
▶ Expressive Language Disorder Stimulant drug effects on attention deficit/hyperactiv-
▶ Guanfacine ity disorder: A review of the effects of age and sex of
▶ ICD 10 Research Diagnostic Guidelines patients. Current Pharmaceutical Design, 16(22),
2424–2433.
▶ Methylphenidate
Crichton, A. (2008). An inquiry into the nature and origin
▶ Mood Disorders of mental derangement: On attention and its diseases.
▶ Motivation Journal of Attention Disorders, 12(3), 200–204. Dis-
▶ Motor Planning cussion:205–206.
Curatolo, P., Paloscia, C., D’Agati, E., Moavero, R., &
▶ Neurotransmitter
Pasini, A. (2009). The neurobiology of attention
▶ Norepinephrine
deficit/hyperactivity disorder. European Journal of spectrum disorder compared to attention deficit/

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Attention Process Training (APT) Program 293 A
Still, G. F. (1902). Some abnormal psychical conditions in discrimination of stimuli. Alternating attention
children: the Goulstonian lectures. Lancet, 1902, refers to aptitude for mental flexibility, and
1008–1012.
Tripp, G., & Wickens, J. R. (2009). Neurobiology of divided attention has been defined as the ability A
ADHD. Neuropharmacology, 57(7–8), 579–589. to engage in multiple tasks simultaneously.
van den Hoofdakker, B. J., van der Veen-Mulders, L., In general, process training involves
Sytema, S., Emmelkamp, P. M., Minderaa, R. B., & implementing a structured treatment program to
Nauta, M. H. (2007). Effectiveness of behavioral par-
ent training for children with ADHD in routine clinical improve attention skills in a variety of areas
practice: A randomized controlled study. Journal of (Sohlberg et al., 2001). The APT materials con-
the American Academy of Child and Adolescent sist of tasks that are hierarchically organized to
Psychiatry, 46(10), 1263–1271. target sustained, selective, alternating, and
Vaughan, B., Fegert, J., & Kratochvil, C. J. (2009). Update
on atomoxetine in the treatment of attention-deficit/ divided attention (Sohlberg et al., 2001). The
hyperactivity disorder. Expert Opinion on Pharmaco- hierarchical structure is intended to allow for
therapy, 10(4), 669–676. basic skills to be constantly utilized while devel-
Wehmeier, P. M., Schacht, A., & Barkley, R. A. (2010). oping and practicing more complex skills
Social and emotional impairment in children and ado-
lescents with ADHD and the impact on quality of life. (Palmese & Raskin, 2000). Auditory attention
The Journal of Adolescent Health, 46(3), 209–217. tapes and visual activities are used for some of
World Health Organization (WHO). (1992). The ICD-10 the tasks. APT also includes exercises to facilitate
classification of mental and behavioural disorders. generalization of skills to daily life (Palmese &
Clinical descriptions and diagnostic guidelines.
Geneva: Author Raskin). The APT approach has been referred to
Yoo, J. H., Valdovinos, M. G., & Williams, D. C. (2007). as process-specific cognitive rehabilitation
Relevance of donepezil in enhancing learning and because it is intended to improve particular
memory in special populations: A review of the liter- types of attention skills and does not lead to
ature. Journal of Autism and Developmental Disor-
ders, 37(10), 1883–1901. improvements in overall cognitive functioning
(Sohlberg & Mateer, 1987).
Attention Process Training (APT)
Program APT was developed by Sohlberg and Mateer
(1987) based on experimental attention literature,
Corey Ray-Subramanian clinical observation, and patients’ subjective
Waisman Center, University of Wisconsin- reports of symptoms. It frames attention as
Madison, Madison, WI, USA a multidimensional cognitive capacity (Sohlberg
& Mateer). The APT-II is an extension of the
original APT and is designed to target more com-
Definition plex attention impairments (Murray, Keeton, &
Karcher, 2006).
The Attention Process Training (APT and APT-II)
program is a cognitive rehabilitation intervention
that targets focused, sustained, selective, alternat- Rationale or Underlying Theory
ing, and divided attention (Sohlberg & Mateer,
1987; Sohlberg, Johnson, Paule, Raskin, & APT follows a process-specific approach to cog-
Mateer, 2001). APT developers define focused nitive rehabilitation in that it is intended to
attention as the ability to respond to specific improve functioning in distinct cognitive areas
stimuli. Sustained attention refers to the ability (Sohlberg & Mateer, 1987). The rationale under-
to consistently respond during a continuous or lying APT is that learning specific skills may
repetitive activity. Selective attention is the abil- help improve some of the cognitive problems
ity to activate and inhibit responses based on that result from acquired brain damage
A 294 Attention Process Training (APT) Program
(Park, Proulx, & Towers, 1999). A process- (Sohlberg & Mateer, 1987). Treatment goals are
specific approach can be contrasted with the individualized based on the client’s impairments
functional adaptation and the general stimulation in each of the attention areas targeted (i.e.,
perspectives. The functional adaptation approach sustained, selective, alternating, and divided).
utilizes task analysis and changes in the environ- Each task is designed to offer practice in one or
ment to assist with the challenges associated with more levels of attention. The tasks are either
cognitive impairments. The general stimulation client-paced or therapist-paced depending on the
approach utilizes tasks that facilitate any type of nature of the exercise (Park et al., 1999).
cognitive processing. These prior approaches to The APT-II includes general exercises, each
cognitive rehabilitation have been criticized as requiring approximately 5 min to complete, for
leading to poor generalizability and lacking each of the specific areas of attention emphasized
a theoretical orientation, respectively (Sohlberg in the program (Palmese & Raskin, 2000). Four
& Mateer, 1987; Sohlberg et al., 2001). types of activities are incorporated into APT:
visual cancelation, auditory cancelation, mental
control, and daily life attentional activities
Goals and Objectives (López-Luengo & Vázquez, 2003). Within each
exercise, there are tasks that increase in speed and
The objectives of APT are to improve individ- difficulty. When the client completes the final
uals’ focused attention, sustained attention, selec- activity for a particular sequence, he or she can
tive attention, alternating attention, and divided advance to the next level. Each exercise is
attention skills following an acquired brain repeated until it is completed successfully
injury, although the program has also been used according to specified criteria. Some researchers
with other populations. Individualized treatment have noted that the linguistic demands of APT
goals are created based on the needs of the client tasks need to be taken into account for treatment
in each of these areas of attention. planning with patients who have language
impairments (Murray et al., 2006).
In the area of sustained attention, examples of
Treatment Participants visual activities include cancelation tasks (e.g.,
crossing out all the Ps and Cs in a long series of
Although APT was designed for use with indi- letters) where the client is scored on completion
viduals who have acquired brain injury and most time, omissions, and errors. Audio activities
published research on the APT has been based on include tasks such as having the client press
this population, some researchers have examined a button when he or she hears a target stimulus
the efficacy of APT for individuals with schizo- among a set of distracters (e.g., identifying items
phrenia and aphasia. Little is known about the that are round from a list of words) and is scored
efficacy of the program with other populations. for accuracy (Pero, Incoccia, Caracciolo,
Some have suggested that APT could be benefi- Zoccolotti, & Formisano, 2006). For selective
cial for individuals with autism spectrum disor- attention, tasks from sustained attention are
ders (Ozonoff, South, & Provencal, 2005), included but with more irrelevant and distracting
although published efficacy research to date has stimuli added (e.g., auditory stimuli recorded
not been conducted with this population. over a noisy background). Similar tasks are also
incorporated into the alternating attention activi-
ties but with instructions to change the target
Treatment Procedures stimuli every 15 seconds. The divided attention
activities include completing the visual and audi-
The APT program is comprised of a set of activ- tory cancelation tasks simultaneously, as well as
ities that have a common structure and that range card sorting and Stroop tasks (Pero et al.). Solv-
in complexity and processing speed requirements ing math problems and identifying main ideas
Attention Process Training (APT) Program 295 A
from paragraphs are also examples of APT tasks control subjects who did not receive APT also
(Palmese & Raskin, 2000). showed improvement on this task over time (Park
The program does not specify a particular et al.). Compared to individuals receiving brain A
number of sessions but recommends that injury education, those who received APT in
response time should be decreased by 35% before another study made greater gains on the PASAT
moving on to the next task and that the client (Sohlberg et al., 2000).
achieve 85% accuracy on each task (Pero et al., Another task on which individuals with brain
2006). Researchers examining the efficacy of the injury who have completed APT have shown
APT program have generally implemented the improvement is the consonant trigrams activity
intervention for a range of four to ten weeks at (Park et al., 1999), which involves recalling three
a frequency of one to nine sessions per week consonants heard after counting backward by
(e.g., Coelho, 2005; Palmese & Raskin, 2000; threes. It is intended to measure memory under
Sohlberg & Mateer, 1987; Sohlberg, conditions of distraction.
McLaughlin, Pavese, Heidrich, & Posner, 2000). Researchers have also found some support for
improved performance on the Trails-B task for
individuals with brain injury who completed APT
Efficacy Information compared to a group who completed a brain
injury education program (Sohlberg et al.,
There is some evidence that APT may lead to 2000). This task requires participants to draw
improvements in specific attentional skills but lines connecting a sequence of ascending num-
not in general cognitive functioning. Most of the bers and letters (e.g., 1-A-2-B-3-C-4-D. . .).
efficacy research for APT has been based on In addition to attention tasks, some studies
single-case designs with small sample sizes have examined performance on executive func-
(e.g., Coelho, 2005; Murray et al., 2006; Palmese tion tasks following the APT program in samples
& Raskin, 2000; Pero et al., 2006; Sohlberg & with brain injury and schizophrenia (López-
Mateer, 1987), although a few studies have incor- Luengo & Vázquez, 2003; Sohlberg et al.,
porated between-group designs with random 2000). One such task on which participants have
assignment (e.g., López-Luengo & Vázquez, shown improvement after completing APT is on
2003; Sohlberg et al., 2000). variations of the Stroop task (Stroop, 1935;
In general, researchers have found some sup- Mohlman, 2008; Sohlberg et al., 2000).
port for improvement on sustained, selective, and
divided attention tasks, as well as reading com-
prehension, in certain situations (Boman, Outcome Measurement
Lindstedt, Hemmingsson, & Bartfai, 2004;
Coelho, 2005; Kurtz, Moberg, Mozley, Swanson, A variety of outcome measures including attention
Gur, & Gur, 2001; Murray et al., 2006; Palmese tasks, questionnaires, and participant interviews
& Raskin, 2000; Pero et al., 2006; Sohlberg et al., have been used in APT efficacy research. However
2000; Sohlberg & Mateer, 1987). However, stud- the most commonly used outcome measures
ies have not consistently found evidence of appear to be the paced auditory serial addition
improvement in attention skills resulting from task (PASAT; Gronwall, 1977), consonant tri-
APT (e.g., López-Luengo & Vázquez, 2003; grams (Peterson & Peterson, 1959), Trails B, and
Silverstein et al., 2005). variations of the Stroop task (Stroop, 1935).
For example, individuals with brain injury
who have completed the APT program have Paced Auditory Serial Addition Task
shown improvement on the paced auditory serial The PASAT measures rate of information
addition task (PASAT; Gronwall, 1977), processing and was designed to assess the rate
a measure of sustained attention and information and degree of progress for clients recovering
processing speed (Park et al., 1999). However, from concussion (Gronwall, 1977). It is
A 296 Attention Process Training (APT) Program
comprised of a randomized presentation of an (e.g., naming “yellow” for the word “red” printed
auditory digit sequence, and the participant is in yellow ink). The task can also be completed by
expected to add each new digit to the preceding having participants read the list of color words
one (Sohlberg et al., 2000). Subsequent trials are while ignoring the ink color in which they are
presented at increasingly faster rates. Scores can printed. Many variations of this original task have
be calculated as the correct number of responses been developed that utilize different types of
at each trial pace or average time per correct conflicting stimuli (MacLeod, 1991).
response (Gronwall, 1977). The PASAT is con-
sidered to require two types of attention:
sustained attention and the ability to identify Qualifications of Treatment Providers
and correct errors during the activity (Park
et al., 1999). Some have questioned whether Psychologists, speech-language pathologists,
improvement on this task following APT is due occupational therapists, special education staff,
to the intervention or is an effect of repeated and related professionals with appropriate train-
testing (Pero et al., 2006). ing in cognitive rehabilitation would generally be
considered qualified to implement APT.
Consonant Trigrams/Brown-Peterson Task
This task measures memory skills under condi-
tions of distraction (Park et al., 1999). Individuals See Also
participating in this task hear three consonants
followed by a number. They are then asked to ▶ Attention
count backward by threes for a predetermined ▶ Auditory Discrimination
number of seconds (e.g., 3, 9, 18). After the set ▶ Auditory Processing
time has elapsed, the participant is expected to ▶ Executive Function (EF)
recall the three consonants heard at the beginning ▶ Information Processing Speed
of the trial. Delays of varying lengths between the ▶ Memory
end of the counting backward and the instruction ▶ Reaction Time
to recall the consonants are also incorporated into ▶ Short-Term Memory
the assessment (Park et al.). ▶ Visual Processing
▶ Visual Scanning
Trails B
Trails B was originally part of the Army Individual
Test Battery and is a task that measures visual
scanning, mental flexibility, planning abilities,
and working memory (Corrigan & Hinkeldey, Boman, I.-L., Lindstedt, M., Hemmingsson, H., & Bartfai,
1987; Sohlberg et al., 2000). Participants are A. (2004). Cognitive training in home environment.
asked to draw lines connecting consecutively num- Brain Injury, 18, 985–995.
Coelho, C. A. (2005). Direct attention training as
bered and lettered circles and alternate between the
a treatment for reading impairment in mild aphasia.
two (e.g., in the order 1-A-2-B-3-C-4-D. . .). Trails Aphasiology, 19, 275–283.
B can be scored as number of seconds required to Corrigan, J. D., & Hinkeldey, N. S. (1987). Relationships
complete the task (Corrigan & Hinkeldey, 1987). between parts A and B of the trail making test. Journal
of Clinical Psychology, 43, 402–409.
Gronwall, D. M. A. (1977). Paced auditory serial-addition
The Stroop Task task: A measure of recovery from concussion. Percep-
The Stroop task measures the interference effects tual and Motor Skills, 44, 367–373.
of conflicting stimuli (Stroop, 1935). Participants Kurtz, M. M., Moberg, P. J., Mozley, L. H., Swanson,
C. L., Gur, R. C., & Gur, R. E. (2001). Effectiveness of
are shown a list of color words and asked to name
an attention- and memory-training program on neuro-
the colors in which the words are printed (e.g., psychological deficits in schizophrenia. Neuroreh-
red, yellow) and ignore the words themselves abilitation and Neural Repair, 15, 75–80.
Attributions (First Order/Second Order) 297 A
López-Luengo, B., & Vázquez, C. (2003). Effects of
attention process training on cognitive functioning of Attribution of Mental States
schizophrenic patients. Psychiatry Research, 119,
41–53. A
MacLeod, C. M. (1991). Half a century of research on the ▶ Attributions (First Order/Second Order)
Stroop effect: An integrative review. Psychological
Bulletin, 109, 163–203.
Mohlman, J. (2008). More power to the executive?
A preliminary test of CBT plus executive training for Attributions (First Order/Second
treatment of late-life GAD. Cognitive and Behavioral Order)
Practice, 15, 306–316.
Murray, L. L., Keeton, R. J., & Karcher, L. (2006).
Treating attention in mild aphasia: Evaluation of atten- Francesca Happé
tion process training-II. Journal of Communication MRC Social, Genetic and Developmental
Disorders, 39, 37–61. Psychiatry Centre at the Institute of Psychiatry,
Ozonoff, S., South, M., & Provencal, S. (2005). Executive
functions. In F. R. Volkmar, R. Paul, A. Kiln, & D. King’s College London, London, UK
Cohen (Eds.), Handbook of autism and pervasive
developmental disorders: Vol. 1, diagnosis, develop-
ment, neurobiology, and behavior (pp. 606–627). Synonyms
Palmese, C. A., & Raskin, S. A. (2000). The rehabilitation
of attention in individuals with mild traumatic brain Attribution of mental states
injury, using the APT-II programme. Brain Injury, 14,
535–548.
Park, N. W., Proulx, G.-B., & Towers, W. M. (1999).
Evaluation of the attention process training Definition
programme. Neuropsychological Rehabilitation, 9,
135–154. Attribution is a concept in psychology referring to
Pero, S., Incoccia, C., Caracciolo, B., Zoccolotti, P., & people’s tendency to attribute traits and causes to
Formisano, R. (2006). Rehabilitation of attention in
two patients with traumatic brain injury by means of help explain what they observe. First- and second-
‘attention process training’. Brain Injury, 20, 1207– order attributions refer more specifically to the
1219. attribution of mental states to self or others to
Peterson, L. R., & Peterson, M. J. (1959). Short-term explain and predict observable behavior (see
retention of individual verbal items. Journal of Exper-
imental Psychology, 58, 193–198. ▶ Theory of Mind). Attribution of mental states,
Silverstein, S. M., Hatashita-Wong, M., Solak, B. A., such as beliefs and desires, has been widely stud-
Uhlhaas, P., Landa, Y., Wilkniss, S. M., et al. (2005). ied in false belief paradigms (Frith & Frith, 2010).
Effectiveness of a two-phase cognitive rehabilitation First-order mental state attribution tasks require
intervention for severely impaired schizophrenia
patients. Psychological Medicine, 35, 829–837. the participant to represent another person’s
Sohlberg, M. M., Johnson, L., Paule, L., Raskin, S. A., & thoughts about the world, e.g., Sally thinks the
Mateer, C. A. (2001). Attention process training-II: ball is in the basket. Second-order tasks require
A program to address attentional deficits for persons representation of one person’s belief about another
with mild cognitive dysfunction (2nd ed.). Wake For-
est, NC: Lash & Associates. person’s mental state, e.g., Sally thinks Ann knows
Sohlberg, M. M., & Mateer, C. A. (1987). Effectiveness of the ball is in the box. An everyday life example of
an attention-training program. Journal of Clinical and attribution of mental states would be when we
Experimental Neuropsychology, 9, 117–130. understand whether someone is telling a joke or
Sohlberg, M. M., McLaughlin, K. A., Pavese, A.,
Hedrich, A., & Posner, M. I. (2000). Evaluation of telling a lie: we attribute to the liar, but not to the
attention process training and brain injury education joker, the intension to make us believe what he or
in persons with acquired brain injury. Journal of she says. Several tests exist for assessing the abil-
Clinical and Experimental Neuropsychology, 22, ity to attribute mental states (e.g., Happé, 1994;
656–676.
Stroop, J. R. (1935). Studies of interference in serial verbal White et al., 2009).
reactions. Journal of Experimental Psychology, 18, A large body of research has demonstrated
643–662. that most children and many adults with ASD
A 298 Atypical
find it difficult to make mental state attributions, objective test of Theory of Mind for adults with
especially attributing to another person a state of autism. Autism Research, 4, 149–154.
Williams, D., & Happé, F. (2009). What did I say? Versus
knowledge that is different from their own or what did I think? Attributing false beliefs to self
from reality (Baron-Cohen, Tager-Flusberg, & amongst children with and without autism. Journal of
Cohen, 2000). This may underlie a range of social Autism and Developmental Disorders, 39(6), 865–873.
and communicative symptoms in ASD, such as
overliteral language use/understanding, difficulty
adapting conversation to listeners’ interests/
knowledge, and difficulty understanding decep- Atypical
tion. An interesting question in recent research
(e.g., Williams & Happé, 2009) is whether some ▶ Exceptionality
people with ASD may have difficulty attributing
mental states to self, with implications for self-
awareness and the ability to reflect upon one’s
own thoughts and feelings. Atypical Antipsychotics
Attribution of mental states has become a key
task for use during functional neuroimaging Maureen Early1, Logan Wink1,2,
investigations of brain differences in ASD. Craig Erickson1,2 and Christopher J. McDougle3
1
A range of different tasks suggest key regions Christian Sarkine Autism Treatment Center,
including the medial prefrontal cortex are less Indianapolis, IN, USA
2
activated in people with ASD compared to con- Department of Psychiatry, Indiana University
trols when attributing thoughts (in response to, School of Medicine, Indianapolis, IN, USA
3
e.g., animated shapes, story vignettes; Frith & Lurie Center for Autism/Harvard Medical
Frith, 2010). School, Lexington, MA, USA
See Also Synonyms
▶ Theory of Mind Novel antipsychotics; Second-generation anti-

psychotics (SGAs)
References and Readings Indications

Baron-Cohen, S., Tager-Flusberg, H., & Cohen, D. J.
(Eds.). (2000). Understanding other minds. Oxford: Aripiprazole (Abilify)
Oxford University Press. Schizophrenia in adults and pediatric patients
Frith, U., & Frith, C. (2010). The social brain: Allowing (age 13–17 years); Acute manic or mixed epi-
humans to boldly go where no other species has been. sodes of bipolar I disorder in adults and pediatric
Philosophical Transactions of the Royal Society B,
365, 165–176. patients (age 10–17 years), alone or as an adjunct
Happé, F. G. E. (1994). An advanced test of theory of to lithium or valproate; Major depressive disorder
mind: Understanding of story characters’ thoughts and in adults (adjunctive treatment); Agitation asso-
feelings by able autistic, mentally handicapped and ciated with schizophrenia or manic or mixed epi-
normal children and adults. Journal of Autism and
Developmental Disorders, 24, 129–154. sodes of bipolar I disorder (adults).
White, S. J., Hill, E., Happé, F., & Frith, U. (2009).
Revisiting the Strange Stories: revealing mentalising Clozapine (Clozaril)
impairments in autism. Child Development, 80, Acute schizophrenia; Acute schizoaffective
1097–1117.
White, S. J., Coniston, D., Rogers, R., & Frith, U. (2011). disorder; Treatment-refractory schizophrenia;
Developing the Frith-Happé animations: A quick and Maintenance therapy in schizophrenia; Manic
Atypical Antipsychotics 299 A
episodes of bipolar disorder; Depression with Mechanisms of Action
psychotic features.
When considering mechanisms of action of anti- A
Olanzapine (Zyprexa) psychotics, it is important to note that the patho-
Schizophrenia in adults and pediatric patients physiologies of psychiatric conditions treated by
(age 13–17 years); Acute manic or mixed epi- these drugs (i.e., schizophrenia, bipolar disorder,
sodes of bipolar I disorder in adults and pediatric and autism) are unknown; therefore, the precise
patients (age 13–17 years), alone or as an adjunct mechanisms of action of the atypical antipsy-
to lithium or valproate; Acute agitation in schizo- chotics are unknown.
phrenia and mania in bipolar I disorder; in com-
bination with fluoxetine for depressive episodes Aripiprazole
associated with bipolar I disorder in adults; in Aripiprazole is a dopamine type 2 (D2) receptor
combination with fluoxetine for treatment- partial agonist, not a full antagonist like the other
resistant depression (adults). atypical antipsychotics. This drug acts as a D2
receptor antagonist when coadministered with
Olanzapine and Fluoxetine Hydrochloride a dopamine (DA) agonist but acts as a D2 receptor
(Symbyax) agonist when administered without another DA
Acute depressive episodes of bipolar I disorder in agonist. Aripiprazole acts as an antagonist in
adults; Treatment-resistant depression in adults. overactive DA pathways and an agonist in under-
active DA pathways. This drug’s antagonist
Paliperidone (Invega) activity at serotonin type 2A (5-HT2A) receptors
Schizophrenia; Acute treatment of schizoaffective may cause reductions in extrapyramidal symp-
disorder, alone or as an adjunct to mood stabilizers toms (EPS) and improve the negative symptoms
and/or antidepressants. of schizophrenia, and its partial agonist activity at
serotonin type 1A (5-HT1A) may cause improve-
Quetiapine (Seroquel) ment in the negative and cognitive symptoms of
Schizophrenia, including global symptoms, schizophrenia, depression, and anxiety.
positive symptoms, negative symptoms, cogni-
tion, and aggression; Bipolar disorder (adults); Clozapine
Major depressive disorder in adults (adjunctive Clozapine exhibits low affinity for and quick
treatment). dissociation from dopamine type 2 (D2) receptors
and high affinity for the serotonin type 2A
Risperidone (Risperdal) (5-HT2A) and serotonin type 1C (5-HT1C) recep-
Schizophrenia in adults and pediatric patients tors, adrenergic receptors, cholinergic receptors,
(age 13–17 years); Acute manic or mixed epi- and dopamine type 4 (D4) receptors, mainly in the
sodes of bipolar I disorder in adults, alone or as extrastriatal cortex as compared to the striatal
an adjunct to lithium or valproate; Acute manic or cortex. This drug also increases the release of
mixed episodes of bipolar I disorder in pediatric dopamine (DA) in the prefrontal cortex. This
patients (age 10–17 years); Irritability associated effect of the drug may alleviate the negative
with autistic disorder in pediatric patients symptoms and cognitive deficits of schizophrenia
(age 5–16 years). since these two aspects of the disorder may result
from dopaminergic hypoactivity in the prefrontal
Ziprasidone Hydrochloride (Geodon) and cortex.
Ziprasidone Mesylate (Geodon)
Schizophrenia in adults; Acute manic or mixed Olanzapine
episodes of bipolar I disorder in adults, alone or Olanzapine has high relative serotonin type 2A
as an adjunct to lithium or valproate; Acute agi- (5-HT2A) receptor blocking activity compared to
tation of schizophrenia in adults that of dopaminergic (DA) receptors. This drug
A 300 Atypical Antipsychotics
increases expression of c-fos in the caudate symptoms of psychosis. Also, the dizocilpine-
nucleus and increases serum glutamate levels. induced disruption of prepulse inhibition of
Also, olanzapine increases brain glutamate levels 5-HT2A antagonists may improve sensory gating
in patients who exhibit improvement in the neg- deficits in schizophrenia which may be caused
ative symptoms of schizophrenia. by glutamatergic dysregulation. The a-
adrenergic antagonist activity may cause an
Paliperidone increase in dopamine (DA) levels in the medial
Paliperidone is a dopamine type 2 (D2), serotonin prefrontal cortex which may improve negative
type 2A (5-HT2A), a1- and a2-adrenergic, and symptoms and cognition in schizophrenia.
histaminergic 1 (H1) receptor antagonist. This Dopaminergic hypoactivity in the prefrontal
drug is expected to have a mechanism very sim- cortex is a potential cause of negative symptoms
ilar to that of risperidone since it is the major and cognitive deficits in schizophrenia. The a-
active metabolite of that drug, although patients adrenergic antagonist activity of this drug also
have been reported to have responded positively may reduce the risk for the development of
to paliperidone after failing to respond to an extrapyramidal symptoms (EPS) and improve
adequate trial of risperidone. cognition in individuals with frontal dementias.
When taken with haloperidol, the selective sero-
Quetiapine tonin type 2 (5-HT2) antagonism reduces neuro-
Quetiapine exhibits a high relative blockade of leptic-induced parkinsonism and akathisia by
serotonin type 2A (5-HT2A), serotonin type 2B increasing DA metabolism in the striatum and
(5-HT2B), and serotonin type 2C (5-HT2C) recep- preventing an increase in D2 receptor density
tors compared to that of dopamine (DA) recep- which causes a decrease in the effects of D2
tors. This drug exhibits a greater degree of receptor blockade and DA supersensitivity.
binding in the extrastriatal cortex than in the
striatal cortex. Quetiapine has partial agonist Ziprasidone
activity at 5-HT2A which causes an increased The antipsychotic effects of ziprasidone may be
DA level in the mesocortical DA pathway in due to the affinity of this drug for dopamine type
individuals in which this pathway is hypoactive, 2 (D2) receptors in the striatum and its strong
thereby causing improvement in the negative and antagonism for serotonin type 2A (5-HT2A)
cognitive symptoms of schizophrenia. Also, this receptors. The 5-HT2A receptor antagonism
compound exhibits brief, high occupancy of of this drug and its strong serotonin type 1A
dopamine type 2 (D2) receptors for 2–3 h after (5-HT1A) receptor agonism may improve the
dose administration in patients who exhibit negative and cognitive symptoms of schizophre-
improvement in psychosis, extrapyramidal symp- nia by facilitating the release of dopamine (DA)
toms (EPS), and prolactin. Imaging studies show in the prefrontal cortex.
that this drug has means of 74% 5-HT2A receptor
binding and 30% D2 receptor binding for 450 mg/
day dosing and means of 76% 5-HT2A receptor Specific Compounds and Properties
binding and 41% D2 receptor binding for 750 mg/
day dosing. The specific compounds currently marketed in the
United States that act as atypical antipsychotics
Risperidone are aripiprazole, clozapine, olanzapine,
Risperidone acts as an antagonist at the seroto- paliperidone, risperidone, ziprasidone, and
nin type 2A (5-HT2A), dopamine type 2 (D2), a1- quetiapine. The unique chemical structure of
and a2-adrenergic, and histaminergic 1 (H1) each atypical antipsychotic accounts for its bind-
receptors. Selective 5-HT2A antagonists block ing activity as detailed in the “Mechanisms of
amphetamine- and phencyclidine-induced loco- Action” section of this entry. The chemical struc-
motor activity and thereby may improve tures of these compounds are pictured in Figs. 1–7.
Atypical Antipsychotics, Cl Cl
Fig. 1 Chemical structure
of aripiprazole O
A
N N NH
N N
N N
N N
Cl
N N S
H H
Atypical Antipsychotics, Fig. 2 Chemical structure of Atypical Antipsychotics, Fig. 3 Chemical structure of
clozapine olanzapine
Clinical Use (Including Side Effects) Olanzapine

Olanzapine is used in autism spectrum disorders for
Aripiprazole global improvement of severe behavioral symp-
Aripiprazole is used in autistic disorder to toms, overall symptoms of autism, motor restless-
improve symptoms of aggression, irritability, ness/hyperactivity, social relatedness, affectual
and self-injurious behavior. Doses used in studies relations, sensory responses, language use, self-
range from 2.5 to 15 milligrams per day (mg/ injurious behaviors, aggression, irritability, anxiety,
day). Side effects of aripiprazole include nausea, and depression. The dose for this drug may be
weight gain, akathisia, headache, insomnia, agi- between 5 and 20 mg/day and is used in children,
tation, anxiety, and mild transient somnolence. adolescents, and adults. Side effects of olanzapine
include sedation and weight gain. Also, this drug has
Clozapine a moderate risk of orthostasis and anticholinergic
Clozapine is used in autism spectrum disorders effects; a low, dose-dependent risk of EPS; a low
(ASDs) to improve symptoms of aggression. risk of increased liver enzyme levels; and a very low
Doses of 276 mg/day in an adolescent and risk of TD, seizures, and hematologic effects.
283.33 mg/day in children have been used to
treat ASDs. Side effects of clozapine include Paliperidone
a very high risk of sedation; a high risk of anti- Paliperidone has been used in autism spectrum
cholinergic effects, sialorrhea, orthostasis, and disorders to improve symptoms of irritability,
weight gain; a moderate risk of seizures and including aggression, self-injurious behaviors,
hematologic effects; a low risk of increased and tantrums. Doses of 6–12 mg/day have been
liver enzyme levels; and a very low risk of extra- used in adolescents with autism. Side effects of
pyramidal symptoms (EPS) and neuroleptic paliperidone include orthostatic hypotension,
malignant syndrome (NMS). weight gain, weight loss, and sedation.
A 302 Atypical Antipsychotics
Atypical Antipsychotics, O
Fig. 4 Chemical structure O N
of paliperidone
N
N
F OH
O
N
HO
HN
HO O
Atypical Antipsychotics,
S O HO
of quetiapine
O
O N
N
Fig. 6 Chemical structure N
of risperidone F
Cl
S N
N
N
NH
of ziprasidone O
Quetiapine References and Readings
Quetiapine is used in autism spectrums disorders
Barnard, L., Young, A. H., Pearson, J., Geddes, J., &
(ASDs) to improve symptoms of aggression,
O’Brien, G. (2002). A systematic review of the use of A
hyperactivity, and inattention. Doses used in
atypical antipsychotics in autism. Journal of Psycho-
studies of quetiapine for use in the treatment of pharmacology, 16, 93–101.
ASDs include means of 225 mg/day and 477 mg/ Biederman, J., Spencer, R., & Wilens, T. (2004). Psy-
day in children and adolescents; a mean of chopharmacology. In J. M. Wiener & M. K. Dulcan
(Eds.), The American psychiatric publishing textbook
292 mg/day in adolescents; and a mean of
of child and adolescent psychiatry (3rd ed.,
249 mg/day in a group of children, adolescents, pp. 931–973). Washington, DC: American Psychiat-
and adults. Side effects of quetiapine include ric Publishing.
agitation, sedation, weight gain, aggression, and Brown, C. S., Markowitz, J. S., Moore, T. R., & Parker,
N. G. (1999). Atypical antipsychotics: Part II: Adverse
sialorrhea. Also, this drug has a low risk of anti-
effects, drug interactions, and costs. The Annals of
cholinergic effects, orthostasis, and increased Pharmacotherapy, 33, 210–217.
liver enzyme levels and a very low risk of EPS, Chen, N. C., Bedair, H. S., McKay, B., Bowers, M. B., Jr.,
NMS, seizures, and hematologic effects. & Mazure, C. (2001). Clozapine in the treatment of
aggression in an adolescent with autistic disorder. The
Journal of Clinical Psychiatry, 62, 479–480.
Risperidone Citrome, L. (2010). Paliperidone palmitate – Review of
Risperidone is used in autistic disorder to the efficacy, safety and cost of a new second-
improve symptoms of aggression, irritability, generation depot antipsychotic medication. Interna-
tional Journal of Clinical Practice, 64, 216–239.
repetitive behavior and language, hyperactivity,
Daniel, D. G., Copeland, L. F., & Tamminga, C. (2006).
social withdrawal, nonverbal communication, Ziprasidone. In A. F. Schatzberg & C. B. Nemeroff
and social responsiveness. An effective dose (Eds.), Essentials of clinical psychopharmacology
for children with pervasive developmental dis- (2nd ed., pp. 297–305). Washington, DC: American
order (PDD) may range from 1 to 1.2 mg/day,
Goff, D. C. (2006). Risperidone. In A. F. Schatzberg &
whereas an effective dose for children with C. B. Nemeroff (Eds.), Essentials of clinical psycho-
autism may be 1.8 mg/day. An effective dose pharmacology (2nd ed., pp. 285–295). Washington,
for adults with autism may be 2.9 mg/day. Side DC: American Psychiatric Publishing.
Marder, S. R., & Wirshing, D. A. (2006). Clozapine. In
effects of risperidone include sedation,
A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials
increased prolactin, weight gain, and of clinical psychopharmacology (2nd ed., pp. 229–
hypersalivation. Also, this drug has a high risk 243). Washington, DC: American Psychiatric
for orthostasis; a moderate, dose-dependent risk Publishing.
Martinez, M., Marangell, L. B., & Martinez, J. M. (2011).
of EPS; and a very low risk of tardive dyskinesia
Psychopharmacology. In R. E. Hales, S. C. Yudofsky,
(TD), NMS, anticholinergic effects, seizures, & G. O. Gabbard (Eds.), Essentials of psychiatry
hematologic effects, and elevated liver enzyme (3rd ed., pp. 455–524). Washington, DC: American
levels. Psychiatric Publishing, Inc.
Miyamoto, S., Duncan, G. E., Marx, C. E., & Lieberman,
J. A. (2005). Treatments for schizophrenia: A critical
Ziprasidone review of pharmacology and mechanisms of action of
Ziprasidone is used in autism spectrum disorders antipsychotic drugs. Molecular Psychiatry, 10, 79–
to improve symptoms of aggression, irritability, 104.
Posey, D. J., Stigler, K. A., Erickson, C. A., & McDougle,
and agitation. A dose used in studies of
C. J. (2008). Antipsychotics in the treatment of autism.
ziprasidone for use in the treatment of ASDs Science in medicine, 118, 6–14.
includes a mean of 59 mg/day in children and Printz, D. J., & Lieberman, J. A. (2006a). Aripiprazole. In
adolescents. Side effects of ziprasidone include A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials
of clinical psychopharmacology (2nd ed., pp. 277–
sedation and mild weight gain. Also, this drug has
283). Washington, DC: American Psychiatric
a low risk of orthostasis and increased liver Publishing.
enzyme levels and a very low risk of EPS, anti- Printz, D. J., & Lieberman, J. A. (2006b). Quetiapine.
cholinergic effects, seizures, and hematologic In A. F. Schatzberg & C. B. Nemeroff (Eds.), Essen-
tials of clinical psychopharmacology (2nd ed.,
effects.
A 304 Atypical Autism
pp. 263–275). Washington, DC: American Psychiatric disorder). Alternatively, atypical autism can be
Publishing. diagnosed when there is a late onset of symptom-
Schatzberg, A. F., Cole, J. O., & DeBattista, C. (2003).
Antipsychotic drugs. In Manual of clinical psycho- atology. Atypical autism (as defined by ICD-10)
pharmacology (4th ed., pp. 159–243). Washington, is seen as being equivalent to the DSM-IV-TR
DC: American Psychiatric Publishing. diagnostic category of pervasive developmental
Schultz, S. C., Olson, S., & Kotlyar, M. (2006). disorder not otherwise specified (PDD NOS).
Olanzapine. In A. F. Schatzberg & C. B. Nemeroff
(Eds.), Essentials of clinical psychopharmacology Like PDD NOS, atypical autism is poorly
(2nd ed., pp. 245–275). Washington, DC: American defined, resulting in a research literature that can
Psychiatric Publishing. be difficult to interpret and conclusions difficult to
Stigler, K. A., Erickson, C. A., Mullet, J. E., Posey, D. J., reach. Atypical autism, as defined by the ICD,
& McDougle, C. J. (2010). Paliperidone for irritability
in autistic disorder. Journal of Child and Adolescent lacks operationalized diagnostic criteria, resulting
Psychopharmacology, 20, 75–78. in inconsistencies and variability in the way in
Tsai, L. Y. (2004). Autistic disorder. In J. M. Wiener & which the diagnosis is applied. Although it now
M. K. Dulcan (Eds.), The American psychiatric pub- appears to be more common than autistic disorder,
lishing textbook of child and adolescent psychiatry
(3rd ed., pp. 261–260). Washington, DC: American in general it remains poorly understood. This is
Psychiatric Publishing. likely due, in no small part, to the lack of a clear
U.S. Food and Drug Administration. (2010a). Atypical definition. Although it is often assumed that find-
antipsychotics drug information. Retrieved from http:// ings relating to autism apply to atypical autism, the
www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafe-
tyInformationforPatientsandProviders/ucm094303.htm lack of operationalized diagnostic criteria has
U.S. Food and Drug Administration. (2010b). undoubtedly hampered specific research into this
Drugs@FDA. Retrieved from http://www.accessdata. diagnostic category and contributed to inconsis-
fda.gov/scripts/cder/drugsatfda/index.cfm tent findings across studies. Studies often fail to
describe how they operationalized or defined their
samples of atypical autism or PDD NOS. The
ICD-10 provides specifiers to further define the
Atypical Autism diagnosis of atypical autism (see section “Catego-
rization”); however, studies generally do not use
Kylie M. Gray these specifiers. Difficulties therefore remain in
Centre for Developmental Psychiatry and interpreting and comparing findings across stud-
Psychology, School of Psychology and ies. The broadening of the PDD NOS category in
Psychology Monash University, ELMHS, DSM-IV (Volkmar, Shaffer, & First, 2000) has
Monash Medical Centre, Clayton, VIC, Australia also contributed to difficulties in interpretability
of results across studies, although with DSM-IV-
TR (American Psychiatric Association, 2000) this
Synonyms was remedied. Further definition of atypical autism
or PDD NOS in research (see, e.g., Mandy,
Other pervasive developmental disorder; Charman, Gilmour and Skuse (2011)) would assist
Pervasive developmental disorder not otherwise with furthering knowledge in this area.
specified (PDD NOS); Pervasive developmental This entry will focus on research studies
disorder, unspecified involving individuals with atypical autism.
Where necessary, this is supplemented with
research findings with samples with PDD NOS.
Atypical autism is often described as a subthresh- Categorization

old diagnosis, presenting with some symptoms of
autism but insufficient to meet criteria for The category of pervasive developmental disor-
a diagnosis of childhood autism (or autistic der (PDD) was introduced in DSM-III (American
Atypical Autism 305 A
Psychiatric Association, 1980) and included the other pervasive developmental disorder, and per-
subthreshold diagnosis of atypical PDD, which vasive developmental disorder, unspecified are
subsequently became pervasive developmental considered to be broadly equivalent to the A
not otherwise specified (PDD NOS) in DSM-III- DSM-IV-TR (American Psychiatric Association,
R (American Psychiatric Association, 1987). 2000) diagnosis of PDD NOS.
Reflecting thinking at the time, ICD-9 catego- In the proposed draft diagnostic guidelines for
rized autism (299.0 Infantile Autism) under the DSM-5 (American Psychiatric Association,
category of childhood psychoses and included 2011), the diagnosis of PDD NOS will no longer
a code for other specified early childhood psy- be possible and will be subsumed under the cat-
choses, including atypical childhood psychosis egory of autism spectrum disorders. It is not yet
(299.8) (World Health Organisation, 1978). known whether there will be any changes to the
With the revision of these classification systems category of pervasive developmental disorders in
to the current DSM-IV (American Psychiatric the revision of ICD-10.
Association, 2000) and ICD-10 (World Health
Organisation, 1992), the systems share
a common approach to coding and are conceptu- Epidemiology
ally the same (Volkmar, 1998).
The ICD-10 (World Health Organisation, Atypical autism is rarely the focus of prevalence
1992) provides diagnostic criteria for atypical studies, and differing labels and combining of
autism (F84.1) under the category of pervasive groups other than autistic disorder can make the
developmental disorders. The diagnosis is for extraction and interpretation of prevalence fig-
cases where age of onset is after the age of three ures difficult. A number of population and birth
(criteria the same for childhood autism except for cohort studies have included figures on the prev-
age of onset), or all three sets of criteria for alence of atypical autism. The UK-based studies
childhood autism are not met (subthreshold). in children have reported differing prevalence
Criteria in the domains of abnormalities in recip- figures of 10.5/10,000 (Lingam, Simmons,
rocal social interaction, or communication, or Andrews, Miller, Stowe, & Taylor, 2003), 10.9/
restricted, repetitive, and stereotyped patterns of 10,000 (Williams, Thomas, Sidebotham, &
behavior, interests, and activities are the same as Emond, 2008), and 27/10,000 (Baird et al.,
for childhood autism (F84.0) except that it is not 2000), while a recent birth cohort study (6-year-
necessary to meet the criteria for number of areas olds) in Stockholm reported a prevalence of 22/
of abnormality. Specifiers can then be used to 10,000 (Fernell & Gillberg, 2010). A study in the
indicate atypicality in age of onset (F84.10), Faroe Islands (considered a genetic isolate)
atypicality in symptomatology (F84.11), or atyp- reported a population prevalence of atypical
icality in both age of onset and symptomatology autism of 0.12%, while acknowledging that this
(F84.12). The DSM-IV (American Psychiatric is possibly an underestimate particularly in terms
Association, 2000) defines PDD NOS as includ- of higher functioning children (Ellefsen,
ing atypical autism. Kampmann, Billstedt, Gillberg, & Gillberg,
The ICD-10 also has two additional diagnoses, 2007). A Danish population study reported sepa-
namely, other pervasive developmental disorder rate prevalence rates for atypical autism (3.3/
(F84.8, with no diagnostic criteria specified) and 10,000) and PDD NOS (14.6/10,000), which
pervasive developmental disorder, unspecified when taken together are similar to those rates
(F84.9). The latter disorder is defined as reported by Fernell and Gillberg (2010) and
a residual category for cases where there is Baird et al. (2000). Gender ratios have been
a lack of information or contradictory findings, reported by a very small number of studies, with
but where symptomatology fits the general a higher proportion of males with autistic disor-
description for a pervasive developmental disorder compared to atypical autism, 6.5:1 compared
der. The ICD-10 diagnoses of atypical autism, to 3.8:1 in Stockholm (Fernell & Gillberg, 2010),
and no reported gender differences between PDD atypical autism was diagnosed later than child-
NOS (85.3% male) and autistic disorder (85.9% hood autism, with atypical autism generally diag-
male) in a birth cohort of 4–6-year-olds in Staf- nosed at 5–6 years of age and childhood autism at
ford in the UK (Chakrabarti & Fombonne, 2005). 3–4 years (Fernell & Gillberg, 2010; Lingam
A series of review studies by Fombonne, most et al., 2003).
recently in 2009, reviewed 43 prevalence sur- Research has demonstrated that outcome in
veys, 17 of which provided separate estimates autism and other pervasive developmental disor-
of the prevalence of atypical autistic syndromes ders is associated with the acquisition of expres-
(PDD NOS and atypical autism) (Fombonne, sive language skills by the age of 5–6 years,
2009). Fourteen of these studies reported cognitive ability, and early social-
a higher prevalence of atypical autism syndromes communicative skills (Gillberg & Steffenburg,
compared to autistic disorder, 37.1/10,000 and 1987; Kobayashi, Murata, & Yoshinaga, 1992;
20.6/10,000 respectively. Like the prevalence of Mundy, Sigman, & Kasari, 1990; Nordin &
autism, the reported prevalence of atypical Gillberg, 1998; Sigman & Ruskin, 1999). Longi-
autism has increased over time. Similarly, this tudinal studies have reported that initial diagnosis
increase is typically discussed in relation to (i.e., atypical autism or PDD NOS compared to
changes in diagnostic criteria, increased aware- autistic disorder) is not related to outcomes
ness, diagnostic substitution, changes in special (Baghdadli et al., 2007; Turner, Stone, Pozdol,
education policies, and increases in the availabil- & Coonrod, 2006) and therefore has limited use
ity of services. What is however clear from these in predicting developmental outcomes.
studies is that there is a significantly large popu-
lation of children with atypical autism who have
treatment needs similar to those of children with Clinical Expression and
autism. Pathophysiology
The reliability and stability of the diagnoses of

Natural History, Prognostic Factors, atypical autism and PDD NOS have been
Outcomes questioned. In a study of subtypes of pervasive
developmental disorders in children, Mahoney
A small number of studies have investigated the et al. (1998) reported interrater agreement for
early signs and symptoms in children later diag- diagnoses of Asperger’s disorder, autism, and
nosed with atypical autism, with mixed results. atypical autism across three raters. Kappa values
One study looked at first symptoms and diagnosis revealed good agreement for the diagnosis of
in children with atypical autism, comparing the autism (.55), Asperger’s disorder (.56), and non-
parent-reported onset of symptomatology to that PDD (.67), but poor agreement in the case of
of children diagnosed with childhood autism atypical autism (.18). Consistent with the results
(Oslejskova, Kontrova, Foralova, Dusek, & of studies in children with atypical autism,
Nemethova, 2007). Significant group differences research in toddlers with autism and PDD NOS
were found in age of first symptoms, with parents has reported good agreement between clinicians
of children with atypical autism reporting first on the diagnosis of autism, but low rates of agree-
symptoms at an average of 36.7 months (comment for PDD NOS (Chawarska, Klin, Paul, &
pared to 23.5 months for children with childhood Volkmar, 2007; Stone et al., 1999).
autism). There were however no significant group In relation to diagnostic stability, research has
differences in age at diagnosis. In contrast, focused on individuals with PDD NOS. While
Walker et al. reported no difference between diagnoses of autistic disorder have been shown
autism and PDD NOS in terms of age at which to be relatively stable in toddlers, the same is not
abnormalities were first identified by parents true of PDD NOS (Chawarska et al., 2007; Stone
(2004). Two epidemiological studies found that et al., 1999; Turner et al., 2006; van Daalen,
Kemner, Dietz, Swinkels, Buitelaar, & van responsiveness, auditory responsiveness, and
Engeland, 2009). A meta-analysis of the diagnos- nonverbal communication (Kurita, 1997).
tic stability of PDD NOS reviewed eight studies, Overall, these findings are consistent with the A
reporting higher rates of stability for a diagnosis idea of atypical autism being a subthreshold
of autistic disorder compared to PDD NOS (Ron- diagnosis for children with a significant degree
deau, Klein, Masse, Bodeau, Cohen, & Guile, of impairment, but not to the degree that criteria
2010). It was concluded that a diagnosis of for childhood autism are met.
PDD NOS prior to 36 months was unstable Further information on symptom presenta-
(35% stability) over time, highlighting the need tion comes from studies with children with a
for reassessment. It has been suggested that low diagnosis of PDD NOS. Consistent with the
diagnostic stability may be attributable to the results of the studies with children with atypical
later emergence of stereotyped and repetitive autism, a number have reported generally find-
behaviors in young children (Kleinman et al., ing children with PDD NOS to have signifi-
2008; Sutera et al., 2007). cantly less impairments in the social,
The lack of operationalized diagnostic communication, and restricted and repetitive
criteria for atypical autism and the variability symptom domains compared to children with
in which the diagnosis is applied have possibly autistic disorder (Fodstad, Matson, Hess, &
resulted in a significant amount of heterogene- Neal, 2009; Walker et al., 2004). De Bruin,
ity in the presentation of individuals; as such, Verheij, and Ferdinand (2006) reported that
there is as yet no consensus regarding the symp- children with PDD NOS have similar cognitive
tom profile for atypical autism or PDD NOS profiles as children with autism, although in
(Mandy et al., 2011). Two studies have exam- contrast Walker et al. (2004) found that children
ined symptom profiles in children with atypical with PDD NOS scored better than children with
autism, focusing on high-functioning children autism on measures of adaptive behavior and
with atypical autism, Asperger’s disorder, and nonverbal reasoning and problem-solving
childhood autism (Kanai, Koyama, Kato, skills. An investigation of communication
Miyamoto, Osada, & Kurita, 2004; Kurita, impairments using the Children’s Communica-
1997). In a comparison of children with high- tion Checklist (Bishop, 1998) with children
functioning atypical autism and childhood with high-functioning autism, Asperger’s disor-
autism, symptom patterns were examined der, and PDD NOS found that while all groups
using the Childhood Autism Rating Scale demonstrated significantly more impairment
(CARS) (Kurita, Miyake, & Katsuno, 1989), than the typically developing control group,
rated by clinicians blind to the child’s diagno- there was little difference across the autism sub-
sis. The children with atypical autism scored types. In a comprehensive study, Mandy et al.
significantly lower on the CARS total score. (2011) operationalized the definition of PDD
There were no significant group differences on NOS and compared the symptom profiles of
11 of the 15 CARS items. After controlling for children with autistic disorder, Asperger’s dis-
IQ and total CARS score, the children with order, and PDD NOS on independent measures
atypical autism were found to be significantly of symptomatology. They found that the over-
less impaired on two items of the CARS (rela- whelming majority (97%) of children with PDD
tionships with people and general impressions) NOS presented with a symptom profile charac-
and were more impaired in anxiety reaction terized by significant impairment in social inter-
compared to the children with childhood action and communication skills without
autism. In a comparison of high-functioning repetitive stereotyped behavior. The remaining
atypical autism and Asperger’s disorder, the children presented with a symptom pattern of
Asperger’s disorder group were significantly significant social impairment and repetitive ste-
less impaired than the atypical autism group reotyped behavior without communication
on total CARS score, imitation, visual impairment. These results are inconsistent
with the view of PDD NOS being a condition studies, has overall found no evidence for differ-
with marked heterogeneity. The children with ences between these conditions and autistic dis-
PDD NOS demonstrated significantly less rou- order (Towbin, 2005).
tinized and repetitive behaviors, sensory diffi-
culties, feeding, and visuospatial problems
compared to the children with autistic disorder Evaluation and Differential Diagnosis
and Asperger’s disorder. These findings have
implications for the proposed draft criteria for The assessment process for atypical autism is
DSM-5 (American Psychiatric Association, the same as that recommended for autism and
2011). With PDD NOS to be subsumed under other pervasive developmental disorders. In
the diagnostic category of autism spectrum dis- making a differential diagnosis, whether the
order (ASD), it may be that individuals criteria are met for a diagnosis of autism or
presenting with marked impairments in social Asperger’s disorder needs to be considered,
interaction and communication, without repeti- and degree of intellectual disability needs to be
tive stereotyped behavior, will not meet the taken into account. Differentiating atypical
proposed diagnostic criteria for ASD. autism from language disorder is also important.
High rates of comorbid mental health prob- It has been demonstrated that children with PDD
lems have been reported in atypical autism and NOS can be differentiated from children with
PDD NOS. A Danish study compared a sample language disorders on the basis of more severe
of 89 individuals diagnosed as children with social impairment and a greater need for rou-
atypical autism to a matched control sample tines and order (Mayes, Volkmar, Hook, &
from the general population (Mouridsen, Rich, Cicchetti, 1993). Research with children with
& Isager, 2008). Using the Danish Psychiatric a significant degree of disruptive behavior has
Register, they demonstrated that over a 36-year also highlighted the need to consider a diagnosis
follow-up period, elevated rates of co-occurring of atypical autism. In a cohort of primary
psychiatric diagnoses were found in those with school–aged children, significant impairments
atypical autism. The most prevalent of these in social and communication domains were
was schizophrenia spectrum disorder. High identified in children with significant disruptive
levels of depression, anxiety, and disruptive behavior, with 28% meeting criteria for
behavior disorder have been reported in chil- a diagnosis of atypical autism (Donno, Parker,
dren with PDD NOS (de Bruin, Ferdinand, Gilmour, & Skuse, 2010).
Meester, de Nijs, & Verheij, 2007; Pearson Differentiating ADHD and atypical autism in
et al., 2006), highlighting the importance of young children can be problematic, with children
considering comorbid mental health problems often first diagnosed with ADHD (Jensen,
when conducting diagnostic assessments for Larrieu, & Mack, 1997). In a retrospective
atypical autism. study, parents of children with PDD NOS or
It has been reported that while comorbid med- ADHD reported on the symptoms of their chil-
ical conditions in autism are associated with dren in their first 4 years (Roeyers, Keymeulen, &
degree of intellectual disability, they may be Buysse, 1998). Early differences were infrequent,
more frequent in individuals with atypical although children with ADHD showed more
autism, although results are mixed across studies hyperactive behaviors during the 7–12-month
(Gillberg & Coleman, 1996; Juul-Dam, period; this difference was not maintained as the
Townsend, & Courchesne, 2001; Rutter, Bailey, PDD NOS children became active with age. As
Bolton, & Le Couteur, 1994). A study by Hara children aged, the difference became more appar-
(2007) found no differences between individuals ent, with children with PDD NOS demonstrating
with autism and atypical autism in terms of epi- more pronounced social difficulties, withdrawal,
lepsy. Biological research on atypical autism and anxiety, stereotyped motor behaviors, unusual
PDD NOS, including neuroimaging and genetic behaviors, and better scores on cognitive
assessments compared to children with ADHD treatment outcomes. Importantly, the impact that
(Jensen et al., 1997; Luteijn et al., 2000; Roeyers early childhood intervention may or may not
et al., 1998; Scheirs & Timmers, 2009). have on adult outcomes remains unknown. A
Research on treatment approaches specifically
for individuals with atypical autism is lacking; it
Treatment is assumed that treatment needs and approaches
are similar to those for individuals with autism.
As for autism, treatment for individuals with atyp- Whether existing evidence-based treatments pro-
ical autism needs to include a range of services and duce greater effects in individuals with atypical
approaches. Behavioral, educational, and develop- autism remains an area for further research. As is
mental approaches to the treatment of communi- the case for autism, it has been concluded that no
cation deficits, social difficulties, and behavior single treatment approach or method has been
problems have been demonstrated to result in shown to be effective for PDD NOS (Towbin,
improvements for individuals with autism and 2005), with treatment approaches needing to
are likely to be helpful for individuals with atypi- take into account the specific strengths, impair-
cal autism. Although there are no drugs that spe- ments, and needs of each individual.
cifically treat autism, medication and medication
in combination with parent training approaches
have been shown to reduce severe behavior prob- See Also
lems such as aggression, self-injurious behavior,
severe tantrums, and irritability (King, 2000; ▶ Diagnostic Process
Research Units on Pediatric Psychopharmacology ▶ Pervasive Developmental Disorder Not
(RUPP) Autism Network 2005a, b, 2009). Otherwise Specified
Early intervention has been highlighted as a
specific area of importance in the treatment of
children with autism. Treatment gains have been References and Readings
demonstrated in adaptive functioning, develop-
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problems (Dawson, Matson, & Cherry, 1998; and statistical manual of mental disorders (3rd ed.).
Howlin, Magiati, & Charman, 2009; Rogers &
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early intervention programs has also demon- rev ed.). Washington, DC: Author.
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A 312 Audition
Whittingham, K., Sofronoff, K., Sheffield, J., & Sanders, considered moderate hearing loss; between 56
M. R. (2009). Stepping stones triple P: An RCT of a and 70 dB HL is considered moderately
parenting program with parents of a child diagnosed
with an autism spectrum disorder. Journal of severe hearing loss; between 71 and 90 dB HL
Abnormal Child Psychology, 37(37), 469–480. is considered severe hearing loss; and greater
Williams, E., Thomas, K., Sidebotham, H., & Emond, A. than 91 dB HL is considered profound hearing
(2008). Prevalence and characteristics of autistic spec- loss. Hearing sensitivity would be evaluated in
trum disorders in the ALSPAC cohort. Developmental
Medicine & Child Neurology, 50(9), 672–677. an individual with autism spectrum disorders if
World Health Organisation. (1978). International classi- questions regarding hearing abilities existed, but
fication of diseases: Mental disorders: Glossary and more systematic research needs to be completed
guide to their classification (9th ed.). Geneva: Author. regarding auditory acuity in the population of
World Health Organisation. (1992). The ICD-10 classifi-
cation of mental and behavioural disorders: Diagnos- individuals with autism.
tic criteria for research. Geneva: Author.
See Also
Audition ▶ Hearing Sensitivity

▶ Hearing Threshold
▶ Hearing
Auditory Acuity Hall, J. (1992). Handbook of auditory evoked responses.

Needham Heights, MA: Allyn & Bacon.
Justice, L. (2006). Communication sciences and disorders:
Jennifer McCullagh An introduction. Columbus, OH: Pearson.
Department of Communication Disorders, Rosenhall, U., Nordin, V., Sandstrom, M., Ahlsen, G., &
Southern Connecticut State University, Gillberg, C. (1999). Autism and hearing loss. Journal
New Haven, CT, USA
349–357.
Synonyms
Hearing sensitivity; Hearing threshold Auditory Brain Area
▶ Auditory Cortex
Definition
Auditory acuity describes how sensitive the

auditory system is to sound. Auditory acuity is Auditory Brainstem Response (ABR)
assessed by determining the intensity at which
a tone is just audible. Frequencies important for Jennifer McCullagh
speech perception are typically tested (octave Department of Communication Disorders,
frequencies from 250 to 8,000 Hz). Normal Southern Connecticut State University,
hearing sensitivity is defined as hearing thresh- New Haven, CT, USA
olds from 250 to 8,000 Hz between –10 and
15 dB HL. Hearing sensitivity between 16 and
25 dB HL is considered minimal or borderline; Synonyms
between 26 and 40 dB HL is considered mild
hearing loss; between 41 and 55 dB HL is Brainstem auditory evoked response (BAER)
Auditory Cortex 313 A
Definition
Auditory Brainstem Response, ABR
Auditory brainstem response (ABR), sometimes A
called brainstem auditory evoked response ▶ Brainstem Auditory Evoked Potentials
(BAER), is an electrophysiologic test that assesses
the auditory system through the low brainstem.
This test can assess hearing sensitivity in individ-
uals who cannot respond to traditional testing; thus, Auditory Cortex
it is often used in newborn hearing screenings and
on populations that are nonverbal. The ABR is Rajesh Kana
completed by placing electrodes on the individual’s Department of Psychology, University of
head and ears and placing earphones in their ears. Alabama-Birmingham, Birmingham, AL, USA
Responses are elicited using click and tonal stimuli
which are delivered through the earphones. Five
waveforms are typically present in the ABR (waves Synonyms
I, II, III, IV, and V); however, wave V is the
waveform used for threshold testing. Individuals Auditory brain area
with autism spectrum disorders might not be able to
consistently respond to traditional tests of hearing
sensitivity; therefore, ABR may be useful in Definition
establishing hearing sensitivity for these
individuals. The human auditory cortex occupies a large
portion of the superior temporal gyrus located
along the sylvian fissure dorsally and the superior
See Also temporal sulcus ventrally (Brodmann area 41, 42,
and 22). The dorsal surface of the superior tem-
▶ Auditory Acuity poral gyrus is located within the sylvian fissure
▶ Brainstem Audiometry and is divided into Heschl’s gyrus, the planum
▶ Hearing temporale, and the planum polare. Studies have
suggested that the primary auditory cortex in
humans is mainly confined to the anterior-medial
wall of Heschl’s gyrus. This brain region is vital
References and Readings in decoding and processing spoken language and
sounds. The planum temporale, also vital in audi-
Hall, J. (1992). Handbook of auditory evoked responses.
Needham Heights, MA: Allyn & Bacon. tory processing, is located posterior to Heschl’s
Rosenblum, S. M., Arick, J. R., Krug, D. A., Stubbs, E. G., gyrus and lies on the superior surface of the
Young, N. B., & Pelson, R. O. (1980). Auditory posterior superior temporal sulcus. While high-
brainstem evoked responses in autistic children.
frequency sounds activate a small lateral region
215–225. anterior to the intersection of Heschl’s gyrus and
Rosenhall, U., Nordin, V., Sandstrom, M., Ahlsen, G., & the superior temporal gyrus and a more extensive
Gillberg, C. (1999). Autism and hearing loss. Journal medial region posterior to the tip of Heschl’s
gyrus, low-frequency sounds activate lateral
349–357.
Skoff, B. F., Fein, D., McNally, B., Lucci, D., Humes- regions centered on mid-Heschl’s gyrus and
Bartlo, M., & Waterhouse, L. (1986). Brainstem audi- extending posteriorly along the superior temporal
tory evoked potentials in autism. Psychophysiology, gyrus.
23, 462.
Neuroimaging research has identified anatom-
Skoff, B. F., Mirsky, A. F., & Turner, D. (1980).
Prolonged brainstem transmission time in autism. ical and functional abnormalities in the planum
Psychiatry Research, 2, 157–166. temporale in individuals with autism spectrum
A 314 Auditory Discrimination
disorder. While anatomical abnormalities include have been observed in autistic individuals with-
abnormal asymmetry, altered minicolumn orga- out savant skills (see Heaton, 2003). Bonnel et al.
nization, and altered cell type and count, the (2010) studied auditory perception in individuals
functional abnormalities include abnormal with high-functioning autism and Asperger’s
feature extraction and sensitivity to sounds. syndrome and showed that enhanced pitch
discrimination was more prevalent in those with
late speech onset and was not associated with
See Also atypical discrimination of stimuli that were spec-
trally and/or temporally complex. Research iden-
▶ Auditory Acuity tifying enhanced discrimination of pitch change
▶ Auditory Processing in linguistic stimuli (Jarvinen-Pasley & Heaton,
▶ Cortical Language Areas 2007) has shown that atypical pitch processing is
▶ Primary Sensory Areas not limited to music but generalizes across audi-
▶ Wernicke’s Aphasia tory domains. This suggests that difficulties in
understanding pitch-mediated linguistic cues or
prosody, demonstrated in a number of studies
References and Readings (for review McCann & Peppe, 2003), are not
perceptual in origin but result from abnormalities
Binder, J. R., Rao, S. M., Hammeke, T. A., Yetkin, F. Z., in higher-order cognitive operations. Building on
Jesmanowicz, A., Bandettini, P. A., et al. (1994). Func-
the enhanced perceptual functioning model, the
tional magnetic resonance imaging of human auditory
cortex. Annals of Neurology, 35, 662–672. neural complexity hypothesis (see Samson et al.,
Boddaert, N., Chabane, N., Belin, P., Bourgeois, M., 2010) is able to account for enhanced pitch
Royer, V., Barthelemy, C., et al. (2004). Perception discrimination as well as abnormalities in
of complex sounds in autism: Abnormal auditory
processing acoustically complex stimuli.
cortical processing in children. American Journal of
Psychiatry, 161, 2117–2120. According to this model, autism is characterized
Celesia, G. G. (1976). Organization of auditory cortical by a bias toward the perceptual features of audi-
areas in man. Brain, 99, 403–414. tory information. At the behavioral level, this can
Palmen, S., van Engeland, H., Hof, P., & Schmitz, C.
be associated with enhanced processing of low-
(2004). Neuropathological finding in autism. Brain,
127, 2572–2583. level stimuli and atypical processing of higher-
Zatorre, R. J., Belin, P., & Penhune, V. (2002). Structure order information, such as greater focus toward
and function of auditory cortex: Music and speech. the perceptual aspects of speech stimuli.
Trends in Cognitive Sciences, 6, 37–46.
See Also
Auditory Discrimination ▶ Autistic Savants

▶ Enhanced Perceptual Functioning
Pamela Heaton
Department of Psychology, University
of London, London, UK
Bonnel, A., McAdams, S., Smith, B., Berthiaume, C.,

Definition Bertone, A., Ciocca, V., et al. (2010). Enhanced
pure-tone pitch discrimination among persons with
While enhanced discrimination and memory for autism but not Asperger syndrome. Neuropsychologia,
48(9), 2465–2475.
musical pitch have been widely described in the
Heaton, P. (2003). Pitch memory, labeling and
literature on musical savants with autism, it is disembedding in autism. Journal of Child Psychology
only in more recent times that such abilities and Psychiatry, 44(4), 543–551.
Auditory Integration Therapy 315 A
Jarvinen-Pasley, A., & Heaton, P. (2007). Evidence for The AIT technique became widely popular
reduced domain-specificity in auditory processing in after the 1991 publication of Annabel Stehli’s
autism. Developmental Science, 10(6), 786–793.
McCann, J., & Peppe, S. (2003). Prosody in autism The Sound of a Miracle: A Child’s Triumph A
spectrum disorders: A critical review. International over Autism. In this book Stehli described the
Journal of Language & Communication Disorders, full recovery of her daughter, who was diag-
38(4), 325–350. nosed with autism and schizophrenia, after
Samson, F., Hyde, K. L., Bertone, A., Soulieres, I.,
Mendrek, A., Ahad, P., et al. (2010). Atypical 10 hours of AIT at Berard’s clinic. In 1994,
processing of auditory temporal complexity in the American Speech-Language-Hearing Asso-
autistics. Neuropsychologia, 49, 546–555. ciation (ASHA) published a review of the
existing data on AIT in response to such
accounts linking AIT to increased eye contact,
social awareness, verbalizations, auditory com-
Auditory Evoked Potential (AEP) prehension, and articulation and reduced tan-
trums and hyperacusis (i.e., oversensitivity to
▶ Auditory Potentials certain frequency ranges of sound) in children
with autism spectrum disorders, learning diffi-
culties, attention deficit disorder, and dyslexia.
Currently, several professional organizations
Auditory Integration Therapy (including the American Speech-Language-
Hearing Association, the American Academy
Sarita Austin of Audiology, the Educational Audiology
Laboratory of Developmental Communication Association, and the American Academy of
Disorders, Yale Child Study Center, New Haven, Pediatrics) indicate that AIT should be consid-
CT, USA ered an experimental rather than an evidence-
based treatment due to the lack of scientific data
supporting its benefits.
Definition While in the United States the majority of AIT
practitioners use the original Berard or a modified
Auditory integration training (AIT) is an inter- methodology, there are other methods of AIT in
vention technique created to attempt to improve existence (including the Tomatis and Clark
the way individuals with autism spectrum disor- methods).
ders (ASD) recognize and respond to sound
and to reduce other behaviors associated
with ASD. AIT has also been referred to as Rationale or Underlying Theory
auditory enhancement training (AET) and
audio-psycho-phonology (APP). Dr. Guy Berard, an ear, nose, and throat (ENT)
physician, first introduced auditory integration
training (AIT) suggesting that many learning
Historical Background and behavioral disorders, “including autism,”
are associated with hypersensitivity to sound at
Auditory integration training (AIT) was first particular frequencies possibly resulting in
written about in 1982 in a book by the otolaryn- disturbances in learning and discomfort. He
gologist Guy Berard, which was translated in suggested that although many children with
1993 from French to the English title Hearing autism spectrum disorders (ASD) can hear
Equals Behavior. In his writing, Berard suggests sound, the way in which they process sounds is
that various disorders (“autism,” hyperactivity, different and can result in reduced emotional
depression, learning difficulties) are associated responsiveness and repetitive behaviors even if
with atypical sensitivity to sound. hypersensitivity to sound does not exist.
A 316 Auditory Integration Therapy
Goals and Objectives eliminated, as they become “flattened.”

He explains that the “peaks and valleys” in the
In 1982, Dr. Berard suggested that auditory original audiograms reflect areas of hyper- and
integration training (AIT) would involve hyposensitivity, but there is debate as to whether
a “reeducation” of the hearing process for indi- these patterns truly indicate auditory
viduals with autism spectrum disorders (ASD) “abnormalities.”
targeting the atypical sound perception theorized Following the recommended 20 auditory
to be present in a variety of behavioral and learn- integration therapy (AIT) sessions in Dr. Berard’s
ing disorders. Specifically, he suggests the train- method, an audiogram is obtained and reviewed,
ing of the middle ear muscles and auditory while changes in behavior patterns are examined
nervous system is targeted through listening to measure outcome. In efficacy studies of AIT,
exercises. outcome measures have included post-
intervention assessments in the following areas:
cognitive ability, core features of autism (i.e.,
Treatment Participants social interaction, communication, and behav-
ioral problems), hyperacusis, auditory
Auditory integration training (AIT) has been processing, behavioral problems, attention and
promoted by Dr. Berard as a useful intervention concentration, activity level, quality of life in
for a variety of disorders (e.g., learning disabil- school and at home, and adverse events.
ities, behavior disorders, autism, pervasive devel- The United States Food and Drug Administra-
opmental disorder, attention deficit disorder, tion (FDA) banned the import of the Berard’s
attention deficit hyperactivity disorder, tinnitus, original equipment (Audiokinetron or Ears
progressive deafness, hyperacusis, allergic Education and Retraining System) used for AIT
disorders, depression, suicidal tendencies, poor as a medical device based on finding that there
organizational skills) and has also been was no sufficient evidence to support that it
recommended for reducing foreign accents and benefited individuals medically. The FDA
writer’s block. regards the Audiokinetron as an educational aid
but not appropriate for the treatment or curing of
any medical conditions, such as autism spectrum
Treatment Procedures disorders. The Digital Auditory Aerobics (DAA)
device was introduced as a result of this limited
Auditory integration training (AIT) begins with access to the Audiokinetron in the United States.
an audiogram (i.e., a graph showing the results of The 20 compact disks (CDs) (each containing 30
a pure-tone hearing test) to determine whether min of modulated music) available with this
auditory “abnormalities” exist. The treatment device are believed to match the output of the
involves ten consecutive days of therapy centered Audiokinetron device. Other AIT programs are
upon listening to music (that has been modified to available (e.g., Samonas Sound Therapy,
dampen certain sound frequencies and intensities The Listening Program) which provide music
to correspond to those found abnormal on on CDs and promise similar results to Berard’s
the audiogram) for 30 minutes twice a day. It is AIT programs.
recommend that sessions occurring on the same
day be separated by at least 3 hours, while a 2-day
interruption of therapy on weekends is allowed. Efficacy Information
Audiograms are also used to determine if filter
settings need to be adjusted mid-intervention and The efficacy of Auditory Integration Training
to monitor response to treatment post-interven- (AIT) continues to be debated. A review of the
tion. Berard asserts that following AIT, available existing research indicates that three
audiograms show that auditory distortions are studies suggest improvements with AIT at
Auditory Integration Therapy 317 A
3 months post-intervention based on reported Qualifications of Treatment Providers
improved performance scores on the Aberrant
Behavior Checklist. It should be noted that inves- The majority of auditory integration training A
tigators in these studies were associated with (AIT) practitioners are speech-language pathol-
organizations that promote or directly provide ogists or audiologists but have also included
AIT. Similar results have not yet been replicated psychologists, physicians, social workers, and
by any independent studies. The review high- teachers. No training is required to operate the
lights the fact that the studies examining AIT Digital Auditory Aerobics (DAA) device that is
were not randomized controlled trials (used to currently used within the United States to pro-
minimize bias), did not contain control or alter- vide AIT based on Berard’s method. Other AIT
native treatment group, and involved single or programs do provide trainings to practitioners
very few participants or used surveys or animals. (e.g., The Listening Program [2½ days],
The American Speech-Language-Hearing Samonas Sound Therapy [offers a credentialing
Association (ASHA) issued a report on AIT, in process following pre-workshop training, initial
which it states that more research is needed to and advanced workshop training, and a year of
determine whether AIT is a beneficial interven- practice]). The American Speech-Language-
tion for individuals with autism spectrum disor- Hearing Association, the American Academy
ders (ASD). In studies where children or adults of Audiology, the Educational Audiology Asso-
with ASD (ages 3–39 years) were selected and ciation, and the American Academy of Pediat-
randomly assigned to study treatment groups, rics nonetheless all state that AIT should be
though no adverse effects were reported, no note- considered an experimental rather than an evi-
worthy changes were found in the participants’ dence-based treatment due to the limited amount
ability to process sound, their quality of life, or of scientific research studies supporting its
their core and associated features of ASD follow- benefits.
ing AIT. ASHA expressed concerns that clear
criteria (based on evidence-based research) are
not available, indicating which individuals will See Also
be most appropriate for AIT, and families could
find both their financial resources and hope ▶ Aberrant Behavior Checklist
strained or depleted by investing in interventions ▶ American Speech-Language-Hearing
that lack empirical support. In addition, the pro- Association Functional Assessment of
fessional organization had reservations regarding Communication Skills
the variability in AIT treatment protocols and the ▶ Auditory Processing Disorder
possible noise-induced hearing loss that might be
associated with AIT devices, as sufficient data on
the risk to participants regarding intensity of References and Readings
sound and length of presentation is not currently
American Academy of Audiology. (1993). Position state-
available for the devices.
ment: Auditory integration training. Audiology Today,
Considering that ASD behaviors can often 5(4), 21.
resemble auditory processing disorders (APD), American Academy of Pediatrics. (1998). Auditory inte-
ASHA has also ruled out the diagnosis of APD, gration training and facilitated communication for
autism. Pediatrics, 102(2), 431–433.
for which AIT is often suggested, in children with
American Speech-Language-Hearing Association Work-
ASD unless reliable testing reveals deficits on ing Group on Auditory Integration Training. (2003,
multiple assessments. In the case that a child March). Auditory integration training. (Technical
with ASD does meet this guideline, the benefit Report). Rockville, MD: Author. Retrieved from
www.asha.org/docs/html/TR2004-00260.html
of receiving intervention involving listening
Berard, G. (1993). Hearing equals behaviour. New
tasks with limited social interaction can also be Canaan, CT: Keats Publishing. (Original work
questioned. published 1982).
A 318 Auditory Perceptual Disorder
Berard, G. (1995). Concerning length, frequency, number,

and follow-up AIT sessions. The Sound Connection Auditory Perceptual Disorder
Newsletter, 2(3), 5–6. Available from The Society for
Auditory Intervention Techniques.
Bettison, S. (1996). The long-term effects of auditory ▶ Central Auditory Processing Disorder
training on children with autism. Journal of Autism
and Developmental Disorders, 26(3), 361–373.
Edelson, S., Arin, D., Bauman, M., Lukas, S., Rudy, J.,
Sholar, M., et al. (1999). Auditory integration training: Auditory Potentials
A double-blind study of behavioural and electrophys-
iological effects in people with autism. Focus on
Autism and Other Developmental Disabilities, 14(2), Stanley E. Lunde
73–81. Psychology, UCLA-MRRC Laboratories,
Educational Audiology Association (1997). Auditory inte- Lanterman Developmental Center, Pomona,
gration training: Educational Audiology Association
CA, USA
position statement. Educational Audiology Newsletter,
14(3), 16.
Feigin, J. A., Kapun, J. G., Stelmachowicz, P. G., &
Gorga, M. P. (1989). Probe-tube microphone measures Synonyms
of ear canal sound pressure levels in infants and chil-
dren. Ear and Hearing, 10(4), 254–258.
Gillberg, C., & Coleman, M. (2000). The biology of autis- Auditory evoked potential (AEP)
tic syndromes (3rd ed.). London: MacKeith Press.
Gilmore, T., Madaule, P., & Thompson, B. (1989).
About the Tomatis method. Toronto: Listening
Definition
Center Press.
Gringras, P. (2000). Practical paediatric psychopharmaco-
logical prescribing in autism: The potential and the An auditory potential is an electroencephalo-
pitfalls. Autism, 4(3), 229–247. graphic (EEG) response, less than a millivolt,
Mudford, O. C., & Cullen, C. (2005). Auditory integration
time-locked to an auditory sound such as a click,
training: A critical review. In J. W. Jacobson, R. M.
Foxx, & J. A. Mulick (Eds.), Controversial therapies tone, or speech sound. It is recorded from scalp
for developmental disabilities: Fad, fashion, and electrodes and consists of averaged responses to
science in professional practice (pp. 351–362). a series of sounds. Averaging removes back-
ground EEG activity, usually considered to be
Rimland, B., & Edelson, S. M. (1994). The effects of
auditory integration training on autism. American unrelated to the auditory potential.
Journal of Speech-Language Pathology, 3(2), 16–24. A brief sound such as a click triggers at least
Rimland, B., & Edelson, S. (1995). Brief report: A pilot 15 waveform peaks that unfold over the first
study of auditory integration training in autism.
second (Picton, Hillyard, Krausz, & Galambos,
Journal of Autism and Developmental Disorders,
25(1), 61–70. 1974). These alternating positive and negative
Sinha, Y., Silove, N., Wheeler, D. M., & Williams, K. J. peaks reflect the flow of auditory information
(2009). Auditory integration training and other sound from the brainstem to the cortex. The short-
therapies for autism spectrum disorders (Review).
latency peaks appearing during the first tenth of
Stehli, A. (1991). The sound of a miracle. A child’s a second (10 ms) originate from the primary
triumph over autism. New York: Doubleday. auditory pathway of the brainstem.
Tharpe, A. M. (1998). Treatment fads versus evidence- The later auditory potentials, a subset of
based practice. In F. H. Bess (Ed.), Children with hear-
event-related potentials (ERPs), represent the
ing impairment: Contemporary trends (pp. 179–188).
Nashville, TN: Vanderbilt Bill Wilkerson Center Press. sum of neural activity originating from spatially
Veale, T. (1993, July). Effectiveness of AIT using the BCG distinct sources. They are usually studied
device (Clark method): A controlled study. Paper with multiple scalp electrodes that enable
presented at the World of Options International
determination of waveform scalp topography.
Autism conference, Toronto, Canada.
Zollweg, W., Palm, D., & Vance, V. (1997). The efficacy Mid-latency auditory peaks, which appear dur-
of auditory integration training: A double blind study. ing the 10–50-ms interval, have few well-
American Journal of Audiology, 6(3), 39–47. established clinical findings. Attention effects
Auditory Processing 319 A
are seen under some conditions during the later References and Readings
part of this interval.
Andreassi, J. L. (2007). Psychophysiology: Human
Long-latency peaks appearing between 50 and
behavior and physiological response (5th ed.). A
1,000 ms have received the most study. The spe-
cific timing of these peaks depends on both the Handy, T. C. (Ed.). (2005). Event-related potentials:
auditory stimulus characteristics and the task A methods handbook. Cambridge, MA: MIT Press.
demands. They are named starting with the initial Jeste, S. S., & Nelson, C. A. (2009). Event related
potentials in the understanding of autism spectrum
positive peak (P1) at 50 ms usually maximal at
disorders: An analytical review. Journal of Autism
the frontocentral electrodes. Next is the negative and Developmental Disorders, 39, 495–510.
peak (N1) at around 100 ms, maximal at the Luck, S. J. (2005). An introduction to the event-related
vertex. P2 peaks at 150–200 ms. The negative potential technique. Cambridge, MA: MIT Press.
Picton, T. W., Hillyard, S. A., Krausz, H. I., & Galambos,
peak (N2) is typically maximal at 200–300 ms
R. (1974). Human auditory evoked potentials. I:
at central sites. The P3 peak at 300–400 ms is Evaluation of components. Electroencephalography
attention dependent. Amplitude is inversely and Clinical Neurophysiology, 36, 179–190.
related to stimulus probability, and latency is
positively related to task difficulty. Developmen-
tally, the scalp location of the maximum depends
on task conditions. Auditory Processing
These waveform peaks each reflect several
underlying components. The waveform peaks Courtenay Norbury
should be distinguished from the components, Psychology Department, Royal Holloway,
which refer to potential neural sources. Unless University of London, Egham, Surrey, UK
the component is large such as P3b, it usually
needs to be isolated with difference waves or by
experimental design (Luck, 2005). The compo- Synonyms
nent peaks are often identified by the number of
milliseconds to peak, e.g., N75 and P100. Audi- Central Auditory Processing Disorder (CAPD)
tory ERPs are also used to study language
processing. An N400 component, maximal
over central and parietal sites, is seen when Short Description or Definition
there is a semantic deviation from expectations,
e.g., the last word in a sentence is out of context. Central auditory processing disorder (CAPD)
P3a, P3b, and N400 components do not appear may be considered when a child is having dif-
before ages 3 or 4 years. A central, frontal neg- ficulties producing or understanding verbal lan-
ative component, at 400–500 ms, reflecting guage. Lack of appropriate response to what
attention has been identified in early infants others say may cause people to think the child
and labeled “Nc.” A recent review concluded may be deaf; however, audiological examina-
that persons with autism show differences in tion of children with CAPD is entirely normal.
many of the long-latency components (Jeste & These children can hear and detect sounds, but
Nelson, 2009). their ability to process these sounds meaning-
fully is not developing as expected. These chil-
dren may have difficulty recognizing sounds or
See Also discriminating between different sounds. CAPD
is a controversial diagnosis that is not currently
▶ Brainstem Auditory Evoked Potentials part of conventional diagnostic systems but is
▶ Electroencephalogram (EEG) increasingly identified in the USA and Australia
▶ Event-Related Potential (ERP) and to a more limited extent in the UK and
▶ Evoked Potentials rest of Europe. According to the American
A 320 Auditory Processing
Speech-Language-Hearing Association (ASHA) a minimum of an audiologist and a speech-

(2005), CAPD refers to difficulties in the per- language pathologist. Peripheral hearing should be
ceptual processing of auditory information in thoroughly investigated using hearing thresholds,
the central nervous system and is demonstrated immittance measures, and otoacoustic emissions
by poor performance in one or more of the (Dawes & Bishop, 2009). There are, however, no
following tasks: sound localization and laterali- firm guidelines as to what standardized tests of
zation; auditory discrimination; auditory pattern auditory processing should be included, how
recognition; temporal aspects of audition, many tests are required to tap the range of skills
including temporal integration, temporal dis- that may be compromised, or what cutoff would be
crimination (e.g., temporal gap detection), tem- indicative of a clinically significant impairment in
poral ordering, and temporal masking; auditory central auditory functioning.
performance in competing acoustic signals Part of the controversy surrounding this disor-
(including dichotic listening); and auditory per- der appears to stem from the methods of assess-
formance with degraded acoustic signals. ment and the degree to which they involve speech
Despite this characterization, there remains little stimuli (Dawes & Bishop, 2009). When such tasks
professional agreement about how CAPD are included, it is difficult to ascertain the origin of
should be defined, diagnosed, or treated the problem: If a child’s language is impaired, he
(Dawes & Bishop, 2009). or she might perform poorly on tests of speech
discrimination in noise because of limitations in
linguistic ability rather than a central auditory
Epidemiology processing disorder. On the other hand, many lan-
guage-based tasks will require the auditory
There are currently no epidemiological data processing abilities listed above. ASHA (2005)
concerning CAPD in children. clarifies the situation to some extent by stating:
although abilities such as phonological awareness,

attention to and memory for auditory information,
Natural History, Prognostic Factors, and auditory synthesis, comprehension and interpretation
Outcomes of auditorily presented information, and similar skills
may be reliant on or associated with intact central
There are currently no longitudinal studies of auditory function, they are considered higher order
cognitive-communicative and/or language-related
children with CAPD with which to address ques- functions and, thus, are not included in the definition
tions of history, prognosis, or adult outcomes. of CAPD.
Differential diagnosis is a clinical concern;

Clinical Expression and Dawes and Bishop (2009) point out that 50% of
Pathophysiology children meeting criteria for CAPD also meet
criteria for other developmental disorders such
Reported symptoms of CAPD may include difficul- as ADHD, autism spectrum disorder (ASD), or
ties understanding speech in noise, difficulties fol- specific language impairment (SLI). The degree
lowing or understanding verbal instructions, poor of overlap raises issues about CAPD as a coherent
attention and high distractibility, and communica- diagnostic entity, and some have argued that the
tion, language, reading, and academic difficulties. choice of diagnostic label reflects the conceptu-
alization of the problem by the professional
assessing the child (Ferguson, Hall, Riley &
Evaluation and Differential Diagnosis Moore, 2011). In other words, a child with poor
attention and language delay may be diagnosed
ASHA (2005) best practice guidelines recommend with CAPD by an audiologist, DLD by a speech-
diagnosis by a multidisciplinary team that includes language pathologist, or ADHD/ASD by
Auditory Processing 321 A
a clinical psychologist. The difficulty is in deter- would be that children with ADHD would have
mining the nature of the relationship between difficulties across modalities, whereas children
auditory processing difficulties and the develop- with CAPD would be impaired only on the audi- A
mental disorders associated with those difficul- tory tests. The more difficult issue to tease apart is
ties. For example, if a child presents with delayed whether performance on either measure by chil-
language development, it may be reasonable to dren with ADHD reflects attention skills or is
assume that these language difficulties are the indicative of a central processing disorder.
result of difficulties processing sound. However, With regard to ASD, perceptual anomalies are
as noted above, language difficulties may inter- frequently reported in both research and clinical
fere with the child’s ability to do tasks that assess settings, though again these are rarely confined to
auditory perceptual performance. Equally, there the auditory modality. In addition, the child with
may be a third factor that disrupts both language ASD is likely to have social deficits that may
development and auditory processing, yielding mimic auditory disorder. For example, not
a strong association between the two even though responding to parents calling the child’s name is
they may be causally unrelated (see Bishop, 2011 an early indicator of ASD but may also signal an
for discussion). auditory deficit. Dawes and Bishop (2009)
Tests of CAPD frequently require children to reported that children with ASD are overrepre-
make judgments about sounds; even when the stim- sented at assessment centers specializing in
uli are tones rather than speech sounds, language CAPD. Research studies that use electrophysio-
ability may affect performance. For example, Mar- logical techniques (e.g., ERP) have suggested that
shall, Snowling and Bailey (2001) reported that the auditory impairments that characterize ASD
many typically developing children spontaneously arise because of a speech-specific, postsensory
adopted a strategy of labeling tones as “high” or impairment related to attentional orienting
“low” and that this labeling facilitated performance (Ceponiene, Lepisto, Shestakova, Vanhala, Alku,
on similarity judgment tasks. Thus, children with N€a€at€anen, & Yaguchi, 2003; Whitehouse &
SLI may be disadvantaged on assessments of Bishop, 2008). Dawes and Bishop (2009) further
CAPD, though it is the case that a substantial suggested that such top-down influences on audi-
minority of children with SLI do experience auditory processing would require a different treatment
tory difficulties (see Dawes & Bishop, 2009). It is approach to developing listening skills from the
less clear that these auditory difficulties are causally treatments recommended for CAPD.
related to language impairment, though feasibly In sum, it is likely that auditory processing prob-
that may contribute to language learning difficulties lems are one of a number of “collateral” deficits
(Bishop, 2011). However, it is also clear that many commonly found in across a range of neurodeve-
children diagnosed with CAPD have considerable lopmental disorders (Dawes & Bishop, 2009).
language difficulties and often do not differ from Thus, assessment in a multidisciplinary setting
children with SLI with regard to language and will be necessary for documenting auditory deficits
cognitive profile (Ferguson et al., 2011). These and considering these deficits in relation to the
findings again raise the question of whether these child’s overall cognitive, linguistic, and social pro-
are diagnostically and etiologically distinct catego- file. Where possible, assessment of auditory skills
ries or whether they reflect professional biases. that do not explicitly involve speech-based stimuli
These tasks also require children to listen care- is preferable in order to avoid the confounding
fully and attend to subtle sound differences over effects of impaired language development.
a large number of trials. Even typically developed
children may find this challenging; for children
with ADHD, it may be impossible. In order to Treatment
differentiate CAPD and ADHD, Dawes and
Bishop (2009) advocate the use of behavioral Bishop (2011) highlighted the importance of
measures that tap visual attention. The prediction establishing the causal role of auditory processing
A 322 Auditory Processing
in other developmental disorders because of the ▶ Language Disorder

implications for treatment. If auditory difficulties ▶ Specific Language Impairment
contribute to attention or language difficulties, then
it would make sense to train auditory skills with
positive downstream effects for language and atten-
tion. However, if auditory deficits are associated,
but do not play a causal role in disorder, such American Speech-Language-Hearing Association (2005).
treatments would not be effective. Several com- Central Auditory Processing Disorders. Retrieved
puter-based training packages have been devel- March 22, 2011. http://www.asha.org/docs/html/
tr2005-00043.html
oped, with Fast ForWord (Scientific Learning
Bishop, D. V., (2011). Auditory processing disorder –
Corporation) being the most popular and widely a cause of language problems or an incidental finding?
used in clinical and education contexts. This pro- Wellcome Trust Guest Blog. Retrieved April 11,
gram was not specifically designed for CAPD but is 2011. http://wellcometrust.wordpress.com/2011/03/30/
auditory-processing-disorder-a-cause-of-language-probl
based on a theoretical framework in which devel-
ems-or-an-incidental-finding/
opment language and literacy learning difficulties Ceponiene, R., Lepisto, T., Shestakova, A., Vanhala, R.,
arise from impairments in rapid auditory temporal Alku, P., N€a€at€anen, R., & Yaguchi, K. (2003). Speech-
processing (Tallal & Piercy, 1973). Fast ForWord is sound-selective auditory impairment in children
with autism: they can perceive but do not attend.
comprised of adaptive computer games that include
Proceedings of the National Academy of Sciences,
acoustically modified speech; the degree of modi- 100, 5567–5572.
fication gradually diminishes as the child improves Dawes, P., & Bishop, D. V. (2009). Auditory processing
performance on the language-based tasks. It is most disorder in relation to developmental disorders of lan-
guage, communication and attention: A review and
widely used for children diagnosed with SLI or
critique. International Journal of Language & Com-
dyslexia; however, rigorous trials of Fast ForWord munication Disorders, 44(4), 440–465.
and similar computer-based intensive auditory Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R.
training have not yielded clinically significant (2011). Communication, listening, cognitive and
speech perception skills in children with auditory
improvements in language or literacy functioning
processing disorder or SLI. Journal of Speech, Lan-
(Loo, Bamiou, Campbell, & Luxon, 2010; Strong, guage, and Hearing Research, 54, 211–227.
Torgeson, Torgeson, & Hulme, 2011). Loo, J. H., Bamiou, D. E., Campbell, N., & Luxon, L. M.
There is currently a dearth of studies investigat- (2010). Computer-based auditory training (CBAT):
Benefits for children language and reading-related
ing treatment efficacy for children diagnosed with
learning difficulties. Developmental Medicine and
CAPD. For the most part, Dawes and Bishop Child Neurology, 52, 708–717.
(2009) report that current clinical practices do not Marshall, C., Snowling, M. J., & Bailey, P. (2001). Rapid
aim to treat the auditory deficit directly, but rather auditory processing and phonological ability in nor-
mal readers and readers with dyslexia. Journal of
aim to reduce the impact of auditory processing
Speech, Language, and Hearing Research, 44,
deficits through environmental modification (e.g., 925–940.
sitting the child nearer to the classroom teacher, Moore, D., Ferguson, M. A., Edmondson-Jones, A. M.,
waiting to have the child’s visual attention before Ratib, S., & Riley, A. (2010). Nature of auditory
processing disorder in children. Pediatrics, 126(2),
speaking) or by enhancing the auditory signal (e.g.,
e382–e390.
using a directional microphone in the classroom). Strong, C., Torgeson, C. J., Torgeson, D., & Hulme, C.
However, the effect of these modifications on (2011). A systematic meta-analytic review of evidence
developing auditory skills or improving language for the effectiveness of the “Fast ForWord” language
intervention program. Journal of Child Psychology
and academic outcomes is largely unknown.
and Psychiatry, 52(3), 224–235.
Tallal, P., & Piercy, M. (1973). Defects of non-verbal
auditory perception in children with developmental
See Also aphasia. Nature, 241, 468–469.
Whitehouse, A. J. O., & Bishop, D. V. M. (2008). Do
children with autism ‘switch off’ to speech sounds?
▶ Auditory Discrimination An investigation using event-related potentials.
▶ Hearing Developmental Science, 11, 516–524.
Auditory Verbal Learning 323 A
auditory system codes frequency, intensity, and
Auditory Processing Disorder time which are essential to the perception of
sound and therefore speech. A
▶ Central Auditory Processing Disorder
▶ Verbal Auditory Agnosia
See Also
▶ Auditory Cortex
Auditory System ▶ Cochlea
▶ Hearing
Jennifer McCullagh
Department of Communication Disorders,
Southern Connecticut State University, References and Readings
New Haven, CT, USA
Clarke, W., & Ohlemiller, K. (2008). Anatomy and
physiology of hearing for audiologists. Clifton Park,
NY: Thomson, Delmar Learning.
Synonyms Musiek, F. E., & Baran, J. A. (2007). The auditory system:
Anatomy, physiology, and clinical correlates. Boston:
Anatomy of human ear; Hearing system; Sensory Pearson.
system for sense of hearing
Definition Auditory Verbal Agnosia
The auditory system includes the outer, middle, ▶ Verbal Auditory Agnosia
and inner ears, as well as the central auditory
nervous system. The outer ear includes the
pinna and the external auditory meatus (ear
canal). The tympanic membrane (eardrum) is Auditory Verbal Learning
the boundary between the outer and middle ear.
The middle ear is housed in the mastoid portion Laura B. Silverman and Allison R. Canfield
of the temporal bone and is a completely Department of Pediatrics, University of
enclosed cavity that is connected to the naso- Rochester School of Medicine and Dentistry,
pharynx by the Eustachian tube. The middle ear Rochester, NY, USA
houses the three smallest bones in the body, the
malleus, incus, and stapes, also known as the
ossicular chain. The inner ear is called the Definition
cochlea, which contains the sensory hair cells
and auditory nerve fiber endings that convert Auditory verbal learning refers to the process of
mechanical energy from the middle ear into elec- acquiring and retaining new information about
trical energy. The VIII cranial nerve, vestibulo- the sound patterns and/or meanings of words,
cochlear nerve, brings the auditory information sentences, stories, and other nonword sequences,
to the central auditory nervous system which after hearing them read aloud. A person’s ability
consists of the brainstem nuclei (cochlear nuclei, to learn the underlying sound structures and
superior olivary complex, lateral lemniscus, meanings of words creates the foundation for
inferior colliculus, and medial geniculate body), that person’s ability to ultimately understand
the primary auditory cortex in the temporal lobe speech and use language to communicate with
and the association auditory cortices. The entire others. One of the core features of ASD is
A 324 Auditory Verbal Learning
“a delay in, or total lack of, the development of Research on auditory verbal learning contin-
spoken language” (American Psychiatric Associ- ued into the twentieth century, heavily influenced
ation, 2000). Thus, characterizing the strategies by Ebbinghaus’ work and also by behaviorism,
that people develop and use to learn language with a focus on stimulus–response aspects of
during auditory verbal learning tasks could language learning. Then in the 1950s and 1960s
help to illuminate the mechanisms underlying there was a shift to studying cognitive “media-
communication skills in autism. tors,” which were thought to be conscious mental
processes that can be deployed to improve verbal
learning performance. This shift was heavily
Historical Background influenced by verbal mediation theory and
cognitive psychology, which examined internal
Research on auditory verbal learning began with cognitive processes rather than focusing specifi-
the seminal work of Hermann Ebbinghaus, in the cally on observable behaviors. In the late 1960s
late 1800s. Ebbinghaus believed that learning and 1970s, John Flavell extended findings related
verbal material required the formation of new to verbal mediation and described verbal learning
associations between words. He also posited abilities from a developmental standpoint,
that the strength of these associations could be proposing that younger children have more
intensified with repeated exposure and practice. trouble learning verbal information than older
Thus, he designed a research program to test this individuals because they have a production
hypothesis, using himself as a research subject. deficiency. In other words, younger children fail
He developed lists of “nonsense syllables,” which to spontaneously produce and use strategies to
consisted of consonant-vowel-consonant improve their performance. It was noted these
combinations that have no specific meanings children often showed significant improvements
associated with them. For example, DAX and on auditory verbal learning tasks, once they were
YAT would be considered nonsense syllables, directly instructed to use specific strategies. For
since they are not words in the English language. example, Flavell found that younger children
CAT would not be a nonsense syllable since it has were less likely to verbally repeat words to them-
a known meaning. Ebbinghaus attempted to selves while learning the words from a list, while
learn his lists of nonsense syllables by older children were more likely to use verbal
slowly reading and repeating the lists to himself. rehearsal with increasing age, and the spontane-
Next, Ebbinghaus tried to recall as many of the ous use of this strategy was associated with
syllables as he could. He discovered that his improvements on task performance.
memory for the syllables improved with repeated Flavell’s research initiated a flurry of
practice of the material. In addition, he noted subsequent training studies examining whether
that his ability to learn the syllables initially direct instruction in strategy use improved
improved rapidly and then more slowly over children’s auditory verbal learning abilities. In
time, until he learned the material in its entirety. other words, researchers took children who were
By characterizing these patterns, Ebbinghaus was not yet actively using strategies on their own and
the first to identify and map out verbal learning set out to see whether prompting them to
curves (patterns of learning over time and with use rehearsal, organization, and elaboration
repetition). He similarly identified patterns of improved verbal learning ability. Overall, they
forgetting over time and found that forgetting found that the ability to use learning strategies
occurs less quickly, when the material is typically develops in broad strokes throughout
overlearned (repeatedly practiced, even after childhood, adolescence, and early adulthood.
achieving perfect recall of the list). In addition, For example, there are gradual developmental
Ebbinghaus examined serial position effects and increases in the ability to use semantic strategies
discovered that words are easier to learn at the and word meaning to aid verbal learning, from
beginning and end of a verbal learning list. the preschool years through adolescence.
These advancements in semantic strategy use are meaningful sentences. They were asked to
generally accompanied by related improvements recall as much as they could remember, in each
in verbal recall performance. Children often condition. Children without autism remembered A
begin using word meaning to facilitate verbal significantly more sentences than word strings,
learning during elementary school, and as pre- while children with ASD did not show more
adolescents they are more likely to use semantic efficient learning of meaningful information.
strategies successfully when tasks include words Researchers also read children strings of
with strong associated meanings, and when there unrelated words and strings of related words
are directions that explicitly instruct them to use from a shared semantic category, such as colors
these strategies. By adulthood people can use or utensils. Children with ASD were much
word meaning to facilitate verbal learning, even less likely to group words together from the
when there are no explicit directions to do so, and same category than children without autism.
when words are more subtly semantically related Collectively, these studies suggest that children
to one another. Similarly, verbal rehearsal also with ASD were less likely to use word meaning to
changes across development, with younger chil- aid auditory verbal learning. They were also more
dren rehearsing single words repetitively, while likely to rely on phonological features or sound
older adolescents rehearse multiple words in patterns of the words rather than word meaning.
clusters. This shift from single-word to multi- It is important to note that these early studies
word rehearsal is also associated with improved primarily involved children who had ASD and
auditory verbal learning performance. intellectual disability. Subsequent research
looked at both high- and low-functioning individ-
uals with ASD; although studies yielded mixed
Current Knowledge findings, they generally support the observation
that people with ASD are less likely than those
In the late 1960s researchers began examining without ASD to use word meaning to improve
how children with ASD learn words and more learning and memory of verbal information.
complex verbal information. This interest
stemmed from the observation that individuals Using Word Order to Improve Learning:
with ASD could engage in echolalia and Primacy and Recency Effects
use stereotyped language without necessarily The location and order of words within a word-
understanding the core meaning of the words learning list can also be used to improve auditory
that they echoed. The ability to learn the sound verbal learning skills. Scientists have studied
patterns but not the meaning of words was whether individuals remember certain parts of
surprising since typically developing people a list more readily than other parts, and whether
found it easier to learn meaningful information recalling words from the beginning, middle, or
compared to meaningless sets of words or sound end of a list is associated with better learning and
strings (Marks & Miller, 1964). memory overall. Remembering words from the
beginning or first portion of a list is referred to
Using Word Meaning to Improve Learning: as the primacy effect. This pattern of recall
Semantic Strategies is thought to reflect the active use of verbal
Hermelin and O’Connor were among the first to rehearsal, a strategy that involves repeating
examine the relationship between word meaning words over and over again to facilitate retention.
and auditory verbal learning abilities in ASD. Verbal rehearsal has been shown to improve
They did so by comparing children with ASD auditory verbal learning in typically developing
and those without ASD on their ability to learn individuals. Conversely, remembering words
and immediately recall verbal information with from the end of a word list is often referred to as
varying semantic relationships. They presented a recency effect, and is thought to reflect a more
children with meaningless word strings and shallow level of processing that involves simply
A 326 Auditory Verbal Learning
echoing back the sounds that were most recently recall on later trials. This suggests less efficient
heard. Low-functioning individuals with auditory verbal learning over time. In other
ASD tend to rely more heavily on rote memory words, their ability to learn new verbal informa-
abilities and are more likely than people without tion over time slows down more quickly over
autism to simply echo back words from the end of repeated trials in comparison to people without
a list. In other words they tend to show a stronger ASD. In addition, individuals with ASD were less
recency effect than people without ASD. likely to cluster words together based on shared
This suggests that they rely on more simple and semantic categories or the order in which they
less efficient learning strategies than individuals appeared in the original list. In this case, slower
without autism, who are more likely to use verbal learning was likely attributable to less efficient
rehearsal to aid learning. Individuals who are use of learning strategies over time.
high-functioning with ASD show a different pat- To summarize our current knowledge, the
tern of verbal learning and memory. They have research to date suggests some general trends in
demonstrated typical primacy and recency effects auditory verbal learning abilities in ASD. First,
when compared to people without autism. The individuals with ASD are less likely than people
degree to which individuals with autism group without ASD to use word meaning and semantic
words together, based on order, varies across structure to enhance their learning abilities.
studies; some research has found typical serial Second, they are also less likely to use other
position effects while other studies have not. active learning strategies, like verbal rehearsal
Although overall, individuals with autism appear and serial clustering. Finally, when word lists
less able to actively deploy learning strategies are read repeatedly, individuals with ASD
efficiently to support their verbal learning. tend to learn words less efficiently over time.
Although these are general trends observed in
Using Repetition to Improve Learning: the research literature, patterns of auditory verbal
Learning Curves and Retention over Time learning have not been entirely consistent across
To examine auditory verbal learning over time, all studies, and these trends are observed more
researchers have used experimental paradigms often in low-functioning individuals than in
that involve reading a single list of words over higher-functioning individuals with ASD.
a series of repeated trials. Verbal learning curves
are quantified over time to determine how much
new information an individual retains with Future Directions
each repetition of the verbal material. Some
researchers have used the California Verbal There are a number of possible avenues for
Learning Test (CVLT; a standardized measure future research on auditory verbal learning
of verbal learning and memory) to examine in ASD. First, future research could adopt
the rate of verbal learning in ASD compared to a developmental perspective, using longitudinal
controls. During the CVLT participants hear studies that examine auditory verbal learning
a single list of nouns read aloud on five consecu- abilities as people age and develop throughout
tive learning trials. After each trial, participants their lifespan. Our knowledge about auditory
are asked to immediately recall as many words as verbal learning in ASD comes largely
they remember. The list has a fixed word order from cross-sectional studies, which provide
and an underlying semantic structure, meaning a snapshot of verbal learning abilities by
that each word on the list belongs to one capturing performance at a single time point in
of a few semantic categories, such as fruits or a person’s life. Larger scale longitudinal studies
furniture. When compared to people without focusing on the emergence and active use of
ASD, adolescents and adults with high- different types of verbal learning strategies at
functioning ASD show typical rates of verbal multiple points within a person’s life would help
learning on early learning trials and poorer to identify whether specific patterns of learning
are simply delayed in ASD or whether they References and Readings
remain consistently impaired throughout the
American Psychiatric Association. (2000). Diagnostic and
lifespan. Knowing more about the development
statistical manual of mental disorders (4th ed., text A
and use of learning strategies and auditory verbal
rev.). Washington, DC: Author.
learning skills over time could help to shape Aurnhammer-Frith, U. (1969). Emphasis and meaning in
interventions designed to improve verbal learn- recall in normal and autistic children. Language and
ing and communication in this population. Speech, 12, 29–38.
Baddeley, A. D., & Hitch, G. (1974). Working memory.
In the same vein, training studies could be
In G. A. Bower (Ed.), The psychology of learning and
conducted to explicitly instruct individuals with motivation (pp. 47–89). New York: Academic Press.
ASD to use strategies known to improve auditory Bennetto, L., Pennington, B. F., & Rogers, S. J. (1996).
verbal learning performance. Such studies could Intact and impaired memory functions in autism. Child
Development, 67, 1816–1835.
help to evaluate whether explicit instruction on
Beversdorf, D. Q., Anderson, J. M., Manning, S. E.,
strategy use would improve verbal learning in the Nordgren, R. E., Felopulos, G. J., Nadeau, S. E.,
short term. In addition, this line of research would et al. (1998). The effect of semantic and emotional
also help to determine whether improvements context on written recall for verbal language in high-
functioning adults with autism spectrum disorder.
due to instruction could be sustained over time,
Journal of Neurology, Neurosurgery, & Psychiatry,
without additional instruction and maintenance. 65, 685–692.
Finally, there has been considerable theorizing Bjorklund, D. F., Muir-Broaddus, J. E., & Schneider, W.
about underlying neurobiological mechanisms (1990). The role of knowledge in the development
of strategies. In D. F. Bjorklund (Ed.), Children’s
responsible for impaired auditory verbal learning
strategies: Contemporary views of cognitive develop-
in ASD. In particular, temporal and frontal lobe ment. Hillsdale, NJ: Erlbaum.
regions have been implicated, as well as more Boucher, J. (1978). Echoic memory capacity in autistic
distributed problems with connectivity. Most children. Journal of Child Psychology and Psychiatry,
19, 161–166.
studies investigating auditory verbal learning in
Boucher, J. (1981). Immediate free recall in early
ASD compare performance on list-learning childhood autism: Another point of behavioural
tasks in individuals with ASD to patterns of similarity with the amnesic syndrome. British Journal
performance in individuals with known brain of Psychology, 72, 211–215.
Boucher, J., & Warrington, E. K. (1976). Memory deficits
lesions. This approach provides a starting point
in early infantile autism: Some similarities to the amne-
for identifying underlying neural mechanisms. sic syndrome. British Journal of Psychology, 67, 73–87.
However, future research could extend Bowler, D. M., Gaigg, S. B., & Gardiner, J. M. (2008).
this research by utilizing imaging techniques to Subjective organisation in the free recall learning of
adults with Asperger’s Syndrome. Journal of Autism
identify patterns of brain activation during verbal
learning tasks in individuals with ASD, and to Flavell, J. H., Beach, D. H., & Chinsky, J. M. (1966).
specify whether particular regions of the brain are Spontaneous verbal rehearsal in a memory task as
related to less efficient verbal learning in this a function of age. Child Development, 39, 53–58.
Fyffe, C., & Prior, M. (1978). Evidence for language
population.
recoding in autistic, retarded and normal children:
A re-examination. British Journal of Psychology, 69,
393–402.
See Also Hermelin, B., & O’Connor, N. (1967). Remembering of
words by psychotic and subnormal children. British
▶ California Verbal Learning Test, Children’s Journal of Psychology, 58, 213–218.
Version (CVLT-C) Marks, L. E., & Miller, G. A. (1964). The role of semantic
and syntactic constraints on the memorization of
▶ Language Acquisition English sentences. Journal of Verbal Learning and
▶ Memory Verbal Behavior, 3, 1–5.
▶ Memory Assessment Minshew, N. J., & Goldstein, G. (1993). Is autism an
▶ Semantic Memory amnesic disorder? Evidence from the California
Verbal Leaning Test. Neuropsychology, 7, 209–216.
▶ Wide Range Assessment of Memory and Minshew, N. J., & Goldstein, G. (2001). The pattern
Learning (WRAML) of intact and impaired memory functions in autism.
A 328 Auditory Verbal Learning Test
Journal of Child Psychology and Psychiatry, 42, including spoken and written modes of communi-
1095–1101. cation” (American Speech-Language-Hearing
Pressley, M., & Schneider, W. (1997). Introduction to
memory development during childhood and adoles- Association, 2005, p. 1). AAC is used to support
cence. Mahwah, NJ: Lawrence Erlbaum Associates. communication in individuals whose speech does
Ramondo, N., & Milech, D. (1984). The nature and not meet their ongoing, daily communication
specificity of the language coding deficit in autistic needs. It is also used with those who require pic-
children. British Journal of Psychology, 75, 95–103.
Schneider, W., & Sodian, B. (1997). Memory strategy torial or written supports to assist with language
development: Lessons from longitudinal research. comprehension and/or emotional regulation.
Developmental Review, 17, 442–461.
Schwartz, S. (1981). Language disabilities in infantile
autism: A brief review and comment. Applied Psycho-
linguistics, 2, 25–31. Historical Background
Tager-Flusberg, H. (1991). Semantic processing in the
free recall of autistic children: Further evidence for One of the earliest descriptions of what was orig-
a cognitive deficit. British Journal of Developmental inally referred to as “nonspeech communication”
Psychology, 9, 417–430.
Tulving, E. (1962). Subjective organization in free with persons with autism can be found in Premack
recall of “unrelated” words. Psychological Review, and Premack (1974). Previously, the Premacks
69, 344–354. had taught Sarah, a female chimpanzee, to asso-
ciate varicolored plastic shapes with over 130
words in semantic categories that included
nouns, verbs, adjectives, and prepositions,
Auditory Verbal Learning Test among others. Based on this research, the
Premacks then taught an 8-year-old boy with
▶ Rey Auditory Verbal Learning Test (Rey autism who could not speak and had a severe
AVLT) visual impairment to use plastic chips to commu-
nicate. The success of this intervention was
followed by a number of additional research pro-
jects in which individuals with autism were taught
Augmentative and Alternative to use the plastic chip system (see Mirenda, 2009).
Communication Simultaneous with these efforts, another pair
of language researchers was teaching a chimp
Pat Mirenda named Washoe to communicate using sign lan-
Department of Educational & Counseling guage (Gardner & Gardner, 1969). Like the work
Psychology and Special Education, Centre for of the Premacks, this successful research was also
Interdisciplinary Research and Collaboration in applied to children with autism and showed
Autism, The University of British Columbia, considerable promise. Orthographic symbols
Vancouver, BC, Canada (i.e., alphabet letters) were also used with people
with autism in the early days of AAC, via struc-
tured teaching interventions that were initiated to
Definition teach associations between printed words
with their referents (e.g., LaVigna, 1977).
Augmentative and alternative communication In addition, in the 1970s, another team of animal
(AAC) is both an area of research and a set of researchers initiated a longitudinal project
clinical and educational practices. AAC involves designed to teach chimps to communicate using
“attempts to study and, when necessary, compen- abstract lexigrams composed of geometric forms
sate for temporary or permanent impairments, (Rumbaugh, 1977). The results of this project
activity limitations, and participation restrictions were successfully applied to 13 boys with severe
of persons with severe disorders of speech- cognitive impairments – two of whom had
language production and/or comprehension, autism – in a project initiated in the mid-1980s
Augmentative and Alternative Communication 329 A
(Romski & Sevcik, 1996). It was also around this help to overcome the negative learning history
time that graphic symbols (i.e., icons) such as with speech that many individuals with autism
photographs and line drawings began to replace experience as a result of prolonged lack of pro- A
manual signs, either used alone or combined with gress. AAC provides an alternative learning path
speech (i.e., total communication) as the AAC that can support language, literacy, and some-
modality used most often with people with autism times even speech development at the same
(Beukelman & Mirenda, 2005). Today, people time as providing a means of functional commu-
with autism have access to a wide variety of nication (Beukelman, & Mirenda, 2005).
AAC techniques, including manual signs, picto-
rial and other types of symbols, written words,
and voice output communication aids (usually Goals and Objectives
referred to as speech-generating devices or
SGDs) that produce voice output. The goal of AAC is to facilitate an individual’s
ability either to (a) communicate more effec-
tively to others (i.e., augmented output) or
Rationale or Underlying Theory (b) understand communication from others (i.e.,
augmented input). Although AAC is not aimed at
Several rationales underlie the use of AAC for promoting speech or literacy development or pro-
individuals with autism (Wendt, 2009). First, duction, skills in one or both of these areas may
some individuals with autism do not show evi- increase as a side effect in some individuals.
dence of a strong motor or vocal imitative reper-
toire and may have difficulty producing complex
motor movements such as those required for Treatment Participants
speech. However, the motor movements required
to produce a manual sign or point to exchange AAC can be used with individuals with autism
a pictorial symbol, letter, or word are less com- across the range of age and ability, although it is
plex and thus easier to teach than those required usually used with school-aged children, adoles-
for speech. Second, learning to associate a visual cents, and adults who do not develop functional
symbol such as a sign or picture with a referent speech despite other types of interventions (e.g.,
may be less demanding of verbal memory and speech-language therapy). AAC can play an
abstract understanding. This may be especially important role in early communication interven-
true with regard to graphic symbols, which tion because it provides young children with an
require recognition rather than recall memory immediate way to communicate with their par-
for accurate production. Recall memory requires ents and other communication partners and may
a search of one’s memory for potential symbols decrease the likelihood that problem behaviors
(e.g., manual signs) that convey a particular mes- will emerge early in life (Romski et al., 2009).
sage, while recognition memory does not require AAC can also be used to support language com-
this search because the potential candidates (e.g., prehension in individuals of all ages across the
graphic symbols on a communication display) are autism spectrum in the form of, for example,
already visible. Cognitive scientists would argue written or pictorial activity schedules and symbol
that discriminations that require recognition scripts (McClannahan & Krantz, 1999; Mirenda
rather than recall memory are easier to achieve & Brown, 2009).
because fewer cognitive resources are involved.
Third, the relatively strong visual-spatial
strengths of many individuals with autism may Treatment Procedures
facilitate the learning and use of visual-spatial
symbols such as photographs or line drawings Communicating without speech requires the use
(Mirenda & Brown, 2009). Finally, AAC may of symbols to represent messages. A symbol is
A 330 Augmentative and Alternative Communication
something that stands for something else. There that represent the vocabulary needed in specific
are two main types of AAC symbols: unaided and activities (e.g., animals when talking about the
aided. Unaided symbols do not require external zoo), paired with aided language modeling and
aids or devices and include gestures, body lan- other strategies, can be useful in promoting the
guage, vocalizations, and manual signs. Aided ability to share information (Drager, Light, &
symbols require devices that are external to the Finke, 2009). Individuals with autism also need
body, such as communication books/boards, to be able to engage in social closeness interac-
alphabet displays, and specialized computers tions that involve getting the attention of others
with voice output (i.e., SGDs). Typically, (e.g., “Let’s go play!”), making socially appro-
a combination of AAC techniques, in addition priate and meaningful comments (e.g., “That was
to whatever functional speech is in a person’s great!” or “That tastes bad”), and using humor to
repertoire, is used for multimodal communica- connect to other people. They also need to learn
tion. A decision about which AAC techniques to communicate the social etiquette messages
are appropriate for a given individual requires that are expected in specific cultures (e.g.,
assessment of the person’s current communica- “please,” “thank you,” “excuse me,” “hello,”
tion abilities, communication needs, symbol “goodbye”). Instruction and practice in a wide
understanding, language comprehension, and lit- range of social routines are needed to teach peo-
eracy skills, among other factors (Beukelman & ple with autism to communicate messages that
Mirenda, 2005). are socially acceptable and respectful (Drager
Simply providing an individual with one or et al., 2009).
more AAC techniques rarely results in functional Ideally, AAC instruction is provided across
communication, just as providing someone with people, activities, and environments. Family
a piano rarely results in that person becoming an members are usually involved in making deci-
accomplished pianist. Individualized instruc- sions about AAC techniques and priorities and
tional strategies are also necessary to teach the should also be taught to support AAC use in home
use of AAC symbols, aids, or devices to commu- and community settings. Educational personnel
nicate the four basic types of messages: (a) wants play a key role in providing instruction to chil-
and needs, (b) information sharing, (c) social dren and adolescents, while vocational supporters
closeness, and (d) social etiquette (Light, 1988). and other service providers play this role with
Of these, messages for wants and needs are the adults.
easiest to learn and the ones that most children
acquire first. Individuals communicate about
wants and needs when they learn to say things Efficacy Information
like “I want” and “I don’t want” Structured
instructional approaches such as the Picture Research reviews of AAC use with individuals
Exchange Communication System (PECS; with autism provide information about the state
Bondy & Frost, 2009) can be useful for teaching of the evidence with regard to both unaided and
individuals to make requests and to reject. aided techniques to support communicative out-
Information-sharing messages enable an indi- put (Prelock, Paul, & Allen, 2011; Schlosser &
vidual to exchange information with classmates, Wendt, 2008; Wendt, 2009). Research on the use
teachers, family members, and others. For exam- of manual signs and gestures indicates strong
ple, most parents ask their children, “What did intervention effectiveness for acquisition and
you do at school today?” when they come home production, as well as for collateral outcomes
after school, and they expect children to be able such as speech comprehension and production
to answer. In addition, most people have a need to (Millar, 2009; Schlosser & Wendt, 2008;
exchange more complicated information, such as Wendt, 2009). There is also some evidence indi-
when they want to ask or answer questions in cating that total communication (i.e., manual sign
a class or in the community. Providing symbols plus speech) results in better outcomes than either
Augmentative and Alternative Communication 331 A
sign or speech alone, although many of the com- activity to another and to complete multiple-step
parative studies, which were conducted primarily tasks (Mirenda & Brown, 2009; Schlosser &
in the 1970s and 1980s, lack methodological Wendt, 2008). Additional research is needed to A
rigor (Schlosser & Wendt, 2008). Research on determine the effectiveness of other types of aug-
the use of graphic symbols (e.g., photographs, mented input supports such as contingency maps
line drawings) has focused primarily on teaching and rule scripts (Mirenda & Brown, 2009).
requesting for various purposes (e.g., access to
play activities, receiving assistance, and
obtaining desired items) and offers solid empiri- Outcome Measurement
cal support in this regard (Schlosser & Wendt,
2008; Wendt, 2009). Numerous studies that have Most AAC research with individuals with autism
examined the effectiveness of PECS provide has involved single-subject research methodol-
strong support for this approach to teaching ogy in which outcomes are measured in terms of
beginning communication skills, especially one or more discrete behavioral variables that are
requesting, to children with autism. Some the target(s) of a specific intervention. For exam-
research has also compared AAC modalities and ple, if the goal of an intervention is to teach SGD
instructional techniques (e.g., PECS instruction use during social routines with classmates, the
to teach the use of line drawing symbols versus frequency of appropriate SGD activations by par-
systematic instruction in manual signs). The ticipants with autism might be counted across
results suggest that PECS instruction is more multiple sessions (Trottier et al., 2011). This
effective and efficient than instruction in manual type of outcome measurement can establish
signs, at least for requesting, but that speech causal (i.e., functional) relationships between
production may increase with both (Schlosser & specific independent and dependent variables.
Wendt, 2008). Increased speech production con- Behavioral outcome measures are typically used
current with AAC use appears to be strongly to document specific AAC outcomes in school,
related to pretreatment speech imitation skills home, and community settings.
(Wendt, 2009).
Reviews of the SGD research have concluded
that SGDs are a “viable and effective AAC Qualifications of Treatment Providers
option” for teaching requesting to individuals
with autism (Schlosser, Sigafoos, & Koul 2009, AAC interventions require a team approach in
p. 165). Prelock, Paul, and Allen (2011) noted that order to be maximally successful (Beukelman &
SGD outcomes have included improvements in Mirenda, 2005). AAC teams require active
language comprehension, increased requesting, involvement of the person who requires AAC
and effective communicative interactions, with and his or her family members as well as pro-
increased speech production as a collateral benefit fessionals such as speech-language pathologists
(see also Millar, 2009). A few studies have exam- (SLPs) and educators with specific training in
ined the use of graphic symbols on SGDs for social AAC. Depending on the individual, other profes-
communication in play routines and for other types sionals (e.g., psychologist, occupational thera-
of interactions, but more research in this area is pist, vision specialist) may also be appropriate
needed (Trottier, Kamp, & Mirenda, 2011). team members. Because SLPs often play
Research on the impact of AAC applications such a leadership role on an AAC team, the American
as Proloquo2go for the iPad/iPod Touch is only in Speech-Language-Hearing (2006), p. 9) identi-
its infancy. fied the ability to incorporate a “range of AAC
With regard to augmented comprehension, applications to promote social communication,
research provides strong evidence that visual language, literacy, and related cognitive behav-
activity schedules are effective in helping indi- iors and behavior and emotional regulation” as
viduals with autism to transition from one a key skill for SLPs working with this population.
A 332 Augmentative and Alternative Communication
See Also State of the art and future directions. Augmentative and
Alternative Communication, 4, 66–82.
McClannahan, L. E., & Krantz, P. J. (1999). Activity
▶ Alternative Communication schedules for children with autism: Teaching
▶ Augmentative and Assistive Technology independent behavior. Bethesda, MD: Woodbine
▶ Communication Board House.
▶ Communication Disorder/Communication Millar, D. (2009). Effects of AAC on the natural speech
development of individuals with autism spectrum
Impairment disorders. In P. Mirenda & T. Iacono (Eds.), Autism
▶ Communicative Acquisition in ASD spectrum disorders and AAC (pp. 171–194).
▶ Gestures Baltimore: Paul H. Brookes.
▶ Icon Mirenda, P. (2009). Introduction to AAC for individuals
with autism spectrum disorders. In P. Mirenda & T.
▶ Language Interventions Iacono (Eds.), Autism spectrum disorders and AAC
▶ Manual Sign (pp. 3–22). Baltimore: Paul H. Brookes.
▶ Pictorial Cues/Visual Supports (CR) Mirenda, P., & Brown, K. (2009). A picture is worth
▶ Picture Exchange Communication System a thousand words: Using visual supports for
augmented input with individuals with autism
▶ Speech-Language Pathologist (SLP) spectrum disorders. In P. Mirenda & T. Iacono
▶ Symbol Use (Eds.), Autism spectrum disorders and AAC
▶ Total Communication (TC) Approach (pp. 303–332). Baltimore: Paul H. Brookes.
▶ Voice Output Communication Aids Prelock, P., Paul, R., & Allen, E. (2011). Evidence-based
treatments in communication for children with autism
spectrum disorders. In B. Reichow, D. Doehring, D.
Cicchetti, & F. Volkmar (Eds.), Evidence-based prac-
References and Readings tices and treatments for children with autism
(pp. 93–169). New York: Springer.
American Speech-Language-Hearing Association. Premack, D., & Premack, A. (1974). Teaching visual
(2006). Knowledge and skills needed by language to apes and language-deficient persons. In
speech-language pathologists for diagnosis, R. Schiefelbusch & L. L. Lloyd (Eds.), Language
assessment, and treatment of autism spectrum perspectives – Acqquisition, retardation, and
disorders across the lifespan [Knowledge and Skills]. intervention (pp. 347–376). Baltimore: University
Retrieved from www.asha.org/policy Park Press.
American Speech-Language-Hearing Association. Romski, M. A., & Sevcik, R. (1996). Breaking the speech
(2005). Roles and responsibilities of speech-language barrier: Language development through augmented
pathologists with respect to augmentative and alterna- means. Baltimore: Paul H. Brookes.
tive communication: Technical report. ASHA Supple- Romski, M. A., Sevcik, R., Smith, A., Barker, R. M.,
ment, 24, 1–17. Folan, S., & Barton-Hulsey, A. (2009). The system
Beukelman, D., & Mirenda, P. (2005). Augmentative and for augmenting language: Implications for young
alternative communication: Supporting children and children with autism spectrum disorders. In P. Mirenda
adults with complex communication needs (3rd ed.). & T. Iacono (Eds.), Autism spectrum disorders and
Baltimore: Paul H. Brookes. AAC (pp. 219–245). Baltimore: Paul H. Brookes.
Bondy, A., & Frost, L. (2009). The picture exchange Rumbaugh, D. (1977). Language learning in the
communication system: Clinical and research chimpanzee: The LANA Project. New York: Academic
applications. In P. Mirenda & T. Iacono (Eds.), Autism Press.
spectrum disorders and AAC (pp. 279–302). Schlosser, R., Sigafoos, J., & Koul, R. (2009). Speech
Baltimore: Paul H. Brookes. output and speech-generating devices in autism
Drager, K., Light, J., & Finke, K. E. (2009). Using AAC spectrum disorders. In P. Mirenda & T. Iacono
technologies to build social interaction with young (Eds.), Autism spectrum disorders and AAC
children with autism spectrum disorders. In P. Mirenda (pp. 141–170). Baltimore: Paul H. Brookes.
& T. Iacono (Eds.), Autism spectrum disorders and Schlosser, R., & Wendt, O. (2008). Augmentative and
AAC (pp. 247–278). Baltimore: Paul H. Brookes. alternative communication intervention for children
Gardner, R., & Gardner, B. (1969). Teaching sign with autism. In J. Luiselli, D. Russo, W. Christian, &
language to a chimpanzee. Science, 165, 664–672. S. Wilcynski (Eds.), Effective practices for children
LaVigna, G. (1977). Communication training in mute with autism (pp. 325–389). New York: Oxford Univer-
autistic adolescents using the written word. Journal sity Press.
of Autism and Childhood Schizophrenia, 17, 115–132. Trottier, N., Kamp, L., & Mirenda, P. (2011). Effects of peer-
Light, J. (1988). Interaction involving individuals using mediated instruction to teach use of speech-generating
augmentative and alternative communication systems: devices to school-age children with autism spectrum
Augmentative and Assistive Technology 333 A
disorder in social game routines. Augmentative and Assistive technology that addresses communi-
Alternative Communication, 27(1), 26–39. cation needs is called augmentative and alterna-
Wendt, O. (2009). Research on the use of manuals signs
and graphic symbols in autism spectrum disorders: tive communication or AAC. Augmentative and A
A systematic review. In P. Mirenda & T. Iacono alternative communication supports and services
(Eds.), Autism spectrum disorders and AAC augment, clarify, or enhance a person’s existing
(pp. 83–139). Baltimore: Paul H. Brookes. forms of communication (Cafiero, 2005).
Assistive technology services are typically
provided by individuals in disciplines such as
speech pathology, occupational therapy, physical
Augmentative and Alternative therapy, engineering, and special education. The
Communication (AAC) Device Rehabilitation Engineering and Assistive Tech-
nology Society of North America (RESNA) has
▶ Assistive Devices developed a certification program so that profes-
▶ Communication Board sionals from related fields can be certified as an
assistive technology practitioner (ATP). They
have also articulated standards of practice,
which are principles and rules that promote the
Augmentative and Assistive highest ethical standards in the field of assistive
Technology technology.
Maureen Nevers
Augmentative Communication Consultant, Historical Background
Center on Disability & Community Inclusion,
Burlington, VT, USA Among the first group of statutes that directly
affected the development and application of
assistive technologies were Section 504 of the
Definition Rehabilitation Act of 1973 and the Americans
with Disabilities Act of 1990, which prohibited
The term assistive technology refers to a broad discrimination and facilitated access to assistive
range of devices, services, strategies, and prac- technology. The second group of statutes pro-
tices that address the problems faced by individ- vided actual services that may include assistive
uals who have disabilities (Cook & Polgar, 2008). technologies and included the Individuals with
As defined in the Assistive Technology Act of Disabilities Education Act (1990) and its amend-
1998 (amended in 2004), an assistive technology ments (1997 and 2004) and health programs such
device is “any item, piece of equipment or prod- as Medicaid and Medicare (Cook & Polgar,
uct system, whether acquired commercially off 2008). In 1998, The Assistive Technology Act
the shelf, modified, or customized, that is used to replaced earlier legislation (the Technology-
increase, maintain, or improve functional capa- Related Assistance for Individuals with Disabil-
bilities of individuals with disabilities” (Assistive ities Act of 1988 and its amendments in 1994)
Technology Act, page 1710 118 STAT. 2652 s. and provided the first published, formal, legal
602). Assistive technology devices are often definition of assistive technology.
described as “low-technology” supports, which
are inexpensive and easy to obtain, or “high-tech-
nology” supports, which tend to be more expen- Current Knowledge
sive and difficult to obtain. Assistive technology
practices encourage consideration of simpler Assistive technology services assist a person with
tools first, moving to more complex and special- a disability to select, obtain, or use an assistive
ized tools only as needed. technology device. Assistive technology services
A 334 Augmentative and Assistive Technology
may include a functional evaluation of the person’s interface. The three parts of the interface include
needs; selecting, acquiring, and maintaining the control interface, the selection set, and the
a device; and providing training and technical assis- selection methods. The control interface, or
tance to the person with a disability, their family, input device, is the hardware used to operate
and other individuals involved in their lives. As part the device. The selection set are the items that
of the provision of these services, the assistive are available for the user to choose and can be
technology practitioners share knowledge with the represented in text, symbols, pictures, or speech.
user, developing effective strategies related to the The last part of the interface, the selection
use of the assistive technology device. Strategies method, has to do with how the user makes the
are specific ways of using a device more effectively selection. The user might use a direct selection
and initially may be identified by the assistive tech- method, where they indicate their choice by
nology practitioner. Over time and with increased directly accessing the item they want by
experience with the device, the assistive technology pointing to it or looking at it. Indirect selection
user may become better at identifying their own requires multiple steps in order for the user to
strategies for facilitating their performance. indicate their selection. Scanning is one type of
Consideration of a person’s assistive technol- indirect selection where the selection set is
ogy needs requires an evaluation of the user’s presented to the user sequentially and the user
abilities and challenges and an understanding of initiates some sort of movement to signal when
the context for use of the assistive technology. their choice is presented.
Based on the needs identified in this process, the
appropriate assistive technology devices and ser- Aids for Vision Impairments
vices are selected. Some assistive technology Aids for individuals with vision impairments can
devices or supports are selected to enhance the either enhance their vision or, if the person has no
input to the user or to facilitate interaction vision, act as an alternative means of obtaining
between the user and their environment. These visual information. Large-print books, Braille,
general purpose assistive technologies include digital books, talking computer software, magni-
supports for seating, assistive technology inter- fication aids, and optical aids are examples of
face, vision, and hearing. Other assistive technol- assistive technology for vision impairments.
ogy supports are specifically designed to enhance
output or to facilitate performance of an activity. Aids for Hearing Impairments
Assistive technologies for performance include Aids for individuals with hearing impairments
supports for cognition, communication, mobility can either enhance their hearing or, if the person
and transportation, and manipulation and envi- has no hearing, will act as an alternative means of
ronmental control. obtaining auditory information. Hearing aids,
speech processors, alerting or listening devices,
Seating Systems and captioning are all examples of assistive
Seating systems help the user by improving their technology for hearing impairments.
posture and motor control, maintaining skin
integrity, and increasing their comfort. Proper Assistive Technologies for Cognitive
seating systems will reduce the energy required Augmentation
by the user to maintain their position and Assistive technologies for cognitive augmenta-
allow them to participate in a range of activities. tion compensate for challenges that affect cogni-
Seating systems can include adjustable chairs, tive skills such as attention, memory, information
standers, wedges, straps, and cushions. processing, knowledge representation and orga-
nization, problem-solving, language, and learn-
Assistive Technology Interface ing (Cook & Polgar, 2008). Memory aids allow
Information is shared between the human user and for the storage or retrieval of information and are
the assistive technology via the human/technology often found in handheld digital devices such as
audio recorders, cell phones, and digital assis- including ASD, it is important to address
tants. Time management devices aid in planning, these concerns. The evidence suggests that AAC
prioritizing, and executing tasks. These include interventions do not negatively impact speech A
a range of styles of timers, watches, alarms, and production (Light et al., 1999). In fact, AAC
calendars. Prompting and cuing devices inform intervention may have a positive impact on
the user that an action should be taken and speech production, and speech development can
provide visual, verbal, or auditory cues to accom- continue to be targeted along with AAC
plish the task. Stimuli control devices can be approaches.
auditory, visual, or media representation and Multimodal Communication. A multimodal
address attention or perception problems by communication system incorporates many differ-
manipulating the information presented to the ent methods, or modes, of communicating for the
user. Concept organization tools help the user most effective results. Whether we use AAC
organize, sort, and retrieve ideas and facts. supports or not, we all use a variety of methods
Language and learning tools assist in reading to communicate depending on our purpose,
or writing and support the memory requirements the context, and the audience. For people who
of language. Alternate input technologies offer use AAC supports, the ability to use more than
the user different modalities for providing input one mode provides a broader range of options for
commands or information to a device, for exam- getting their message across. Especially when
ple, voice recognition software. Alternate output children are young, it is important to provide
technologies offer the user a nontraditional them with opportunities to learn how to use
means of acquiring feedback or information a range of supports and tools. Over time, they
from a device, such as print or screen displays. will be able to make informed choices about
The learning styles of children with ASD show which techniques work best in which situations.
a strong preference for static information, and, as The particular forms that are selected will depend
a result, they often benefit from use of visual on the application and the user’s facility with the
supports (Cook & Polgar, 2008). The use of modes. The user should use the method that is
visual supports facilitates understanding of rou- the most efficient and effective for the situation.
tines and expectations and often decreases A balanced communication system will often
anxiety levels and behavior problems for many include forms that exist along the same contin-
persons with ASD (Cafiero, 2005). A frequently uum as other types of assistive technology,
used visual support is a visual schedule that may starting with no-tech and continuing through
include objects, photos, drawings, and/or words high-tech supports. No-tech communication
to represent a series of activities in the order in methods, also called “unaided communication”
which they will occur. techniques, use the person’s own body and do not
require any equipment. Aided communication
Augmentative and Alternative relies on devices or supports that are external
Communication (AAC) Systems to the person’s body and can be described as
AAC and Speech AAC typically supplement low-tech, mid-tech, or high-tech, depending on
a person’s existing communication abilities, the use of electronic components. Each of these
including any natural speech, rather than forms is described in more detail below.
replacing it. Parents may be concerned that the Unaided/No-Tech Supports. As described ear-
introduction of alternate forms of communication lier, unaided communication supports use
will inhibit their child’s need or ability to speak. a person’s own body with no requirement for
They may resist the use of AAC, feeling that by equipment. Examples include speaking, pointing,
using pictures or sign or a speech device, their gestures, facial expressions, and manual signing.
child will lose the motivation to learn to talk. The strength of unaided methods is that they
Because of the potential benefits of AAC systems do not require preparation or management of
for children with communication challenges, materials. They are always available and cannot
A 336 Augmentative and Assistive Technology
be lost, broken, or damaged. When used in a symbols are often displayed on a single page that
context that has information to support a person’s is placed on the face of the device, which is called
message, gestures, vocalizations, and facial an overlay. Overlays are considered “static” dis-
expressions can be very effective forms of plays because their appearance does not change.
communication. For devices that allow storage of multiple sets of
Low-tech Supports. Low-tech communication recordings, the user (or partner) must physically
systems include nonelectronic and paper-based change the display when they change the set of
materials. Communication boards, communica- messages. These multiple sets of recordings are
tion books, and communication displays (e.g., often called “levels,” with devices ranging from
picture exchange communication system or a single level (one set of recordings) to multiple
PECS) are all examples of low-tech supports. levels (e.g., 4, 6, or 8 sets of messages).
The benefits of low-tech supports are that they A few mid-tech supports have a keyboard dis-
are typically inexpensive, lightweight and porta- play. As the user types, the letters and words are
ble, and easily customized. Individuals who use displayed in a message window or screen that is
high-tech communication supports often create usually above the keyboard. The message is then
a printed copy of the displays to use in situations spoken by either the person using AAC or by the
when the device is unavailable or impractical. device, depending on the features of the device
Mid-tech Supports. Mid-tech AAC systems and the user’s needs and preferences. When the
include tools that require some energy source device speaks what a user has typed, it is using
(e.g., batteries), utilize digitized (recorded) a form of technology called “text to speech,”
speech, and have fixed (e.g., paper-based) dis- which refers to the process of converting the
plays. These devices are typically less expensive text entered by the user into spoken output.
than the high-tech systems and have more limited High-tech Supports. High-tech AAC systems
capabilities and customization options. Examples are usually the most complex and specialized
of mid-tech supports that are commercially avail- form of communication support. High-tech com-
able include recordable photo frames and books. munication aids are electronic (e.g., battery or
Although they are more limited in functions, there electric power source), use a touch-screen (versus
is a broad range of styles, sizes, prices, and fea- static or paper) display, and incorporate synthe-
tures within the mid-tech category. The basic fea- sized (computer generated) speech options.
tures of most mid-tech devices include some sort High-tech communication aids are often called
of housing for the electronic components, an inter- “speech-generating devices” or SGDs. Because
nal recorder with varying lengths of recording they are computer-based, high-tech SGDs offer
time, a display area for visual representations of many more options for how messages can be
the messages, and an area to activate the message. organized, displayed, and generated. The type of
The simplest mid-tech devices contain one display most often used in high-tech devices is
recorded message that is played when the user called a “dynamic display,” where the message
touches the display or message cell. Other devices targets displayed on the device will change based
allow multiple messages to be recorded, which are on the user’s selection. Because the change is
then played sequentially each time the single tar- electronic, the user does not need to physically
get (cell) is activated. By adding more targets, or change the display as they do with mid-tech
activation locations, to the display, the user has devices. Most high-tech SGDs allow the user to
access to more options for communication mes- determine the number of cells, or targets, that are
sages. More complex mid-tech devices offer 2, 4, displayed on the screen. Some devices will allow
6, 8, 12, 15, 20, or more individual message the user to create their own cell size and config-
options on a single display. Each message is typ- uration, while others offer a specific set of page
ically represented by some sort of symbol, which layout options. Many devices come with page
helps the user recall the message that will be sets where the display, messages, representations
spoken when that button is selected. These (symbol), and behaviors (button actions) have
already been programmed. By selecting from communicate for many different purposes, or func-
a set of preprogrammed displays, the person tions, such as requesting, commenting, directing,
using the device can make necessary edits to asking questions, accepting, and rejecting. A
individualize their communication support.
In addition to options for the display, high- Technologies for Mobility
tech devices are not limited to speaking Manual and power wheelchairs are examples of
a message when a button is selected. The individ- assistive technology that enhances a person’s
ual cells can be programmed to complete any mobility. Mobility aids allow the user to move
number of actions, including speaking a word or within and around their environments and can
phrase, typing the word on the screen display, be customized with a range of features to provide
navigating to another page, or clearing the dis- the optimal functioning for the user.
play area. When the user touches the screen, the
device will respond by completing the specific Technologies for Transportation
action that has been programmed for that target Transportation aids allow the user to transition
location. The user knows what action will follow between environments, such as school, home,
the selection of the target based on the text or work, and community. The support can be pro-
symbol that is on that button and through experi- vided for personal or public transportation, such
ence with using the button. as wheelchair vans, wheelchair lifts, and special-
Speech-generating devices typically have ized car seats.
a specific location for viewing the message that
the user has created called a “message window.” Technologies for Manipulation and
The user can monitor the construction of their Environment Control
message as they select the series of letters, Activities that require manipulation necessitate the
words, or symbols necessary to form the message. use of the upper extremities, usually the hands and
Until recently, high-tech dynamic-display fingers, to accomplish activities. Using a computer
devices were the least available and most expen- keyboard or mouse, hand writing, and performing
sive type of communication support. With the many daily living acts such as dressing, preparing
increase in the use of portable electronics in the food, and hygiene tasks require manipulation.
general population, the availability of these When the purpose of the action is to operate elec-
devices for people requiring AAC has also tronic items in the person’s surroundings, it is
increased. Software applications that support considered an environmental control. Individuals
communication have been developed for com- who use environmental control systems can use
mercially available electronic devices and can assistive technology to remotely operate things
easily be added to cell phones and portable such as a door, light, television, or telephone.
music players. It is important that a person Pointers, reachers, switches, alternate keyboards,
using this type of technology for communication computer access tools, and remote controls all
be provided with appropriate support to learn the provide assistance in manipulating or controlling
skills needed to benefit from the tool. the environment.
Symbols. A communication symbol is used to
represent the messages and ideas of the user.
These symbols can take a variety of forms, Future Directions
including very concrete (e.g., objects, parts of
objects) to less concrete (e.g., photographs) to As the application of the principles of universal
abstract (e.g., line drawings and text). design increases accessibility for all, the need for
Vocabulary. Vocabulary refers to the words specialized products for individuals decreases.
and messages that are expressed by the communi- Universal design promotes planning buildings,
cator. A comprehensive communication system environments, and materials to incorporate
will include vocabulary that allows the user to accessibility features so that the broadest range
A 338 Australian Scale for Asperger’s Syndrome
of users may benefit. This approach reduces the

need to use assistive technology to make individ- Australian Scale for Asperger’s
ual adaptations. Syndrome
Janine Robinson
See Also CLASS, Cambridgeshire & Peterborough NHS
Foundation Trust, Cambridge, UK
▶ American Sign Language (ASL)
▶ Facilitated Communication
▶ Gestures Synonyms
▶ Manual Sign
▶ Nonverbal Communication ASAS; ASAS-R: Australian Scale for Asperger’s
▶ Pictorial Cues/Visual Supports (CR) Syndrome – Revised
▶ Picture Exchange Communication System
▶ Sign Language
▶ Total Communication (TC) Approach Description
▶ Visual Scanning
▶ Visual Supports The Australian Scale for Asperger’s Syndrome
▶ Visual-Motor Function (ASAS) is a rating scale that aims to assist in the
identification of children likely to be at risk of the
condition. The scale is based on current formal
References and Readings diagnostic criteria, research literature on associated
conditions and features, as well as extensive clinical
American Speech-Language-Hearing Association. experience of the authors (Garnett & Attwood,
(2002). Augmentative and alternative communication: 1998). While acknowledging the core sets of criteria
Knowledge and skills for service delivery (Knowledge
developed by organizations, viz., American Psychi-
and skills). Available from www.asha.org/policy
American Speech-Language-Hearing Association. atric Association and the World Health Organiza-
(2006). Guidelines for speech-language pathologists tion (DSM-IV and ICD-10 respectively), they adopt
in diagnosis, assessment, and treatment of autism the clinically derived diagnostic criteria of Gillberg
spectrum disorders across the life span (Guidelines).
and Gillberg. Attwood views these as “clear, con-
Available from www.asha.org/policy
Assistive Technology Act of 2004, Pub. L. No. 108–364. cise and comprehensive” (Attwood, 1998, p. 23).
Beukelman, D., & Mirenda, P. (1998). Augmentative and The rating scale is designed to be completed
alternative communication: Management of severe by parents, teachers, or other professionals who
communication disorders in children and adults
know the child. It is comprised of six sections,
(2nd ed.). Baltimore: Brookes.
Cafiero, J. M. (2005). Meaningful exchanges for people A–F, and covers behaviors and abilities consis-
with autism. Bethesda, MD: Woodbine House. tent with a primary-school-age child with
Cook, A. M., & Polgar, J. M. (2008). Cook and Hussey’s Asperger’s syndrome. These include social and
assistive technologies principles and practice.
emotional issues, communication skills, cogni-
St. Louis, MO: Mosby Elsevier.
Mirenda, P. (2001). Autism, augmentative communicative skills, specific interests, movement skills,
tion, and assistive technology: What do we really and a range of other characteristics such as sen-
know? Focus on Autism and Other Developmental sory sensitivities, age of language development,
Disorders, 16(3), 141–151.
Mirenda, P. (2008). A back door approach to autism and
and facial tics or twitches.
AAC. Augmentative and Alternative Communication, The scale consists of 24 questions, each with an
24(3), 220–234. example of the behavior or skill being determined.
Schlosser, R. W., & Wendt, O. (2008). Effects of augmen- Responses are scored on a Likert scale from 0 to 6,
tative and alternative communication intervention
with 0 indicating rarely and 6 frequently. Within
on speech production in children with autism:
A systematic review. American Journal of Speech- this scale, 0 is deemed the usual level expected of
Language Pathology, 17, 212–230. a child of that age.
Australian Scale for Asperger’s Syndrome 339 A
The final section (F) consists of a further and adolescents who had an autistic spectrum con-
10 features or behaviors which the respondent dition (Garnett, 2007). She also sought to evaluate
completes as appropriate by ticking the box. the association between family and peer relation- A
While no specific cutoff is noted, the authors ships with psychological health of this group and
suggest that when the majority of the questions are the level of AAS in those with a diagnosis. Garnett
answered in the affirmative with scores between 2 conducted a validation study, the results of which
and 6, a referral for full diagnostic assessment may were presented in an unpublished Ph.D. in 2007.
be indicated. High scores do not, by definition, Further significant revisions have been made,
imply the condition. Full clinical assessment, if and the new measure has been submitted for
this were to be undertaken, would enable further publication as a commercial product (Garnett,
examination of the six core areas rated in the scale. personal communication, 2011).
The authors revised the scale for use with The ASAS has been translated into German,
children and adolescents aged 5–18 years and this version has been validated on a German
(ASAS-R, unpublished Ph.D. thesis, 2007). Current sample of 51 children (Melfsen, Walitza,
revisions are in progress to produce a new measure. Attwood, & Warnke 2005).
The ASAS was originally developed by Garnett as Limited data exist on the psychometric properties
part of a master’s thesis in 1993. The scale was of the original measure.
further developed by Garnett and Attwood and Table 1 gives the areas evaluated by the
presented at a conference in Australia in 1998. ASAS. (Table 1).
Only one other scale existed specific to the higher In the original study (Garnett, unpublished mas-
functioning end of the spectrum, viz., the Autism ter’s thesis, 1993), ASAS ratings were provided for
Spectrum Screening Questionnaire (ASSQ) devel- 60 children and adolescents (3–19 years). Each
oped by Ehlers and Gillberg in Sweden in 1993. group consisted of 20 children: (1) diagnosed with
Owing to limited knowledge about Asperger’s AS, (2) clinical group with mixed diagnosis, and
syndrome among professionals at this time, (3) normal controls. In addition, participants were
coupled with the sometimes subtle presentation of assessed for level of receptive language.
features, many children were not being identified as Multivariate analysis of covariance
warranting referral to specialist assessment ser- (MANCOVA) was then conducted for each area
vices. Developing screening measures was one score by diagnosis with the receptive language
way to assist in the identification of possible fea- score as the covariate. The nonclinical and AS
tures and abilities consistent with the condition in groups were found to be statistically significantly
order to make appropriate onward referrals. While different in each area to <.0001.
screening measures, such as the ASAS, were Discriminant function analysis revealed that
overinclusive, they could facilitate the process the ASAS accurately predicted membership of
whereby possible cases were not missed. the groups: 90% for AS, 65% for the mixed
In the first instance, the ASAS was developed clinical group, and 100% for the control group.
for use with primary school children. More recently No further data were available on test-retest
(2006), Garnett and Attwood revised the original reliability, internal consistency, or discriminant
scale which has been adapted for use with 5- to 18- validity of the scale. Small sample sizes and no
year-olds (ASAS-R). The ASAS-R was effectively formal testing as a screening instrument were raised
a new measure of core dimensions of Asperger’s as weaknesses in the scale.
syndrome. Garnett was especially interested in the The ASAS was translated into German, and the
association of Asperger/autism symptomatology scale was validated in a study by Melfsen et al.
(AAS) with the psychological health of children (2005). Mothers of children who were inpatients at
A 340 Australian Scale for Asperger’s Syndrome
Australian Scale for Asperger’s Syndrome, affected more significantly, the identified child’s
Table 1 Areas of behaviors and skills consistent with features or behaviors are not registered as severe,
Asperger’s syndrome (Attwood, 1998)
hence not deemed necessary to assess further.
Social and emotional Other characteristics While the ASAS was one of the earliest attempts
abilities
at screening for Asperger’s syndrome in children,
Communication skills Sensory
an increasing range of screening tools are now
Cognitive skills Flapping/rocking
available. These cover various age ranges, and
Specific interests High pain threshold
Movement skills Delayed speech
while some, like the ASAS, may be completed
Unusual facial expressions/tics by laypersons, others are clinician-rated scales.
Nonetheless, in clinical practice, these are not infre-
quently employed alongside other measures, hence
a local psychiatric hospital were asked to partici- providing a wealth of information from a range of
pate. Three groups of children were rated on the sources, i.e., clinicians, parents, and teachers.
ASAS (German version), viz., AS group (18), • Autism Spectrum Quotient (AQ-child)
referred for assessment but not diagnosed (18), • Checklist for Autism in Toddlers
and a group with mixed psychiatric conditions (15). (18–24 months)
Melfsen et al. (2005) report ANOVA results • Child Behavior Checklist (36–71 months)
which indicate that the scale successfully differen- • Childhood Autism Spectrum Test (4–11 years)
tiated between the three groups. Further stepwise • Developmental Behavior Checklist – Early
discriminant analysis indicated that group member- Screen (20–51 months)
ship was accurately predicted (60.78%). On the • Gilliam Autism Rating Scale (36–71 months)
basis of these findings, the authors concluded that • Modified Checklist for Autism in Toddlers
the ASAS was a useful screening instrument for (17–48 months)
children with Asperger’s syndrome. • Screening Tool for Autism in Toddlers
The authors have conducted reliability and (24–35 months)
validity studies on the most recent version of the • Social Communication Questionnaire
ASAS, but these are not yet available. Further- (48 months; mental age >24 months)
more, these data effectively relate to a different While a small validation study in Germany
measure with a different purpose. The proposed (Melfsen et al., 2005) has confirmed the ASAS’s
revised measure aims to assess five dimensions of ability to differentiate between three clinical groups,
AS to provide information on severity in each viz., children with a known diagnosis of AS, children
dimension and will therefore be helpful to assist referred for suspected AS, and those referred for
in guiding treatment postdiagnosis (Garnett, per- other psychiatric conditions, little current informa-
sonal communication, 2011). tion is available regarding the scale’s usefulness as
a screening measure or how it compares with other
screening measures. Furthermore, lack of clear cut-
Clinical Uses off scores or indication of the meaning of a particular
score renders the instrument difficult to interpret in
As per the current range of screening measures for its current form. Since the scale does not require
children, adolescents, and adults, the ASAS con- training or qualification and could hence be
tinues to serve the clinical purpose of identifying employed by clinicians and laypersons alike, the
those children and adolescents who are most at lack of clarity about screening scores and their mean-
risk of having an autistic spectrum condition. ing contributes to the difficulties with interpretation.
Not unlike diagnostic instruments, screening Nonetheless, if employed as a simple guide prior to
instruments may not identify those who have discussion about full screening and assessment, the
more subtle difficulties, such as girls, and those brief, structured scale facilitates an initial evaluation
of very significant cognitive abilities. In addition, of the child’s behavior and presentation within clear
perhaps in a high-risk family, where others may be areas consistent with the autistic spectrum.
Autism 341 A
The ASAS has undergone significant revi- Garnett, M. S. (2007). Children and adolescents with
sions, and it would appear that the purpose of Asperger’s syndrome: Validation of a new measure of
symptomatology and a structural test of family and peer
the various versions is necessarily different. The influences. Ph.D. thesis, School of Psychology, Univer- A
ASAS has not been replaced by the ASAS-R, and sity of Queensland.
the former still serves as a screening instrument Goldstein, S. (2002). Review of the Asperger’s syndrome
(Garnett, personal communication, 2011). diagnostic scale. Journal of Autism and Developmental
Disorders, 32, 611–614.
Garnett has suggested the potential value of the Howlin, P. (2000). Assessment instruments for Asperger
ASAS-R in providing directions for intervention. syndrome. Child Psychology & Psychiatry Review,
When used in conjunction with additional data 5(3), 120–129.
regarding family cohesion and peer victimization, Krug, D. A., Arick, J. R., & Almond, P. (1980). Behavior
checklist for identifying severely handicapped individ-
this may assist in selecting areas for treatment. uals with high levels of autistic behavior. Journal of
However, she notes the need for further research Child Psychology and Psychiatry, 21(3), 221–229.
to establish the tool’s sensitivity to clinical change. Melfsen, S., Walitza, S., Attwood, A., & Warnke, A.
(2005). Validation of the German version of the Aus-
tralian Scale of Asperger’s Syndrome (ASAS).
Zeitschrift f€ur Kinder- und Jugendpsychiatrie und
See Also Psychotherapie, 33(1), 27–34.
Scott, F., Baron-Cohen, S., Bolton, P., & Brayne, C. (2002).
▶ Asperger Syndrome The CAST (Childhood Asperger Syndrome Test): Pre-
liminary development of UK screen for mainstream pri-
▶ Autistic Disorder mary-school children. Autism, 6(1), 9–31.
▶ Checklist for Autism in Toddlers Woodbury-Smith, M., Robinson, J., Wheelwright, S., &
▶ Child Behavior Checklist in Autism Baron-Cohen, S. (2005). Screening adults for Asperger
▶ Gilliam Autism Rating Scale (GARS) syndrome using the AQ: A preliminary study of its
diagnostic validity in clinical practice. Journal of
▶ Modified Checklist for Autism in Toddlers Autism and Developmental Disorders, 35(3), 331–335.
(M-CHAT)
▶ Screening Measures
▶ Screening Tool for Autism in Toddlers
Autism
References and Readings Fred R. Volkmar
Attwood, T. (1998). Asperger’s syndrome. A guide for
parents and professionals. London: Jessica Kingsley. Professor of Child Psychiatry, Pediatrics and
Attwood, T. (2006). The complete guide to Asperger’s Psychology, School of Medicine,
syndrome. London: Jessica Kingsley. Yale University, New Haven, CT, USA
Auyeung, B., Baron-Cohen, S., Wheelwright, S., &
Allison, C. (2008). The autism spectrum quotient:
Children’s version (AQ-Child). Journal of Autism
and Developmental Disorders, 38(7), 1230–1240. Synonyms
Baron-Cohen, S., Hoekstra, R. A., Knickmeyer, R., &
Wheelwright, S. (2006). The autism-spectrum quotient
Autistic
(AQ)-adolescent version. Journal of Autism and
Asperger’s syndrome – A total population study. Journal Definition
of Child Psychology and Psychiatry, 34, 1327–1350.
Ehlers, S., Gillberg, C., & Wing, L. (1999). A screening
questionnaire for asperger syndrome and other high- The term “autism” (or autistic) has had several
functioning autism spectrum disorders in school age uses in psychiatry. Originally introduced by
children. Journal of Autism and Developmental Disor- Bleuler to describe self-centered thinking in
ders, 29, 129–141.
schizophrenia, he modified the term from the
Garnett, M., & Attwood. T. (1998). The Australian Scale for
Asperger’s Syndrome. Paper presented at the 1995 Aus- Greek word for self. In the 1930s, the first child
tralian National Autism Conference, Brisbane, Australia. psychiatrist, Leo Kanner, became aware of
A 342 Autism Behavior Checklist
a group of children who had unusual patterns of Kanner, L. (1973). The birth of early infantile autism. Jour-
social engagement and learning. He published his nal of Autism & Childhood Schizophrenia, 3(2), 93–95.
Rutter, M. (1972). Childhood schizophrenia reconsidered.
first 11 cases in 1943 using the term “early infan- Journal of Autism & Childhood Schizophrenia, 2(4),
tile autism” to emphasize the apparent congenital 315–337.
lack of social engagement which he believed Volkmar, F. R., & Klin, A. (2005). Issues in the classifica-
to be one of the two cardinal features of the tion of autism and related conditions. In F. R. Volkmar,
A. Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of
disorder (the other being insistence on same- autism and pervasive developmental disorders (3rd ed.,
ness/resistance to change). Although children Vol. 1, pp. 5–41). Hoboken, NJ: Wiley.
with features suggestive of autism had been
described for centuries (likely including some
feral children like Victor the Wild Boy in
France), Kanner was the first to describe the Autism Behavior Checklist
syndrome in detail. Interestingly, independent of
Kanner’s work, the Austrian medical student Arlette Cassidy
Hans Asperger also used the term in his descrip- Psychologist, The Gengras Center, University of
tion of a similar condition in highly verbal but Saint Joseph, West Hartford, CT, USA
socially isolated and eccentric boys.
Although he initially emphasized the unique
aspects of the condition, Kanner’s use of the term Synonyms
also suggested a link to schizophrenia given
Bleuler’s earlier use of the term, and indeed until ABC
1980 autism was not recognized as an official diag-
nosis and children with what today would be said to
have autism were instead thought to exhibit a form Description
of childhood schizophrenia. By the late 1970s, this
state of affairs changes with recognition of the The Autism Behavior Checklist (ABC) is one
uniqueness of autism (based on clinical features, component of the Autism Screening Instrument
onset, family history, neurobiological and genetic for Educational Planning (ASIEP) and is the only
findings) led to its explicit recognition as a category one that has been evaluated psychometrically.
of disorder distinct from schizophrenia. The ABC is a 57-item behavior rating scale
assessing the behaviors and symptoms of autism
for children 3 and older. The instrument consists
See Also of a list of 57 questions divided into five catego-
ries: (1) sensory, (2) relating, (3) body and object
▶ Asperger, Hans use, (4) language, and (5) social and self-help.
▶ Autistic Disorder Each item has a weighted score ranging from 1 to
▶ Kanner, Leo 4. The ABC is designed to be completed inde-
pendently by a parent or a teacher familiar with
the child for at least 3–6 weeks. It should take
from 10 to 20 min to complete. The protocol is
References and Readings then returned to a trained professional for scoring
Asperger, H. (1944). Die “autistichen Psychopathen” im
and interpretation.
Kindersalter. Archive fur psychiatrie und
Nervenkrankheiten, 117, 76–136.
Bleuler, E. (1911). Dementia praecox oder Gruppe der Historical Background
Schizophrenien (J. Zinkin, Trans.). New York:
International Universities Press.
Kanner, L. (1943). Autistic disturbances of affective contact. The Autism Behavior Checklist (ABC) was
Nervous Child, 2, 217–250. published in 1980 and is part of a broader tool,
Autism Cymru 343 A
the Autism Screening Instrument for Educational in conjunction with other diagnostic instruments
Planning (ASIEP). The content of the ABC was and methods, the ABC can be useful as
based on other autism screening instruments a symptom inventory to be used by clinicians in A
available at the time of its development. structuring their evaluation.
Psychometric Data References and Readings
The ABC’s item score weights and cutoff Coonrod, E. E., & Stone, W. L. (2005). Screening for
autism in young children. In F. R. Volkmar, R. Paul,
scores were developed using over 1,000 com-
A. Klin, & D. Cohen (Eds.), Handbook of autism and
pleted questionnaires from children and adults pervasive developmental disorders (Assessment, inter-
with autism, intellectual disabilities, visual and ventions, and policy, Vol. 2). Hoboken, NJ: John
hearing impairments, and emotional disturbance, Wiley & Sons.
Krug, D. A., Arisk, J. R., & Almond, P. J. (1980a). Autism
as well as those with typical developmental pro-
screening instrument for educational planning. Aus-
files. Higher subtest or total scores reflect greater tin, TX: ProEd.
impairments and more severe levels of autism Krug, D. A., Arisk, J. R., & Almond, P. J. (1980b). Behav-
symptomology. ior checklist for identifying severely handicapped indi-
viduals with high levels of autistic behavior. Journal of
Although widely used for years, several con-
Child Psychology and Psychiatry and Allied Disci-
cerns about its psychometric properties have been plines, 21(3), 221–229.
identified. For example, studies have found inter- Krug, D. A., Arisk, J. R., & Almond, P. J. (1993). Autism
rater reliability to be much lower than those screening instrument for educational planning
(2nd ed.). Austin, TX: ProEd.
reported in the initial study during development.
Lord, C., & Corsello, C. (2005). Diagnostic instruments in
In addition, the ABC subscales were not empiri- autism spectrum disorders. In F. R. Volkmar, R. Paul,
cally derived and were established by grouping A. Klin, & D. Cohen (Eds.), Handbook of autism and
items based on face validity. Later studies have pervasive developmental disorders (Assessment, inter-
ventions, and policy, Vol. 2). Hoboken, NJ: John
also shown significant differences between par-
Wiley & Sons.
ent and teacher reports, although it is not clear Volkmar, F. R., Cicchetti, D. V., Dykens, E., Sparrow,
whether the discrepancies indicate weaknesses S. S., Leckman, J. F., & Cohen, D. J. (1988). An
specific to the ABC or reflect differences encoun- evaluation of the autism behavior checklist. Journal
of Autism and Developmental Disorders, 18(1), 81–97.
tered commonly when using multiple informants.
Perhaps more important are questions concerning
the sensitivity and specificity of the ABC. Several
studies have suggested the cutoff score of 67
leads to a high number of false negatives. Studies Autism Cymru
lowering of the cutoff scores to 58 and 45 respec-
tively have shown increased sensitivity and Adam Feinstein
decreased specificity. The ABC has been shown Autism Cymru and Looking Up, London, UK
to correlate significantly with the Gilliam Autism
Rating Scale (GARS), but correlations with the
Childhood Autism Rating Scale (CARS) have Major Areas or Mission Statement
been variable.
Autism Cymru is Wales’s pioneering national
charity for Wales. It is a practitioner-led charity
Clinical Uses set up in 2001 to improve the lives of people in
Wales with an autistic spectrum disorder and
The ABC is primarily designed to identify chil- their families. It has a dedicated national brief
dren with autism within a population of school- in Wales and in the projection of Welsh practice
age children with severe disabilities. When used within and outside Wales. Autism Cymru takes
A 344 Autism Cymru
the view that everyone with an autistic spectrum Professor Sue Leekam became the first chair of
disorder in Wales should receive a service autism at Cardiff University and head of the new
appropriate to their assessed needs, whatever Welsh Autism Research Centre, based at the
their age and wherever they live. In order to university’s school of psychology and supported
achieve this, Autism Cymru actively promotes by Autism Cymru. Autism Cymru works in part-
at both national and local levels the practice of nership with Mudiad Ysgolian Meithrin with
strategic, collaborative, and multidisciplinary funding from Children in Need to train Welsh
partnerships and highly focused coordination medium playgroup leaders across Wales.
of services to people with autistic spectrum dis- Autism Cymru works in partnership with
orders and their families. Autism Cymru’s pri- Autism Northern Ireland (PAPA) on UK and
mary task was successfully to influence the European campaigns to improve the lives of
Welsh Assembly Government to establish the those with autism and to project best practice
world’s first government-led strategy for autism, in each country. Autism Cymru works with local
which was launched at Autism Cymru’s third authorities and local health boards to develop
International Autism Conference in Cardiff in local strategies for autism. Autism Cymru
April 2008. Autism Cymru’s Chief Executive, works with local education authorities in Wales
Hugh Morgan OBE, heads up the implementa- to deliver its Inclusive Schools and ASDs:
tion of the Assembly Government’s Action Plan Whole School Training and Research Project.
for Autism. Autism Cymru works in partnership with the
North Wales Police and Dyfed Powys Police to
operate the Emergency Services ASD Attention
Landmark Contributions Card Scheme which raises awareness of autism
among members of the emergency services in
Wales is the only country in the world with Wales.
a national strategy for autism. Autism Cymru has worked with Bro
Morgannwg NHS Trust on a research project
connected to the criminal justice system. Autism
Major Activities Cymru operates the AWARES EDUNET website
and School Fora for education professionals.
Autism Cymru runs the pioneering bilingual Autism Cymru publishes books and bilingual
websites, Awares (www.awares.org). Every information booklets for professionals, parents,
November, Autism Cymru’s editor, Adam and people with autism. Publications include All
Feinstein, runs the Awares international online About Autistic Spectrum Disorders and My
autism conference (www.awares.org/conferences), Brother Gwern, a book for siblings of children
the largest event of its kind in the world, with more with autism which won an award at Welsh
than 60 world autism experts taking part, along Language in Healthcare Awards 2006. Autism
with thousands of delegates. Professor Simon Cymru’s work also takes place on an interna-
Baron-Cohen has called this event “the finest tional stage and with European partners, includ-
online conference on the planet.” Autism Cymru ing Autism-Europe. For example, its 2009–2012
together with Autism Northern Ireland, Scottish European-funded Deis Cyfle project (Opportuni-
Society for Autism, and the Irish Society for ties for people with autism in education and
Autism has launched the Celtic Nations Autism employment) reached out to over 5,700 people
Partnership. This will lead to shared opportunities across Wales and Ireland. The charity is also the
for joint working in Northern Ireland, Scotland, sole national autism charity governed by
and Republic of Ireland, in addition to Autism those living in Wales. Autism Cymru’s Chair is
Cymru’s existing work in Wales. Professor Bill Fraser CBE. Its Patron is Lord
Autism Cymru carries out research in part- Dafydd Wigley and its President is Dame
nerships with universities in Wales. In 2010, Stephanie Shirley.
Autism Diagnostic Interview-Revised 345 A
Health Organization [WHO], 1990) and DSM-IV
Autism Diagnostic Interview-Revised (American Psychiatric Association [APA], 1994)
criteria as specified by the authors. In addition to A
So Hyun (Sophy) Kim1, Vanessa Hus1 and the three domains of behavior, there is a fourth
Catherine Lord2 domain, abnormality of development evident at
1
Department of Psychology, University of or before 36 months, to indicate whether the child
Michigan, Ann Arbor, MI, USA meets criteria for age of onset. Each domain has
2
Center for Autism and the Developing Brain, a cutoff; a child must meet or exceed cutoffs in all
New York-Presbyterian Hospital/Westchester four areas to receive an ADI-R classification of
Division, White Plains, NY, USA “autism.” Separate cutoffs are available for the
communication domain, depending on whether
or not the child is verbal (defined as showing
Synonyms “functional use of spontaneous, echoed, or ste-
reotyped language that, on a daily basis involves
ADI-R phrases of three words or more that at least some-
times include a verb and are comprehensible to
other people,” a score of 0 on item 30 overall
Abbreviations level of language). Other criteria including using
lower cutoffs with the same set of items have
ADOS Autism diagnostic observation been used to create an algorithm for broader
schedule classification of autism spectrum disorders
ASD Autism spectrum disorders (ASD) as in several collaborative studies
(Dawson, Webb, Carver, Panagiotides, &
McParland, 2004; Lainhart et al., 2006; Risi
Description et al., 2006). The diagnostic algorithm for
children 4 years old and above is based on the
The Autism Diagnostic Interview-Revised “ever/most abnormal” codes, but current behav-
(ADI-R; Le Couteur, Lord, & Rutter, 2003; Lord, ior algorithm forms are available to facilitate
Rutter, & Le Couteur, 1994) is a standardized, a clinical diagnosis for children from 2 years old
semi-structured, investigator-based interview and above.
administered by trained clinicians to parents or A toddler version of the ADI-R was also
caregivers of individuals referred for a possible developed several years ago to provide descrip-
autism spectrum disorder (ASD). The ADI-R tive data for research with children under 4 years
includes 93 items in three domains of functioning: of age. The Toddler ADI-R has a total of 125
communication, reciprocal social interactions, and items, including 32 new questions and codes
restricted, repetitive, and stereotyped patterns of about the onset of autism symptoms and general
behavior, as well as other aspects of behaviors. All development. Other items are identical to the
items in the ADI-R are coded for current and past ADI-R, with the exception that the Toddler
behavior. Current refers to whether the behavior ADI-R does not have codes for behaviors
has occurred in the past 3 months. For some items, between 4 and 5 years of age.
“past” refers to whether the behavior “ever” Previous analyses suggested that the diagnos-
occurred, whereas others ask whether the behavior tic algorithm was useful for children with
was present during a specifically defined period a nonverbal mental age above 2 years
between 4 and 5 years of age (referred to as “most (Le Couteur et al., 1989; Lord et al., 1994; Rutter,
abnormal 4 to 5”). Le Couteur & Lord, 2003). Thus, the interview
Up to 42 of the interview items are systemat- had been appropriate for the diagnostic assess-
ically combined to produce a formal, diagnostic ment of any person within the age range
algorithm for autism based on the ICD-10 (World extending from early childhood to adult life,
A 346 Autism Diagnostic Interview-Revised
provided that they have a nonverbal mental age demand for diagnostic instruments for very
above 2 years. Recently, however, newly devel- young children, which prompted the develop-
oped algorithms for toddlers and young pre- ment of the new diagnostic algorithms for tod-
schoolers have shown improved predictive dlers and young preschoolers (Kim & Lord,
validity compared to the preexisting algorithms 2011). The final algorithms for toddlers and
for young children from 12 to 47 months of age young preschoolers contain fewer items than the
(Kim & Lord, 2011). These algorithms extend the original algorithms and are appropriate for use
use of the ADI-R to children as young as with children 12 to 47 months of age.
12 months and a nonverbal developmental level
of at least 10 months. In addition, these new
algorithms include items present in both the tod- Psychometric Data
dler and standard versions of the ADI-R, allowing
for use of the algorithms with either version. Psychometric properties for the original ADI
Most items in the ADI-R relate to behaviors were reported for a sample of 16 children and
that are rare in individuals who do not have ASD adults with autism and 16 children and adults
and/or who do not have profound intellectual with intellectual disabilities; each group included
disabilities. Thus, numerical estimates of the individuals that spanned wide ranges of age and
scores of typically developing children based on performance IQ (with a mean age of 12.28 years
general population have not been obtained. How- and a standard deviation of 3.43 from
ever, there have been several comparisons to a performance IQ of 43 to 71). Participants were
children and adolescents with other disorders, carefully selected and blindly interviewed and
which have been used in the development of the coded. Interrater reliability was assessed, with
diagnostic algorithms (Le Couteur et al., 1989; multirater kappas ranging from 0.25 to 1 for
Lord et al., 1994; Kim & Lord, 2011). each item. Intraclass correlations were above
Researchers have used individual domain scores 0.94 for all subdomain and domain scores. The
or an overall total of the three domains as esti- majority of individual items showed good dis-
mates of autistic symptom severity, though the criminative validity between the autism group
validity of this approach has not been directly and the group of individuals with nonautism
tested. Scores have been published for many intellectual disabilities (Le Couteur et al., 1989).
research populations but not yet systematically Psychometric properties for the development
dimensionalized. of the algorithms for the current ADI-R were
based on a sample of 25 children with autism
and 25 children with intellectual disabilities
Historical Background who were carefully selected and blindly
interviewed and coded (Lord et al., 1994; Rutter,
The ADI was first developed in 1989 (Le Couteur Le Couteur, & Lord, 2003). These children
et al., 1989), which was modified in 1994 (Lord ranged in chronological age from 36 to
et al., 1994). The 1994 version was somewhat 59 months, with nonverbal mental ages ranging
shorter than the original in order to make the from 21 to 74 months. Using a sample of 10
interview more feasible in both clinical and children, interrater reliability was assessed;
research settings. The current version of the multirater kappas ranged from 0.63 to 0.89 for
ADI-R was published in 2003 by Western Psy- each item. Using the same sample, intraclass
chological Services. correlations were above 0.92 for all subdomain
The development of the toddler version of the and domain scores. In addition, after the initial
ADI-R was completed in 2006 for research pur- standardization of the ADI-R in 1989, a separate
poses. Following the development of the toddler sample of 53 children with autism and 41
version of the ADI-R, there was an increase in nonautistic children with intellectual disabilities
Autism Diagnostic Interview-Revised 347 A
or language impairments was used to further for toddlers and preschoolers between 12 to
assess the validity of the ADI-R (Lord, 47 months of age using a sample of 491 children
Storoschuk, Rutter, & Pickles, 1993). The results with ASD, 136 with nonspectrum disorders (NS), A
of the study showed that the interrater reliability and 67 with typical development (Kim & Lord,
was as high as the initial study, with multirater 2011). The new ADI-R algorithms consist of two
kappas ranging from 0.62 to 0.96 for individual different cutoff scores: one for research (more
items. Test-retest reliability was also very high, restrictive, higher specificity with lower sensitiv-
with all coefficients in the 0.93–0.97 range. ity) and one for clinical purposes (more inclusive,
The majority of individual items in the current higher sensitivity with lower specificity). They
ADI-R showed good discriminative validity also include “ranges of concern” for clinical use
between children with autism and children with (discussed below). In this sample, sensitivity
intellectual disabilities (see Lord et al., 1994). using the clinical cutoff ranged from 80% to
The existing algorithms differentiated children 94% and specificity ranged from 70% to 81%
with autism over 36 months of age from children for the comparison of nonautism ASD vs. NS.
with nonspectrum disorders, showing high sensi- Using the research cutoffs, the comparison of
tivity and specificity (both over 0.90). Further nonautism ASD vs. NS resulted in sensitivity
analyses of data from preschool children revealed ranging from 80% to 84% and specificity ranging
that the ADI-R algorithms differentiated children from 85% to 90%.
over 2 years with ASD from those with other
developmental disorders. However, for children
under 2 years, discrimination between nonverbal Clinical Uses
children with ASD and nonverbal children with-
out ASD was poor, resulting in low specificity, The ADI-R offers a profile of a child, adolescent,
especially for children with mental ages under or adult which includes information regarding
18 months, (Lord et al., 1993). reciprocal social interactions, language and com-
In a more recent study including a larger munication, and restricted, repetitive, and stereo-
sample (Risi et al., 2006), the ADI-R showed typed behaviors and interests. Items are scored
high sensitivity (above 80%) for children with based on caregivers’ detailed descriptions of the
ASD under 3 years of age, but lower specificity history and behaviors of their child, thus allowing
for the comparison of nonautism ASD versus the clinician to gather both quantitative and qual-
nonspectrum disorders (around 70%). Ventola itative information. One important caveat for clin-
and colleagues (2006) reported that, for children ical users to recognize is that diagnostic
between 16 and 37 months of age, the diagnostic classifications based on the algorithms and true
classifications made based upon the ADI-R algo- clinical diagnosis are not the same. Clinical diag-
rithm resulted in lower sensitivity than those nosis is based on multiple sources of information,
made using the Autism Diagnostic Observation including direct observations (Le Couteur, Haden,
Schedule (ADOS; Lord, Rutter, DiLavore, & Hammal, & McConachie, 2007; Risi et al., 2006;
Risi, 1999), Childhood Autism Rating Scale Kim & Lord, in press). Risi and colleagues (2006)
(CARS; Schopler, Reichler, & Renner, 1980), or found a better balance of sensitivity and specificity
clinical judgment using the DSM-IV criteria. when the ADI-R and the ADOS were used in
Wiggins and Robins (2008) also found that combination compared to when each instrument
ADI-R algorithms resulted in poor sensitivity was used alone. The combined use of these instru-
for children in the same age range when the ments resulted in sensitivity and specificity of 82%
standard cutoff for the RRB domain was included and 86%, respectively, for children with autism
in the diagnostic criteria. Given the low sensitiv- compared to children with nonspectrum disorders
ities and specificities being reported for young over age 3 years. For younger children, sensitivity
children, new ADI-R algorithms were developed and specificity for the same diagnostic comparison
A 348 Autism Diagnostic Interview-Revised
using both instruments were 81% and 87%, children in the mild-to-moderate or moderate-to-
respectively. In contrast, when each instrument severe ranges of concern should receive further
was used alone, specificities ranged from 59% to evaluation and follow-up, including other cogni-
72%. Le Couteur and her colleagues (2007) also tive and language assessments, and recommen-
examined the combined use of the ADOS and dations for treatment. In addition to ranges of
ADI-R for preschoolers with ASD using revised concern, single cutoff score can be used when
ADOS algorithms (Gotham, Risi, Pickles, & Lord, more strictly stratified groupings are necessary,
2007). Consistent with Risi’s 2006 study, the such as for intervention, neuroimaging, or genetic
authors found that combining information from research. These different alternatives allow clini-
both ADOS and ADI-R provided improved diag- cians and researchers to be transparent about the
nostic accuracy compared to either instrument in choices they make, recognizing that diagnostic
isolation. Similarly, using the newly developed decisions about ASD in very young children are
ADI-R algorithms for toddlers and young pre- less stable and precise than for older children and
schoolers and the revised ADOS and new ADOS- adolescents.
Toddler algorithms, Kim & Lord (2011) also found In addition to the diagnostic algorithms, the
that for very young children, the combined use of ADI-R includes a current behavior algorithm
the ADOS and ADI-R improved diagnostic valid- form that can be used in clinical settings to assess
ity compared to when each instrument was used changes that occur during or after interventions or
alone. Thus, even though the ADI-R provides that may reflect increasing developmental matu-
information about the individual’s history and rity or changing life circumstances. Because the
description of his or her current functioning from current behavior algorithm form has not been
a broad range of contexts, the ADI-R alone cannot empirically validated, it is not intended to be
be used to make a clinical diagnosis. used as a diagnostic algorithm. The development
The diagnostic algorithm cutoffs allow classi- of a new algorithm is underway by the authors in
fication of ASD based on patterns of behavior, anticipation of an updated protocol and algorithm
meeting the current DSM-IV or ICD-10 diagnos- with new criteria. A shorter version of the ADI-R
tic criteria for autistic disorder. In addition to that can be used over the phone is also in the
single cutoff scores, the new algorithms for tod- process of being developed and validated.
dlers and young preschoolers provide clinicians The ADI-R provides a useful structure to
and researchers with several different options for obtain history and understand a caregiver’s per-
the diagnostic classification of young children. spective on his or her child’s symptoms associ-
For clinical purposes, ranges of concern (little- ated with ASD. However, it requires substantial
to-no concern, mild-to-moderate concern, and practice to administer reliably, and it takes
moderate-to-severe concern) that represent the approximately two to three hours to administer.
severity of autism symptoms in young children The ADI-R should only be used by appropriately
are also provided. A clinician or a researcher can experienced clinicians who are familiar with
use these ranges of concern to inform decisions ASD and relevant behaviors. Training workshops
about whether or not a child should be followed and videotapes are available to help clinicians
up with further assessments or should be quickly and researchers understand the scoring and
referred for treatment services irrespective of administration of the ADI-R. For research use,
diagnostic cutoffs. Scores that fall in the little- interviewers must meet standards for reliability.
to-no range of concern indicate that the child is
reported to have no more behaviors associated
with ASD than children in the same age range See Also
who do not have ASD. On the contrary, a child
who scores in the mild-to-moderate range has ▶ Autism Diagnostic Observation Schedule
a number of behaviors consistent with, but per- ▶ Autism Diagnostic Observation Schedule
haps not unique to, ASD. For clinical purposes, (ADOS): Toddler Module
Autism Diagnostic Observation Schedule 349 A
References and Readings with possible pervasive developmental disorders.
American Psychiatric Association [APA]. (1994). Diag- 24(5), 659–685.
nostic and statistical manual of mental disorders Lord, C., Storoschuk, S., Rutter, M., & Pickles, A. (1993). A
(4th ed.). Washington, DC: Author. Using the ADI-R to diagnose autism in preschoolers.
Dawson, G., Webb, S., Carver, L., Panagiotides, H., & Infant Mental Health Journal, 14(3), 234–252.
McPartland, J. (2004). Young children with autism Risi, S., Lord, C., Gotham, K., Corsello, C., Chrysler, C.,
show atypical brain responses to fearful versus neutral Szatmari, P., et al. (2006). Combining information
facial expressions of emotion. Developmental Science, from multiple sources in the diagnosis of autism spec-
7(3), 340–359. trum disorders. Journal of the American Academy of
DiLavore, P., Lord, C., & Rutter, M. (1995). The pre- Child and Adolescent Psychiatry, 45, 1094–1103.
linguistic autism diagnostic observation schedule Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism
(PL-ADOS). Journal of Autism and Developmental diagnostic interview-revised. Los Angeles, CA: West-
Disorders, 25, 355–379. ern Psychological Services.
Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The Schopler, E., Reichler, R. J., & Renner, B. R. (1980). The
autism diagnostic observation schedule (ADOS): Childhood Autism Rating Scale (CARS). Los Angeles,
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37(4), 613–627. Allen, S., Green, J., et al. (2006). Agreement among
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and young preschoolers from 12 to 47 months of age. Disorders, 36(7), 839–847.
Journal of Autism and Developmental Disorders. Wiggins, L. D., & Robins, D. L. (2008). Excluding the
Epub ahead of print retrieved July 29, 2011. ADI-R behavioral domain improves diagnostic agree-
doi: 10.1007/s10803-011-1213-1. ment in toddlers. Journal of Autism and Developmen-
Kim, S., & Lord, C. (2012). Combining information from tal Disorders, 38(5), 972–976.
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Genetics. Part A, 140(21), 2256–2274. Schedule
Le Couteur, A., Haden, G., Hammal, D., &
McConachie, H. (2007). Diagnosing autism spectrum
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Le Couteur, A., Lord, C., & Rutter, M. (2003). Autism
diagnostic interview-revised. Los Angeles, CA: West-
ern Psychological Services. Synonyms
Le Couteur, A., Rutter, M., Lord, C., Rios, P.,
Robertson, S., Holdgrafer, M., et al. (1989). Autism
diagnostic interview: A semistructured interview for
ADOS
parents and caregivers of autistic persons. Journal of
Autism and Developmental Disorders, 19, 363–387.
Lord, C., Luyster, R., Gotham, K., & Guthrie, W. J. Description
(2000). Autism diagnostic observation schedule-
toddler module. Los Angeles, CA: Western Psycho-
logical Services. The Autism Diagnostic Observation Schedule
Lord, C., Rutter, M., DiLavore, P., & Risi, S. (1999). (ADOS) is a semi-structured observation scale
Autism diagnostic observation schedule: Manual. designed to observe social behavior and commu-
Los Angeles, CA: Western Psychological Services.
nication in children and adults referred for possi-
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism
diagnostic interview-revised: A revised version of ble diagnosis of autism spectrum disorder (ASD).
a diagnostic interview for caregivers of individuals Originally developed as a research instrument, it
A 350 Autism Diagnostic Observation Schedule
became commercially available through Western Pickles, & Rutter, 2000) consists of four mod-
Psychological Services in 2001 (Lord, Rutter, ules based on age and language level, with
DiLavore, & Risi, 1999) and is used widely “higher” modules generally requiring more lan-
in clinical, school, community, and research guage and social demands. Each module takes
settings. The goal of the ADOS is twofold: approximately 35–60 min to administer. Mod-
to help clinicians and researchers discriminate ule 1 is for individuals with a minimum of no
autism from other disorders and typically devel- speech or the emergence of simple phrases.
oping individuals and to characterize social Module 2 is designed for individuals who use
and communicative behaviors associated with flexible three-word phrases, but are not yet
autism (Lord, Rutter, Goode, Heemsbergen, speaking fluently. Modules 3 and 4 are for indi-
Jordan, Mawhood, & Schopler, 1989). It is viduals with fluent speech. For the purposes of
often used in conjunction with the Autism Diag- the ADOS, three-word phrases are defined as
nostic Interview-Revised (ADI-R; Rutter, Le “regular spontaneous meaningful use of three-
Couteur, & Lord, 2003), a parent interview. word utterances including a verb,” while fluent
When used by a skilled clinician, together, these speech is defined as “producing a range of flex-
two instruments form the “gold standard” for the ible sentence types, providing language behav-
diagnosis of ASD. ior the immediate context and describing
The format of the ADOS is unique. It is logical connections within a sentence” (Lord
a structured interaction between an examiner et al., 1999).
and individual in which the examiner’s behav- Though each module of the ADOS has differ-
ior is standardized using a hierarchy of struc- ent language requirements, the overall format and
tured and unstructured social behaviors. The structure is the same. In fact, there is considerable
examiner creates a “social world” in which overlap of tasks across modules. In each module,
occasions for specific behaviors are purpose- the examiner interacts with the individual,
fully orchestrated in order to observe the pres- administering a series of tasks, or “presses” for
ence – or absence – of an expected response. For particular social behaviors. Modules 1 and 2 are
example, with an older child or adult with fluent conducted while moving around a room and
language, the examiner might initiate include play-based tasks appropriate for young
a conversation and observe whether the individ- children or individuals with very limited lan-
ual participates in a reciprocal exchange or asks guage. Modules 3 and 4 generally take place
about the examiner’s experiences. With a child while sitting at a table and include tasks involving
or adolescent with limited language, the exam- more conversation.
iner might observe whether the individual con- Immediately after the administration of all
veys shared enjoyment in an activity, such as tasks, the examiner rates the individual’s behav-
bubble play, by smiling, laughing, or requesting ior on items across domains including communi-
for the activity to continue. The ADOS goes cation, social interaction, play or imagination,
beyond measuring the frequency of behaviors and stereotyped behaviors and restricted inter-
and also focuses on the quality of social behav- ests. Ratings, or codes, are made on an ordinal
ior, allowing the examiner to make informed scale from 0 to 3, with 0 indicating no evidence of
decisions regarding the presence of features abnormality related to autism and 3 indicating
associated with a diagnosis of ASD. Because definite evidence, such that behavior interferes
of the movement between structured and with interaction. Selected items from each
unstructured tasks, and the need for keen obser- domain are used to generate a diagnostic algo-
vation within such tasks, it is imperative the rithm. These items were selected for their ability
ADOS is administered by a skilled examiner to discriminate between ASD and nonspectrum
familiar with ASD. disorders and also for their relevance to DSM-IV
The original version of the ADOS (Lord, and ICD-10 criteria. A classification of autism or
Risi, Lambrecht, Cook, Leventhal, DiLavore, non-autism ASD is made when thresholds on the
Autism Diagnostic Observation Schedule, Table 1 ADOS algorithms
Adapted Adapted
Module T Module T Module 1 Module 1 Module 2 Module 3 Module 4 module 1 module 2
A
Some Single Some
Age No words words <5 words words Phrases Fluent Fluent No words words
12–30 m X
21–30 m X X
30–35 m X X X X
3–4 yrs X X X X
5–9 yrs X X X X
10+ yrs X X X X X X X
social affect and restricted and repetitive behav- Historical Background

ior domains, and a combined social affect and
restricted and repetitive behavior total, are The first version of the ADOS was developed
exceeded. When combined with information primarily as a diagnostic research tool. Direct
from other sources, including but not limited to observation, in addition to observations in famil-
a parent interview and clinical judgment, an iar settings and parent interviews, was an impor-
ADOS classification of autism or ASD may lead tant part of diagnostic assessment, but such
to a diagnosis on the spectrum. observations were not conducted in a standard-
Since its publication by WPS in 1999, the ized fashion across clinicians or patient. Further-
ADOS has expanded considerably. Revised algo- more, researchers needed a method in which to
rithms for modules 1–3 were developed to examine features specific to autism, such as
improve the instrument’s sensitivity and specific- impairments in social interaction and communi-
ity (Gotham, Risi, Pickles, & Lord, 2007), and cation, independent of those accounted for by
a toddler module appropriate for children under intellectual disability. A series of publications
30 months old has been available for research highlight the development of the ADOS from
purposes (Luyster et al., 2009). The revised its first version to the significantly expanded
ADOS algorithms and the new toddler module versions in use today (Table 2).
were released commercially by WPS in 2012 in The first ADOS (Lord et al., 1989) was
the second edition of the ADOS (ADOS-2; Lord, intended for individuals between five and
Rutter, DiLavore, Risi, Gotham, & Bishop, 2012; 12 years old, with an expressive language level
Lord, Luyster, Gotham, & Guthrie, 2012) (see of at least three years. It included only eight tasks,
Table 1 for a summary of ADOS algorithms). with two sets of materials based on developmen-
Adapted versions of modules 1 and 2 with mod- tal level and chronological age. The validation
ified tasks and materials are in development for sample included 20 children and adolescents
adolescents and adults with limited language with autism and 20 children with intellectual
(Hus, Maye, Harvey, Guthrie, Liang, & Lord, disability matched for chronological age, verbal
2011).The ADOS-Change (ADOS-C; Colombi, IQ, and gender. The measure showed promise in
Carr, MacDonald, & Lord, 2011), a measure distinguishing children with autism from those
using ADOS item descriptions with expanded with intellectual disability.
codes ranging from 0 to 5, has also been created. As public awareness of autism increased and
This measure is scored by watching an unstruc- more younger and nonverbal children were
tured interaction between an adult and child and referred to clinics for diagnostic evaluations,
will be used to measure response to intervention there became a need to develop a “downward
in young children. extension” of the ADOS that would be
Autism Diagnostic Observation Schedule, Table 2 History of the ADOS in JADD publications
Publication Contribution
Autism Diagnostic Observation Schedule: A Standardized – First published version of the ADOS
Observation of Communicative and Social Behavior (Lord
et al., 1989)
The Pre-Linguistic Autism Diagnostic Observation Schedule – Introduction of alternate version of ADOS more
(DiLavore, Lord, & Rutter, 1995) appropriate for individuals with very limited language
The Autism Diagnostic Observation Schedule-Generic: – Consolidation of ADOS and PL-ADOS
A Standard Measure of Social and Communication Deficits – Introduction of four module structure
Associated with the Spectrum of Autism (Lord et al., 2000) – Appropriate for broader range of social
communication deficits and age
– Accompanied by commercial release of ADOS by
Western Psychological Services (Lord et al., 1999)
The Autism Diagnostic Observation Schedule: Revised – Revised algorithms for improved diagnostic validity
Algorithms for Improved Diagnostic Validity (Gotham et al., – Algorithms grouped by developmental and language
2007) ability
– Inclusion of restricted and repetitive behaviors in
algorithm totals
The Autism Diagnostic Observation Schedule-Toddler – Introduction of ADOS-Toddler
Module: A New Module of a Standardized Diagnostic Measure – Appropriate for use in children under 30 months with
for Autism Spectrum Disorders (Luyster et al., 2009) mental age of at least 12 months
Standardizing ADOS Scores for Measure of Severity in – Created standardized severity metric to measure
Autism Spectrum Disorders (Gotham, Pickles, & Lord, 2009) change in ADOS assessments over time, age, and
module
appropriate for younger children with no-phrase version (Lord et al., 1989) and the PL-ADOS
speech. The Pre-Linguistic Autism Diagnostic (DiLavore et al., 1995). It aimed to improve the
Observation Schedule (PL-ADOS; DiLavore, tendencies to overdiagnose autism in children
Lord, & Rutter, 1995) was intended for children with insufficient language ability and underdiag-
less than 6 years old with limited language. It nose children with higher language abilities. Fur-
included 12 tasks with 31 overall ratings. All thermore, it sought to extend the current tasks to
tasks were administered in the context of play be appropriate for adolescents and adults. The
and were informed by the increasing amount of ADOS-G differed from its predecessors in that
research on early indicators of autism, particu- it spanned a broader developmental and age
larly those studies focusing on joint attention, range and was the first to introduce the use of
functional and symbolic play, imitation, and modules across different developmental and
early patterns of language development. The language levels. It was also the first version to
PL-ADOS was validated on a sample of 63 chil- provide continuous scores from ASD to autism,
dren with autism or developmental delay and thus making it applicable for children with
matched for chronological age or language broader ranges of social and communication
level. Overall, the algorithm was successful impairments.
at differentiating autism from developmental The ADOS-G was normed on a sample of
delay, but its performance was not as good 381 children, adolescents, and adults spanning
when discriminating verbal children with autism a broader diversity of spectrum and nonspectrum
from nonverbal children with developmental disorders. The sample included a group of indi-
delay, and children with autism who had some viduals diagnosed with autism, PDD-NOS, and
expressive language tended to be underclassified a group designated as “nonspectrum,” which
by the instrument. included individuals with diagnoses of mental
The ADOS-Generic (ADOS-G; Lord et al., retardation, language disorder, attention-deficit/
2000) was developed directly from its original hyperactivity disorder, oppositional defiant
disorder, anxiety, depression, and obsessive- ADOS assessments over time, age, and module
compulsive disorder and children who were and to identify trajectories of autism severity.
typically developing. The ADOS-G algorithms Raw scores have been mapped onto a 10-point A
were successful at discriminating ASD from severity metric with lower scores indicating less
nonspectrum, but were not as good at making autism impairment.
distinctions between children with milder forms As calibrated severity scores were being
of ASD. Upon WPS publication of the ADOS-G developed, a new module of the ADOS, the
in 1999, the “G” was dropped and the instrument ADOS-Toddler, was also underway. Advance-
became solely known as the ADOS. Gotham et al. ments in the understanding of autism in very
(2007) and colleagues sought to improve the young children, particularly infants and tod-
diagnostic validity of the ADOS by validating dlers, increased the need for diagnostic tools
revised algorithms for modules 1–3 on a signifi- appropriate for use in that developmental
cantly larger sample of children with ASD and level. Because the ADOS, even with revised
nonspectrum diagnoses. The new algorithms algorithms, had limited applicability for chil-
were grouped into developmental cells to reduce dren with nonverbal mental ages below
the effects of age and IQ and included more 15 months, the toddler module was created.
similar items across modules with the same num- The toddler module consists of a combination
ber of items per algorithm to increase compara- of ADOS and some new tasks and is intended
bility. Factor analyses yielded two domains for use in children 12–30 months chronological
representing features of social affect and age, with nonverbal mental ages of at least
restricted and repetitive behaviors (RRBs); thus, 12 months, and who are walking
the new algorithms required thresholds to be met independently. It includes two algorithms, non-
in social affect, RRB, and a combined total, in verbal 12–20 months/12–30 months and verbal
order to meet classification criteria for autism or 21–30 months. Because of the relative instabil-
ASD. This was a significant departure from ear- ity of diagnostic classifications in very young
lier versions of the ADOS in which RRBs were children, the toddler algorithms differ from
not included on the algorithm and social interac- those of the ADOS-G in two ways. First, they
tion and communication were considered sepa- yield research classifications of ASD or
rately. Specificity in children with nonverbal nonspectrum and do not make distinctions
mental ages of 15 months and younger continued between autism and ASD, and second, they pro-
to pose problems in distinguishing children with vide clinical “ranges of concern,” (little-to-no,
ASD from those with other language-based dis- mild-to-moderate, and moderate-to-severe
orders or intellectual disability. Since the publi- concern for ASD) indicating the degree of
cation of the revised algorithms, however, several need for continued clinical monitoring.
replications with larger and more diverse samples The ADOS has developed considerably since
have been conducted with consistent results the first 1989 version, and research on expanded
supporting the improved diagnostic validity of applications of the instrument continues today.
the new algorithms. Continued testing of the ADOS is occurring in
Though higher scores on the ADOS do indi- clinical and community-based settings, in addi-
cate a greater number of behaviors consistent tion to the application of translated versions for
with core deficits of ASD and, to some degree, use in languages other than English.
greater severity of impairment, ADOS scores
were not standardized for this purpose. The crea-
tion of revised algorithms paved the way for Psychometric Data
the development of calibrated severity scores
(Gotham et al., 2009). Severity scores that Reliability. Across all ADOS modules, intraclass
reduced the effects of IQ and chronological age correlations for the social, communication, social
were developed to promote the comparison of communication, and restricted and repetitive
Autism Diagnostic Observation Schedule, Table 3 Interrater reliability: percent agreement

Toddlera Module 1b Module 2b Module 3b Module 4b
Interrater (items) 84 91.5 89 88.2 88.3
Interrater (algorithm) 87 93 87 81 84
a
Luyster et al., 2009
b
Lord et al., 2000
Autism Diagnostic Observation Schedule, Table 4 Sensitivities and specificities for current and revised ADOS
algorithms: autism versus nonspectrum (Gotham et al., 2007)
Current ADOS Current ADOS Revised ADOS Revised ADOS
classification classification classification classification
N ¼ 1,157 Se Sp Se Sp
Mod 1, no words, nvma < ¼15 100 19 97 50
AUT ¼ 69 NS ¼ 16
Mod 1, no words, nvma > 15 97 91 95 94
AUT ¼ 306 NS ¼ 33
Mod 1, some words 88 96 97 91
AUT ¼ 201 NS ¼ 76
Mod 2, younger 97 93 98 93
AUT ¼ 58 NS ¼ 30
Mod 2, age 5+ 96 97 98 90
AUT ¼ 126 NS ¼ 30
Mod 3 86 89 91 84
AUT ¼ 129 NS ¼ 83
Mod 4 93 93 N/A N/A
AUT ¼ 16 NS ¼ 15
domains were 0.93, 0.84, 0.92, and 0.82, respec- Clinical Uses
tively, and mean weighted kappas across items
ranged from 0.65 to 0.78. Test-retest reliability The ADOS is intended for use by clinicians
ranged from 0.59 to 0.82. For the toddler module, familiar with autism. Valid administration and
intraclass correlation was 0.96 for the entire pro- interpretation of results is dependent on the
tocol and mean weighted kappa was 0.67. Test- clinical skill of the examiner and requires
retest reliability was 0.86 for the 12–20/21–30 substantial training. The ADOS can be used
nonverbal algorithm and 0.95 for verbal 21–30. clinically upon completion of a two-day
Interrater reliability across all modules is WPS-certified clinical course or from WPS
reported in Table 3. training DVDs. Even with training, however,
Diagnostic validity. Algorithm cutoffs for the administration of the ADOS should not be
ADOS were excellent for autism and ASD rela- attempted without significant practice in
tive to nonspectrum disorders, with even greater administering the tasks, in observing features
performance with the introduction of revised of autism as specified by the ADOS items, and
algorithms. Algorithm cutoffs for the toddler in scoring. For those using the ADOS in
module yielded high sensitivity and specificity. research settings, more rigorous requirements
Sensitivities and specificities for current and for use exist. Individuals must attend
revised algorithms of the ADOS are reported in a standardized training workshop and then
Tables 4 and 5 and in Table 6 for the toddler obtain reliability with workshop leaders and
module algorithms. within the research site. As specified in Lord
Autism Diagnostic Observation Schedule, Table 5 Sensitivities and specificities for current and revised ADOS
algorithms: non-autism ASD versus nonspectrum (Gotham et al., 2007)
Current ADOS
classification
Current ADOS
classification
Revised ADOS
classification
Revised ADOS
classification
A
N ¼ 685 Se Sp Se Sp
Mod 1, no words, nvma < ¼15 95 6 95 19
ASD ¼ 20 NS ¼ 16
Mod 1, no words, nvma > 15 88 67 82 79
ASD ¼ 51 NS ¼ 33
Mod 1, some words 67 84 77 82
ASD ¼ 75 NS ¼ 76
Mod 2, younger 76 70 84 77
ASD ¼ 49 NS ¼ 30
Mod 2, age 5+ 86 77 83 83
ASD ¼ 36 NS ¼ 30
Mod 3 68 77 72 76
ASD ¼ 186 NS ¼ 83
Mod 4 86 93 N/A N/A
ASD ¼ 14 NS ¼ 15
Autism Diagnostic Observation Schedule, fun” when module 3 would be more appropriate)
Table 6 Sensitivities and specificities for toddler module can result in underclassification. When in doubt,
algorithms: ASD versus nonspectrum (Luyster et al., however, a clinician should adopt a conservative
2009)
approach and chose a lower module as language
N ¼ 234 Se Sp difficulties may confound the social demands of
12–20/nonverbal 21–30 87 86 a higher one.
ASD ¼ 87 NS ¼ 64
Perhaps the most important practice in using
Verbal 21–30 81 83
ASD ¼ 59 NS ¼ 24 the ADOS is to recognize its limitations. The
ADOS is only one of multiple sources of infor-
mation that should be considered when deter-
mining whether criteria for ASD are met. It is
et al. (2000), research reliability is defined as possible to meet classification thresholds on the
agreement of 80 % or above on ADOS proto- ADOS algorithm and not meet formal criteria
cols and algorithms on three consecutive scor- for an autism diagnosis. Conversely, a clinician
ings for modules 1 and 2 and modules 3 and 4, with information from parent report and obser-
separately. vations in different settings may assign
Selecting the correct module for use in the a diagnosis of ASD even without an accompa-
ADOS is also crucial for obtaining an accurate nying ADOS classification. The ADOS was
classification. Clinicians and researchers can use developed as a companion instrument to the
the results of standardized tests or parent report to ADI-R, and indeed, both the ADOS and ADI
inform module choice, but as an individual’s yield higher sensitivities and specificities
language often varies in unstructured together than when used separately (Risi et al.,
versus structured environments, the collection 2006). In the hands of a skilled clinician with
of a spontaneous language sample at the begin- ample training and multiple sources of informa-
ning of an ADOS administration is highly tion, the ADOS provides a unique contribution
recommended. Administration of an “easier” to the observation of social and communicative
module (e.g., selecting module 2 for a child features of autism and greatly aids in the diag-
with fluent speech because the tasks are “more nosis of ASD.
A 356 Autism Diagnostic Observation Schedule (ADOS): Toddler Module
See Also Luyster, R., Gotham, K., Guthrie, W., Coffing, M.,
Petrak, R., Pierce, K., et al. (2009). The Autism diag-
nostic observation schedule - toddler module: A new
▶ Autism Diagnostic Interview-Revised module of a standardized diagnostic measure for
▶ Autism Diagnostic Observation Schedule Autism Spectrum Disorders. Journal of Autism and
(ADOS): Toddler Module Developmental Disorders, 39, 1305–1320.
▶ Prelinguistic Autism Diagnostic Observation Risi, S., Lord, C., Gotham, K., Corsello, C., Chrysler, C.,
Szatmari, P., Cook, E. H., Leventhal, B. L., & Pickles, A.
Schedule (2006). Journal of the American Academy of Child and
Adolescent Psychiatry, 45, 1094–1103.
Rutter, M., Le Couteur, A., & Lord, C. (2003). The autism
diagnostic interview - revised (ADI-R). Los Angeles,
References and Readings CA: Western Psychological Services.
Colombi, C., Carr, T., MacDonald, M., & Lord, C. (2011,

March). Developing a measure of treatment out-
comes: The autism diagnostic observation schedule-
change. Poster presented at the Society for Research
in Child Development Biennial Conference, Mon- Autism Diagnostic Observation
treal, CA. Schedule (ADOS): Toddler Module
DiLavore, P. C., & Lord, C. (1995). The pre-linguistic
autism diagnostic observation schedule. Journal of
Rhiannon Luyster
Gotham, K., Pickles, A., & Lord, C. (2009). Standardizing Department of Communication Sciences and
ADOS scores for a measure of severity in autism Disorders, Emerson College, Boston, MA, USA
spectrum disorders. Journal of Autism and Develop-
mental Disorders, 39, 693–705.
Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The
autism diagnostic observation schedule: Revised algo- Synonyms
rithms for improved diagnostic validity. Journal of
Autism and Developmental Disorders, 37, 613–627. ADOS-T
Hus, V., Maye, M., Harvey, L., Guthrie, W., Liang, J., &
Lord, C. (2011, May) The adapted ADOS – Prelimi-
nary findings using a modified version of the ADOS for
adults who are nonverbal or have limited language. Description
Poster presented at the International Meeting for
Autism Research, San Diego, CA.
The Autism Diagnostic Observation Schedule –
Lord, C., Luyster, R. J., Gotham, K., & Guthrie, W.
(2012). Autism diagnostic observation schedule, Toddler Module (or ADOS-T; Luyster et al.,
(ADOS-2), Part II: Toddler module (2nd ed.). Los 2009) is a semi-structured assessment of social
Angeles, Western Psychological Services. engagement, communication, and play using a set
Lord, C., Risi, S., Lambrecht, L., Cook, E. H.,
Leventhal, B. L., DiLavore, P. C., Pickles, A., &
of planned “presses” within a naturalistic social
Rutter, M. (2000). The autism diagnostic observation interaction. It is intended for children under
schedule - Generic: A standard measure of social and 30 months of age who have nonverbal mental
communication deficits associated with the spectrum age of at least 12 months. Other guidelines for
of autism. Journal of Autism and Developmental
use include independent walking and minimal
Disorders, 30, 205–223.
Lord, C., Rutter, M., DiLavore, P., & Risi, S. (1999). language; once the child masters three-word
Autism diagnostic observation schedule (ADOS). phrases, the Toddler Module is no longer consid-
Los Angeles: Western Psychological Services. ered appropriate.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K.,
Eleven activities are included in the Toddler
& Bishop, S. L. (2012). Autism diagnostic observation
schedule, (ADOS-2), Part 1: Modules 1–4 (2nd ed.). Module, along with 41 overall codes. Two algo-
Los Angeles, Western Psychological Services rithms are associated with the module, including
Lord, C., Rutter, M., Goode, S., Heemsbergen, J., one for all children between 12 and 20 months of
Jordan, H., & Schopler, E. (1989). Autism diagnostic
observation schedule: A standardized observation of
age and nonverbal children between 21 and
communicative and social behavior. Journal of Autism 30 months of age and a second algorithm for
and Developmental Disorders, 19, 185–212. verbal children between 21 and 30 months of
Autism Diagnostic Observation Schedule (ADOS): Toddler Module 357 A
age. These algorithms include formal cutoffs, within the autism spectrum. For similar reasons,
which are primarily intended for research use an emphasis was placed on using algorithm
and provide binary classification of ASD or ranges of concern in order to encourage a focus A
nonspectrum. Each algorithm also has three on clinical monitoring and follow-up rather than
“ranges of concern,” which are intended for assigning a formal diagnosis to a very young
clinical use and provide three classifications of child.
concern: little to no, mild to moderate, and mod-
erate to severe. The Toddler Module can be
administered in a professional’s office or play- Psychometric Data
room, although a familiar caregiver must be pre-
sent. Codes are completed immediately after Instrument development involved both validity
Toddler Module completion and are based on and reliability studies (Lord et al., 2012). The
all behavior during the administration. Each validity study was completed using data from
code can be scored between 0 and 3, with higher 182 children. Analyses were repeated using two
scores indicative of greater abnormality. overlapping samples, one of which included each
child only once and a second that included mul-
tiple visits from some children. The final set of 41
Historical Background codes was selected in order to yield markedly
different distributions across diagnostic groups
The Toddler Module was developed in response or to have high clinical or theoretical importance.
to a research and clinical need for a standardized In addition, codes were chosen in a manner that
instrument for use in very young children at high minimized collinearity with other codes or sam-
risk for, or suspected of having, an autism spec- ple characteristics. Two algorithms were gener-
trum disorder (ASD). Research had indicated that ated by selecting items that met theoretical and
the ADOS Module 1 was over-inclusive (mean- empirical thresholds for optimal group classifica-
ing it exhibited relatively poor specificity) for tion. Each algorithm includes items in two
children with nonverbal mental ages under domains – social affect (SA) and restricted, repet-
16 months (Gotham, Risi, Pickles, & Lord, itive behaviors (RRB) – and cutoff scores were
2007). The Toddler Module was developed for selected based on maximal sensitivity and speci-
use in this very young population and was ficity. Using formal cutoffs, sensitivity and spec-
intended to aide in both clinical and research ificity exceeded 86% on the younger/nonverbal
efforts targeted at children who fell below the algorithm, and they exceeded 83% on the verbal
floor of the ADOS. algorithm.
The creation of the Toddler Module was based The reliability study included ratings from 7
primarily on the Module 1 of the ADOS (Lord independent, “blind” raters on 14 Toddler Mod-
et al., 2000), which provides a series of semi- ule administrations (8 from children with ASD, 3
structured, play-based tasks and activities to from typically developing children, and 2 from
probe for a range of behaviors. Module 1 items children with non-ASD developmental disabil-
that were appropriate for infants and toddlers ities, one child contributed two administrations).
were included, and additional tasks were created Inter-rater reliability was evaluated using
based on a review of literature on early social and weighted kappas for nonunique pairs of raters,
communicative development. Some other impor- with kappas between .4 and .74 considered good
tant changes were made based on current knowl- and kappas at or above .75 considered excellent.
edge of early development in children with ASD, Three codes were not included in the reliability
including a shift from three classifications on the analyses because of limited variability; 30 codes
algorithm (autism, ASD, nonspectrum) to two had kappas equal to or above .60 and the
(ASD, nonspectrum), based on extensive evi- remaining eight codes exceeded .45. Inter-rater
dence of the instability of specific diagnoses item reliability was measured using percent
A 358 Autism Science Foundation
agreement and the full range of 0–3 scores: the deficits associated with the spectrum of Autism. Jour-
mean percent agreement was 84%. All items nal of Autism and Developmental Disorders, 30(3),
205–223.
exceeded 71%, and 30 of 41 items had exact Luyster, R., Gotham, K., Guthrie, W., Coffing, M.,
agreement of at least 80%. Inter-rater agreement Petrak, R., Pierce, K., et al. (2009). The Autism diag-
on the algorithms’ (younger/nonverbal and ver- nostic observation schedule-toddler module: A new
bal) diagnostic cutoffs was 97% and 87%, respec- module of a standardized diagnostic measure for
autism spectrum disorders. Journal of Autism and
tively; inter-rater agreement for ranges of Developmental Disorders, 39(9), 1305–1320.
concern was 70% and 87%, respectively. Test-
retest reliability was also satisfactory across both
algorithms.
Autism Science Foundation

Clinical Uses
Alison Singer
Clinical usage of the Toddler Module should be Autism Science Foundation, NY, USA
accompanied by other sources of information.
The ranges of concern may be useful in providing
an indication of the degree to which a child is Major Areas or Mission Statement
exhibiting symptoms consistent with an ASD, but
in some cases, these behaviors may be attribut- The Autism Science Foundation is a 501(c)3
able to other, non-ASD etiologies. Therefore, nonprofit that provides funding to scientists and
informed clinical judgment is critical in organizations conducting, facilitating, and pro-
interpreting results within a broader developmen- moting autism research. ASF also provides infor-
tal framework. Examining the profile of scores mation about autism to the general public and
across the 41 codes may be useful in identifying serves to increase awareness of autism spectrum
areas of difficulty for the child and can help in disorders and the needs of individuals and fami-
education and intervention planning. lies affected by autism. The organization was
founded by Alison Singer and Karen London,
parents of children with autism.
See Also ASF adheres to rigorous scientific standards
and values and believe that outstanding research
▶ Prelinguistic Autism Diagnostic Observation is the greatest gift that can be offered to families.
Schedule The Autism Science Foundation’s mission is
premised on the following facts and principles:
• Autism is known to have a strong genetic com-
ponent. Research must aim to discover the
References and Readings mechanisms of action that trigger autism, as
well as safe, effective and novel treatments to
Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The
Autism diagnostic observation schedule: Revised enhance the quality of life for children and
algorithms for improved diagnostic validity. Journal adults currently affected.
of Autism and Developmental Disorders, 37(4), • Early diagnosis and early intervention are criti-
613–627.
Lord, C., Luyster, R., Gotham, K., Guthrie, W., Risi, S., &
cal to helping people with autism reach their
Rutter, M. (2012). Autism diagnostic observation potential, but educational, vocational and sup-
schedule – Toddler module manual. Los Angeles, port services must be applied across the lifespan.
CA: Western Psychological Services. Science has a critical role to play in creating
Lord, C., Risi, S., Lambrecht, L., Cook, E. H. J.,
Leventhal, B. L., DiLavore, P., et al. (2000). The
evidence-based, effective lifespan interventions.
Autism diagnostic observation schedule-generic: • Vaccines save lives; they do not cause autism.
A standard measure of social and communication Numerous studies have failed to show a causal
Autism Screening Instrument for Educational Planning (ASIEP-2) 359 A
link between vaccines and autism. Vaccine guide federal spending on autism research, and
safety research should continue to be reports annually on the most promising autism
conducted by the public health system in research findings. A
order to ensure vaccine safety and maintain
confidence in our national vaccine program,
but further investment of limited autism See Also
research dollars is not warranted at this time.
▶ Autism Speaks
▶ Vaccinations and Autism
Major Activities
ASF offers pre- and postdoctoral fellowships to References and Readings

students who have shown a commitment to
a career in autism research and who have fresh, Autism Science Foundation
Latest Autism Science
new research ideas.
Vaccines and Autism
ASF hosts a bimonthly series called “Science Offit, P. (2008). Autism’s false prophets. New York:
and Sandwiches,” designed to bring autism Columbia University Press.
researchers and community stakeholders together
to exchange ideas. These events are held across
the United States.
ASF also provides funds to autism community Autism Screening Instrument for
stakeholders to enable them to attend the Interna- Educational Planning (ASIEP-2)
tional Meeting for Autism Research (IMFAR).
ASF works closely with other health-care enti- Sarah Butler and Catherine Lord
ties, including the American Academy of Pediat- Center for Autism and the Developing Brain,
rics (AAP), the Centers for Disease Control and New York-Presbyterian Hospital/Westchester
Prevention (CDC), and the National Institutes of Division, White Plains, NY, USA
Health (NIH), to ensure that accurate information
about autism spectrum disorders is widely avail-
able. ASF’s leaders and board members are fre- Synonyms
quently called upon by major news media to
comment on issues relevant to autism research ASIEP-2
and public policy.
ASF’s president, Alison Singer, is a public
member of the Interagency Autism Coordinat- Description
ing Committee. The Interagency Autism Coor-
dinating Committee (IACC) is a federal The Autism Screening Instrument for Educa-
advisory committee that coordinates all efforts tional Planning (ASIEP; Krug, Arick, & Almond,
within the Department of Health and Human 1978) was created to facilitate autism diagnoses
Services (HHS) concerning autism spectrum and to monitor the educational progress of
disorder (ASD). Through its inclusion of both individuals with autism (Arick, Krug, Fullerton,
federal and public members, the IACC helps to Loos, & Falco, 2005). First created in 1978, the
ensure that a wide range of ideas and perspec- ASIEP was revised in 1980 and a second edition,
tives are represented and discussed in a public the ASIEP-2, was released in 1993 (Krug, Arick,
forum. This committee provides advice to the & Almond, 1980; Krug, Arick, & Almond, 1993).
Secretary of Health and Human Services regard- The authors claim that the ASIEP-2 can identify
ing federal activities related to autism spectrum individuals with high levels of behaviors associ-
disorders, drafts an annual strategic plan to ated with autism (Frye & Walker, 1998) and can
A 360 Autism Screening Instrument for Educational Planning (ASIEP-2)
be applied to individuals with autism from associated with autism, but not a sufficient diag-
age 18 months to adults (Olmi & Oswald, nostic tool (Volkmar et al., 1988).
1998). The autism behavior checklist (ABC) is The autism behavior checklist (ABC) is
the most widely used subset of the ASIEP a 57-item checklist of behavioral characteristics
(Olmi & Oswald). and is meant to be filled out by individuals being
assessed, their parents, and their teachers. Items
fall into five behavior categories: sensory, relat-
Historical Background ing, body and object use, language, and social and
self-help. Each item is weighted from 1 to 4, and
The ASIEP was first created in 1978, with the the sum of the scores from the five categories is
ASIEP-2 following in 1993 (Krug, Arick, & calculated to produce the total score (Olmi &
Almond, 1978; Krug et al. 1993). The ASIEP Oswald, 1998). Krug et al. (1980) reported good
was designed to provide clinicians with an addi- interrater reliability. However, due to some con-
tional measure to diagnose autism (Arick et al. cerns about reliability and validity resulting from
2005). The ASIEP-2 is different from other their evaluation of the ABC, Volkmar et al.
diagnostic measures, except the PDD behavior suggest that the ABC is best used as a screening
inventory (Cohen & Sudhalter, 2005), in that it measure for individuals with frequent autistic
also provides information helpful in monitoring behavior, rather than as a diagnostic tool
progress and in creating educational programs (Volkmar et al., 1988).
tailored to the specific needs of the individual The sample of vocal behavior (SVB) subtest
with autism. assesses the characteristics of preverbal and
emerging spontaneous language in the areas
of repetitiveness, noncommunication, intelligi-
Psychometric Data bility, and babbling (Olmi & Oswald, 1998).
The goal is to elicit 50 vocalizations from the
The ASIEP-2 is comprised of five separately child to score. Scoring categories include variety,
standardized subtests: autism behavior checklist function, articulation, and length. Psychometric
(ABC), sample of vocal behavior, interaction studies of the SVB have demonstrated acceptable
assessment, educational assessment, and progno- reliability and validity, but had small sample
sis of learning rate (Krug et al. 1993). For each of sizes and thus were less rigorous than those
the subtests, raw scores can be converted to stan- applied to the ABC (Olmi & Oswald). Overall,
dard scores using tables provided in the ASIEP-2 the authors found that the ASIEP-2 had high
manual (Olmi & Oswald, 1998). The ABC can be test-retest reliability (Frye & Walker, 1998).
used for individuals of all ages and levels of In addition, significant differences between the
autism, while the other four subtests are to be utterances of preschool- and school-age children
used with individuals whose language and social with autism compared to those with typical
functioning are between 3 and 49 months development were observed in standardization
(Krug et al.). The ASIEP-2 is meant to be used studies of matched samples.
by professional educators and requires that the During the interaction assessment subtest,
examiners are knowledgeable about autism and four types of behaviors are assessed: interaction,
have had at least three weeks of interaction with constructive independent play, no response, and
the child being assessed (Frye & Walker, 1998). aggressive negative. Rater reliability is depen-
Overall, the ASIEP-2 has been shown to have dent on training and experience (Olmi & Oswald,
adequate validity and reliability (Frye & Walker). 1998). One study using the interaction assess-
The diagnostic validity has been questioned ment found high median agreement (89%)
by other researchers who have found the measure among the ratings (Frye & Walker, 1998). Other
to be an adequate screening measure to identify reliability statistics are unavailable for this
individuals with high levels of behaviors measure.
Autism Services Center (ASC), Huntington, West Virginia 361 A
The educational assessment subtest is Frye, V. H., & Walker, K. C. (1998). Book review: Autism
designed to assess the child’s abilities in five screening instrument for educational planning, second
edition (ASIEP-2). Journal of Psychoeducational
areas: staying in seat, receptive language, expres- Assessment, 16, 280–285. A
sive language, body concept, and speech imita- Krug, D. A., Arick, J. R., & Almond, P. J. (1978). Autism
tion (Olmi & Oswald, 1998). The educational screening instrument for educational planning.
assessment is intended to assess skills that most Austin, TX: ProEd.
Krug, D. A., Arick, J. R., & Almond, P. J. (1980). Autism
children with autism lack (Frye & Walker, 1998). screening instrument for educational planning,
The prognosis of learning rate subtest was Revised. Austin, TX: ProEd.
created to assess the individual’s ability to learn Krug, D. A., Arick, J. R., & Almond, P. J. (1993). Autism
newly presented information based on reinforce- screening instrument for educational planning
(2nd ed.). Austin, TX: ProEd.
ment procedures and without verbal or physical Olmi, J. D., & Oswald, D. P. (1998). [Review of the test
cues (Olmi & Oswald, 1998). There is limited Autism Screening Instrument for Educational
psychometric data for this subtest. Planning , Second Edition]. In The thirteenth mental
measurements yearbook. Available from http://www.
unl.edu/buros/.
Volkmar, F. R., Cicchetti, D. V., Dykens, E., Sparrow, S. S.,
Clinical Uses Leckman, J. F., & Cohen, D. J. (1988). An evaluation of
the autism behavior checklist. Journal of Autism and
The ASIEP-2 was created not only as an assistive Developmental Disorders, 18, 81–97.
diagnostic tool but also as a method to track indi-
vidual progress and aid in the creation of appropriate
education strategies (Krug et al. 1993). One way that
the ASIEP-2 differs from other psychological diag- Autism Screening Questionnaire
nostic measures is that it is designed to be adminis- (ASQ)
tered as often as needed to assess progress without
concerns about test-retest effects, as the measure ▶ Social Communication Questionnaire
demonstrated a lack of practice effects (Frye &
Walker, 1998). This makes the ASIEP-2 particu-
larly useful for educational planning. In addition,
the ABC can be used in clinical settings to create Autism Services Center (ASC),
a behavior description; however, it is not sufficient Huntington, West Virginia
as a primary diagnostic tool (Frye & Walker).
Arlette Cassidy
See Also Saint Joseph, West Hartford, CT, USA
▶ Autism Behavior Checklist

▶ Autism Diagnostic Observation Schedule Major Areas or Mission Statement
ASC was founded in 1979 on the belief that each

person with a developmental disability has
References and Readings the capacity for growth and development. Each
Arick, J. R., Krug, D. A., Fullerton, A., Loos, L., & Falco, R.
individual has a right to services that enhance
(2005). School-based programs. In F. R. Volkmar, well-being, quality of life, and opportunities to
R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of learn. Each should have access to the most normal
autism and pervasive developmental disorders and least restrictive social and physical environ-
(3rd ed., pp. 730–771). Hoboken, NJ: Wiley.
Cohen, I. L., & Sudhalter, V. (2005). The PDD behavior
ments consistent with his or her needs. Those with
inventory. Lutz, FL: Psychological Assessment even the most challenging behaviors can respond to
Resources. dignified interaction in a structured, meaningful
A 362 Autism Services Center (ASC), Huntington, West Virginia
program with appropriately trained and supervised Supported Employment: Supported employ-
staff and the appropriate client/staff ratio. ASC ment services enable individuals to engage in
encourages the use of best clinical practices and paid, competitive employment in integrated com-
believes everyone has the right to effective munity settings. The services are for individuals
treatment. who have barriers to obtaining employment due
to the nature and complexity of their disabilities.
These services are designed to assist individuals
Landmark Contributions for whom competitive employment at or above
minimum wage is unlikely without the supports.
Major Activities Respite Care: Respite care is a service pro-
Serving people with autism, other developmental vided to an individual by trained staff due to the
disabilities, and those who care for and about them. short-term absence of the primary caregiver.
Autism Services Center employs trained staff Adult Companion Services: Adult companion
to provide a comprehensive array of services for services are complementary to residential habili-
individuals with developmental disabilities. tation services and provide nonmedical care,
Service Coordination: Service coordination supervision, socialization, and assistance in tasks
services are provided for individuals with devel- such as meal preparation, laundry, and shopping.
opmental disabilities who reside in Cabell, Therapeutic Consultants: Therapeutic consul-
Wayne, Mason, and Lincoln Counties in WV. tants provide training for primary care providers
Service coordination establishes a potentially such as direct care staff and family members in
lifelong process for accessing a range of services, person-specific aspects and methods of positive
instructions, and assistance. The service coordi- behavior support intervention and instruction.
nator assists an individual with a developmental Nursing Services: Nursing services are pro-
disability in making meaningful choices and vided by registered nurses (RNs) and licensed
works to ensure quality, accessibility, account- practical nurses (LPNs) within the scope of the
ability, and continuity of support services. West Virginia Nurse Practice Act.
Residential Habilitation: Residential Habilita- Family Support: The family support program
tion services, which occur in a client’s residence and allocates funds for services and equipment that
in the community, provide instruction and assis- are not funded by Medicaid or insurance compa-
tance for the acquisition and maintenance of skills, nies. These funds are to assist individuals and
which allow for a client to live and socialize more their family with such things as clothing, medical
independently. Residential habilitation services care, wheelchair ramps, and respite based on the
may also include behavioral intervention to reduce needs of the family.
and eliminate challenging behaviors and replace Applied Behavioral Analysis (ABA): The
them with socially valuable, adaptive behaviors, applied behavioral analysis (ABA) program or
and skills. Autism Services Center owns and/or applied behavior analysis is a scientific approach
supervises residences in the Huntington, WV, area. to understanding behavior, how it is affected by
Day Habilitation: Day habilitation services the environment and how learning takes place. It
take place away from an individual’s home and is a mixture of psychological and educational
include activities in community environments to techniques tailored to meet the needs of each
facilitate skills acquisition. The programs are individual. ABA methods are used to measure
designed to assist an individual in achieving behavior, teach functional skills, and evaluate
increased independence and/or to maintain their progress.
current skills in activities of daily living.
Prevocational Training: Prevocational train-
ing programs are designed to assist an individual References and Readings
in the acquisition and maintenance of basic work
and work-related skills. www.autismservicescenter.org
Autism Society 363 A
locations nationwide. The Autism Society’s
Autism Society website is one of the most visited websites on
autism in the world, and its quarterly journal, A
Cathy Pratt Autism Advocate, has a broad national readership.
Indiana Resource Center for Autism, Indiana The Autism Society also hosts a comprehensive
University, Bloomington, IN, USA national conference on autism that covers issues
ranging from early identification to adult options
each year. Autism Source, the national informa-
Major Areas or Mission Statement tion and referral center, and the Autism Society’s
strong chapter network serve thousands of fami-
The Autism Society lies each year who are searching for help in their
The Autism Society was founded in 1965 by journey with autism.
Dr. Bernard Rimland, Dr. Ruth Sullivan, and The Autism Society’s national office is
a group of parents of children with autism. At headquartered in Bethesda, Maryland, and is
that time, little was known about this rare disabil- governed by a board of directors that includes
ity. As they met in their living rooms, these par- people on the spectrum. The Autism Society’s
ents were determined to create awareness and Panel of Professional Advisors sets the standards
understanding of this disorder and to provide for their Options Policy that governs the organiza-
support for families living with autism. tion’s programs. The Autism Society’s Advisory
The Autism Society mission is to improve the Panel of People on the Spectrum of Autism is
lives of all affected by autism. The Autism Soci- a first-of-its-kind advisory panel comprised solely
ety works to ensure that every child and adult of individuals with autism, who help Autism Soci-
with autism lives an independent, fulfilled, and ety staff create programs and services that will
productive life. advocate for the rights of all people with autism
to live fulfilling, interdependent lives. The mem-
bership base of the Autism Society encompasses
Major Activities a broad and diverse group of parents, family mem-
bers, special education teachers, administrators,
The Autism Society supports individuals with medical doctors, therapists, adult agency person-
autism and their families through the three criti- nel, nurses, and aides, as well as countless other
cal stages of autism: personnel involved in the education, care, treat-
• Early Detection and Intervention: The Autism ment, and support of individuals on the autism
Society promotes early identification and spectrum across the age span.
access to effective treatment before age 3. Recognizing and respecting the diverse range
• Building a Strong Foundation from Childhood of opinions, needs, and desires of this group, the
through Adolescence: The Autism Society Autism Society embraces an overall philosophy
helps parents and caregivers build education that chooses to empower individuals with autism
and treatment programs so that each child and their parents or caregivers to make choices
reaches their fullest potential. best suited to the needs of the person with autism,
• A Life of Happiness and Dignity: The Autism a policy it calls the Options Policy. All activities
Society works to ensure that every adult with of the Autism Society are guided by the Options
autism has access to services and support sys- Policy. Revisited on a regular basis by the orga-
tems to ensure they achieve the highest quality nization, the Options Policy has stood the test of
of life and personal happiness. time. It states that:
Through its strong chapter network, the The Autism Society promotes the active and
Autism Society has spearheaded numerous informed involvement of family members and the
pieces of state and local legislation and offers individual with autism in the planning of individ-
family and individual support in over 150 ualized, appropriate services and supports. The
A 364 Autism Speaks
Board of the Autism Society believes that each for information by providing timely, frequent,
person with autism is a unique individual. Each relevant, and professional communication.
family and individual with autism should have • The Autism Society works to ensure that every
the right to learn about and then select the options chapter is a successful chapter, sustained by
that they feel are most appropriate for the indi- a collaborative relationship between the
vidual with autism. To the maximum extent pos- national office and chapters to realize mutual
sible, we believe that the decisions should be benefit and to protect the interests of both.
made by the individual with autism in collabora- • The Autism Society advocates for multidis-
tion with family, guardians, and caregivers. ciplined approaches to autism research
Services should enhance and strengthen natural focused on improving the quality of life for
family and community supports for the individual individuals across the autism spectrum and
with autism and the family whenever possible. The their families.
service option designed for an individual with • The Autism Society works to ensure financial
autism should result in improved quality of life. self-sufficiency and growth for all Autism
Abusive treatment of any kind is not an option. Society operating units and integrated opera-
We firmly believe that no single type of pro- tions across all levels of the Autism Society.
gram or service will fill the needs of every indi- At the very core of the Options Policy is the
vidual with autism and that each person should belief that no single program or treatment will
have access to support services. Selection of benefit all individuals with autism and that
a program, service, or method of treatment should ultimate parents should have informed choices.
be on the basis of a full assessment of each per- Furthermore, the recommendation of what is
son’s abilities, needs, and interests. We believe “best” or “most effective” for a person with autism
that services should be outcome based to insure should be determined by those people directly
that they meet the individualized needs of involved – the individual with autism, to the extent
a person with autism. possible, and the parents or family members.
With appropriate education, vocational train-
ing and community living options and support
systems, individuals with autism can lead digni- References and Readings
fied, productive lives in their communities and
strive to reach their fullest potential. Autism Society (2012). For more information about the
Autism Society. Retrieved on 28 June 2012, from
In addition to the Options Policy, the Autism
www.autism-society.org
Society has created guiding principles to further
define their work. These guiding principles include:
• The Autism Society’s efforts are focused
on meaningful participation and self-
determination in all aspects of life for individ- Autism Speaks
uals on the autism spectrum and their families.
• The Autism Society promotes individual, Geraldine Dawson1 and Michael Rosanoff2
1
parental, and guardian choice to assure that Department of Psychiatry, University of North
people on the autism spectrum are treated Carolina, NC, USA
2
with dignity and respect. Autism Speaks, New York, NY, USA
• The Autism Society proactively informs,
influences, guides, and develops public policy
at the federal, state, and local levels, including Major Areas or Mission Statement
setting agendas for policymakers and legisla-
tors, for the benefit of the autism community. Autism Speaks is North America’s largest autism
• The Autism Society is the respected voice of science and advocacy organization. Its goal is to
the autism community and the primary source change the future for all who struggle with autism
Autism Speaks 365 A
spectrum disorders (ASD). Autism Speaks is ded- completed by 2010. The vast majority (82%) of
icated to funding global biomedical research into respondents reported the major finding as a novel
the causes, prevention, treatments, and cures for discovery, while only 5% reported a negative A
ASD; raising public awareness about ASD and its result. The impacts of these research findings
effects on individuals, families, and society; and were most often to inform future research strate-
bringing hope to all who deal with the hardships gies and translate basic science discoveries into
of this disorder. The organization is committed to novel diagnostic and treatment methods. The 107
raising the funds necessary to support these goals. completed research grants resulted in over 1,000
Autism Speaks aims to bring the autism commu- presentations at scientific conferences, scientific
nity together as one strong voice to urge the abstracts, and peer-reviewed journal publica-
government and private sector to listen to the tions. For fellowship grants that aim to attract
concerns and take action to address this urgent new scientists to the field of autism, 88% of
global public health crisis. The core values fellows reported that it was their first experience
reflected in Autism Speaks’ mission statement in autism research and 95% intended to stay in the
are (1) recognition that individuals with ASD field. Finally, for each dollar Autism Speaks
and their families often face struggle, which invested in these grants, investigators secured
inspires a sense of urgency; (2) commitment to $10 in additional funding, with close $100 mil-
discovery through scientific excellence; and lion dollars in leveraged funding to date includ-
(3) the belief and commitment that parents are ing over $77 million in federal grants.
partners in this effort. Dissemination of new knowledge and building
upon existing findings are critical to maximizing
the impact of Autism Speaks’ research invest-
Landmark Contributions ments and to accelerating the pace of scientific
discovery. To ensure that new knowledge
Funding Autism Science resulting from Autism Speaks-supported research
Since its inception in 2005, Autism Speaks has can be accessed, read, applied, and built upon, the
made enormous strides, committing over $170 mil- organization expects its researchers to publish
lion to research through 2014. In support of its their findings in peer-reviewed journals. It is
mission to improve the future for all who struggle a condition of Autism Speaks’ Public Access
with ASD, Autism Speaks provides funding along Policy that all peer-reviewed articles supported
the entire research continuum – from discovery to in whole or in part by its grants must be made
development to dissemination – for innovative pro- available in the PubMed Central online archive.
jects that hold considerable promise in significantly
improving the lives of persons with autism. Annu- Science Programs and Initiatives
ally, Autism Speaks accepts applications through In addition to investigator-initiated research
a number of grant funding mechanisms for inves- grants, Autism Speaks supports a number of
tigator-initiated research projects. This includes targeted clinical programs and initiatives. The
cornerstone mechanisms such as the Pilot, Basic Autism Treatment Network (ATN) is the first
& Clinical, Treatment, and Predoctoral Fellowship network devoted to addressing the medical con-
Awards, as well as targeted mechanisms including ditions associated with ASD and providing com-
Postdoctoral Fellowships in Translational Autism prehensive care. With the help of $12 million in
Research and the Suzanne and Bob Wright Trail- federal funding, the ATN is developing national
blazer Award. standards for the medical treatment of ASD
across 17 sites in the United States and Canada.
Assessing the Impact of Research Grant The Autism Genome Project – a collaboration of
Funding 120 scientists from 19 countries – uses Autism
A survey was conducted to assess the outcomes Speaks genetic database (Autism Genetic
and impact of Autism Speaks-funded grants Resource Exchange) and brain bank (Autism
A 366 Autism Speaks
Tissue Program) to identify new genes that con- of only three disease-specific awareness days of
tribute to autism risk, leading to multiple discov- its kind. Autism Speaks celebrates World Autism
eries that impact the understanding of the biology Awareness Day through its “Light It Up Blue”
and treatment of autism. The Toddler Treatment initiative that has featured the illumination of
Network and High Risk Baby below Siblings major US and international landmarks in blue
Research Consortium are collaborations of 23 light, including the Empire State Building, Niag-
scientists from 19 universities who have devel- ara Falls, and the Kingdom Tower in Riyadh,
oped guidelines for early recognition of infants at Saudi Arabia. Autism Speaks’ web site,
risk and early intervention approaches for young autismspeaks.org, has grown to be the most com-
toddlers with autism. Autism Speaks funded the prehensive and most visited website on autism
launch of the Interactive Autism Network (IAN), with over 2.7 million visitors in 2010. Walk Now
the first national online autism registry, which is for Autism Speaks awareness and fundraising
accelerating autism research by linking more events are held in more than 80 cities across
than 10,000 registered families to researchers North America, and more than 350,000 individ-
nationwide. As part of its international develop- uals participated in 2010.
ment efforts, Autism Speaks launched the Global
Autism Public Health Initiative (GAPH), an Family Services
ambitious advocacy effort that aims to increase Autism Speaks has provided to families easily
autism awareness, enhance capacity and explore accessible and understandable tools and
unique opportunities in research, and improve resources for the autism community. The 100
service delivery worldwide. Through this effort, Day Kit – available in English and Spanish –
Autism Speaks supported the translation and provides a roadmap for newly diagnosed families
adaptation of diagnostic instruments in languages on how to move forward effectively during the
spoken by 1.75 billion people across the globe. first 100 days following diagnosis. The Asperger/
Great advances in the understanding of autism’s High-Functioning Autism Kit assists families in
biology have led Autism Speaks to dedicate getting the critical information they need in the
increased emphasis to translational research. first 100 days after a diagnosis specific to
Their translational research program seeks to Asperger syndrome. The School Community
accelerate the pace at which basic scientific dis- Tool Kit assists members of the school commu-
coveries are translated into new and effective nity in understanding and supporting students
ways of diagnosing, and treating autism spectrum with autism. Most recently developed, the Tran-
disorders. This includes “bench to bedside” sition Tool Kit is a guide to assist families on the
investigations that move the most promising journey from adolescence to adulthood. The
medicines and other interventions from the labo- Autism Video Glossary is a free web-based tool
ratory into clinical trials in real world settings to help parents and professionals learn more
such as hospitals, clinics and communities – about the early warning signs of autism. An
with the goal of improving outcomes for individ- online Resource Guide provides families with
uals on the autism spectrum. almost 30,000 resources on everything from diag-
nosis and treatment centers to autism-friendly
Awareness barbers. Autism Speaks’ Family Services
Autism Speaks’ award-winning “Learn the Community Grants program has thus far funded
Signs” campaign with the Ad Council has nearly $3 million to expand innovative and effec-
received more than $258 million in donated tive community services around the country for
media and helped raise awareness of autism to people with autism of all ages. The organization
unprecedented levels. Through collaboration is a primary organizer of Advancing Futures for
between the State of Qatar and Autism Speaks, Adults with Autism, which is working to priori-
the UN sanctioned a World Autism Awareness tize the needs for adults with autism in order to
Day to be celebrated in perpetuity on April 2, one develop a national policy agenda.
Autism Speaks 367 A
Advocacy autism-related areas. They provide
Autism Speaks has played a leading role at the researchers with larger awards in order to pur-
federal and state levels to advocate for legislation sue leads that have already shown promise in A
that benefits people with autism and their fami- pilot studies.
lies. The Combating Autism Act of 2006 autho- • Dennis Weatherstone Predoctoral Fellow-
rized nearly $1 billion in autism research and ships are awarded to support highly motivated
support, and current efforts are focusing on graduate students with an interest in devoting
reauthorizing and expanding research and service their careers to autism research.
funding at the federal level. Among the organi- • Postdoctoral Fellowships in Translational
zation’s key goals for the next 5 years is to fight Autism Research are designed to support
for legislation that will end autism insurance dis- promising, well-qualified postdoctoral scien-
crimination in all 50 states, as well as at the tists in their pursuit of research training that
federal level. Thirty-one states now require insur- involves translation of biological discoveries
ance companies to cover evidence-based medi- toward novel and more effective methods for
cally necessary autism treatments, including treating or diagnosing ASD. This is accom-
behavioral health treatments, with legislation plished by encouraging multidisciplinary col-
pending in about ten additional states. It also laboration among basic scientists, applied
plans to work with the federal government to set researchers, and clinicians.
a national policy agenda for services and support • Suzanne and Bob Wright Trailblazer Awards
of adults with autism. are designed to accelerate the pace of autism
science. In commemoration of Autism
Speaks’ fifth anniversary and to honor the
Major Activities organization’s pioneering cofounders, the
Trailblazer Award is designed to respond
Research Grant Programs quickly in funding highly novel projects with
Autism Speaks offers many types of grants that the potential to be transformative and/or to
target critical areas of autism research. The goal overcome significant research roadblocks.
is to facilitate and promote efforts that will pro-
duce significant findings to lead to discoveries of Science Initiatives
the causes and development of treatments and As important as individual grants, initiative pro-
improvements in the lives of people with autism. jects give Autism Speaks a much more proactive
• Pilot Research Grants stimulate the explora- role in promoting specific research. Initiatives
tion of new avenues of research through frequently involve formation of collaborative
2-year awards aimed at testing novel ideas research efforts, support of targeted research,
related to autism. These grants serve to bring organization of research meetings, and creation
new investigators into the field and allow of research resources.
researchers to collect preliminary data, which • The Autism Genome Project (AGP) is the
can permit them to compete for larger grants largest study ever conducted to find the genes
in future. associated with inherited risk for autism. The
• Treatment Research Grants address the ultimate goal is to enable doctors to biologi-
urgent need to develop effective therapies cally diagnose autism and researchers to
to treat those living with the disorder today develop universal medical treatments and
by supporting research focused on all a cure.
aspects of treatment, including behavioral, • The International Autism Epidemiology Net-
psychosocial, biomedical, and technological work (IAEN) is an effort to understand the
interventions. prevalence and causes of autism, particularly
• Basic and Clinical Research Grants build across diverse genetic and cultural settings.
upon established research in a broad range of The activities of this network led to
A 368 Autism Spectrum Disorder (ASD)
a multinational registry program to examine • The Autism Tissue Program (ATP) is dedi-
pre and perinatal factors associated with cated to increasing and enhancing the avail-
autism in the largest cohort of children with ability of postmortem brain tissue to as many
autism to date. qualified scientists as possible to advance
• The Global Autism Public Health Initiative autism research. Brain tissue allows scientists
(GAPH) aims to increase public and profes- to go far beyond the constraints of other tech-
sional awareness of autism spectrum disor- nologies and study autism on both a cellular
ders worldwide, to enhance research and molecular level. www.autismtis-
expertise and international collaboration, sueprogram.org
and to improve service delivery in under- • The Autism Treatment Network (ATN) is
served populations. a network of hospitals and medical centers
• The Environmental Factors in Autism Initia- working together to improve the quality of
tive targets research that seeks to understand care for individuals with autism. The clini-
and identify the potential role environmental cians in the ATN provide comprehensive,
factors play in triggering autism. coordinated, multidisciplinary care to families
• The Innovative Technology for Autism Initia- in their communities, and are dedicated to
tive was established to lead in the development establishing standards of care for autism that
of products that provide real world solutions to can be shared across the wider medical com-
issues faced by those with autism, their fami- munity. www.autismspeaks.org/atn
lies, educators, healthcare specialists, and • The Autism Clinical Trials Network (ACTN) is
researchers. a collaboration of medical and research cen-
• The High Risk Baby Siblings Research Con- ters working together on clinical trials of
sortium (BSRC) aims to accelerate the under- promising pharmaceutical or nutritional treat-
standing of the earliest markers of autism by ments for autism. The ACTN approach
bringing together the major research groups in enables sites to enroll children around the
the field to investigate infant siblings of chil- country in a single study, allowing sites to
dren with ASD, including studying the hetero- reach recruitment goals in a much shorter
geneity of symptoms and developing best amount of time and accelerating progress
clinical practices. toward scientifically proven treatments.
www.autismspeaks.org/ctn
• The Interactive Autism Network (IAN) is an
Clinical Programs innovative online project designed to acceler-
Autism Speaks’ clinical programs assist the ate the pace of autism research by linking
research community in a variety of ways and researchers and families. In addition, families
include the following: of children with an ASD can share information
• The Autism Genetic Resource Exchange in a secure online setting and become part of
(AGRE) is a repository (gene bank) of the nation’s largest online research effort.
genetic and clinical information from fami- www.ianproject.org
lies with two or more members diagnosed To learn more about Autism Speaks, please
with an ASD that is made available to autism visit www.AutismSpeaks.org.
researchers worldwide. For over 10 years,
AGRE has accelerated the pace of autism
research by collecting genetic and clinical
data and providing it to researchers,
allowing them to focus efforts on their Autism Spectrum Disorder (ASD)
investigations rather than data collection.
www.agre.org ▶ Asperger Syndrome
Autism-Europe 369 A
3. Promoting awareness of the appropriate care,
Autism Spectrum Disorders education, and well-being of persons with
ASD. A
▶ Pervasive Developmental Disorder 4. Liaising with other non governmental organi-
zations sharing similar objectives.
5. Promoting the exchange of accurate and
evidence-based information about ASD,
Autism-Europe good practices and experience.
In order to implement its objectives and max-
Aurélie Baranger imize its impact on EU policies, Autism-Europe
Autism-Europe, Bruxelles, Belgium has built strategic alliances with European social
partners. AE currently holds the vice-Presidency
of the European Disability Forum (EDF). It is
Major Areas or Mission Statement also a founding member of the European Coali-
tion for Community Living (ECCL) and the Plat-
form of European Social NGOs.
Landmark Contributions
AE is widely recognized as a credible, represen-

Autism-Europe (AE) is a European umbrella tative organization across Europe and among
organization representing persons with autism parents, decision makers, social partners, the
and their families. AE was founded in 1983 and scientific community, and other stakeholders.
nowadays ensures liaison among more than 80 This is demonstrated by the frequent ongoing
member associations of parents of persons with contacts and requests for advice, intervention,
autism in 30 European countries, including 20 partnership and collaboration in European and
Member States of the European Union, govern- national projects, initiatives, and events.
ments, and European and international institu- In 1996, the Charter of Rights for persons with
tions. AE is also consulted by the World Health Autism was adopted as a written declaration by
Organisation on matters relating to autism. the European Parliament following its adoption
Its aim is to raise awareness across Europe of by the Autism-Europe’s Congress in Den Haag in
the fundamental rights and needs of people with 1992.
ASD by representing them at EU level, and to In March 2004, the Committee of Ministers
promote positive actions and policies built on the of the Council of Europe made public the deci-
social model of disability and aimed at the active sion taken by the European Committee of
inclusion of people with ASD, in line with Social Rights of November 4, 2003, whereby
the guiding principles of the UN Convention on France was found to have failed to fulfill its
the rights of persons with disabilities. educational obligations to persons with autism
Its overarching statutory mission is to improve under the European Social Charter. This deci-
the life of all persons with autism by promoting sion upheld the collective complaint that
their rights. AE members identified the following Autism-Europe had lodged in 2003 against
strategic objectives as their priorities: France. Autism-Europe’s complaint was the first
1. Representing persons with ASD before all EU collective action to defend the rights of people
institutions. with disabilities in Europe. Its importance in
2. Promoting the rights and dignity of persons this respect was highlighted by the Council of
with ASD. Europe.
A 370 Autism-Europe
Also as a consequence, the Council of Europe European and national authorities responsible
published in 2007 the Resolution ResAP(2007)4 for the care of individuals with disabilities.
on the education and social inclusion of children
and young people with autism spectrum disor-
ders drafted with the cooperation of Autism- Major Activities
Europe.
Over the years, persons with ASD have been Representing persons with autism and
the target of false beliefs and they and their defending their interests at the European
families have constantly suffered the conse- level
quences of unreliable treatments. Autism- Autism-Europe’s engagement in defending
Europe has made every effort to disseminate the rights of persons with ASD, by means of
reliable, evidence-based information through legal instruments, such as the collective com-
collaboration with important professional orga- plaint against France lodged before the Council
nizations such as IACAPAP, ESCAP, and of Europe’s Committee on Social Rights has been
INSAR. widely recognized by the European Institutions.
Autism-Europe’s international congresses, Autism-Europe is considered as one of the key
organized every 3 years, provide an interdisci- EU networks in the field of disability and as such
plinary forum to examine state-of-the-art is regularly consulted in the process of policy-
scientific knowledge and current cultural making to raise the concerns of persons with ASD
approaches in the field of ASD. Autism-Europe and also benefit from the support of the European
ensures the high scientific quality of its interna- Commission to promote measures against
tional congresses through the support and partic- discrimination.
ipation of internationally renowned experts in the
field of ASD. Disseminating Evidence-Based Information
During the VIII Autism-Europe International about Autism as well as Promoting the
congress (Oslo, September 2, 2007), a Position Exchange of Knowledge and Best Practices
Paper on Care for Persons with Autistic Spec- on the Appropriate Care, Education, and
trum disorders was presented and officially Well-Being of Persons with ASD
adopted by Autism-Europe, the International Disseminating accurate and evidence-based
Association of Child and Adolescent Psychiatry information about autism is key in order to
and Allied Professions (IACAPAP), and the enhance understanding of autism within society
European Society for Child and Adolescent Psy- and prevent abuse. The recognition of the specific
chiatry (ESCAP). It reflects the views of Autism- needs of persons with Autistic Spectrum Disor-
Europe, IACAPAP, and ESCAP on the approach ders is essential to foster their inclusion in the
to Autism Spectrum Disorders. community and improve their quality of life.
Autism-Europe also published in 2009 the In order to promote self-advocacy, Autism-
document Persons with Autistic Spectrum Europe has published a number of information
Disorders: Identification, Understanding, Inter- documents and toolkits. Many documents of
vention, drafted by a team of European experts – Autism-Europe are translated into easy-to-read
Catherine Barthélémy, Joaquı́n Fuentes, Patricia format.
Howlin, and Rutger van der Gaag. The document, Autism-Europe’s publications – which are
which was drafted on a pro-bono basis by these available on its website – include:
experts, enables a better understanding of ASD • Information documents about Autistic Spec-
and the needs of those affected by this condition. trum Disorders drafted in cooperation with
This document is addressed not only to parents experts.
but also for all professionals who are involved in • Position papers and reports addressed to Euro-
interventions for persons with ASD, and for pean decision makers and public authorities.
Autistic Disorder 371 A
• Toolkits for self-advocates, taking into Disability Forum (EDF). AE strives for the recog-
account the latest legislative developments at nition of the complex needs of persons with
EU level. autism, and other kinds of disabilities requiring A
• Newsletters about the latest EU developments a high level of support. It is also a founding mem-
in the field of disability. ber of the World Autism Organization, the Euro-
• LINK magazine to share information about pean Coalition for Community Living (ECCL),
important developments at EU and national and the Platform of European Social NGOs.
levels.
Autism-Europe is also involved in a number of
European projects – notably in the field of References and Readings
research, life-long learning and deinstitutionaliza-
tion – in order to share its expertise and dissemi- All the publications of Autism-Europe are available on its
website. http://www.autismeurope.org/
nate the results across Europe.
Every 3 years, Autism-Europe organizes an
International Congress which aims at bringing
together self-advocates, families, and profes-
sionals in order to share knowledge about state-
Autistic
of-the-art scientific findings in research and
▶ Autism
intervention.
The IX International Congress took place in
Catania in October 2010, all the videos of the
session are available on the Congress website Autistic Disorder
and on Youtube. The congress was attended by
over 1,200 delegates. Many of the most promi- Fred R. Volkmar
nent researchers in the field of autism were pre- Director – Child Study Center, Irving B. Harris
sent as speakers. AE has built a relationship of Professor of Child Psychiatry, Pediatrics and
trust with both the scientific community and the Psychology, School of Medicine,
professionals working in the field of ASD, which Yale University, New Haven, CT, USA
allows a fruitful cooperation in order to enhance
the rights-based approach to care and
intervention. Synonyms
Promoting General Awareness of Autism Childhood autism; Infantile autism; Kanner’s

Every year, Autism-Europe also holds the Euro- autism
pean Days of Autism in October to share infor-
mation at European level and raise awareness
about ASD across Europe. Short Description or Definition
A wide range of activities are also organized
by Autism-Europe and its members to mark the Autistic disorder is the prototypical autism
World Autism Awareness Day adopted by the spectrum/pervasive developmental disorder.
United Nations. The condition, first described by Leo Kanner in
1943, is marked by severe and sustained prob-
Liaising with Other Non Governmental lems in social development (autism) along with
Organizations Sharing Similar Objectives unusual communication and a range of problems
Finally, Autism-Europe cooperates closely with typically subsumed under the term “resistance to
other European and international NGOs. It cur- change” – the last take the form of restricted or
rently holds the vice-Presidency of the European stereotyped patterns of behavior and interest as
A 372 Autistic Disorder
well as literal difficulties tolerating change. presence of social delay and deviance, communi-
The onset of the condition is in the first years of cation problems, and unusual behaviors. His pro-
life. While many individuals with the condition posal had a major influence on the criteria for
eventually exhibit intellectual disabilities, these infantile autism when the condition was first
rates have decreased with earlier detection and recognized officially in DSM-III (APA, 1980).
intervention.
In his first description of 11 cases, Kanner
emphasized two essential features: (1) an inborn Categorization
disturbance of affective contact, i.e., with an
apparently congenital “inability to relate” to Autism is presently recognized as one example of
people in usual ways, and (2) difficulties with the pervasive developmental disorders. The latter
change/insistence on sameness, including motor term was coined in 1980 for the overarching
stereotypies, which Kanner viewed as an attempt category of which autism was the prototype in
by the child to maintain sameness. Although he DSM-III (APA, 1980) and is synonymous with
did not emphasize communication problems as the more frequently used term “autism spectrum
central to the definition of the condition, he did disorder.” Over time, the categorical definition of
note a variety of unusual communication features autism has evolved in some ways since Kanner’s
including mutism (in many cases) and, for those first description. The current ICD-10/DSM-IV
with speech, pronoun reversal and echolalia. definitions of childhood autism are essentially
Although remaining profoundly influential, his the same (ICD-10, which has both a clinical and
original description also was misleading in research version, provides more potential for dif-
some respects, e.g., he did not appreciate the ferentiation of atypical presentations of autism;
extent of cognitive (although often highly see DSM-IV entry). In the current approach,
scattered) delays and his mention of high SES associated medical conditions (if any) and other
levels in parents suggested that the disorder was developmental and psychiatric problems (e.g.,
somehow more frequent in highly educated fam- intellectual disability) are also coded in the
ilies. The latter contributed to an early mistaken multiaxial approach adopted by DSM-IV (Rutter
impression that care-taking contributed to patho- et al., 1969). Although rates of association of
genesis. His use of the term “autism” was based autism with other medical conditions have been
on Bleuler’s early use of the word to describe much debated, the strongest associations are with
self-centered thinking in schizophrenia – this a limited number of genetic conditions such as
suggested a connection to childhood schizophre- Fragile X syndrome and tuberous sclerosis
nia/psychosis that proved unwarranted. On the (Rutter, Bailey, Bolton, & Le Couter, 1994).
other hand, Kanner’s emphasis on developmental
aspects of early social skills and his rich
description were a landmark in the field. Epidemiology
Early research on the condition was compli-
cated by confusion of the condition with Many epidemiological studies have now been
childhood psychosis/schizophrenia and the conducted. The median rate of autistic disorder
emphasis on possible environmental/experiential (if strictly defined) is somewhere between 1 in
factors in causation. Over time, the work of 800 to 1,000 individuals (Fombonne, 2005).
Kanner (1971) and Rutter (1972) helped clarify Although there is a widespread impression of
the lack of association with schizophrenia, and increased rates of autism changes in diagnostic
follow-up studies noted association with factors criteria, increased public awareness, better diag-
strongly suggestive of a familial, brain-based nosis among more cognitively able individuals,
disorder (Folstein & Rutter, 1977; Volkmar & and other factors likely account for much of this
Nelson, 1990). Rutter (1978) proposed a highly impression. Smaller and more thorough studies
influential definition of autism based on the also report higher rates.
There is a noteworthy male predominance in reasonable agreement that after age 3 years the
autism (usually between three and five times as diagnosis becomes relatively stable (prior to that
many cases in boys than in girls), but among time some, but not all diagnostic features, may be A
lower IQ individuals the difference becomes apparent). Often social-communication problems
less pronounced. Conversely among the most are more dramatic in younger children, but the
cognitively able persons, the difference is even required difficulties with change/stereotyped
more striking. Cultural and ethnic issues have mannerisms may be the last to develop.
been relatively uncommonly studied. Clearly, By school age, children with autism often
the early impression of a high-SES class predom- develop more social interest but also may have
inance was unfounded (likely reflecting selective more behavioral difficulties (Loveland & Tunali-
bias in initial referrals) (Grinker, 2007). Within Kotoski, 2005). The latter can include agitation,
the United States, there is more concern about motor mannerisms, and self-injurious behavior.
underdiagnosis in individuals coming from lower As first noted by Kanner in adolescence, some
SES/poverty (Mandell, Ittenbach, Levy, & Pinto- children make gains while others lose ground
Martin, 2007). Cultural issues may impact treat- (Kanner, 1971; Shea & Mesibov, 2005). More
ment with considerable variations in entitlements and more adults are able to be self-sufficient
and practice from country to country. with many now attending college and
postsecondary school programs (Volkmar &
Wiesner, 2009). Positive prognostic factors
Natural History, Prognostic Factors, and include higher levels of language and cognitive
Outcomes ability around age 5 years (prognosis can be dif-
ficult, however, and presumably depends on
The long-term outcome for children with autism a range of factors) (Coplan, 2000).
appears to be improving (see Howlin, 2005).
This does not appear to simply be a result of
increased diagnosis among more able individ- Clinical Expression and
uals. Rather earlier detection and intervention Pathophysiology
appear to have an important positive benefit for
most children (National Research Council, Marked changes over the course of develop-
2001). Over time, the number of individuals ment are common. A unifying theme, however,
with autism who are capable of adult self- across development is the persistence of social
sufficiency and independence as adults has difficulties. Although early speculation cen-
increased substantially. That being said, even tered on the possible relevance of experience
with provision of good programs, not every to pathogenesis, many different lines of
child makes substantial improvement. Various research have strongly implicated neurobiolog-
issues, including factors apart from the child, ical factors. This work includes the observation
can impact outcome, e.g., in some countries, of markedly increased rates of epilepsy as well
available services are limited, and even in more as various persistent neurological signs and
developed countries, factors like poverty may symptoms (Minshew, Sweeney, Bauman, &
delay or impede case detection and service Webb, 2005; Volkmar & Nelson, 1990). Over
provision. the last decade, new approaches to neuromaging
Diagnostic issues are most complex in young have also illustrated areas of possible difference
children (those under 3), although the increased associated with autism relative to factors such
body of work on infants and infant siblings of as perception of biological motion or relevance
children with autism has contributed to greater of faces (Schultz et al., 2000; Pinkham,
awareness of the diagnostic challenges and need Hopfinger, Pelphrey, Piven, & Penn, 2008).
for more robust methods of early detection A growing body of research has focused
(Chawarska, Klin, & Volkmar, 2008). There is on social information processing in the
A 374 Autistic Disorder
brain – areas of interest include structures such severe communication problems. In mental retar-
as the amygdala (e.g., in social perception and dation without autism, social skills are usually
social thinking), frontal lobe regions and other not dramatically different from other cognitive
areas involved in social information processing, abilities and may be an area of strength.
and the fusiform face area. A common source of confusion is the frequent
Postmortem studies have revealed some abnor- presence of stereotyped mannerisms in associa-
malities in specific brain regions as well as tion with severe intellectual impairment.
changes in overall architecture of the fine structure As a practical matter, stereotyped mannerisms
of the brain (Casanova, 2007). Animal model are not particularly diagnostic of themselves
work was originally limited to lesion studies and have significance for autism only when
(Bachevalier & Loveland, 2006) but now includes associated with social-communication deficits.
genetic studies (e.g., based on knock out gene Children, adolescents, and adults with autism
models) (Gupta & State, 2007). The strong role typically have problems in various areas (cogni-
of genetic factors has been suggested by various tion, adaptive functioning, communication,
studies of siblings who are at substantially social skills, and behavioral difficulties). Many
increased risk for autism. It appears that multiple different tests have been developed for purposes
genes are involved (O’Roak & State, 2008). Sev- of screening (Coonrod & Stone, 2005) and diag-
eral approaches have been used to identify poten- nosis (Lord & Corsello, 2005). Children with
tial contributing genetic mechanisms (Abrahams autism present many challenges for assessment,
& Geschwind, 2008). and considerable skills may be needed (Volkmar
Although the lay press has devoted consider- & Wiesner, 2009). Provision of a comprehensive,
able attention to the role of environmental factors integrated view of the individual (attending to
(including immunizations) in autism, substantive both strengths and weaknesses) with provision
data are lacking (Offit, 2008; Wing and Potter, of an intervention program should be the goal of
2008). assessment (Volkmar & Wiesner, 2009).
Evaluation and Differential Diagnosis Treatment
Autism presents several major challenges for eval- A substantial body of work supports the use of
uation and diagnosis. Challenges include marked behavioral and educational interventions in autism
variability in skills, involvement of a range of (Volkmar & Wiesner, 2009). Increasingly much of
service providers, and the potential for major this work is strongly evidence based (Reichow &
change with intervention. Autism should be dif- Wolery, 2009). The most effective programs rely
ferentiated from other related disorders as well as on behavior modification and special education
other developmental disorders (e.g., of language with a goal of minimizing negative effects of
or intellectual development) and from unusual autism on learning and maximizing more norma-
profiles of development associates with sensory tive developmental processes. Drug treatments
difficulties (e.g., deafness) or with severe neglect. can be helpful in some instances (particularly for
Differences between autism and related disorders agitation and behavioral difficulties) but do not
as defined in DSM-IV and ICD-10 relate both to seem to address core social dysfunction (at least
historical information and current clinical presen- to date). Agents like the second-generation neuro-
tation (key features are summarized in Table 1). leptic risperidone have been shown, in double-
Assessment is complicated by the often strik- blind studies, to be more effective than placebo
ingly varied cognitive profiles. In autism, nonver- (McCracken et al., 2002).
bal skills are typically more preserved than verbal Alternative and complementary treatments are
ones. In language disorders, social interest and common but lack substantive efficacy data.
motivation remain even in the face of sometimes Parents should be helped to understand the
Autistic Disorder, Table 1 Differential diagnostic features of autism and nonautistic pervasive developmental
disorders
Feature
Autistic
disorder
Asperger’s
disorder
Rett’s
disorder
Childhood Pervasive developmental
disintegrative disorder disorder NOS
A
Age at recognition 0–36 Usually 5–30 >24 Variable
(months) >36
Sex ratio M>F M>F F (?M) M>F M>F
Loss of skills Variable Usually not Marked Marked Usually not
Social skills Very poor Poor Varies Very poor Variable
with age
Communication skills Usually poor Fair Very poor Very poor Fair to good
Circumscribed Variable Marked NA NA Variable
interests (mechanical) (facts)
Family history – Sometimes Frequent Not No Sometimes
similar problems usually
Seizure disorder Common Uncommon Frequent Common Uncommon
Head growth No No Yes No No
decelerates
IQ range Severe MR to Mild MR to Severe MR Severe MR Severe MR to normal
normal normal
Outcome Poor to good Fair to good Very poor Very poor Fair to good
M male, F female, MR mental retardation, NA not applicable
Adapted, with permission, from Volkmar, F. R., & Cohen, D. (1985). Nonautistic pervasive developmental disorders.
In R. Michaels et al. (Eds.), Psychiatry (chap. 27.2, p. 4). Philadelphia, PA: Lippincott-Raven
importance of pursuing proven treatments social-emotional behavior in autism. Neuroscience

(Volkmar & Wiesner, 2009). Except in selected and Biobehavioral Reviews, 30(1), 97–117.
Casanova, M. F. (2007). The neuropathology of autism.
cases, traditional psychotherapy is not usually Brain Pathology, 17(4), 422–433.
helpful, and even in these cases, it often takes Chawarska, K., Klin, A., & Volkmar, F. (Eds.). (2008).
on a much more explicit, “life coaching,” model. Autism spectrum disorders in infants and toddlers:
Diagnosis, assessment, and treatment. New York:
Guilford Press.
Coonrod, E. E., & Stone, W. L. (2005). Screening for
See Also autism in young children. In F. Volkmar, A. Klin,
R. Paul, & D. J. Cohen (Eds.), Handbook of autism
▶ Asperger’s Disorder and pervasive developmental disorders (3rd ed.).
New York: Wiley.
▶ DSM-IV Coplan, J. (2000). Counseling parents regarding prognosis
▶ Pervasive Developmental Disorder Not in autistic spectrum disorder. Pediatrics, 105(5), E65.
Otherwise Specified Folstein, S., & Rutter, M. (1977). Genetic influences and
infantile autism. Nature, 265(5596), 726–728.
Fombonne, E. (2005). Epidemiological studies of perva-
sive developmental disorders. In F. R. Volkmar, A.
References and Readings Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of
autism and pervasive developmental disorders
Abrahams, B. S., & Geschwind, D. H. (2008). Advances in (3rd ed., Vol. 1, pp. 42–69). Hoboken, NJ: Wiley.
autism genetics: on the threshold of a new neurobiol- Grinker, R. R. (2007). Unstrange minds. New York: Basic
ogy. (erratum appears in Nat Rev Genet. 2008 Jun; Books.
9(6):493). (Research Support, N.I.H., Extramural Gupta, A. R., & State, M. W. (2007). Recent advances in
Research Support, Non-U.S. Gov’t Review). Nature the genetics of autism. Biological Psychiatry, 61(4),
Reviews Genetics, 9(5), 341–355. 429–437.
American Psychiatric Association. (1980). Diagnostic Howlin, P. (2005). Outcomes in autism spectrum disorders.
and statistical manual. Washington, DC: APA Press. In F. R. Volkmar, A. Klin, R. Paul, & D. J. Cohen (Eds.),
Bachevalier, J., & Loveland, K. A. (2006). The Handbook of autism and pervasive developmental disor-
orbitofrontal-amygdala circuit and self-regulation of ders (3rd ed., Vol. 1, pp. 201–222). Hoboken, NJ: Wiley.
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Kanner, L. (1971). Follow-up study of eleven autistic Rutter, M. (1972). Childhood schizophrenia reconsidered.
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Reichow, B., & Wolery, M. (2009). Comprehensive Definition
synthesis of early intensive behavioral interventions
for young children with autism based on the UCLA In 1887, J. Langdon Down coined the term “idiot-
young autism project model. Journal of Autism and
savant” to describe intellectually handicapped
individuals with outstanding talents. Subsequent
Autobiographical Memory 377 A
research has suggested that these skills are most There is a final fundamental question that results
commonly seen in the domains of art, music, and from the definitional shift from “idiot-savant” to
numerical calculation. A change in terminology savant syndrome. There is currently no consensus A
from “idiot-savant” to “savant syndrome” was about whether intellectually able, talented indi-
later proposed by Treffert (1989) who also viduals with autism should be accorded savant
outlined a hierarchical system for categorizing status (see Heaton & Wallace, 2004; Miller,
levels of talent proficiency. In addition to 1998). The rise in the numbers of intellectually
avoiding the negative connotations of the earlier able individuals diagnosed with autism and ASD,
term, Treffert’s new term reflected an increased and the observed increase in the prevalence of
awareness that intellectual disability was not special talents in these groups (Howlin et al.,
a necessary feature of the savant syndrome. 2009), bring the importance of resolving this
Although savant skills have been described question into focus. The study of savant
in individuals with Tourette’s syndrome, syndrome has implications for both theory and
frontotemporal dementia, manic depression, lan- practice, and the development of new definitions
guage impairment, and congenital blindness, the and methodologies will be an important future
savant syndrome is most strongly associated with goal for psychologists working in this area.
autism spectrum disorders. The early prevalence
rate for savant skills, based on parental report,
was 9.8%, a figure that was ten times greater than See Also
in intellectually handicapped populations
(see Heaton & Wallace, 2004, for details). ▶ Enhanced Perceptual Functioning
However, in the most recent investigation of ▶ Treffert, Darold
savant-type skills, Howlin, Goode, Hutton, and ▶ Weak Central Coherence
Rutter (2009) observed greatly increased preva-
lence rates and suggested that up to a third of
individuals with autism may possess unusual References and Readings
talents.
Prominent theoretical accounts of autism have Heaton, P., & Wallace, G. L. (2004). Annotation:
The savant syndrome. Journal of Child Psychology
implicated atypical cognitive processing and
and Psychiatry, 45(5), 899–911.
enhanced perceptual discrimination and memory Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2009).
in the emergence of talents (see Mottron, Savant skills in autism: Psychometric approaches and
Dawson, & Soulieres 2009). However, it has parental reports. Philosophical Transactions of the
Royal Society B: Biological Sciences, 364(1522),
also been suggested that enhanced pattern detec-
1359–1367.
tion, systematizing tendencies, exceptional rote Miller, L. K. (1998). Defining the savant syndrome.
memory, and obsessive traits are important Journal of Developmental and Physical Disabilities,
characteristics that will be observed in savants. 10, 73–85.
Mottron, L., Dawson, M., & Soulieres, I. (2009).
There are several major challenges facing
Enhanced Perception in savant syndrome: Patterns,
researchers working in this area. First are diffi- structure and creativity. Philosophical Transactions
culties in determining exactly how the definitions of the Royal Society B: Biological Sciences,
of Treffert’s (1989) three-tier categories should 364(1522), 1385–1391.
Treffert, D. A. (1989). Extraordinary people: Under-
be operationalized. Quantifying skill levels in
standing “idiot-savants”. New York: Harper & Row.
domains like art and music, where standardized
assessments are not available, introduces
a degree of subjectivity that could compromise
cross-group comparisons. Some savant skills, for
example, calendar calculating, are rare in typical Autobiographical Memory
populations, and questions about appropriate
comparison groups must be carefully addressed. ▶ Episodic Memory
A 378 Autobiographical Writings
on the basis of parental report, neuropsychologi-

Autobiographical Writings cal evaluation, and clinical assessment of
behaviors. This was followed by a long tradition
Laura Crane of research on individuals with autism that
Department of Psychology, Goldsmiths, provided further insight into the nature of the
University of London, New Cross, London, UK condition, often on individuals with low intellec-
tual abilities who may not be able to verbally
express their experiences (e.g., Hermelin &
Definition O’Connor, 1970). It was not until much later
that (often, but not exclusively, high-functioning)
Autobiographical writings refer to personal individuals provided their own personal reports
narratives about the self. The autobiographical of living with autism. Complementing the earlier
writings of individuals with autism include life clinical accounts and experimental investiga-
stories, memoirs, letters to correspondents, online tions, these autobiographical writings enabled
blogs and articles, entries in online chat rooms, a greater understanding of the experience of liv-
and accounts of experiences (as told to ing with autism.
researchers or clinicians). Notable autobiograph-
ical writings in the autism field include those of
Temple Grandin, Donna Williams, David Current Knowledge
Miedzianik, Lianne Holliday Willey, Therese
Jolliffe, Wendy Lawson, Daniel Tammet, and Theories of autism would predict that individuals
Tito Mukhopadhyay. While some autobiograph- with autism would not elect to express their
ical writings of individuals with autism were thoughts, feelings, and emotions through
originally intended for publication, others were autobiographical writings. As well as displaying
initially private correspondence that has been impairments in aspects of the self (including
made public at a later date. Many autobiograph- self-awareness, self-referential cognition, and
ical writings are solely the work of an individual introspection), individuals with autism character-
with autism, while others have been edited or istically have written and verbal communication
cowritten, usually by an individual without difficulties. Despite this, more than 50 autobiog-
autism. Although some autobiographical works raphies and memoirs of individuals with autism
explicitly outline the degree of editing and/or have been published, and several more appear
cowriting by individuals without autism, this is online. Autobiographical writings have also
not always the case. Autobiographical writings appeared in the form of entries in chat rooms
have been used as a tool through which one can and blogs, as well as letters or articles. They are
gain an “inside” view of living with an autism clearly a popular method of expression for indi-
spectrum disorder. Individuals with autism have viduals with autism.
also used their autobiographical writings for Autobiographical writings have provided
purposes of advocacy, using their personal researchers, clinicians, and the general public
experiences to enable people to have a better with comprehensive and insightful accounts of
understanding of autism. living with autism from a personal perspective.
One of the most well-known individuals with
autism to have produced autobiographical
Historical Background works is Temple Grandin – a highly successful
and articulate professor of animal science, who
Early clinical accounts of autism (e.g., Asperger, was diagnosed with autism as a child. These
1944/1991; Kanner, 1943) provided an insight writings include her autobiography Emergence
into the world of autism from an observer per- (which was edited by a children’s writer) in
spective, making inferences about the individual addition to a number of articles that were
Autobiographical Writings 379 A
independently written (e.g., Grandin, 1984). of 11. Tito’s autobiographical writings are
Marked differences between her entirely self- largely his own work and, to ensure the integrity
produced and her externally edited autobio- of his writings, all changes or additions by editors A
graphical writings have been noted, the former or cowriters have been carefully and clearly
exhibiting a higher number of written character- noted in the text.
istics that are typical of an individual with In between these two extremes of the autism
autism. These include unexplained changes in spectrum are individuals such as David
topic and a failure to provide readers with perti- Miedzianik and Barry (both of which are
nent background information that is necessary to documented in Happé, 1991), who perhaps
fully understand the text (see Happé, 1991, for represent a more typical existence on the (verbal)
an analysis of this work). Sacks (1995) referred autism spectrum. Barry’s letters to
to Grandin’s Emergence as “unprecedented,” as a correspondent were entirely self-motivated
this was the first “inside narrative” of autism. works that received no external editing. They
Another high-functioning female autobiogra- displayed features of autism including social
pher who has been diagnosed with autism is naivety, perseveration on topics, the use of
Donna Williams. As well as authoring parroted material, and the introduction of topics
a number of autobiographies (including Nobody without providing sufficient background infor-
Nowhere and Somebody Somewhere), Williams mation for readers. In contrast, David
shares her autobiographical writings through an Miedzianik’s autobiographical writings (despite
online blog, which provides regular autobio- flitting between one subject to another) demon-
graphical entries. In recent years, several other strate consideration for the reader’s state of knowl-
high-profile individuals with autism have edge, usually introducing information with an
elected to use online blogging as a means of explanation. As with the majority of autobiograph-
communicating their autobiographical writings. ical writings in autism, these two cases clearly
These include Daniel Tammet (an adult with demonstrate the striking range of abilities (and
autism famed for his remarkable memory abili- disabilities) found within the autism spectrum.
ties), who has also published a memoir of his Researchers and clinicians have used the
life, Born on a Blue Day. Blogging has become autobiographical writings of individuals with
an increasingly popular tool for individuals with autism to gain an insight into the mind of indi-
autism in recent years and, as they are easily viduals with this disorder. Autobiographical
updatable, blogs are a useful and rapid means writings can provide readers with personal
of communicating the current thoughts of indi- accounts of the core symptoms of autism (for
viduals with autism. example, specifying real-world instances of
Although the published autobiographical social and communication difficulties, or repet-
writings and blogs of high-functioning adults itive behaviors, interests, and activities). In par-
with autism have provided an insight into the ticular, they provide a stark reminder of the
experiences of autism at one extreme of the different manifestations of the key signs and
autism spectrum, autobiographical writings have symptoms of autism in different individuals.
also stemmed from individuals with autism that This can allow professionals to better under-
have more disabling communication impair- stand the specific needs of individuals with
ments. Tito Mukhopadhyay is a writer and poet autism. The actual writings themselves can
who is nonverbal, but communicates through his also provide an insight into the features of the
sophisticated writings. He therefore allows disorder. For example, the writings of individ-
readers a window onto life with autism and severe uals with autism often demonstrate commonly
communication difficulties. He is also one of the noted characteristics of autism including persev-
few individuals with autism to have produced eration on topics of interest, unusual changes in
writings as a child, writing The Voice of Silence topic, a lack of empathy, and a failure to appre-
at the age of 8 and Beyond the Silence at the age ciate the prior knowledge of the reader. Writing
A 380 Autobiographical Writings
about personal thoughts, feelings, and experi- who produce autobiographical writings must
ences may be a medium of choice for individuals have a relatively high degree of written language
with autism as this removes the need for social abilities. Not only are the majority of these indi-
interactions and spoken communication. This is viduals among the most verbally fluent and
especially true of online blogging and chat intellectually able persons on the autism spec-
rooms, which have become a very popular trum, their autobiographical writings have
means for sharing autobiographical writings tended to make them celebrities within the
and experiences in recent years. This vehicle of autism field. As such, their experiences (espe-
communication has been used to help typical cially in their latter years) are perhaps somewhat
individuals understand more about autism. It atypical of the everyday experiences of individ-
can also provide a forum for individuals with uals with autism. Problems therefore arise
autism to discuss their interests and may allow regarding the generalizability of their writings,
an insight into the strengths and weaknesses of and it is important for future research to examine
the autism community. a wide range of autobiographical writings, from
individuals across different levels of the autism
spectrum. Although researchers have explored
Future Directions online writings of individuals with autism (e.g.,
Jones, Zahl, & Huws, 2001), which affords an
Although researchers have attempted to study, insight into the experiences of a broader range of
and make inferences from, the autobiographical individuals with autism, questions concerning
writings of individuals with autism, there are authenticity arise.
many difficulties faced when interpreting these Third, there is a lack of an appropriate
writings. First, such an analysis often requires comparison group against which to compare
a subjective approach to interpretation. Qualita- the autobiographical writings of individuals
tive researchers must make judgments about the with autism. Most published autobiographical
underlying motivations and intentions of individ- writings are from typical adults, usually those
uals with autism, which may be erroneous and in the public eye with rather unusual lives
lead to both false-positive and false-negative con- (e.g., politicians, celebrities) or from profes-
clusions (see Happé, 1991, for a discussion). sional writers. These do not provide suitable
Using a more quantitative approach, researchers comparisons for the autobiographical writings
have used content analytic techniques to examine of individuals with a neurodevelopmental disor-
the frequency of specific terminology or phrases der. Some researchers have compared the auto-
within autobiographical writings (e.g., Crane & biographical writings of adults with autism with
Goddard, 2008; Crane, Goddard, & Pring, 2010). those of adults with schizophrenia (see Happé,
This technique may be overly superficial and 1991, for a comparison of Grandin’s autobio-
especially problematic given the language and graphical writing with that of a female with
communication atypicalities noted in individuals schizophrenia), but these comparisons are lim-
with autism. Future research should attempt to ited. The selection of a suitable comparison
merge both qualitative and quantitative group is also confounded by the lack of interest
approaches to the assessment of autobiographical in works of fiction that is commonly noted in
writings in autism. individuals with autism (Happé, 1991). As this
A second issue regards how the autobio- group may not read fictional works to the same
graphical writings of individuals with autism degree as typical adults, this may influence the
are typically from a very able and high- content and structure of their autobiographical
functioning subgroup of individuals with the writings. These difficulties mean that it is prob-
disorder. Although some published works are lematic to draw inferences on the typicality or
from individuals with severe communication atypicality of the autobiographical writings of
difficulties (e.g., Tito Mukhopadhyay), those this group, or to determine how they are similar
Autobiographical Writings 381 A
to or different from the writings of individuals veridical representations of the past – they are
without autism. The selection of a range of reconstructions of experiences. As such, doubts
appropriate comparison works is crucial for can be raised concerning the accuracy of the A
future research in this area. events and experiences referred to in the autobio-
Another important direction for future graphical writings of individuals with (and
research is to establish the degree to which the without) autism. This is an important factor to
autobiographical writings of individuals with take into account when evaluating, and drawing
autism are the work of the individual themselves. inferences from, the autobiographical writings of
Published autobiographical writings (in particu- individuals with autism (as well as the writings of
lar, life stories, memoirs, and autobiographies) typical comparison adults).
are often subject to high levels of editing or
rewriting by publishers, editors, or cowriters.
Indeed, Temple Grandin’s autobiographical See Also
work Emergence was cowritten with
a children’s writer who rewrote and formatted ▶ Advocacy
sections of the book and structured it to make it ▶ Asperger Syndrome
easier to read. This significantly limits the ▶ Autistic Savants
conclusions that can be drawn from the autobio- ▶ Episodic Memory
graphical text itself. Indeed, Grandin’s ▶ Expressive Language
autobiographical writing My Experiences as an ▶ Giftedness
Autistic Child is markedly different to Emergence ▶ High-Functioning Autism (HFA)
and displays several characteristics that are typi- ▶ Memory
cal of an adult on the autism spectrum ▶ Narrative Assessment
(e.g., switching between topics, failing to provide ▶ Savant Skills (in Autism)
the reader with pertinent background knowledge
regarding a topic). Analysis of writings that
clearly delineate the text composed by individ- References and Readings
uals with autism and that inserted or changed by
editors or cowriters is important for future Asperger, H. (1944/1991). “Autistic psychopathy” in
childhood. In U. Frith (Ed.), Autism and Asperger
research, as is the analysis of online writings,
syndrome (pp. 37–92). Cambridge: Cambridge
which tend to be solely the work of the individual University Press.
with autism (without subsequent editing). Chamak, B., Bonniau, B., Jaunay, E., & Cohen, D. (2008).
Future research could also consider gender What can we learn about autism from autistic persons?
Psychotherapy and Psychosomatics, 77, 271–279.
differences in the autobiographical writings of
Crane, L., & Goddard, L. (2008). Episodic and semantic
individuals with autism. Despite a higher number autobiographical memory in adults with autism spec-
of males than females being diagnosed with trum disorder. Journal of Autism and Developmental
autism, it appears that more women with autism Disorders, 38(3), 498–506.
Crane, L., Goddard, L., & Pring, L. (2010). Self-defining
express themselves in writing and publish their
and everyday autobiographical memories in adults
work. Future work should therefore aim to com- with autism spectrum disorder. Journal of Autism and
pare the autobiographical writings of males and Developmental Disorders, 40(3), 383–391.
females with autism, to ascertain whether there Grandin, T. (1984). My experiences as an autistic child
and review of selected literature. Journal of Orthomo-
are similarities or differences in the expressions lecular Psychiatry, 13, 144–175.
of these writings. Grandin, T., & Scariano, M. (1986). Emergence: Labeled
A final point to note regarding the autobio- autistic. Novato, CA: Arena Press.
graphical writings of individuals with autism Hacking, I. (2009). Autistic autobiography. Philosophical
Transactions of the Royal Society B: Biological
concerns their recall of personal experiences.
Sciences, 364(1522), 1467–1473.
Research on autobiographical memories has Happé, F. G. E. (1991). The autobiographical writings of
shown that memories of personal events are not three Asperger syndrome adults: Problems of
A 382 Autonomous Living
interpretation and implications for theory. In U. Frith

(Ed.), Autism and Asperger syndrome. Cambridge, Aversive/Nonaversive Interventions
MA: Cambridge University Press.
Hermelin, B., & O’Connor, M. (1970). Psychological
experiments with autistic children. Oxford: Pergamon Michael D. Powers
Press. The Center For Children With Special Needs,
Holliday Willey, L. (1999). Pretending to be normal. Glastonbury, CT, USA
Living with Asperger’s syndrome. London: Jessica
Kingsley.
Jolliffe, T., Lansdown, R., & Robinson, C. (1992).
Autism: A personal account. Communication, 26, Definition
12–19.
Jones, R. S. P., Zahl, A., & Huws, J. C. (2001). First-hand
accounts of emotional experiences in autism: Aversive and nonaversive interventions refer as
A qualitative analysis. Disability and Society, 16, much to a dynamic yet functional definition of
393–401. both terms as to a set of intervention procedures.
Kanner, L. (1943). Autistic disturbances of affective con- From a technical point of view, an aversive inter-
tact. The Nervous Child, 2, 217–250.
Lawson, W. (1998). Life behind glass. A personal account vention involves the application of an aversive
of autism spectrum. London: Kingsley. stimulus. This would include a noxious event that
Mukhopadyay, T. R. (2000). The mind tree: A miraculous serves as a punisher when it follows behavior,
child breaks the silence of autism. New York: Arcade. one that evokes a behavior that has terminated
Sacks, O. (1995). An anthropologist on mars: Seven par-
adoxical tales. New York: Knopf. the noxious stimulus in past circumstances, or
Tammet, D. (2006). Born on a blue day: A memoir of one that functions as a reinforcer when it is
Aspergers and an extraordinary mind. London: removed after the occurrence of a behavior
Hodder & Stoughton. (Cooper, Heron, & Heward, 2007). A
Volkmar, F. R., & Cohen, D. J. (1985). The experience of
infantile autism: A first-person account by Tony W. nonaversive intervention involves the application
Journal of Autism and Developmental Disorders, 15, of positive reinforcement and/or extinction con-
47–54. tingencies as a consequence to a behavior, or
Williams, D. (1992). Nobody nowhere: The remarkable alteration of the intensity, duration, or magnitude
autobiography of an autistic girl. London: Jessica
Kingsley. of a behavior contingent upon the removal or
Williams, D. (1994). Somebody somewhere: Breaking free presentation of an antecedent stimulus.
from the world of autism. London: Jessica Kingsley.
While treatment in autism has, over the years,

Autonomous Living had many controversies, perhaps none have
been so heated as the discussion of the viability
▶ Independent Living and appropriateness of aversive and
nonaversive procedures to treat a variety of
problems common to the disorder (and to those
with other neurodevelopmental disorders as
Autonomy well). These controversies have pitted, in some-
what of a dichotomous fashion, empirical sci-
▶ Self-advocacy ence against social validity. The result was at
once unfortunate and the stimulus for
a paradigmatic shift. When in its relative
infancy, the science of the experimental analy-
Aventyl Hydrochloride sis of behavior served a very important function:
to prove that even the most recalcitrant of
▶ Nortriptyline human behaviors are subject to the laws of
Aversive/Nonaversive Interventions 383 A
learning and can be improved upon. For gener- imposing the demand to assess for social valid-
ations of clinicians raised on the belief that ity, interventionists had a tool to begin to predict
change was only possible in small increments potential functional relationships between A
for those severely affected by autism, and then change agents and the consumers of change
only through rather drastic psychopharmaco- and to begin to modify those contingencies that
logic interventions, the opportunity to demon- might interfere with long-term maintenance and
strate progress in reducing self-injury, generalization.
aggression, and other destructive behavior as Within the span of a few years, however,
well as to increase prosocial, adaptive behavior a number of flashpoint events occurred that
was a breakthrough. Applications of more basic sharpened the issues concerning treatment of
operant conditioning principles such as positive those whose autism placed themselves, and
and negative reinforcement, extinction, and others, at the greatest risk. Highly publicized
punishment were tactics of choice during this reports of the deaths of clients in the care of
period. Indeed, clinical significance was often otherwise well-known residential programs fol-
defined only in terms of the magnitude of behav- lowing the use of contingent aversive proce-
ior reduction (the end product) but rarely so by dures (e.g., white noise) changed the
the means of reduction. conversation from one of science alone to
As the 1960s progressed through to the late a discussion of human dignity and the right to
1970s, however, means of intervention appro- effective treatment. Suffice it to say that while at
priately became a more prominent consider- times mean-spirited, personal, and derogatory,
ation. The seminal work on social validity by the power of the objectivity of science won out.
Kazdin (1977) and Wolf (1978) reshaped the Indeed, not only did the National Institutes of
narrative around three key points: not only Health fund a number of collaborative research
must the outcome of intervention be socially centers with the mandate to investigate and
valid but also the target of intervention (behav- develop effective interventions that were
ior to be changed) and also the means to achieve nonaversive, but the NIH later convened
that outcome. As a construct, social validity a consensus conference (National Institutes of
imposes the requirement that all factors be con- Health, 1991) in order to issue guidelines for the
sidered before, during, and after treatment. This use of behavior reduction procedures (including
demand served several important functions. It punishment strategies) when treating destruc-
posed the important question, “socially valid tive behavior in those with developmental dis-
for whom?” Were targets, procedures, and out- abilities. The efforts of established collaborative
comes socially valid for the client, the family, research centers, other scientists working in
institutionally based caregivers? Social validity basic and applied settings, and the general
also raised the question of relativity. At different understanding of the effects (and negative
points in time, for different clients, and under effects) of punishment have led over the past
particular circumstances, a treatment procedure 20 years to a highly developed, evolving, evi-
or outcome might or might not be acceptable. dence-based technology of behavior change
But very importantly, at its base, the question of based upon the use of antecedent and consequent
social validity also raised the issue of the gener- control procedures that do not involve the use of
alizability of behavior change. While behavior aversive stimuli. To be certain, the controversy
analysis had evolved very good technologies of has not ended entirely, as those who empirically
generalization and maintenance (Horner, demonstrate the effective use of punishment
Dunlap, & Koegel, 1988), things did not always procedures as a component of a comprehensive
work out as planned. So-called treatment fail- treatment package would argue (Axelrod,
ures continued to occur, often under the contin- 1990). But, as importantly, the exceptional sci-
gencies of more remote or diverse (and ence being developed to understand the often
sometimes less well-understood) events. By complex functional motivators behind severe
A 384 Aversive/Nonaversive Interventions
behavior continues as well and is especially vis- likelihood of behavior reoccurrence, then the
ible in the efforts of those promoting positive stimulus was aversive. Referring back to the
behavior support initiatives in public schools. discussion of social validity earlier, what is aver-
sive to one person may be reinforcing to another.
The only solution is to assess functionally before
Rationale or Underlying Theory and during treatment implementation.
Ultimately, the rationale about which interven-
Given the extensive research base for both aver- tion strategies to employ in a particular case is
sive and nonaversive interventions, it is reasonable a functional one, clarified by a thorough functional
to conclude that considerations about each are behavior assessment/analysis and subjected to rig-
evidence-based. The important considerations, orous outcome evaluation. In the final analysis,
however, lie in the issue of negative effects and intervention must be effective, that is, it must be
generalizability of effects. Both sets of procedures successful in its outcome and have minimal or no
are based on the principles of operant conditioning negative effects associated with it. Treatment strat-
earlier described by Skinner, with many decades egies that are socially valid and empirically based
of subsequent and substantive empirical exten- will best serve the interests of persons with autism
sions of that work. What has evolved over the and related neurodevelopmental disorders.
years is a toolbox of intervention strategies,
many working best as part of multicomponent
procedures. While there may well be occasions Goals and Objectives
for which a punishment procedure – in combina-
tion with positive reinforcement procedures The selection of intervention strategies is based
designed to increase functionally equivalent, alter- on behavioral function, not form. Function can be
native prosocial behavior – is the least restrictive described in several ways. For example, behavior
intervention option, intervention based on punish- can serve to access positive reinforcement in the
ment alone is rarely advised. form of social attention or access to preferred
Nonaversive interventions are broadly orga- materials. The behavior can be functionally
nized around antecedent strategies (those that reinforced by its ability to terminate an aversive
occur before the problematic behavior is emit- or unpleasant event (negative reinforcement).
ted), with the intention of altering the stimulus These functions can be observed in the presence
control and reinforcing value of the existing of others or when the client is alone. In this latter
antecedent “triggers” for the behavior. Conse- case, we suggest that the behavior can be
quent procedures are those delivered after behav- maintained by the positive or negative
ior has been demonstrated. They can include reinforcing contingencies of sensory stimuli
reinforcement-based procedures, extinction, impinging on the client. In all cases, the stated
and variants of interruption and redirection. In goal of intervention should be to improve the
contrast, aversive interventions involve the behavior of the person with autism by teaching
application of an aversive or unpleasant stimulus appropriate replacement skills while simulta-
immediately following the problem behavior, neously reducing or eliminating the behavior
designed to discourage future occurrence of the that is problematic or that interferes with more
behavior. In all cases, however, whether an inter- adaptive functioning. Specific procedures to
vention is aversive or reinforcing to a client is accomplish this are discussed below.
a functional question. If the application of
a stimulus immediately following demonstration
of a specific behavior increases the probability of Treatment Participants
that behavior occurring, the stimulus was
reinforcing. If presentation of the stimulus Treatment procedures for any given client are
immediately following the behavior reduces the selected based upon the results of the functional
Aversive/Nonaversive Interventions 385 A
assessment/analysis but may be modified to differential reinforcement, and its variants (dif-
address the specific target behaviors selected, ferential reinforcement of other, incompatible,
the learning history (history of reinforcement) high rates, or alternative behavior); response A
of the client with the particular behavior, and interruption and redirection (Underwood, Figue-
the availability of resources and competencies roa, Thyer, & Nzeocha, 1989); extinction
of intervenors. Consideration is also given to (Lerman & Iwata, 1996); and noncontingent rein-
such factors as severity, duration, pervasiveness, forcement, whereby reinforcing stimuli are pro-
and frequency of the target behavior when deter- vided to a client independent of the client’s
mining priorities for intervention. behavior (Carr, Severtson, & Lepper, 2009).
Aversive stimuli are noxious events that
serve as punishers when following a behavior,
Treatment Procedures evoke a behavior that has terminated the nox-
ious stimulus in past circumstances, or function
Treatment procedures for nonaversive interven- as a reinforcer when removed after the occur-
tions can be broadly divided into two groups: ante- rence of a behavior (Cooper et al., 2007). While
cedent interventions that occur prior to the the function of an aversive stimulus is always to
behavior and consequent procedures that are cause the cessation of a behavior, its forms are
implemented after the behavior has been emitted. virtually limitless (Repp & Singh, 1990) and
Both seek to reduce the likelihood of behavioral have included smelling aromatic ammonia,
expression in the future by emphasizing the use of contingent water mist to the face, the applica-
positive reinforcement procedures as a key or col- tion of “white noise,” and electric shock. It is
lateral component of the treatment package. Most noteworthy that while the NIH consensus con-
importantly, all treatment should be preceded by ference clearly emphasized the importance of
a thorough functional behavior assessment or anal- using treatment procedures based on positive
ysis in order to determine which stimuli in the behavioral supports, it also provided clear
environment exert control over the target behavior. guidelines for the use of punishment procedures
Antecedent procedures include errorless learn- when they might be deemed clinically
ing, whereby the student is prompted to the correct necessary.
response immediately after the presentation of the
request; interspersing mastered or easy tasks with
difficult tasks in teaching (Weber & Thorpe, 1992); Efficacy Information
the use of choice in the selection of tasks and
reinforcers (Dyer, Dunlap, & Winterling, 1990); The efficacy of antecedent strategies to treat
reducing the information-processing demands of behavior problems has been well documented in
the task or providing an alternative mode of task the research literature, and several in particular
presentation; use of a high-probability request have been identified as evidence-based proce-
sequence (Zuluaga & Normand, 2008); functional dures (Cooper et al., 2007; Powers, Palmieri,
communication training (Carr & Durand, 1985); D’Eramo, & Powers, 2011). It is important to
stimulus change procedures, whereby a novel stim- remember, however, that the use of an antecedent
ulus that is not an antecedent or a consequence to (or any other) strategy does not guarantee suc-
the behavior is interjected into a behavioral cess. Rather, the use of the procedure must be
sequence, interrupting the response-reinforcer rela- based on the results of the functional behavior
tionship (Carr, Robinson, & Palumbo, 1990); and assessment/functional analysis, must be
environmental modifications such as use of visual implemented with fidelity, and must be evaluated
schedules, curriculum adjustment, etc. (Flannery & accurately and objectively. Violation of any of
Horner, 1994; Kern & Dunlap, 1998). these tenets can (and likely will) reduce the effi-
Consequent procedures with demonstrated cacy and efficiency of the correctly chosen treat-
efficacy include positive reinforcement, ment strategy.
A 386 Aversive/Nonaversive Interventions
Outcome Measurement References and Readings
Objective and reliable measurement of treatment Axelrod, S. A. (1990). Myths that (mis)guide our profes-
sion. In A. C. Repp & N. N. Singh (Eds.), Perspectives
effects and outcomes is essential to the correct
on the use of nonaversive and aversive interventions
use of any procedure designed to increase desir- for persons with developmental disabilities
able behavior or to reduce problem behavior. (pp. 59–72). Sycamore, IL: Sycamore.
Fortunately, the use of single-subject experimen- Carr, E. G., & Durand, V. M. (1985). Reducing behavior
problems through functional communication train-
tal designs (SSEDs) have predominated in the
ing. Journal of Applied Behavior Analysis, 18,
literature (Kazdin, 1982), establishing a robust 111–126.
arsenal of potential designs for outcome measure- Carr, E. G., Robinson, S., & Palumbo, L. W. (1990). The
ment. When well used, SSEDs provide excellent wrong issue: Aversive versus nonaversive treatment.
The right issue: Functional versus nonfunctional treat-
internal and external validity, support the devel-
ment. In A. C. Repp & N. N. Singh (Eds.), Perspec-
opment of reliable observations, and ultimately tives on the use of aversive and nonaversive
contribute to the serial replication of findings. To interventions for persons with developmental disabil-
this latter point, the aggregation of large numbers ities (pp. 361–379). Sycamore, IL: Sycamore Press.
Carr, J. E., Severtson, J. M., & Lepper, T. L. (2009).
of individual studies, each with a small subject
Noncontingent reinforcement is an empirically
pool, can generate strong findings of efficacy supported treatment for problem behavior exhibited
(Reichow, Doehring, Cicchetti, & Volkmar, by individuals with developmental disabilities.
2011). Research in Developmental Disabilities, 30, 44–57.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
Applied behavior analysis (2nd ed.). Upper Saddle
River, NJ: Pearson Education, Inc.
Qualifications of Treatment Providers Dyer, K., Dunlap, G., & Winterling, V. (1990). Effects of
choice-making on the serious problem behaviors of
students with severe handicaps. Journal of Applied
While certainly effective when used correctly,
the technology of intervention requires training Flannery, K. B., & Horner, R. H. (1994). The relationship
in the principles and strategies of applied behav- between predictability and problem behavior for stu-
ior analysis. Obviously, with behavior problems dents with severe disabilities. Journal of Behavioural
Education, 4(2), 157–176.
of greater significance (e.g., where personal
Horner, R. H., Dunlap, G., & Koegel, R. L. (1988). Gen-
safety of the client or others is at risk and where eralization and maintenance: Lifestyle changes in
health status can/may be compromised), the applied settings. Baltimore: Paul H. Brookes.
demand for greater levels of sophistication and Kazdin, A. E. (1977). Assessing the clinical or applied
importance of behavior change through social valida-
competency is critical. At a minimum, supervi-
tion. Behavior Modification, 1, 427–451.
sion of assessment and treatment protocols by an Kazdin, A. E. (1982). Single-case research designs:
individual with Board Certification as a Behavior Methods for clinical and applied settings. New York:
Analyst (BCBA) or by a clinician with equivalent Oxford University Press.
Kern, L., & Dunlap, G. (1998). Curricular modifications to
training and experience would be appropriate. In
promote desirable classroom behavior. In J. K. Luiselli
cases where more extraordinary interventions are & M. J. Cameron (Eds.), Antecedent control: Innova-
necessary, or where the risk of harm is greater, it tive approaches to behavioral support (pp. 289–307).
is strongly advisable to have all clinical aspects Baltimore: Paul H. Brookes.
LaVigna, G. W., & Donnellen, A. M. (1986). Alternatives
peer reviewed and vetted by a human rights to punishment: Solving behavior problems with
committee. nonaversive strategies. New York: Irvington.
Lerman, D. C., & Iwata, B. A. (1996). Developing
a technology for the use of operant extinction in clin-
See Also ical settings: An examination of basic and applied
research. Journal of Applied Behavior Analysis, 29,
▶ Board Certified Associate Behavior Analyst 345–382.
National Institutes of Health. (1991). Treatment of
▶ Differential Reinforcement destructive behaviors in persons with developmental
▶ High-Probability Requests disabilities. NIH consensus development conference.
Avoidant Personality Disorder 387 A
Washington, DC: United States Department of Health Statistical Manual of Mental Disorders (DSM)
and Human Services. nomenclature (see below), is similar – although
Powers, M. D., Palmieri, M. J., D’Eramo, K. S., &
Powers, K. M. (2011). Evidence-based treatment not identical – to anxious personality disorder A
of behavioral excesses and deficits for individuals within the International Classification of Dis-
with autism spectrum disorders. In B. Reichow, eases system (World Health Organization
P. Doehring, D. V. Cicchetti, & F. R. Volkmar [WHO], 1992).
(Eds.), Evidence-based practices and treatments for
children with autism. New York: Springer.
Reichow, B., Doehring, P., Cicchetti, D. V., &
Volkmar, F. R. (Eds.). (2011). Evidence-based prac- Short Description or Definition
tices and treatments for children with autism. New
York: Springer.
Repp, A. C., & Singh, N. N. (Eds.). (1990). Perspectives In the most recent DSM revision, the DSM,
on the use of nonaversive and aversive interventions Fourth Edition (DSM-IV; American Psychiatric
for persons with developmental disabilities. Sycamore, Association [APA], 1994), AVPD is classified as
IL: Sycamore. a personality disorder and is described as “a per-
Underwood, L. A., Figueroa, R. G., Thyer, B. A., &
Nzeocha, A. (1989). Interruption and DRI in the treat- vasive pattern of social inhibition, feelings of
ment of self-injurious behavior among mentally inadequacy, and hypersensitivity to negative
retarded and autistic self-restrainers. Behavior Modifi- evaluation that begins by early adulthood and is
cation, 13, 471–481. present in a variety of contexts” (p. 662). As for
Weber, R. C., & Thorpe, J. (1992). Teaching children with
autism through task variation. Exceptional Children, all personality disorders, this mental and behav-
59, 77–86. ioral pattern “deviates markedly from the expec-
Wolf, M. M. (1978). Social validity: The case for subjec- tations of the individual’s culture,. . . is stable
tive measurement of how applied behavior analysis is over time, and leads to distress or impairment”
finding its heart. Journal of Applied Behavior Analysis,
11, 203–214. (p. 629).
Zuluaga, C. A., & Normand, M. P. (2008). An evaluation
of the high-probability instruction sequence with and
without programmed reinforcement for compliance Categorization
with high probability instructions. Journal of Applied
As indicated above, AVPD is classified within the
Personality Disorders section, on axis II in
DSM-IV. Based largely on an earlier, theoreti-
cally derived construct (Millon, 1981), AVPD
AVLT first appeared as a diagnostic entity in DSM,
Third Edition (DSM-III; APA, 1980). This cate-
▶ Rey Auditory Verbal Learning Test (Rey AVLT) gory grew from a trifurcation of the DSM, Second
Edition (DSM-II; APA, 1968) diagnosis, schizoid
personality – which described individuals with
“shyness, over-sensitivity, seclusiveness, avoid-
Avoidant Personality Disorder ance of close or competitive relationships, and
often eccentricity” (p. 42). The broader DSM-II
Daniel F. Becker schizoid personality construct was, in DSM-III,
Department of Psychiatry, University of subdivided into a more narrowly defined schizoid
California, San Francisco, San Francisco, USA personality disorder, as well as schizotypal and
avoidant personality disorders. Schizotypal per-
sonality disorder was thought to describe those
Synonyms individuals who had previously been diagnosed
with borderline schizophrenia and encompassed
Avoidant personality disorder (AVPD), which the eccentricity noted in the DSM-II description.
has been described within the Diagnostic and The distinction between DSM-III avoidant and
A 388 Avoidant Personality Disorder
schizoid personality disorders was construed as the former study, AVPD was more prevalent than
centering on whether or not the individual had the any other personality disorder; in the latter study,
motivation and capacity for emotional involve- it was the second most prevalent among these
ment with others (APA, 1980; Millon, 1981). disorders. Ekselius et al. (2001) observed gener-
Beginning with DSM, Third Edition, Revised ally that individuals with personality disorders
(DSM-III-R; APA, 1987), AVPD was placed more often were younger, were students or unem-
in the cluster C subcategory of personality ployed, received psychiatric treatment, and
disorders, which are characterized by “anxious lacked social supports.
or fearful” (p. 337) clinical presentations.
DSM-III-R aligned AVPD with the clinical con-
cept of “phobic character” (p. 429) and no longer Natural History, Prognostic Factors, and
suggested that it needed to be mutually exclusive Outcomes
with schizoid personality disorder. In DSM-IV,
AVPD remains in cluster C, along with depen- Unfortunately, relatively few studies have
dent and obsessive-compulsive personality directly examined AVPD (Alden, Laposa,
disorders. Taylor, & Ryder, 2002). Instead, most have con-
Although initially formulated in DSM-III as sidered AVPD along with other personality dis-
a monothetic criterion set – requiring, for the orders – in the service of understanding
diagnosis, all five possible symptom criteria – personality pathology more broadly – or within
subsequent revisions have constructed AVPD as the context of studying the effects of comorbid
a polythetic set, requiring any four of seven pos- AVPD on axis I psychiatric disorders. As a result,
sible criteria. Each successive revision – from relatively little is known about the natural history
DSM-III to DSM-III-R, and from DSM-III-R to and progression of AVPD. DSM-IV (APA, 1994)
DSM-IV – has involved adding, deleting, and notes that avoidance often begins in childhood
rewording various criteria. These changes have with shyness – but that, while shyness in most
been based, in part, on empirical evidence individuals dissipates with age, those who pro-
(Baillie & Lampe, 1998; Becker, Añez, Paris, gress to develop AVPD will often become
Bedregal, & Grilo, 2009; Grilo, 2004; increasingly shy and avoidant during adolescence
Hummelen, Wilberg, Pedersen, & Karterud, and young adulthood. Evaluation of the child-
2006). hood antecedents of AVPD has shown that adults
with AVPD – in relation to relevant clinical com-
parison groups – report poorer athletic perfor-
Epidemiology mance during childhood and adolescence, less
involvement in hobby activities during adoles-
Investigations in clinical samples have shown cence, and diminished adolescent popularity
AVPD to be among the most frequently diag- (Rettew et al., 2003).
nosed personality disorders (Alnæs & Torgersen, Personality disorder stability has been shown,
1988; Stuart et al., 1998). Although previous in general, to be modest; for AVPD, 2-year remis-
editions of the DSM indicated only that AVPD sion rates as high as 50% have been reported by
is “apparently common” (APA, 1980, p. 323, the Collaborative Longitudinal Personality Dis-
1987, p. 352) in the general population, DSM-IV orders Study (Grilo et al., 2004). These investi-
states that the general prevalence of this disorder gators have also suggested that personality
is between 0.5% and 1.0% (APA, 1994). How- disorders are hybrids of traits and symptomatic
ever, two large, community-based studies – using behaviors, with the former being more stable. The
DSM-III-R (Torgersen, Kringlen, & Cramer, interaction of these elements over time helps to
2001) and DSM-IV (Ekselius, Tillfors, Furmark, determine diagnostic stability. For AVPD, the
& Fredrikson, 2001) criteria – both yielded much trait-like criteria – which are the most prevalent
higher rates of 5.0% and 6.6%, respectively. In and stable – include regarding oneself as socially
Avoidant Personality Disorder 389 A
inept, feeling inadequate compared to others, and • Is preoccupied with being shamed or rejected
wanting evidence of being liked before making in social situations
social contact (McGlashan et al., 2005). These • Views self as socially inept, personally unap- A
observations suggest that the course, persistence, pealing, or inferior to others
and severity of AVPD – as for all personality • Is unusually reluctant to take personal risks or
disorders – depend upon an interaction of person- to engage in any new activities because they
ality traits and the individual’s behavioral adap- may prove embarrassing
tations to these traits (Lilienfeld, 2005). The Given the polythetic nature of this and other
functional consequences of AVPD are generally DSM-IV personality disorder constructs, psycho-
significant – having a more profound effect on metric studies – especially those demonstrating
psychosocial adaptation than, for instance, major a simple factor structure and good internal con-
depression (Skodol et al., 2002). sistency – have played a key role in establishing
construct validity of AVPD. Overall, such studies
have demonstrated high internal consistency and
Clinical Expression and a unidimensional structure for the DSM-IV
Psychopathology AVPD criterion set (Becker, Añez, Paris,
Bedregal, & Grilo, 2009; Grilo, 2004;
In a seminal description of the AVPD construct, Hummelen, Wilberg, Pedersen, & Karterud,
Millon (1981) describes four levels of clinical 2006).
data that may help in the diagnosis: (1) behavioral
features (e.g., shyness or timidness, apprehen-
siveness or guardedness, touchiness, evasiveness, Evaluation and Differential Diagnosis
restraint of emotional expression, and physical
underactivity with periodic bursts of fidgeting); Although few data exist regarding the diagnostic
(2) self-descriptions or complaints (e.g., feeling process as it relates to AVPD, some evidence has
anxious or ill-at-ease, viewing others as critical or been offered with regard to other personality dis-
humiliating, and uncertainty about one’s self- orders (Zimmerman & Mattia, 1999) or to person-
worth); (3) interpersonal coping style (e.g., antic- ality disorders more generally (Zimmerman,
ipation of censure and derision, minimizing 1994). Such disorders tend to be diagnosed rela-
involvements that might reactivate or duplicate tively infrequently within the clinical interview
past humiliations, and diminishing the impor- process as compared to when semistructured diag-
tance of interpersonal relationships); and nostic interviews are utilized (Zimmerman &
(4) inferred intrapsychic dynamics (e.g., conflict Mattia, 1999). This may be due to a general inat-
between mistrust and the desire for affection, tention to personality disorder in many clinical
tension between derogation by others and self- settings – or, perhaps, to the polythetic nature of
deprecation, and tension between the surrounding these diagnoses. Although it is therefore preferable
distress and the emptiness within). that a semistructured diagnostic interview be used
As noted above, DSM-IV (APA, 1994) in evaluating patients for personality disorders,
requires four of seven possible diagnostic there is considerable variability among such
criteria: instruments. Another concern about the assess-
• Avoids occupational activities that involve ment process is that the diagnosis of personality
significant interpersonal contact, because of disorders is likely to be biased by the patient’s
fears of criticism, disapproval, or rejection acute clinical state (Zimmerman, 1994).
• Is unwilling to get involved with people unless With regard to differential diagnosis, consid-
certain of being liked eration should be given especially to social
• Shows restraint within intimate relationships phobia (or social anxiety disorder) – which, in
because of the fear of being shamed or DSM-IV, is an axis I disorder. In particular, the
ridiculed generalized type of social phobia is characterized
A 390 Avoidant Personality Disorder
by fears of most social situations – and is, there- ▶ DSM-III-R

fore, phenomenologically similar to AVPD ▶ DSM-IV
(APA, 1994). Indeed genetic studies have ▶ Factor Analysis
suggested that there is a common genetic vulner- ▶ ICD 10 Research Diagnostic Guidelines
ability underlying both disorders (Reichborn- ▶ Personality Disorders
Kjennerud et al., 2010). ▶ Prevalence
Consideration should also be given to panic ▶ Psychotic Disorder
disorder with agoraphobia – another axis ▶ Schizophrenia
I psychiatric disorder – although, in this condition, ▶ Selective Serotonin Reuptake Inhibitors
avoidance typically has its onset with a panic (SSRIs)
attack. Finally, with regard to differential diagno- ▶ Social Anxiety Disorder
sis, some other personality disorders should be ▶ Social Phobia
considered. These include the other cluster ▶ Temperament
C disorders, characterized by anxiety and fearful- ▶ Validity
ness – especially dependent personality disorder,
which can similarly be marked by feelings of
inadequacy, sensitivity to criticism, and need for
reassurance – as well as the phenomenologically
reminiscent, but somewhat more disabling, cluster Alden, L. E., Laposa, J. M., Taylor, C. T., & Ryder, A. G.
A conditions: schizoid, schizotypal, and paranoid (2002). Avoidant personality disorder: Current status
personality disorders (APA, 1994). and future directions. Journal of Personality Disor-
ders, 16, 1–29.
Alnæs, R., & Torgersen, S. (1988). DSM-III symptom
disorders (axis I) and personality disorders (axis II)
Treatment in an outpatient population. Acta Psychiatrica
Scandinavica, 78, 348–355.
Studies have shown that psychotherapeutic
and statistical manual of mental disorders (2nd ed.).
intervention is the treatment of choice for person- Washington, DC: Author.
ality disorders in general – and that this conclu- American Psychiatric Association. (1980). Diagnostic
sion holds specifically, as well, for AVPD and statistical manual of mental disorders (3rd ed.).
(Verheul & Herbrink, 2007). In particular, psy-
chodynamic and cognitive-behavioral therapies and statistical manual of mental disorders (Rev.
have proven effective – especially as individual 3rd ed.). Washington, DC: Author.
outpatient modalities, but also in group settings American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.).
and within structured treatment contexts. There is
less evidence in support of pharmacotherapeutic Baillie, A. J., & Lampe, L. A. (1998). Avoidant personal-
intervention, although some have suggested ity disorder: Empirical support for DSM-IV revisions.
treatment with antidepressant medications – Journal of Personality Disorders, 12, 23–30.
Becker, D. F., Añez, L. M., Paris, M., Bedregal, L., & Grilo,
such as selective serotonin reuptake inhibitors –
C. M. (2009). Factor structure and diagnostic efficiency
based, in part, on the potential relationship of the diagnostic and statistical manual of mental disor-
between AVPD and social phobia (Deltito & ders, fourth edition, criteria for avoidant personality
Stam, 1989; Kapfhammer & Hippius, 1998; disorder in Hispanic men and women with substance
use disorders. Comprehensive Psychiatry, 50, 463–470.
Ripoll, Triebwasser, & Siever, 2011). Deltito, J. A., & Stam, M. (1989). Psychopharmacologic
treatment of avoidant personality disorder. Compre-
hensive Psychiatry, 30, 498–504.
See Also Ekselius, L., Tillfors, M., Furmark, T., & Fredrikson, M.
(2001). Personality disorders in the general popula-
tion: DSM-IV and ICD-10 defined prevalence as
▶ Anxiety related to sociodemographic profile. Personality and
▶ DSM-III Individual Differences, 30, 311–320.
Ayres, A. Jean 391 A
Grilo, C. M. (2004). Factorial structure and diagnostic Verheul, R., & Herbrink, M. (2007). The efficacy of
efficiency of DSM-IV criteria for avoidant personality various modalities of psychotherapy for personality
disorder in patients with binge eating disorder. Behav- disorders: A systematic review of the evidence and
iour Research and Therapy, 42, 1149–1162. clinical recommendations. International Review of A
Grilo, C. M., Sanislow, C. A., Gunderson, J. G., Pagano, Psychiatry, 19, 25–38.
M. E., Yen, S., Zanarini, M. C., et al. (2004). Two-year World Health Organization. (1992). The ICD-10 classifica-
stability and change of schizotypal, borderline, avoidant, tion of mental and behavioural disorders: Clinical
and obsessive-compulsive personality disorders. Jour- descriptions and diagnostic guidelines. Geneva: Author.
nal of Consulting and Clinical Psychology, 72, 767–775. Zimmerman, M. (1994). Diagnosing personality disor-
Hummelen, B., Wilberg, T., Pedersen, G., & Karterud, S. ders: A review of issues and research methods.
(2006). An investigation of the validity of the diagnostic Archives of General Psychiatry, 51, 225–245.
and statistical manual of mental disorders, fourth edition Zimmerman, M., & Mattia, J. I. (1999). Differences
avoidant personality disorder construct as a prototype between clinical and research practices in diagnosing
category and the psychometric properties of the diag- borderline personality disorder. The American Journal
nostic criteria. Comprehensive Psychiatry, 47, 376–383. of Psychiatry, 156, 1570–1574.
Kapfhammer, H. P., & Hippius, H. (1998). Pharmacother-
apy in personality disorders. Journal of Personality
Disorders, 12, 277–288.
Lilienfeld, S. O. (2005). Longitudinal studies of personal-
ity disorders: Four lessons from personality psychol- AXCAM
ogy. Journal of Personality Disorders, 19, 547–556.
McGlashan, T. H., Grilo, C. M., Sanislow, C. A., Ralevski,
E., Morey, L. C., Gunderson, J. G., et al. (2005). Two- ▶ CNTN4: Contactin 4
year prevalence and stability of individual DSM-IV
criteria for schizotypal, borderline, avoidant, and
obsessive-compulsive personality disorders: Toward
a hybrid model of axis II disorders. The American
Journal of Psychiatry, 162, 883–889. Ayres, A. Jean
Millon, T. (1981). Disorders of personality: DSM-III, axis
II. New York: Wiley. Winifred Schultz-Krohn
Reichborn-Kjennerud, T., Czajkowski, N., Torgersen, S.,
Neale, M. C., Ørstavik, R. E., Tambs, K., et al. (2010). Department of Occupational Therapy, San José
The relationship between avoidant personality disor- State University, San José, CA, USA
der and social phobia: a population-based twin study.
The American Journal of Psychiatry, 164, 1722–1728.
Rettew, D. C., Zanarini, M. C., Yen, S., Grilo, C. M.,
Skodol, A. E., Shea, M. T., et al. (2003). Childhood Name and Degrees
antecedents of avoidant personality disorder:
A retrospective study. Journal of the American Acad- A. Jean Ayres, PhD, OTR, FAOTA.
emy of Child and Adolescent Psychiatry, 42, 1122– Graduated with a BA in Occupational Therapy
1130.
Ripoll, L. H., Triebwasser, J., & Siever, L. J. (2011). from University of Southern California in 1945.
Evidence-based pharmacotherapy for personality Graduated with an MA in Occupational Therapy
disorders. The International Journal of Neuropsycho- from University of Southern California in 1954.
pharmacology, 14(9), 1257–1288 (available online Graduated with a PhD in Educational Psychology
Feb. 15, 2011).
Skodol, A. E., Gunderson, J. G., McGlashan, T. H., from University of Southern California in 1961.
Dyck, I. R., Stout, R. L., Bender, D. S., et al. (2002).
Functional impairment in patients with schizotypal,
borderline, avoidant, or obsessive-compulsive person- Major Appointments (Institution,
ality disorder. The American Journal of Psychiatry,
159, 276–283. Location, Dates)
Stuart, S., Pfohl, B., Battaglia, M., Bellodi, L., Grove, W., &
Cadoret, R. (1998). The cooccurrence of DSM-III-R Faculty member in the Department of Occupa-
personality disorders. Journal of Personality Disorders, tional Therapy at the University of Southern
12, 302–315.
Torgersen, S., Kringlen, E., & Cramer, V. (2001). The California (USC) from 1955 to 1964.
prevalence of personality disorders in a community Professor in the Department of Special Education
sample. Archives of General Psychiatry, 58, 590–596. at the USC from 1966 to 1977.
A 392 Ayres, A. Jean
Adjunct faculty member in the Department of types of sensory information. She attended the
Occupational Therapy at USC from 1976 to University of Southern California and success-
1984 while running her clinic devoted to serv- fully completed her BA in Occupational Therapy
ing children with sensory integrative in 1945, her MA in Occupational Therapy in
disorders. 1954, and her PhD in Educational Psychology
in 1961. She completed her postdoctoral training
at University of California, Los Angeles
Major Honors and Awards (UCLA), Brain Research Institute working with
the leading neurophysiologists at that time.
Awarded Fellow of the American Occupational Her clinical skills in occupational therapy, with
Therapy Association (FAOTA). a foundation in the engagement in purposeful
Awarded the Eleanor Clark Slagle lectureship in activity, and her neuroscience training provided
1963. her with the unique perspective to understand
Received the highest honor from the American how the nervous system can influence functional
Occupational Therapy Association in 1965, behaviors.
the Award of Merit. Dr. Ayres had a long history in academia and
Named as one of the Outstanding Educators of was a faculty member in the Department of Occu-
America in 1971. pational Therapy at the University of Southern
Charter member of the American Occupational California (USC) from 1955 to 1964. She then
Therapy Association Academy of Research. was a professor in the Department of Special
Honored by the American Occupational Therapy Education at the USC from 1966 to 1977. She
Association in 1988 with the initiation of the returned as an adjunct faculty member in the
award entitled the A. Jean Ayres Award for Department of Occupational Therapy at USC
Theory Development and Application. from 1976 to 1984 while running her
clinic devoted to serving children with sensory
integrative disorders.
Landmark Clinical, Scientific, and Dr. Ayres’ work as an occupational therapist
Professional Contributions with children who had learning disabilities and
sensory processing challenges served as
Dr. A. Jean Ayres originated the Ayres Sensory the impetus for her conceptualization of sensory
Integration theory. She developed the theory into integrative dysfunctions. She encountered indi-
principles of intervention and assessment instru- viduals who would complain of how painful it
ments including the Southern California Sensory was to have their hair brushed or to wear specific
Integration Tests (SCSIT) and then revised this fabrics. This furthered her research endeavors in
instrument as the Sensory Integration and Praxis the area of sensory integration dysfunction and
Tests (SIPT). As an occupational therapist, she theory development. Her development of the the-
introduced the profession to this client-centered, ory of sensory integration expanded, and her
neuroscience-based theory and practice approach numerous publications, books, and approxi-
to support children with sensory integration mately 50 scholarly articles provided further evi-
disorders/sensory processing disorders. dence of this phenomenon. As a clinician,
researcher, and academic, Dr. Ayres recognized
the need to establish a mechanism to identify
Short Biography sensory integrative dysfunction and link theory
to practice. She developed the Southern Califor-
Biography: A. Jean Ayres nia Sensory Integration Tests (SCSIT) in 1972
Dr. A. Jean Ayres was born in 1920 in Visalia, with intensive training courses on theory, test
CA, and reportedly had challenges learning as administration, and interpretation seminars.
a young child, particularly processing various As the research and theory developed further,
Ayres, A. Jean 393 A
Dr. Ayres revised the assessment tool and the Ayres, A. J. (1955a). Proprioceptive facilitation elicited
Sensory Integration and Praxis Test was through the upper extremities. Part 3: Specific
application to occupational therapy. American Journal
published in 1989. of Occupational Therapy, 9, 121–126. A
As an occupational therapist, Dr. Ayres sought Ayres, A. J. (1955b). Proprioceptive facilitation elicited
to support children and provide intervention through the upper extremities. Part 2: Application.
directed not only to fostering improved functional American Journal of Occupational Therapy, 9,
57–58.
skills but to develop an explanation regarding the Ayres, A. J. (1955c). Proprioceptive facilitation elicited
challenges faced by children with sensory integra- through the upper extremities. Part 1: Background.
tive disorders. Her scholarship, clinical expertise, American Journal of Occupational Therapy, 9, 1–9.
and dedication were recognized in several arenas. Ayres, A. J. (1958a). Basics concepts of clinical practice in
physical disabilities. American Journal of Occupational
She was awarded the prestigious Eleanor Clark Therapy, 12, 300–302.
Sagle lectureship in 1963 by the American Occu- Ayres, A. J. (1958b). The visual-motor function.
pational Therapy Association. In her address, she American Journal of Occupational Therapy, 12,
described the theory and practice of sensory inte- 130–138.
Ayres, A. J. (1961). Development of body scheme in
gration and how this unique perspective supports children. American Journal of Occupational Therapy,
participation in everyday tasks. Her substantial con- 15, 99–102.
tributions to advance the profession of occupational Ayres, A. J. (1963). Eleanor Clark Slagle lecture.
therapy were further recognized when she received The development of perceptual motor abilities:
A theoretical basis for treatment of dysfunction.
the Award of Merit in 1965. This is the highest American Journal of Occupational Therapy, 17,
honor awarded by the American Occupational 221–225.
Therapy Association. In 1971, Dr. A. Jean Ayres Ayres, A. J. (1964). Tactile functions: Their relationship
was named as one of the Outstanding Educators of to hyperactivity and perceptual motor behavior.
American Journal of Occupational Therapy, 18, 6–11.
America. Dr. Ayres was a charter member of the Ayres, A. J. (1966a). Interrelationships among perceptual-
Academy of Research of the American Foundation motor functions in a group of normal children.
of Occupational Therapy, and in 1988, the A. Jean American Journal of Occupational Therapy, 20,
Ayres Award for Theory Development and Appli- 288–292.
Ayres, A. J. (1966b). Interrelationships among perceptual-
cation was established in her honor by the Ameri- motor functions in children. American Journal of
can Foundation of Occupational Therapy. Occupational Therapy, 20, 68–71.
Dr. A. Jean Ayres married Franklin Baker in Ayres, A. J. (1969). Deficits in sensory integration in
1969. She died on December 16, 1988, from educationally handicapped children. Journal of Learn-
ing Disabilities, 2, 160–168.
complications of cancer. Franklin Baker died on Ayres, A. J. (1971). Characteristics of types of
September 2, 1989. sensory integrative dysfunction. American Journal of
Occupational Therapy, 25, 329–334.
Ayres, A. J. (1972a). Types of sensory integrative
dysfunction among disabled learners. American
See Also Journal of Occupational Therapy, 22, 13–18.
Ayres, A. J. (1972b). Improving academic scores through
▶ Occupational Therapy (OT) sensory integration. Journal of Learning Disabilities, 5,
▶ Sensory Integration and Praxis Test 338–343.
Ayres, A. J. (1973). Sensory integration and learning
disorders. Los Angeles: Western Psychological
Services.
References and Readings Ayres, A. J. (1974). The Development of Sensory Integra-
tive Theory and Practice: A Collection of the Works of
Selected articles by A. Jean Ayres A. Jean Ayres. Dubuque: Kendall/Hunt Pub.
Ayres, A. J. (1949). An analysis of crafts in the treatment Ayres, A. J. (1977a). Dichotic listening performance
of electroshock patients. American Journal of in learning-disabled children. American Journal of
Occupational Therapy, 3, 195–198. Occupational Therapy, 31, 441–446.
Ayres, A. J. (1954). Ontogenetic principles in the Ayres, A. J. (1977b). Cluster analysis of measures
development of arm and hand functions. American of sensory integration. American Journal of
Journal of Occupational Therapy, 8, 95–99. Occupational Therapy, 31, 362–366.
A 394 Azaleptin
Ayres, A. J. (1977c). Effect of sensory integration on the Ayres, A. J., & Tickle, L. S. (1980). Hyper-responsivity to
coordination of children with choreoathetoid move- touch and vestibular stimuli as a predictor of positive
ments. American Journal of Occupational Therapy, response to sensory integration procedures to autistic
31, 291–293. children. American Journal of Occupational Therapy,
Ayres, A. J. (1982). Sensory integration and the child. Los 34, 375–381.
Angeles: Western Psychological Services. Bowman, O. J. (1989). In memoriam: A. Jean Ayres,
Ayres, A. J. (1989). Sensory integration and Praxis tests. 1920–1988: Therapist, scholar, scientist, and teacher.
Los Angeles, CA: Western Psychological Services. American Journal of Occupational Therapy, 43,
Ayres, A. J., & Mailloux, Z. (1981). Influence of sensory 479–480.
integrations procedures on language development. Amer-
ican Journal of Occupational Therapy, 35, 383–390.
Ayres, A. J., & Mailloux, Z. K. (1983). Possible pubertal
effect on therapeutic gains in an autistic girl. American
Journal of Occupational Therapy, 37(8), 535–540.
Ayres, A. J., Mailloux, Z. K., & Wendler, C. L. (1987).
Azaleptin
Developmental dyspraxia: Is it a unitary function?
Occupational Therapy Journal of Research, 7, 93–110. ▶ Clozapine
B
Babbling Historical Background
Kelly Macy Research findings from the past several decades on

Department of Communication Sciences, the nature of babbling have documented a shift in
The University of Vermont, Burlington, the scientific and clinical evidence regarding the
VT, USA connection between babbling and speech and lan-
guage acquisition. Early literature reported a weak
relationship between babbling and early speech
Definition development (e.g., Jakobson, 1941; Lenneberg,
1967). It was not viewed as being composed of
Babbling can be defined as a type of prelinguistic, linguistic units but rather a biomechanical action
non-cry vocalization, which typically emerges by where the infant lacks control over the sounds
6 or 7 months of age with repetition of the produced. This view, known as the motoric
same consonant vowel (CV) syllable (“ba ba”) hypothesis, asserts that babbling is just a by-
(Johnson, 2008; Paul, 2007). This can also be product of motor development. There was also a
referred to as canonical babbling (Oller, Levine, common misconception that babbling ended prior
Cobo-Lewis, Eilers, & Pearson, 1998) or redu- to the emergence of first words. In recent decades,
plicative babbling and is an important part of the however, there has been a shift to a linguistic
developmental process of emerging speech and hypothesis, which maintains that babbling has
language. Utterances produced with full a neurolinguistic foundation and there is a conti-
stop consonants such as /p/, /b/, /t/, and /d/ and nuity between babbling and early speech forms
vowels are most common at this stage, resulting (Petitto et al., 2000; Vihman, Ferguson, & Elbert,
in utterances such as /baba/ and /dIdI/ 1986). This shift in opinion is based on a strong
(“dee dee”). Variegated babbling, where succes- body of research suggesting that babble and speech
sive syllables are not identical, begins to share phonological characteristics within target lan-
appear between 6 and 10 months of age (Paul, guages and within individual children (Whitehurst,
2007; Proctor, 1989). This consists of a variety of Smith, Fischel, Arnold, & Lonigan, 1991).
CV and consonant-vowel-consonant (CVC) syl-
lables that are not identical (“pa ta”). By the end
of the first year, babbling should begin to imitate Current Knowledge
the intonation and prosody of adult speech.
This is also referred to as jargon babble Progression and presentation of babbling, as well
(Paul, 2007). as the acquisition and use of speech and language,

B 396 Babbling
can vary greatly among children with autism. It is Since differences and delays in babbling are
possible for babbling and other communication frequently found in children with autism, an anal-
milestones to develop normally in this population ysis of the child’s pre-speech vocalizations by
but then later regress. Approximately 25–30% of a speech-language pathologist may help to iden-
children with autism exhibit babbling and begin tify children who are at risk (Mitchell, 1997).
to say words but then stop speaking between the Children who exhibit a loss of babbling should
ages of 15 and 24 months (Johnson, Meyers, & also be referred for an evaluation, as this is a
Council on Children with Disabilities, 2007). serious red flag. Hearing loss, delayed motor
This has been documented by home videos of development, and lack of social interactions may
children who were typically developing, children also contribute to delays in babbling. For children
with early-onset autism, and children with regres- who were born prematurely, corrected gestational
sive-type autism and reported in a study by age (CGA) should be used to compare early devel-
Dawson and Werner (2005). They found that opmental milestones related to babbling.
the regressed children used complex babbling A pediatrician can screen children for speech
and words significantly more often than the and language delays and may recommend
early-onset children did. Furthermore, the chil- further evaluation by a specialist, such as a
dren with regressive-type autism used complex speech-language pathologist. Proctor (1989) and
babble nearly twice as often as typical children. Mitchell (1997) have provided instruments and
Certain children who present with develop- guidelines for assessing vocal development of
mental delays, including those with early-onset infants. Standardized evaluation tools, such as
autism, may be unusually quiet and make few the Communication and Symbolic Behavior
vocalizations. Others may produce atypical Scales Developmental Profile (Wetherby &
vocalizations such as humming and grunting, Prizant, 1993), and criterion-referenced assess-
and fail to exhibit the typical canonical and var- ments such as the Rossetti Infant and Toddler
iegated babbling within the expected time frames Language Scale (Rossetti, 2006) can also be uti-
(Johnson, 2008). Lack of canonical babbling by lized to assess language in the prelinguistic
10 months of age has been shown to predict period.
delays in language development in the second For children who do not follow the expected
year of life (Oller et al., 1998). Current research progression of babbling and demonstrate a delay
with infants who are typically developing and in speech and language development, early inter-
those with developmental delays has supported vention which is specifically tailored to the indi-
the continuity between babbling and its relation- vidual, targets behavior and communication, and
ship to patterns in early speech (Davis & involves the parents or primary caregivers is the
MacNeilage, 1995; Mitchell, 1997). best treatment. Typically, a speech-language
Typically developing infants exhibit a back- pathologist implements this intervention.
and-forth type pattern of babbling and apparent
listening that is coordinated with the caregiver’s
speech and is similar to the conversational turn- Future Directions
taking that is used by older children (Johnson,
2008). Children with autism may continue to Many children who are later diagnosed with
vocalize as if they are not aware of the caregiver’s autism first present to their pediatrician with
speech, with overlapping vocalizations and lack delays and differences in speech and language
of eye contact. Parents may report that their development (Johnson, 2008). Still, autism is
child does not seem to recognize their voice or not typically diagnosed until about 3–5 years of
notice when they enter or leave the room. At the age. Research has shown that early intervention
jargon babble stage near 1 year of age, they may by 2–3 years of age results in more positive out-
lack inflection and prosody that is common by comes for children with autism (Osterling &
this stage. Dawson, 1994). Since language and
Bad Science 397 B
communication impairments are part of the diag- Johnson, C. P., Myers, S. M., & Council on Children with
nostic criteria for autism, and babbling is one of Disabilities. (2007). Identification and evaluation of
children with autism spectrum disorders. Pediatrics,
the earliest developmental communication mile- 120(5), 1183–1193.
stones which has been shown to be an important Lenneberg, E. H. (1967). Biological foundations of
initial phase of speech production ability, lack of language. New York: Wiley. B
babbling by the end of the first year or regression McCune, L., & Vihman, M. (2001). Early phonetic and
lexical development: A productivity approach. Jour-
of early speech skills should be recognized as nal of Speech, Language, and Hearing Research, 44,
a red flag. More studies on the different patterns 670–684.
and progressions of babbling in children with Mitchell, P. R. (1997). Prelinguistic vocal development:
autism spectrum disorders would help profes- A clinical primer. Contemporary Issues in Communi-
cation Science and Disorders (CICSD), 24, 87–92.
sionals to better understand the link with later Oller, D. K., Levine, S., Cobo-Lewis, A., Eilers, R., &
speech and language development and help to Pearson, B. (1998). Vocal precursors to linguistic com-
support earlier identification of children who munication: How babbling is connected to meaningful
may be at risk. speech. In R. Paul (Ed.), Exploring the speech-language
connection (pp. 1–23). Baltimore: Paul H. Brookes.
Osterling, J., & Dawson, G. (1994). Early recognition of
children with autism: A study of first birthday home
See Also videotapes. Journal of Autism and Developmental Dis-
orders, 24, 247–257.
Paul, R. (2007). Language disorders from infancy through
▶ Communication and Symbolic Behavior Scale adolescence: Assessment and intervention
▶ Communicative Acquisition in ASD (pp. 231–243). St. Louis, MO: Mosby.
▶ Rossetti Infant-Toddler Language Scale Petitto, L. A., Zatorre, R., Gauna, K., Nikelski, E. J.,
▶ Speech Delay Dostie, D., & Evans, A. (2000). Speech-like cerebral
activity in profoundly deaf people while processing
▶ Vocalization signed languages: Implications for the neural basis of
human language. Proceedings of the National Acad-
emy of Sciences, 97(25), 13961–13966.
Proctor, A. (1989). States of noncry vocal development in
References and Readings infancy: A protocol for assessment. Topics in Lan-
guage Disorders, 10(1), 26–42.
American Speech Language Hearing Association. (2010). Rossetti, L. (2006). Rossetti infant and toddler language
How does your child hear and talk: Birth to one year. scale: Manual. East Moline, IL: LinguiSystems.
Retrieved from: http://www.asha.org/public/speech/ Sheinkopf, S. J., Mundy, P., Kimbrough Oller, D., &
development/01.htm Steffens, M. (2000). Vocal atypicalities of preverbal
Berko-Gleason, J., & Burstein Ratner, N. (2008). The autistic children. Journal of Autism and Developmen-
development of language (7th ed.). Upper Saddle tal Disorders, 30(4), 345–354.
River, NJ: Prentice Hall. Vihman, M. M., Ferguson, C. E., & Elbert, M. (1986).
Boysson-Bardies, B. (1999). How language comes to chil- Phonological development from babbling to speech:
dren: From birth to two years. Cambridge, MA: MIT Common tendencies and individual differences.
Press. Applied PsychoLinguistics, 7, 3–40.
Davis, B., & MacNeilage, P. F. (1995). The articulatory Wetherby, A. M., & Prizant, B. M. (1993). Communica-
basis of babbling. Journal of Speech and Hearing tion and symbolic behavior scales: Manual. Chicago:
Research, 38, 1199–1211. Riverside.
Dawson, G., & Werner, E. (2005). Validation of the phe- Whitehurst, G. J., Smith, M., Fischel, J. E., Arnold, D. S.,
nomenon of autistic regression using home videotapes. & Lonigan, C. J. (1991). The continuity of babble and
Archives of General Psychiatry, 62, 889–895. speech in children with specific expressive language
Eilers, R. E., Oller, D. K., Levine, S., Basinger, D., Lynch, delay. Journal of Speech and Hearing Research, 34,
M. P., & Urbano, R. (1993). The role of prematurity 1121–1129.
and socioeconomic status in the onset of canonical
babbling in infants. Infant Behavior & Development,
16, 297–315.
Jakobson, R. (1941). Child language, aphasia and phono-
logical universals. (AR Keiler, Trans.) The Hague:
Mouton.
Bad Science
Johnson, C. P. (2008). Recognition of autism before age
2 years. Pediatrics in Review, 29, 86–96. ▶ Pseudoscience
B 398 Banophen™ [OTC]
Barnes, T. R. (2003). The Barnes Akathisia rating

Banophen™ [OTC] scale–revisited. Journal of Psychopharmacology,
17(4), 365–370. Review.
▶ Diphenhydramine
Banophen™ Anti-itch [OTC] BASC-2
▶ Diphenhydramine ▶ Behavior Assessment System for Children,

2nd Edition
Barbiturates
Baseline
▶ Sedative Hypnotic Drugs
Cate Kraper
Clinical Psychology, University of
Barnes Akathisia Scale Massachusetts Boston, Boston, MA, USA
Wouter Staal
Neuroscience, Radboud University Nijmegen Definition
Medical Centre Karakter, Nijmegen,
The Netherlands An assessment of abilities that serves as an
anchor for monitoring subsequent change over
time when combined with follow-up assess-
Definition ments. A baseline assessment may occur prior
to a child entering school, or, if a child is enrolled
The Barnes Akathisia Scale is a scale designed to in an intervention study, prior to administering
rate the severity of drug-induced or Parkinson the treatment. A baseline assessment may involve
disease-based akathisia. Akathisia – literally more than one assessment point, to determine the
meaning not sitting – is characterized by an stability of a behavior prior to introducing an
inner restlessness, causing constant motion of experimental manipulation (e.g., an intervention
hands or feet. Symptoms of akathisia can persist designed to change the behavior assessed during
for years, even after discontinuing the precipitat- the baseline period). Later assessments can be
ing drug. The assessment of akathisia with the compared to the baseline assessment, so that
Barnes Akathisia Scale includes objective and symptoms or abilities may be tracked over time,
subjective questions. and improvements or deterioration in abilities
may be noted. This may be especially helpful
See Also for developmental disorders such as autism, in
which the symptoms and their severity can
▶ Antipsychotics: Drugs change dramatically over time. In cases in
▶ Pyramidal System which deterioration of skills occurs, the combi-
nation of a thorough baseline assessment and
appropriate follow-up assessments can help iden-
tify specific skills that can be targeted in treat-
Barnes, T. R. (1989). A rating scale for drug-induced
ment. Baseline assessments might include
Akathisia. British Journal of Psychiatry, 154, measures of language and communication, social
672–676. skills, self-help skills, play, and IQ.
Bayley Scales of Infants Development-II 399 B
See Also equivalents are also provided for cognitive, lan-
guage, and motor subtests. Growth scores can also
▶ Course of Development be calculated to evaluate a child’s growth over time
▶ Longitudinal Research in Autism for cognitive, language, and motor subtests.
▶ Outcome Studies B
The Bayley Scales of Infant Development (BSID)
Constantino, J. N., Abbacchi, A. M., Lavesser, P. D., Reed, were first published in 1969, with revisions in
H., Givens, L., Chiang, L., et al. (2009). Developmental
1993 (BSID-II) and 2006 (Bayley-III). In its most
course of autistic social impairment in males. Develop-
ment and Psychopathology, 21, 127–138. recent edition, the test was updated to reflect
Gordon, K., Pasco, G., McElduff, F., Wade, A., updates in the field of child development research,
Howlin, P., & Charman, T. (2011). A communication- including information processing and preverbal
based intervention for nonverbal children with autism:
intelligence. However, the Bayley-III still retains
What changes? Who benefits? Journal of Consulting
and Clinical Psychology, 79, 447–457. its focus on more classic themes in child develop-
ment (e.g., Piaget, Vygotsky). Additionally, many
items from the BSID-II were removed or changed
and new items were developed.
Bayley Scales of Infants
Development-II
Psychometric Data
Amanda Steiner
Yale Child Study Center, New Haven, CT, USA Normative data for the cognitive, language, and
motor scales was collected from 1,700 children
aged 1 month to 42 months (with 100 individuals
Synonyms in 17 separate age groups) and closely reflected
the 2000 US Census in terms of parental educa-
Bayley-III tion level, race/ethnicity, and geographic region.
Only children born between 36 and 42 weeks
were included. Children with mental, physical,
Description or behavioral difficulties constituted about 10%
of the total sample. The social-emotional scale
The Bayley-III is a standardized developmental was normed using 456 children, and the adaptive
assessment that evaluates the functioning of infants behavior scale included 1,350 children.
and young children from 1 month to 42 months of
age. It is designed to identify children with devel-
opmental delays and aid in intervention planning. Clinical Uses
The test assesses multiple developmental domains,
including cognitive, language (both receptive and The Bayley-III is designed to be used to identify
expressive), motor (both fine and gross), as well as children with developmental delays. It is
social emotional and adaptive behavior. The cogni- recommended that the Bayley-III be adminis-
tive, language, and motor scales are based primarily tered by an individual with formal graduate or
on direct assessment, whereas the social-emotional professional training in developmental assess-
and adaptive behavior scales are caregiver ques- ment. While it is possible for a psychometrician
tionnaires. Scaled scores are provided for each to administer the Bayley-III, test interpretation
subtest, with composite scores and percentile should occur by an individual with appropriate
ranks for each overall scale. Developmental age training to interpret test data.
B 400 Bayley-III
See Also
Bed-Wetting
▶ Enuresis

Beery VMI
Bayley, N. (1993). Bayley scales of infant and develop-
ment-second edition. San Antonio, TX: The Psycho-
▶ Beery-Buktenica Developmental Test of
logical Corporation.
Bayley, N. (2006a). Bayley scales of infant and toddler Visual-Motor Integration
development-third edition: Administration manual. ▶ Visual-Motor Integration, Developmental
San Antonio, TX: Harcourt Assessment. (VMI) Test
Bayley, N. (2006b). Bayley scales of infant and toddler
development-third edition: Technical manual. San
Antonio, TX: Harcourt Assessment.
Beery VMI Motor Coordination Test
▶ Visual-Motor Integration, Developmental

(VMI) Test
Bayley-III
▶ Bayley Scales of Infants Development-II Beery VMI Visual Perception Test
▶ Visual-Motor Integration, Developmental

(VMI) Test
BCaBA
▶ Board Certified Associate Behavior Analyst

Beery-Buktenica Developmental
Test of Visual-Motor Integration
Trina D. Spencer1 and Lydia Kruse2

BCBA 1
Institute for Human Development, Northern
Arizona University, Flagstaff, AZ, USA
▶ Board Certified Associate Behavior Analyst 2
Human Development and Family Science,
The Ohio State University 202 Schoenbaum
Family Center, Columbus, OH, USA
BCBA-D Synonyms
▶ Board Certified Associate Behavior Analyst Beery VMI; Developmental test of visual-motor
integration; VMI
BDQ Description
▶ Behavior Development Questionnaire The Beery-Buktenica Developmental Test of

▶ Behavioral Development Questionnaire Visual-Motor Integration (▶ Beery VMI; Beery
Beery-Buktenica Developmental Test of Visual-Motor Integration 401 B
& Beery, 2010) is a test of visual-motor coordi- The first three items of the Full Format test,
nation. Visual-motor integration is “the degree to which require scribbling, are designed for use
which visual perception and finger-hand move- with very young children. For the next three
ments are well coordinated” (Beery, 1997, p. 19). items, the examiner models drawing the first
This paper-and-pencil test involves examinees three shapes in the upper blocks of the test B
copying increasingly complex designs. It is form; after each model, the examinee copies the
designed to assess visual-motor integration, same shape in the lower blocks of the test form.
visual perception, and motor coordination skills For examinees aged 19–100, testing starts with
and is designed to indicate the need for support item 7 and the examinee copies the printed shape,
services for problems in one or more of these such as horizontal line, vertical-horizontal cross,
areas. or square, in the lower blocks of the test form.
The Beery VMI includes Short and Full Testing is discontinued when an examinee draws
Format tests and supplemental Visual Perception three items incorrectly in a row.
and Motor Coordination tests. None of the Beery Because the Beery VMI is a brief assessment,
VMI tests is timed. The Short and Full Format testing typically can be completed in one session.
tests involve the examinee copying increasingly The Beery VMI is a paper-and-pencil test that
complex designs with a pencil without an eraser. must be hand-scored by the examiner. Exam-
Both the Short and Full Format tests can inees’ drawings are scored 1 or 0 based on the
be administered to individuals and groups (e.g., degree to which each drawing met relevant
kindergarten class). The Full Format test contains criteria. Accurate scoring requires the use of
30 items and is appropriate for use with children a protractor to make judgments about accuracy
(ages 2–18) and adults (ages 19–100). The items of angles, etc. The examiner’s manual contains
increase in complexity from an imitated mark to many scoring examples and comments about
a three-dimensional star. The Short Format design attempts, which assist with scoring and
test contains 21 items and is designed for use interpretation of the examinee’s drawings.
with children ages 2–7 years old. It takes A total raw score is obtained by adding the num-
about 10–15 min to administer the Short Format ber of designs that were scored as “pass.” The
or Full Format test. The examiner of the Beery examiner’s manual contains tables to convert raw
VMI must have Examiner B qualifications, scores into standard scores, percentiles, and age
which indicates that examiners must have equivalent scores.
a graduate degree in psychology or a related Assessment materials include an examiner’s
field or equivalent training to complete the manual, entitled Beery VMI With Supplemental
assessment. Developmental Tests of Visual Perception and
The Full and Short Format test form pages Motor Coordination For Children and Adults,
contain a table with six blocks; the top three and four different scoring forms: Full, Short,
blocks provide examples of the drawing shapes Visual Perception, and Motor Coordination. The
that the examinee is to copy in the corresponding examiner’s manual contains administration and
block below. The blocks represent the boundaries scoring instructions and age-specific norms,
within which the examinee is to draw the including about 600 age-specific norms for
design. The Visual Perception supplemental test children from birth to age 6. The examiner’s
requires examinees to identify a target design manual also includes teaching suggestions for
among choices, and the Motor Coordination sup- improving visual-motor coordination skills.
plemental test requires examinees to trace The authors of the Beery VMI, Keith and
a geometric shape with a dashed outline using Natasha Beery, have also produced additional
a pencil without an eraser. Each supplemental materials beyond the examiner’s manual to
test takes about 5 min to complete in addition to supplement the assessment and aid in the devel-
administration time for the Short and Full Format opment of related skills. The materials include
tests. the following:
B 402 Beery-Buktenica Developmental Test of Visual-Motor Integration
(a) Developmental Teaching Activities: a 1–4 between 1989 and 1996; however, the
resource that contains 250+ activities that original and more recent versions use a scoring
parents and teachers can use with young system with only 1 point possible per item.
children (birth to age 6) to support the devel-
opment of skills useful for art, academics, and
athletic activities Psychometric Data
(b) My Book of Shapes: a resource that contains
100 geometric paper-and-pencil activities The Beery VMI “is regarded as one of the most
that parents and teachers can use with young valid and reliable instruments for the assessment
children (preschool and kindergarten) to sup- of visual-motor integration” (Kulp & Sortor,
port the development of skills, especially 2003, p. 313) and is used internationally. Stan-
useful for supporting visual-motor skills nec- dardization studies were conducted on the Beery
essary for early literacy and early numeracy VMI. The most recent standardization sample for
development children occurred in 2010 using a nationally rep-
(c) My Book of Letters and Numbers: a resource resentative group of 1,737 children between the
that contains 100 activities for use with ages of 2 and 18 years old. The most recent
children in the second half of their kindergar- standardization sample for adults occurred in
ten year to support the development of skills 2006 using a nationally representative sample
necessary for literacy and numeracy activities 1,021 adults ages 19–100. For more information
(d) Developmental Wall Chart for Visual-Motor about psychometric data, the reader is encour-
Integration: a wall chart with information aged to refer to the Encyclopedia of Autism Spec-
about development of gross and final motor, trum Disorders entry entitled “Visual-Motor
visual, and visual-motor skills for young chil- Integration, Developmental (VMI) test”
dren (birth to age 6) (authored by Dr. Ted Brown) or The Beery-
(e) Beery VMI Stepping Stones Parent Check- Buktenica Developmental Test of Visual-Motor
list: a checklist created for parents to docu- Integration (Beery VMI) with Supplemental
ment their children’s progress from preschool Developmental Tests of Visual Perception and
through early elementary age Motor Coordination and Stepping Stones Age
Norms: Administration, Scoring and Teaching
Manual (Beery & Beery, 2010).
The Beery VMI was first developed in 1967 and Clinical Uses
is currently in its sixth edition. The most recent
normative data was collected in 2010 for children The Beery VMI is used in a number of settings
and 2006 for adults. The current version of the and by a variety of professionals to assess the
assessment looks very similar to its original visual-motor integration skills of a wide range of
version, with four major changes as part of past people. Settings of use include schools, hospitals,
revisions. First, the Visual Perception and the and clinics; professionals who use the Beery VMI
Motor Coordination supplemental tests were include psychologists, occupational therapists,
added in 1997. The addition of these supplemen- neurologists, etc. Given the number of disabilities
tal tests allows the examiner to obtain additional and disorders that include symptoms of visual-
information to identify specific areas of skill motor, visual-perceptual, and motor coordination
weakness. Second, in 2004, the number of items difficulties, the Beery VMI is applicable for use
on the Full Format was increased from the orig- with many people. Autism spectrum disorder
inal number of 24–30. Third, the norms were (ASD) is one such condition that typically
expanded to include a wider age range in 2004 involves motor and visual deficits (American Psy-
and 2006. Finally, scoring was based on a scale of chiatric Association [APA], 2000; Coulter, 2009).
Beery-Buktenica Developmental Test of Visual-Motor Integration 403 B
An advantage of using the Beery VMI for assess- The Beery VMI boasts solid predictive
ment of children with ASD is its nonverbal validity. That is, VMI scores of children in
design, which helps to reduce or eliminate lan- kindergarten “predicted with 85% accuracy
guage confounds observed with other psychoedu- those children who had reading problems seven
cational assessments. years later” (Brown, Unsworth, & Lyons, 2009, B
The Beery VMI is a useful tool as part of p. 395). There is evidence of associations
psychoeducational evaluations because the between children’s Beery VMI scores and math
Beery VMI provides information about and reading performance (Sortor & Kulp, 2003).
children’s writing readiness skills and indicates The Beery VMI was created to be compatible
potential deficits in visual-motor functioning that with the sequential development of children’s
may require intervention, such as occupational skills. Beyond the use of identification of
therapy. The supplemental tests help teams iden- children’s needs, the instrument is also designed
tify specific visual-perceptual or motor coordina- to support the advance of research. The Beery
tion deficits that might not otherwise be identified VMI is described as culture-free and nonverbal,
on the Short and Full Format tests (Kulp & making it appropriate for use with a range of
Sortor, 2003). Also, given the importance of individuals, evidenced by the use of geometric
early identification of developmental delays, the forms instead of letters or numbers. However,
Beery VMI can be used to identify young recent evidence has called into question whether
children’s motor coordination and/or visual the Beery VMI is truly culture-free. Specifically,
perception delays. The Beery VMI is especially research conducted with a South African
helpful in early intervention settings because it preschool population suggested differences in
provides standard scores for children as young as scores between children of socioeconomic status
2 years old, which is rare among psychological (SES) and race (Dunn, Loxton, & Naidoo, 2006),
assessments. Additionally, the Beery VMI is use- with White children and children of higher SES
ful in educational settings because it can be used performing better than their counterparts.
as part of universal screening, which involves
assessing all children (in a class or school) to
determine specific needs. Because it is acceptable See Also
for use with groups, the Beery VMI can provide
educators with information about the skills of ▶ Autism
children in an entire class in a short amount of ▶ Bender Visual-Motor Gestalt Test II
time. There is, however, some evidence that the ▶ Bruininks-Oseretsky Test of Motor Proficiency
Beery VMI falls short in identifying older ▶ Motor Control
children with handwriting dysfunction (Goyen ▶ Motor Planning
& Duff, 2005) despite its standing as a robust ▶ Occupational Therapy (OT)
instrument in the use of identifying visual-motor ▶ Peabody Developmental Motor Scales (PDMS)
integration. As such, clinicians may be cautioned ▶ Psychologist
to not rely solely on the Beery VMI when making ▶ Spectrum/Continuum of Autism
decisions about older children’s handwriting ▶ Visual-Motor Integration, Developmental
needs. Another limitation of using the Beery (VMI) Test
VMI with children with ASD and, potentially,
other disabilities is the requirement of the
examinee to imitate the examiner and/or printed References and Readings
designs. Individuals who lack adequate
attention or memory skills might produce work American Psychiatric Association. (2000). Diagnostic
and earn scores on the Beery VMI that reflect
Text Rev.). Washington, DC: Author.
a low estimate of their true visual-motor integra- Beery, K. E. (1997). The Beery-Buktenica VMI: Develop-
tion ability. mental test of visual-motor integration with
B 404 Behavior
supplemental developmental tests of visual perception Sortor, J. M., & Kulp, M. T. (2003). Are the results of the
and motor coordination: administration, scoring, and Beery-Buktenica developmental test of visual-motor
teaching manual (4th ed.). Parsippany, NJ: Modern integration and its subtests related to achievement test
Curriculum. scores? Optometry and Vision Science, 80(11),
Beery, K. E. (2006). The Beery-Buktenica developmental 758–763.
test of visual-motor integration: Beery VMI (5th ed.). Volker, M., Lopata, C., Vujnovic, R., Smerbeck, A.,
New York: MHS. Toomey, J., Rodgers, J., et al. (2010). Comparison of
Beery, K. E., & Beery, N. A. (2006). The Beery-Buktenica the Bender Gestalt-II and VMI-V in samples of typical
developmental test of visual motor integration admin- children and children with high-functioning autism
istration, scoring, and teaching manual. Bloomington, spectrum disorders. Journal of Psychoeducational
MN: NCS Pearson. Assessment, 28(3), 187–200.
Beery, K. E., & Beery, N. A. (2010). The Beery-Buktenica
developmental test of visual-motor integration (Beery
VMI) with supplemental developmental tests of visual
perception and motor coordination and stepping
stones age norms: Administration, scoring and Behavior
teaching manual. Minneapolis, MN: NCS Pearson.
Beery, K. E., Buktenica, N. A., & Beery, N. A. (2004). The
Beery-Buktenica developmental test of visual motor
Marina Azimova
integration (5th ed.). Bloomington, MN: NCS The Center for Children with Special Needs,
Pearson. Glastonbury, CT, USA
Brown, T., Unsworth, C., & Lyons, C. (2009). An evalu-
ation of the construct validity of the developmental test
of visual-motor integration using the Rasch measure-
ment model. Australian Occupational Therapy Synonyms
Journal, 56(6), 393–402.
Coulter, R. A. (2009). Understanding the visual Operant behavior; Respondent behavior; Skill
symptoms of individuals with autism spectrum disor-
der (ASD). Optometry & Vision Development, 40(3),
164–175.
Cummings, J. A., Hoida, J. A., Machek, G. R., & Definition
Nelson, J. M. (2003). Visual-motor assessment of
children. In C. R. Reynolds, R. W. Kamphaus, &
C. N. Hendry (Eds.), Handbook of psychological and
Behavior is the action or reaction exhibited by
educational assessment of children: Intelligence, a human or animal in response to stimuli. Stimuli
aptitude, and achievement (2nd ed.). New York: may be external and/or internal. In the science of
Guilford Press. behavior, manipulating stimuli is the way to
Dunn, M., Loxton, H., & Naidoo, A. (2006). Correlations
change (modify) behavior. Quite simply, behav-
of scores on the developmental test of visual-motor
integration and copying test in a South African multi- ior is anything a person can do. It is always
ethnic preschool sample. Perceptual and Motor Skills, observable and measurable.
103(3), 951–958.
Goyen, T., & Duff, S. (2005). Discriminant validity of the
developmental test of visual-motor integration in
relation to children with handwriting dysfunction. See Also
Australian Occupational Therapy Journal, 52(2),
109–115. ▶ Operant Behavior
Kulp, M. T., & Sortor, J. M. (2003). Clinical value of the
▶ Respondent Behavior
Beery visual-motor integration supplemental tests of
visual perception and motor coordination. Optometry
and Vision Science, 80(4), 312–315.
Morr, D., & Corimak, S. (2002). Predicting handwriting References and Readings
performance of early elementary students with the
developmental test of visual-motor integration. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
Perceptual and Motor Skills, 95, 661–669. Applied behavior analysis (2nd ed.). Upper Saddle
Pearson Assessments, Inc. (n.d.). Beery VMI product River, NJ: Pearson Merrill Prentice Hall.
description. Retrieved February 25, 2011, from http:// Johnston, J. M., & Pennypacker, H. S. (1993). Strategies
www.pearsonassessments.com/haiweb/cultures/en-us/ and tactics for human behavioral research (2nd ed.).
productdetail.htm?pid¼pag105&mode¼summary Hillsdale, NJ: Erlbaum.
Behavior Analysis 405 B
employed what the methods of what he called
Behavior Analysis “methodological behaviorism” (Mayer et al.,
2012), relying on direct observation and careful
Mary Jane Weiss1 and Thomas Zane2 manipulation of variables to determine their
B
1
Institute for Behavioral Studies, Endicott influence (if any) on behavior. The unique aspect
College, Beverly, MA, USA of Watson’s work was to study behavior
2
The Institute for Behavioral Studies, Endicott as a strict scientist, following the strict rules of
College, Beverly, MA, USA scientific process. Other psychologists (e.g.,
Pavlov, Skinner) followed Watson, adhering
strictly to the application of the scientific method
Synonyms to study aspects of the human condition.
Through this perspective of science, the field
Behavioral Specialist has advanced to the point of acknowledging
that human behavior follows the laws of nature
as do other phenomena. Behavior analysis
Definition has remained true to embracing the role of
science in the study of human behavior and that
Behavior analysis is, “the experimental investi- is its unique contribution to psychology and
gation of variables that influence the behavior of education.
any living organism” (Mayer, Sulzer-Azaroff, & The branch of behavior analysis that later
Wallace, 2012, p. 6). Often, it is used inter- became known as ABA can be traced to a publi-
changeably with applied behavior analysis. cation by Ayllon and Michael (1959), in which
While there is a relationship between the two, personnel in a mental hospital were trained to use
they are not synonymous. There are three behavior strategies to modify the behaviors of
branches of the science of behavior analysis – psychotic residents. Pioneers in the 1960s and
behaviorism, experimental analysis of behavior 1970s made great inroads to changing behavior
(EAB), and applied behavior analysis (ABA) despite poor funding, the reluctance of the scien-
(Cooper, Heron, & Heward, 2007). ABA, there- tific community to publish their work, and the
fore, is one branch of the science of behavior lack of evidence-based strategies to influence
analysis. In addition to these three branches of their lines of research. In the field of education,
the science, there is also a focus on practice exciting results were found with the use of con-
guided by behavior analysis. tingent teacher attention (Hall, Lund, & Jackson,
1968), token economies (Birnbrauer, Wolf,
Kidder, & Tague, 1965), and programmed
Historical Background instruction (Bijou, Birnbruer, Kidder, & Tague,
1966).
The question of why people behave as they do has In 1968, the Journal of Applied Behavior
been answered in many ways. Over the centuries, Analysis was first published. This has been the
many different belief systems have evolved to premiere journal of the discipline since that time.
explain human behavior, including religion, The journal focuses on the use of within-subject
mythology, astrology, and cultural practices. designs to experimentally evaluate the effects of
Psychologists, whose focus is on behavior, have treatments and to experimentally identify con-
developed varying perspectives and theories trolling relationships between variables. For
regarding the causes of behavior, including struc- many years, such within-subject design effects
turalism and psychoanalysis. were considered less important than group design
Eventually, there was an attempt to understand effects (which are commonly done, e.g., in psy-
whether human behavior might be investigated chology). In recent years, there has been some
using the methods of science. At first, Watson progress in this area, as repeated demonstrations
B 406 Behavior Analysis
in multiple single case designs are now being All three branches of the science are essential,
recognized as scientific evidence. and they influence one another. Research is an
Also in 1968, the seminal article on the dimen- essential component to the advancement of the
sions of ABA was published (Baer, Wolf, & science. Both basic and applied research help to
Risley, 1968). In this article, the authors outline refine concepts and develop effective procedures/
seven critical elements of ABA that define inter- interventions.
ventions that are behavior analytic: applied, The main methodologies utilized within
behavioral, analytic, technological, conceptually behavior analysis are within-subject designs.
systematic, and effective. These designs experimentally prove the control-
ling relationships between independent and
dependent variables and rule out extraneous
Current Knowledge explanations. Several commonly used ones are
frequently used in behavioral publications: the
Behaviorism is the theoretical and philosophical reversal design, the multiple baseline design, the
branch of the science. Behaviorists analyze at changing criterion design, and the alternating
conceptual levels and create theoretical accounts treatments design.
of behavior that are consistent with existing data. The Reversal Design: In the reversal design,
Behaviorists may also outline areas in which data on the target behavior are collected prior to
empirical data are absent and may suggest ways intervention (condition A), the intervention is
to rectify gaps in our existing knowledge. Behav- applied (B), the intervention is withdrawn (A),
iorists inspire much of the work of the other and the intervention is reapplied (B). This is
branches, and they maintain the focus of the referred to as an ABAB design. The impact of
science on the theoretical underpinnings and an intervention is examined for its controlling
philosophical stances. influence. Is it the variable responsible for the
The experimental analysis of behavior (EAB) change? Does the behavior revert back to
is the basic science branch. These individuals pretreatment levels in the absence of treatment?
design and conduct experiments in basic science. In this way, one can be more confident that it is
They conduct experiments in laboratories and the treatment itself effecting change. Variations
other highly controlled environments. They may of the design exist (e.g., ABA, BABA). However,
use human or nonhuman participants. In their all of the reversal designs use this basic premise
work, they may discover and clarify basic princi- of reversing the effect of the intervention by
ples of behavior, and they may identify functional withdrawing treatment.
relations between variables. EAB is also the The Multiple Baseline Design: In this design,
branch that creates many of the questions for the intervention is applied in sequential phases
both ABA and EAB to pursue. across participants, behaviors, or settings. Essen-
Applied behavior analysis is the branch of tially, the researcher looks for replication of
behavior analysis in which the tactics derived effect. If an intervention is first applied to one
from the principles of behavior are applied to student with good impact, can it then be extended
improve socially significant behavior, and to others? Similarly, can it be applied across
experimentation is used to identify the vari- settings? If an intervention successfully taught
ables responsible for the improvement in one skill, can it be extended to another? In this
behavior (Cooper et al., 2007). Applied behav- way, the confidence about the utility of this inter-
ior analysts conduct experiments that are vention in this context increases.
designed to identify relations between socially The Changing Criterion Design: In the chang-
significant behavior and its controlling vari- ing criterion design, the criterion for behavioral
ables. They do this to add to the technology effect continually increases. In this design,
of humane and effective behavior change behaviors may be changed gradually, with
procedures. increases in expectations shifting over time.
Behavior Analysis 407 B
The Alternating Treatments Design: In this behavior analysis in application to clinical prac-
design, different approaches or interventions tice. In general, the field is often presented as
can be directly compared. The level of the target reductionistic and is often contrasted with more
behavior can be compared in different conditions. humanistic approaches that have more broad
In other words, the dependent variable is com- appeal. This is a major challenge to the science B
pared in different levels or variations of an inde- of behavior, as it impedes the ability to offer these
pendent variable. If there is a question about powerful interventions to those most in need of
whether a particular independent variable will them. Professionals within the applied arena
make a difference, it can be compared to no often struggle with core misunderstandings of
treatment. If there is a question about the level the science and its applications. In addition,
of intervention to apply (e.g., # minutes of an they often are presented with clinical contexts
activity, richness of reinforcement ratio), the that are ethically challenging. For example,
question can be experimentally answered to many behaviorally based clinical programs are
guide treatment. diluted, combined with other nonverified
In all behavioral research, as well as in applied approaches or delivered at a level of intensity
work inspired by behavioral research, clinicians not associated with likely success. There is
remain committed to the identification of func- a need for all branches of the science to promote
tional relationships. When appropriate, they the accurate and current state of the field, in
utilize within subject designs. This is especially research and clinical arenas.
true when they are evaluating the impact of Applied refers to the commitment of ABA to
a more experimental treatment. At the level of improving the lives of those they serve. Behavior
the individual, the behavior analyst always seeks analysts seek to effect changes that are socially
to demonstrate functional relationships, to iden- significant. To achieve this, they select behaviors
tify variables responsible for change. that are of importance to the individual and to
The delivery of behavior analytic services is their family. They also assess whether changes
a separate domain, as noted above, but is closely have made real-world differences in the lives of
linked to this third branch of the science of behav- the individuals. Many misconceptions exist about
ior analysis, ABA. Practitioners design interven- this particular dimension, as many people think
tions and evaluate their impact. They use of ABA as intervening on all behaviors or as
procedures that are derived from basic research being focused on behavior reduction in the
and that have been shown to produce socially absence of an analysis of importance. In the
significant outcomes by applied researchers. In early days of ABA, when impact was new,
recent years, this application of the science has the focus was on using the science to reduce
become increasingly prominent. The effective- intractable behaviors. However, the science has
ness of ABA in effecting change has been signif- evolved over many decades and is now very
icant, especially in certain populations, such as focused on the importance of targeting behaviors
individuals with autism. This has created that make a real-world difference.
a unique and wonderful opportunity for ABA to Behavioral refers to the focus on behavior.
receive attention in the broader public arena. It Behaviors targeted must be those in need of
has also created threats to the purity of the sci- improvement, must be measurable, and must be
ence, to the portrayal of the science, and to the verified to have changed through objective
public’s understanding of the core characteristics means. This guideline emphasizes the need to
and commitments of ABA. Misconceptions and target and measure behaviors in the natural set-
misrepresentations abound, and the correction of ting of the individual and commits the behavior
these misconceptions and misrepresentations has analyst to using behavioral techniques for all
become imperative. intervention and measurement. It distinguishes
Many myths and misconceptions exist about ABA from other service providing disciplines
behavior analysis and, in particular, about that often speak in generalities and in global
B 408 Behavior Analysis
terms. The commitment to the science requires significance as much as they value social signif-
that all behaviors must be measurable, icance. Effective also implies that behavior ana-
operationally defined, and thoroughly evaluated lysts choose interventions with empirically
objectively for change that is empirically verified effects, do not choose interventions that
verifiable. are unproven, and discourage the continuation or
Analytic refers to the demonstration of pursuit of baseless interventions. In recent years,
a relationship between the manipulated variables this has taken the form of commitment to evi-
and the documented behavioral effects. Experi- dence-based practice. While behavior analysts
menters must be able to control the occurrence have always valued this dimension, its impor-
and nonoccurrence of the behavior. Behavior tance has increased in the context of fad treat-
analysts value this dimension very highly and ments and false claims of effectiveness.
work to prove that such a functional relation Generality refers to the tendency for behavior
exists between the independent variable (variable changes to last over time, appear in untrained
that was manipulated) and the dependent variable environments, and spread to untrained behaviors.
(behaviors targeted). The behavior analyst is If behaviors are not maintained and do not
never content with change alone; there must be extend, the changes are far less significant.
an understanding of WHY the behavior changed, Behavior analysts are committed to teaching
of the variables responsible for the change. behaviors with enduring and transferrable quali-
Technological refers to replicability. Behavior ties. In the earliest days of behavioral interven-
analysts use precision, detail, and clarity in tion, this dimension was not as prominently
describing their interventions so that others can emphasized as it has been in recent years.
replicate their work. Behavioral procedures must Demonstration of the generality of behavior
be replicable to be teachable to others. From both change is now routinely expected and sought.
a research and clinical perspective, then, the In addition, behavior analysis is defined by
technological dimension is essential to behavior several central constructs. Determinism implies
analysis. This is another hallmark characteristic that we can determine the cause and effect of
of science. If a technique is not technological, various occurrences and can determine the vari-
it cannot be subjected to a test. It then ables responsible for change. Behavior is lawful,
becomes analogous to anecdotal reports, and it and functional relationships can be identified.
becomes vulnerable to exaggeration and false Philosophic doubt implies a skeptical worldview.
claims. The requirement for procedures to be Behavior analysts require empirical verification
technological ensures that they are both teachable of hypotheses and do not embrace conclusions
and testable. without confirming evidence. Parsimony implies
Conceptually systematic refers to the founda- that behavior analysts resort to the simplest
tions of behavior analysis. Applied behavior ana- explanation for events, the explanations that
lysts describe their procedures and the impact of require the least inference and speculation. They
these procedures in terms of the basic principles stay close to the data and do not go beyond the
of behavior. This dimension refers to the need for data in explaining their results.
behavior analysts to stay close to their science, to The strength of the science of behavior analy-
link their findings back to the elemental princi- sis comes from commitment to these dimensions
ples of behavior, and to guard against adding and constructs. Furthermore, the integrity of the
superfluous and false explanations. This principle science depends upon the commitment to the
guards against the dilution of the science at the continued development of and adherence to
conceptual and explanatory level. these dimensions and constructs in all branches
Effective refers to a core commitment to the of the science. Behaviorism, experimental analy-
improvement of behavior to a practical and sis of behavior, and applied behavior analysis are
meaningful extent. Behavior analysts do not interrelated, and the dimensions of the science
value statistical significance or theoretical fuel and further define one another.
Behavior Analyst Certification Board 409 B
Future Directions Birnbrauer, J. S., Wolf, M. M., Kidder, J. D., & Tague,
C. E. (1965). Classroom behavior of retarded pupils
with token reinforcement. Journal of Exceptional
Due to its adherence to the methods of science, Child Psychology, 2, 219–235.
behavior analysis has resulted in great strides in Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
understanding, identifying the environmental Applied behavior analysis (2nd ed.). Upper Saddle B
variables that influence a wide variety of animal River, NJ: Pearson.
Hall, R. V., Lund, D., & Jackson, D. (1968). Effects of
and human behavior. One of the areas of the teacher attention on study behavior. Journal of Applied
biggest impact has been on persons with disabil- Behavior Analysis, 1, 1–12.
ities. Acknowledging the benefit of this particular Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012).
perspective in studying human behavior, future Behavior analysis for lasting change (2nd ed.).
Cornwall-on-Hudson, NY: Sloan Publishing.
directions of the application of behavior analysis
should proceed in at least three directions. First,
behavior analysts continue to sharpen its analysis
of human behavior in the areas in which they
have already studied. For example, deeper anal- Behavior Analyst Certification Board
ysis of how to treat disabilities would provide
significant clinical benefit, as has been shown Mary Jane Weiss
already. Second, behavior analysis should branch Institute for Behavioral Studies, Endicott
out into other areas of human behavior not yet College, Beverly, MA, USA
well studied and submit those areas to extensive
scientific analysis. Some of these new areas could
include analysis of human creativity and psycho- Major Areas or Mission Statement
logical disorders, such as obsessive-compulsive
behavior. Third, behavior analysis should pro- Behavior Analyst Certification Board ®
ceed more diligently in applying findings from The Behavior Analyst Certification Board ®,
experimental behavior analysis to the testing of Inc. (BACB ®) is a nonprofit corporation
and solutions for human behavior. This “transla- established in 1998 to meet professional
tional” research, in which experimental findings credentialing needs identified by behavior ana-
are tested in the human/applied area, has the lysts, governments, and consumers of behavior
potential for great payoff. analysis services. The BACB’s mission is to
develop, promote, and implement an interna-
tional certification program for behavior analyst
See Also practitioners. The BACB has established uniform
content, standards, and criteria for the credential-
▶ Applied Behavior Analysis ing process that are designed to meet:
▶ Behaviorism 1. The legal standards established through state,
federal, and case law
2. The accepted standards for national certifica-
References and Readings tion programs
3. The “best practice” and ethical standards of
Ayllon, T., & Michael, J. (1959). The psychiatric nurse as the behavior analysis profession
a behavioral engineer. Journal of the Experimental
Prior to the creation of the BACB, no uniform
Analysis of Behavior, 2, 323–334.
Baer, D. M., Wolf, M. M., & Risley, T. (1968). Some standards existed for evaluating the education,
current dimensions of applied behavior analysis. training, and experience of a behavior-analytic ser-
Journal of Applied Behavior Analysis, 20, 313–327. vice provider. Since its inception, the BACB has
Bijou, S. W., Birnbruer, J. S., Kidder, J. D., & Tague, C.
(1966). Programmed instruction as an approach to
set the standards for education and training in the
teaching of reading, writing, and arithmetic to retarded field of applied behavior analysis and has certified
children. The Psychological Record, 16, 505–522. more than 10,000 individuals (as of 2010).
B 410 Behavior Assessment System for Children, 2nd Edition
The BACB adheres to the national standards Scores: Scores/Interpretation: T scores and
for organizations that grant professional percentiles for general population and clinical
credentials. The BACB certification procedures populations
and examination content undergo regular Ages/grades: Ages: 2:0 through 21:11 (TRS
psychometric review and validation, pursuant and PRS); 6:0 through college age (SRP). English
to a job analysis survey of the profession and and Spanish forms are available.
standards established by content experts in the Scoring/administration programs: BASC-2
field. ASSIST and ASSIST-plus provide scoring,
The Behavior Analyst Certification Board’s reporting, and relationship to DSM-IV-TR diag-
BCBA and BCaBA credentialing programs are nostic criteria. Online administration, scoring, and
accredited by the National Commission for reporting are available for the TRS and PRS scales.
Certifying Agencies, the accreditation body of Publisher: Pearson
the Institute for Credentialing Excellence. Publisher address: Pearson, 19500 Bulverde
The BACB is endorsed by the Association of Road, San Antonio, TX 78259; Telephone:
Professional Behavior Analysts, the Association 800-627-7271; FAX: 800-632-9011; E-mail:
for Behavior Analysis International, Division 25 pearsonassessments@pearson.com; Web: www.
(Behavior Analysis) of the American Psycholog- pearsonassessments.com.
ical Association, and the European Association The Behavior Assessment System for Children,
for Behaviour Analysis. 2nd Edition (BASC-2) is a commonly standard-
The most up-to-date information on the ized set of rating scales and forms used to assess
BACB can be found at www.bacb.com. behavior in children and adolescents. The BASC-2
is normed on current US census population char-
acteristics. Specific norms are not available for
individuals with autism spectrum disorders
Behavior Assessment System for (ASD) or neurodevelopmental disorders. Avail-
Children, 2nd Edition able scales include the Teacher Rating Scales
(TRS), Parent Rating Scales (PRS), Self-Report
Felice Orlich of Personality (SRP), Student Observation System
Autism Psychology Services, Seattle Children’s (SOS), and a Structured Developmental History
Hopsital CAC – Autism Center, Seattle, (SDH).
WA, USA The Teacher Rating Scales (TRS) measure
adaptive and problem behaviors in the preschool
or school setting. Teachers or other qualified
Synonyms observers can rate specific behaviors on a four-
point scale of frequency, ranging from “Never” to
BASC-2 “Almost Always.” The TRS contains 100–139
items. The Parent Rating Scales (PRS) measure
both adaptive and problem behaviors in the com-
Definition munity and home setting. The form requires
a fourth grade reading level and is available in
Acronym: BASC-2 Spanish. Similar to the TRS, parents or caregivers
Author: Kamphaus, Randy W.; Reynolds, can complete forms at three age levels –
Cecil R. preschool (ages 2–5), child (ages 6–11), and ado-
Purpose: Designed to determine behavioral lescent (ages 12–21). The PRS contains 134–160
and emotional functioning in children and items and uses a four-choice response format.
adolescents in preschool through high school Both scales capture internalizing and externaliz-
Administration time: 10–20 min (teacher: TRS ing behavioral adjustment reflected in an overall
and parent: PRS), 30 min (self: SRP) Behavioral Symptoms Index (BSI). Scales
Behavior Development Questionnaire 411 B
uniquely applicable to children and adolescents second edition (BASC-2). Research in Autism Spec-
with ASD include assessment of functional com- trum Disorders, 5(1), 222–229.
Smith, E. A. (2011). Comparing behavior and neuropsy-
munication and social skills. chological functioning using NEPSY and BASC-2
The Self-Report of Personality (SRP) provides scores in a mixed clinical sample. Dissertation
self-assessment of a child or adult’s thoughts Abstracts International: Section B: The Sciences and B
and feelings. Each form – child (ages 8–11), Engineering, 71(7-B), 4508.
Van Slyke, K. B. (2008). Assessing childhood difficulties:
adolescent (ages 12–21), and college (ages Comparing the SDQ and the BASC-2. Dissertation
18–25) – takes about 30 min to complete. The Abstracts International: Section B: The Sciences and
SRP-Interview (SRP-I) form for children 6–7 Engineering, 68(11-B), 7289.
provides simple yes-or-no responses to questions Volker, M. A., Lopata, C., et al. (2010). BASC-2 prs
profiles for students with high-functioning autism
asked by an examiner. The SRP-I takes about spectrum disorders. Journal of Autism and Develop-
20 min to complete. Spanish versions are avail- mental Disorders, 40(2), 188–199.
able for the child and adolescent forms. In addi-
tion to measuring, internalizing (depression/
anxiety/self-esteem), and externalizing problems
(impulsivity/attention), the SRP offers self- Behavior Development
assessment of interpersonal relationships and Questionnaire
social stress.
Recent validity studies of the BASC-2 for use Corey Ray-Subramanian
in individuals with ASD have found that the Waisman Center, University of Wisconsin-
BASC-2 TRS and PRS forms can be effective in Madison, Madison, WI, USA
differentiating between children with high-
functioning autism and typically developing
peers. In a recent study (Ensign, 2010), signifi- Synonyms
cant differences were found between individuals
and typically developing groups on all PRS BDQ; Wing Subgroups Questionnaire (WSQ)
scales. DSM-IV-TR screening indices suggested
that the Developmental Social Disorders Scale
was highly effective in differentiating between Description
the two groups. Hass et al. (2010) found similar
results on the TRS in children receiving an edu- The Behavior Development Questionnaire
cational classification of autism spectrum (BDQ), formerly referred to as the Wing Sub-
disorder. groups Questionnaire, is an assessment tool
used to classify individuals with autism spectrum
disorders into one of three categories based on
References and Readings Wing and Gould’s (1979) categorization scheme:
aloof, passive, and active-but-odd (Castelloe &
Ensign, J. (2010). Psychosocial subtypes on the behavior
Dawson, 1993). These classifications are distin-
assessment system for children, second edition follow-
ing pediatric traumatic brain injury. [Dissertation]. guished based on the individual’s quality of
Dissertation Abstracts International: Section B: The social interaction. The aloof group is considered
Sciences and Engineering, 71(3-B), 2032. to rarely display spontaneous social approaches
Hass, M., Brown, R. S., Brady, J., & Johnson, D. B. (2010)
to others, other than for the purpose of making
Validating the BASC-TRS for use with children and
adolescents with an educational diagnosis of autism. requests, and often rejects social contact from
Remedial and Special Education, 33, 173–183. others. The passive group shares this lack of
doi:10.1177/0741932510383160. spontaneous social approaches but does not reject
Mahan, S., & Matson, J. L. (2011). Convergent and dis-
social approaches from others. The active-
criminant validity of the Autism Spectrum Disorder-
Problem Behavior for Children (ASD-PBC) against but-odd group is described as being willing to
the Behavioral Assessment System for Children, make social approaches to others, but the
B 412 Behavior Development Questionnaire
approaches are considered unusual in quality passive, active-but-odd), interrater agreement, and
(Castelloe & Dawson, 1993). relationships between BDQ results and other con-
The BDQ is a parent- or teacher-completed current measures. Internal consistency, as mea-
questionnaire that is comprised of 13 groups of sured by Cronbach’s alpha, has been shown to
four behavior descriptions. The 13 groups cover range from .63 for the passive classification to .85
various domains such as patterns of social for the active-but-odd category on parent-
approaches, response to social approaches, com- completed questionnaires. For teacher-completed
munication skills, imitation, play skills, unusual BDQs, Cronbach’s alpha has been found to range
motor behavior, resistance to change, physical from .54 for passive to .79 for active-but-odd.
coordination, and challenging behaviors Clinicians’ assignments of children with ASD to
(Castelloe & Dawson, 1993). Parents or teachers Wing’s groups have been shown to be highly cor-
are asked to rate the frequency with which the related with the results of parent-completed BDQs
target individual’s behavior fits the described (Castelloe & Dawson, 1993).
behavior (0 ¼ never; 6 ¼ always). An example Evidence for the distinct nature of the three
item is “When my child is with unfamiliar adults groups has been found in the strong negative
or children he readily approaches others to inter- correlation between the aloof and active-but-odd
act and responds easily to others. His manner of groups (.70 for parent-completed BDQs
interacting is generally appropriate (not awkward and .55 for teacher-completed BDQs) and the
or unusual)” (Castelloe & Dawson, 1993; p. 240). low correlations between aloof and passive (.02
Summary scores are calculated for each of the for parent-completed BDQs and .04 for
four groups (i.e., aloof, passive, active-but-odd, teacher-completed BDQs) and between passive
typical) by totaling the scores across the 13 groups and active-but-odd (.17 for parent-completed
of behavior descriptions. The group for which the BDQs and .13 for teacher-completed BDQs;
individual receives the highest summary score is Castelloe & Dawson, 1993; O’Brien, 1996).
assigned as the overall classification (Castelloe & However, item analysis has shown that 16 of the
Dawson, 1993). 50 items on the BDQ poorly discriminate among
the subtypes (O’Brien, 1996).
The aloof classification has been shown to be
Historical Background associated with lower IQ, lower receptive lan-
guage skills, and more severe symptoms of autism
The BDQ was first reported in published research (Castelloe & Dawson, 1993), as compared to the
by Castelloe and Dawson (1993), and, at that other two classifications. Significant differences
time, the questionnaire was referred to as the have also been found between the aloof
Wing Subgroups Questionnaire, as it is based on and active-but-odd groups on the Peabody
clinical subgroups within ASD introduced by Picture Vocabulary Test and the Vineland Com-
Wing and Gould (1979). Wing and Gould devel- munication and Socialization domains (O’Brien,
oped the classifications to help improve under- 1996). The passive group has been shown to obtain
standing of the relationships between typical lower Maladaptive Behavior scores on the Vine-
autism, mental retardation, and other conditions land and have less physical aggression reported on
involving social impairment. the Autism Behavior Checklist compared to the
other two groups (O’Brien, 1996). Wing’s sub-
group classifications based on clinicians’ judg-
Psychometric Data ments have been associated with differences in
brain activity measured through electroencepha-
Evidence for the validity and reliability of the BDQ lography (EEG; Dawson, Klinger, Panagiotides,
has been provided through the examination of the Lewy, & Castelloe, 1995). In one study, levels of
questionnaire’s internal consistency, the distinct active-but-odd behaviors on the BDQ did not dis-
nature of the three clinical subgroups (i.e., aloof, tinguish children with high-functioning autism
Behavior Modification 413 B
from a group with ADHD or ODD (Downs & Downs, A., & Smith, T. (2004). Emotional understanding,
Smith, 2004). The ADHD/ODD group actually cooperation, and social behavior in high-functioning
children with autism. Journal of Autism and Develop-
displayed more aloof behavior than the high- mental Disorders, 34, 625–635.
functioning autism group (Downs & Smith, 2004). O’Brien, S. K. (1996). The validity and reliability of the
Interrater reliability coefficients, based on Wing Subgroups Questionnaire. Journal of Autism and B
pairs of teachers and teaching assistants complet- Developmental Disorders, 26, 321–335.
Wing, L., & Gould, J. (1979). Severe impairments of
ing the BDQ for a particular child, were found to social interaction and associated abnormalities in
be .60 for the aloof group, .81 for the passive children: Epidemiology and classification. Journal of
group, .77 for the active-but-odd group, and .78 Autism and Developmental Disorders, 9, 11–29.
for the typical group (O’Brien, 1996).
Clinical Uses Behavior Modification
The BDQ can be used by clinicians to categorize Michael D. Powers

individuals with ASD as aloof, passive, or active- The Center for Children with Special Needs,
but-odd and plan intervention goals appropriately Glastonbury, CT, USA
(Castelloe & Dawson, 1993). It has also been
used as an outcome measure in clinical interven-
tion research, and BDQ scores have been found to Definition
change following early intervention (Downs,
Downs, Johansen, & Fossum, 2007). To date, Behavior modification is a treatment approach
little has been published on the specific clinical based on Skinner’s (1938, 1953) principles of
uses of the BDQ. operant conditioning. It seeks to establish desir-
able behavior and reduce or eliminate undesir-
able behavior through the use of empirically
See Also validated procedures, including but not limited
to positive and negative reinforcement, extinc-
▶ Active-But-Odd Group tion, and punishment. Behavior modification
▶ Aloof Group procedures have been used to treat a wide variety
▶ Passive Group of human problems including attention deficit
▶ Wing, Lorna hyperactivity disorder, autism, enuresis and
encopresis, fears and phobias, noncompliant
behavior, and pica, among others.
Castelloe, P., & Dawson, G. (1993). Subclassification of See Also

children with autism and pervasive developmental dis-
order: A questionnaire based on Wing’s subgrouping
scheme. Journal of Autism and Developmental ▶ Applied Behavior Analysis
Disorders, 23, 229–241. ▶ Behavior Therapy
Dawson, G., Klinger, L. G., Panagiotides, H., Lewy, A., & ▶ Negative Reinforcement
Castelloe, P. (1995). Subgroups of autistic children ▶ Positive Reinforcement
based on social behavior display distinct patterns of
brain activity. Journal of Abnormal Child Psychology,
23, 569–583.
Downs, A., Downs, R. C., Johansen, M., & Fossum, M. References and Readings
(2007). Using discrete trial teaching within a public
preschool program to facilitate skill development in Martin, G., & Pear, J. (2003). Behavior modification:
students with developmental disabilities. Education What it is and how to do it (7th ed.). Upper Saddle
and Treatment of Children, 30, 1–27. River, NJ: Prentice Hall.
B 414 Behavior Observation Scale
Skinner, B. F. (1938). The behavior of organisms. Historical Background

New York: Appleton-Century-Crofts.
Skinner, B. F. (1953). Science and human behavior.
New York: MacMillan. The BOS was one of the first diagnostic instru-
ments for autism. Unlike other diagnostic mea-
sures, the BOS was the first autism scale to
emphasize the importance of controlling the
Behavior Observation Scale observed behaviors of a child, as well as the
environment in which the observation took
Sarah Butler and Catherine Lord place. The frequency of these observed behaviors
Center for Autism and the Developing Brain, was used to differentiate among diagnostic
New York-Presbyterian Hospital/Westchester groups. The appearance of some specific rare
Division, White Plains, NY, USA behaviors during play was found to be
a significant indicator, suggesting that the quality
of some specific behaviors, rather than the fre-
Synonyms quency, was more important to diagnose children
with autism (Lord & Corsello, 2005).
BOS
Psychometric Data
Description
The authors of the first factor analyses of the BOS
The Behavior Observation Scale (BOS) is a concluded that it is necessary to create age-
clinician-based measure of behaviors associated specific norms for the frequencies of behaviors
with autism (Freeman, Ritvo, Guthrie, Schroth, & of children with autism. These norms still need to
Ball, 1978). The authors emphasized that be created comparing age-matched groups of
children with autism should be studied within a both nonspectrum typical and intellectually
development context and compared to impaired children (Freeman et al., 1978).
nonspectrum typical and intellectually impaired Some measures of reliability have been com-
children to distinguish behaviors specific to pleted for the BOS. Interrater reliability of the
autism that are of diagnostic significance (Free- BOS was assessed with a sample of 89 children,
man, Schroth, Ritvo, Guthrie, & Wake, 1980). which included 36 with autism and 30 with
The BOS is a checklist of 67 objectively defined nonspectrum intellectual disabilities matched
behaviors. The clinician watches the child interact for mental age and 23 typically developing
with age-appropriate toys through a one-way mirror children (Freeman et al., 1978). Correlation coef-
in the presence of an examiner. The observation ficients for ratings by the observer (watching
consists of recording the frequency of the specified through a one-way mirror) and the examiner (sit-
behaviors in nine 3-min intervals. Three-minute ting in the room) were greater than 0.84 for 55 of
baseline periods are also documented at the begin- the 67 behaviors; the published work did not
ning and end of the play period. The examiner in the include the coefficients for the remaining 12
room presents the child with standard stimuli for items (Morgan, 1988). Internal consistency and
seven of the intervals. During one interval, the test-retest reliability have not been reported for
examiner actively tries to engage the child through the BOS (Parks, 1983).
ball play. The behaviors are scored as not present or Various studies have also examined the valid-
occurring once, twice, or continuously during the ity of the BOS. The content validity of the BOS
three-minute intervals. When not following these comes from the inclusion of ratable behaviors
specific prompts, the examiner sits in one corner of related to the clinical diagnostic criteria of
the room and does not respond to the child if he or autism. This is demonstrated by a factor analysis
she initiates contact (Morgan, 1988). performed from three groups of children: those
Behavior Plan 415 B
with autism, those without autism but with intel- cognitive difficulties, and the BOS provides the
lectual disability, and those with typical develop- means for obtaining that information.
ment (Freeman et al., 1980). According to their
analyses, the authors characterize children with
autism as exhibiting “inappropriate interactions See Also B
with people and objects,” the nonspectrum intel-
lectually impaired group as having “solitary ▶ Autism Diagnostic Observation Schedule
behaviors,” and the typically developing group
as showing “appropriate interactions with people
and objects” (p. 344). References and Readings
In order to determine discriminate validity,
Freeman and colleagues compared groups of Freeman, B. J., Guthrie, D., Rivto, E. R., Schroth, R.,
Glass, R., & Frankel, F. (1979). Behavior observation
children with autism and children without autism
scale: Preliminary analysis of the similarities and
but with intellectual disabilities and found that differences between autistic and mentally retarded
they only differed on 11 of the 67 behaviors that children. Psychological Reports, 44, 519–588.
compose the BOS (Freeman, Guthrie, Rivto, Freeman, B. J., Ritvo, E. R., Guthrie, D., Schroth, P., &
Ball, J. (1978). The behavior observation scale for
Schroth, Glass, & Frankel, 1979). However, the
autism: Initial methodology, data analysis, and prelim-
authors point out that the behaviors that did not inary findings on 89 children. Journal of the American
discriminate between these groups were depen- Academy of Child Psychiatry, 17, 576–588.
dent on the developmental variables of mental Freeman, B. J., & Rivto, E. (1980, May). The behavior
observation scale for autism (BOS): IQ and behavior
and/or chronological age. Freeman and Ritvo
of autistic children. Paper presented at the meeting of
(1980) compared children with autism, cogni- the Western Psychological Association Honolulu
tively impaired children matched for mental Freeman, B. J., Schroth, P., Ritvo, E., Guthrie, D., &
age, and typically developing children matched Wake, L. (1980). The behavior observation scale for
autism (BOS): Initial results of factor analysis. Journal
for chronological age on the BOS. They found
of Autism and Development Disorders, 10, 343–346.
that six items differentiated the low-IQ autism Lord, C., & Corsello, C. (2005). Diagnostic instruments in
group from the cognitively impaired group. autistic spectrum disorders. In F. R. Volkmar, R. Paul,
They concluded that the three groups could be A. Klin, & D. Cohen (Eds.), Handbook of autism and
pervasive developmental disorders (3rd ed.,
discriminated with the BOS if these six items
were coded. No studies have examined how Morgan, S. (1988). Diagnostic assessment of autism:
well the BOS distinguished between children A review of objective scales. Journal of Psychoedu-
with autism and children with other behavior cational Assessment, 6, 139–151.
Parks, S. L. (1983). The assessment of autistic children:
problems (Morgan, 1988).
A selective review of available instruments. Journal of
Clinical Uses
The purpose of the BOS is to diagnose autism Behavior Plan

based on objective observation of behavior
within a developmental context (Morgan, 1988). Jessica Rohrer
Though the intention of the authors was to create The Center for Children with Special Needs,
an agreed-upon diagnostic framework for use in Glastonbury, CT, USA
research (Freeman et al., 1978), the BOS is useful
clinically as well. Freeman et al. add that the BOS
can also be used to document changes in symp- Definition
toms over time. Diagnosis and symptom changes
are necessary for providing adequate therapeutic A behavior plan is an organized plan to aid in
care for any individual with behavioral or the reduction of problem behaviors or increase
B 416 Behavior Plan
desired behaviors. Behavior plans are documents If a behavior plan involves procedures to
which are usually developed by behavior ana- decrease challenging behaviors, it will necessar-
lysts, teachers, counselors, and school psycholo- ily include methods to teach or increase appro-
gists, often with parental input. The documents priate and functionally equivalent responses.
are suitable for implementation in various set- Behavior plans may include several parts,
tings, such as private homes, public or private including antecedent strategies, identified behav-
schools, residential facilities, or vocational iors to decrease, identified behaviors to increase,
facilities. reinforcement system, management strategies,
data collection procedures, protocol for monitor-
ing effectiveness of interventions, strategies for
Historical Background maximizing generalization and maintenance, and
criteria to discontinue.
In the 1970s, the primary focus of behaviorism Antecedent strategies, or antecedent control
and behavior modification changed from primar- procedures, are procedures in which antecedents
ily using aversive procedures to eliminate (i.e., environmental cues, discriminative stimuli,
undesirable behaviors toward the use of rein- establishing operations, or response effort) are
forcement-based techniques to increase desired manipulated to influence a desired or undesired
behaviors (Brown, 1987). In many ways, this behavior. Antecedent strategies may include such
shift increased the quality and effectiveness of techniques as clear delivery of directives, break-
behavioral interventions, as they became more ing tasks down into smaller components, provid-
widely accepted and utilized, and began to be ing and reviewing visual schedules, reviewing
implemented across individuals with diverse contingencies and expectations prior to each
behavioral profiles. task, providing sequencing choices, providing
opportunities for sensory activities, delivering
reinforcement for appropriate behavior, provid-
Current Knowledge ing warnings prior to transitions, modifying aca-
demic tasks to match student’s ability, and
Behavior plans may incorporate various methods making environmental manipulations. These
of behavior modification and are individualized manipulations may include arranging the envi-
for each person. The procedures outlined in behav- ronment to decrease the likelihood of problem
ior plans should be developed based on evidence- behavior (i.e., clearing area of extraneous mate-
based techniques, such as functional behavior rials or positioning the individual away from
assessment or experimental functional analysis dangerous materials). Antecedent strategies can
(see ▶ Functional Analysis). The behavioral func- be diverse and individualized for each individual.
tion(s) identified using these methods are then used Procedures designed to decrease problem
to develop an appropriate behavior plan. behavior and increase replacement skills often
The objectives of developing a behavior plan include a reinforcement-based system. Examples
include identifying and defining target behaviors, of positive reinforcement-based systems are token
recommending procedures to decrease challeng- economy systems (based on differential reinforce-
ing behaviors, and recommending procedures to ment), where individuals earn tokens (to be
increase appropriate behaviors or replacement exchanged for identified reinforcers) based on the
skills. absence of problem behavior and/or engagement
Behaviors targeted to decrease and in alternative behaviors. In order to identify effec-
those targeted to increase must be clearly and tive reinforcers, preference or reinforcer assess-
operationally defined, so that all personnel ments should be conducted. These assessments
implementing the plan will do so consistently. may be informal, such as interviews or anecdotal
These definitions should be observable, clear, reports from parents or caregivers, or observation
concise, and accurate. of the individual in various environments to
Behavior Plan 417 B
determine where he/she allocates time. Preference behavior(s). Time-out can be inclusionary (the
or reinforcer assessments can also be formal, using individual remains in the same environment) or
a validated assessment such as a forced-choice exclusionary (the individual is removed from the
preference assessment (Fisher et al., 1992) or mul- environment in which the behavior occurred). It
tiple-stimulus without replacement (MSWO) pref- is a punishment-based procedure because a stim- B
erence assessment (DeLeon & Iwata, 1996). ulus (reinforcement) is removed contingent on
Once reinforcers have been identified, a token problem behavior, therefore reducing the future
economy system might be considered as likelihood of the occurrence of that behavior.
a procedure within a positive reinforcement- Response blocking attempts to reduce the
based behavior support plan. reinforcing aspects of the behavior by eliminating
A token economy could be based on a DRO contact with the reinforcer. For example, an auto-
(differential reinforcement of other behavior), matically maintained behavior like hand flapping
DRA (differential reinforcement of alternative would be blocked, therefore restricting access to
behavior), or DRI (differential reinforcement of the reinforcing aspects of the behavior. In a
incompatible behavior). In a DRO procedure, response-interruption procedure such as a “hands-
reinforcement is delivered solely for the absence down” procedure, the response is interrupted and
of problem behavior, whereas in DRA or DRI the individual is physically redirected to an alter-
procedures, reinforcement is delivered contin- nate response (i.e., putting hands down). This pro-
gent on the occurrence of an alternative response cedure may also function due to the principle of
or one that is incompatible with the target behav- punishment, as the individual may engage less
ior. A token system could include tokens that can frequently in the behavior in order to avoid the
be physically manipulated by the individual (i.e., redirection procedure.
stickers, coins, or tickets) or they could simply be Response cost, or removal of privileges, is
checkmarks on a list of completed tasks. another consequence-based procedure where a
Some positive reinforcement-based procedures reinforcer (or multiple reinforcers) is removed con-
may not be as specific or structured as a differential tingent upon the occurrence of the target behavior.
reinforcement procedure and may not involve The future of occurrence of the target behavior is
tokens at all. That is, direct reinforcement may be then decreased, as the individual avoids coming in
delivered on a fixed or variable schedule, contin- contact with this aversive contingency. Restitution
gent on appropriate behaviors. Positive reinforce- and overcorrection are typically used with behav-
ment-based procedures can be implemented on iors where the environment is disturbed, such as
their own or in conjunction with a number of property destruction, and refer to procedures
other behavioral intervention procedures. where, contingent on the problem behavior, the
Additional consequence-based interventions individual is required to restore the environment
may include procedures such as time-out, to its original state. For example, if the individual
response blocking or interruption, physical or dumps juice on the floor, he/she would be required
verbal redirection, response cost or removal of to wipe it up. In overcorrection, the individual
privileges, restitution, and overcorrection. These might be required to not only clean up the spilled
procedures involve various behavioral concepts juice but also wipe the rest of the floor.
such as extinction and may utilize principles of Within any behavior plan should be a defined
punishment. Therefore, they are typically used in system for collecting data, including procedures
conjunction with positive reinforcement-based appropriate to the behaviors being measured.
procedures, so as not to focus only on the Data collection methods may include event
decrease of aberrant behavior but also the recording, duration recording, latency recording,
increase of appropriate behavior. or interval recording. Event recording refers to
Time-out is a procedure which decreases a count of behaviors as they occur. When
problem behavior by removing reinforcement reporting this data, it can be summarized as the
contingent on the occurrence of the target total number of behaviors that occurred, the rate
B 418 Behavior Plan
of responding (frequency over time), or percent- specific measures to evaluate the implementation
age of the occurrence of the target behavior as of the plan across implementers.
compared to other behaviors. Duration recording
refers to how long an individual engages in
a certain behavior. This can be reported as total Future Directions
duration per episode, per day, or some other spec-
ified time period. Latency recording refers to the The individuals who develop behavior plans
amount of time between a stimulus and a response. should always consider the ethical responsibili-
For example, this type of recording may be used to ties involved in any behavior modifications and
examine how long it takes an individual to respond continue to explore positive reinforcement-based
once an instruction has been given. Interval methods before those considered more aversive.
recording measures the presence or absence of As the field of behavior analysis progresses,
a target behavior within specified time intervals. behavior plans should incorporate the most recent
Whole-interval, partial-interval, and momentary behavioral technologies to best support individ-
time sampling are all types of interval recording. uals. Currently, behavior plans are commonly
To determine which data collection method to use, utilized in the field of behavior analysis for indi-
it is important to look at the characteristics of the viduals with autism and other developmental dis-
behavior and select a data collection method that abilities. In the future, behavior plans can be used
will best represent the feature that is to be to guide and support the efforts of those who
examined. work not only with developmentally disabled
Data collection is a crucial part of an effective individuals but with people of all backgrounds
behavior plan, as it allows careful analysis of the who may benefit from behavioral strategies.
target behaviors as they are influenced by the
interventions put in place. Data sheets can be
developed by the author of the behavior plan or See Also
by staff or caregivers implementing the plan.
Once a data collection system has been ▶ Applied Behavior Analysis
established, all staff and caregivers involved in ▶ Positive Behavior Support
the plan’s implementation must be aware of the ▶ Token Economy
procedures. It is important that the terms and
methods for data collection have been reviewed
by all people that will be involved in data collec-
tion, as this will increase the likelihood that the Brown, D. P. (1987). Hypnosis and behavioral medicine.
data collected are valid and useful in analyzing Hillsdale, NJ: Lawrence Erlbaum Associates.
the success of the treatments. All people Cooper, J. O., Heron, T. E., & Heward, W. L. (1987).
implementing a behavior support plan should be Applied behavior analysis. Upper Saddle River, NJ:
Prentice-Hall.
fully trained in all aspects of the interventions. DeLeon, I. G., & Iwata, B. A. (1996). Evaluation of
A system to measure and track treatment fidelity a multiple-stimulus presentation format for assessing
should be in place to minimize procedural drift. reinforcer preferences. Journal of Applied Behavior
Procedural drift refers to when, over time, certain Analysis, 29, 519–532.
Fisher, W., Piazza, C. G., Bowman, L. G., Hagopian, L. P.,
interventions or parts of interventions are not Owens, J. C., & Slevin, I. (1992). A comparison of two
carried out as they should be. This inconsistency approaches for identifying reinforcers for persons with
can affect the success of the behavior plan and severe and profound disabilities. Journal of Applied
may result in some or all interventions losing Behavior Analysis, 25, 491–498.
Miltonberger, R. G. (2004). Behavior modification princi-
effectiveness. Treatment fidelity checks can min- ples and procedures (3rd ed.). Belmont, CA:
imize procedural drift by putting into place Wadsworth/Thomson Learning.
Behavior Rating Instrument for Autistic and Atypical Children (BRIAAC) 419 B
Psychometric Data
Behavior Rating Instrument for
Autistic and Atypical Children The BRIAAC consists of eight scales that are
(BRIAAC) developmentally ordered, with the lowest level
representing behaviors uniquely associated B
Sarah Butler and Catherine Lord with autism and the highest level representing
Center for Autism and the Developing Brain, developmental accomplishments typical of
New York-Presbyterian Hospital/Westchester normal 4-year-old children. The scales are
Division, White Plains, NY, USA communication, drive for mastery, vocalization
and expressive speech, sound and speech
reception, body movement, social functioning,
Synonyms psychosexual development, and relationship; in
the 1977 edition, social functioning and
BRIAAC psychosexual development were renamed
social responsiveness and psychobiological
development, respectively (Ruttenberg et al.,
Description 1974). The purpose behind the scoring system is
to reflect the entire range of possible behavior and
The Behavior Rating Instrument for Autistic the importance of each behavior within this range
and other Atypical Children (BRIAAC) was (Ruttenberg, Dratman, Fraknoi, & Wenar, 1966).
created for the purpose of diagnosing autism The interrater reliability of the original version
(Ruttenberg, Kalish, Wenar, & Wolf, 1974). of the BRIAAC was examined using trained stu-
The measure was based on observations in a day dents as raters (Ruttenberg et al., 1966). Spearman
treatment program of children with autism who rank correlation coefficients for the four-core scales
had been diagnosed using Kanner’s (1943) ranged from 0.85 to 0.88, demonstrating high
autism criteria. The measure consists of eight agreement among raters. However, since all of the
subscales that are completed by a trained children observed had been previously diagnosed
examiner who has observed the child for an with autism, the high reliability does not indicate
extensive period of time. The observations the ability to diagnose autism accurately with the
lead to descriptive ratings for each subscale BRIAAC (Ruttenberg et al.).
within the range characteristic of a 3.5- to 4.5- Two of the authors also examined the
year-old typically developing child compared to BRIAAC’s interrater reliability using the scores of
those that are characteristic of a child with severe 113 children with autism as determined by seven
autism. different pairs of raters (Wenar & Ruttenberg,
1976). The correlation coefficients ranged from
0.85 to 0.96 across the eight scales, indicating
Historical Background moderate interrater reliability, as they did not
control for response frequencies.
The BRIAAC was one of the earliest measures of Factor analysis completed by Wenar and
autism created shortly after Rimland’s first diag- Ruttenberg also supported internal consistency
nostic checklist (Lord & Corsello, 2005; Rim- because they found a high loading on one factor,
land, 1964). It was the first measure of autism to which they described as resistance to participation
utilize direct observation of behaviors as in activities, such as interacting with others or the
described in the case notes of defined raters, environment (1976). Cohen et al. also performed
making it a significant milestone of behavior- factor analysis and similarly found that the same
based measures (Parks, 1983). factor accounted for 69% of the variance.
B 420 Behavior Rating Instrument for Autistic and Atypical Children (BRIAAC)
All scales, except psychosexual development, evaluated. In addition, the levels of the scales assist
loaded at 0.80 or higher, suggesting high internal in planning therapeutic programs for children with
consistency (Cohen et al., 1978). This shows that autism because they indicate upcoming develop-
the test is, in fact, measuring a unity factor, leading mental steps and how therapy can progress to meet
to high internal consistency. the child’s developmental needs.
Both the items and the subscales of the BRIAAC
were based on frequent observations of children
with autism in a daycare center by a highly trained See Also
team of specialists. Their observations were incor-
porated into the items and scales, resulting in good ▶ Autism Diagnostic Observation Schedule
content validity (Wenar & Ruttenberg). ▶ Behavior Observation Scale
The BRIAAC presumably has good construct
validity because it is based on Kanner’s autism
criteria (1943), and the children observed References and Readings
were diagnosed according to those same criteria
(Morgan, 1988). In addition, as previously men- American Psychiatric Association. (1980). Diagnostic
tioned, factor analysis demonstrated that the and statistical manual of mental disorders (3rd ed.).
BRIAAC does examine one core factor, the resis- Cohen, D. J., Caparulo, B. K., Gold, J. R., Waldo, M. C.,
tance to engage with others and the environment Shaywitz, B. A., Ruttenberg, B. A., & Rimland, B.
(Wenar & Ruttenber; Cohen et al.). (1978). Agreement in diagnosis: Clinical assessment
Concurrent validity was studied by comparing and behavior rating scales for pervasively disturbed
children. Journal of the American Academy of Child
the BRIAAC scores and clinicians’ ratings of Psychiatry, 17(3), 589–603.
26 children either with autism or typical Kanner, L. (1943). Autistic disturbances of affective con-
development (Wenar & Ruttenberg). Significant tact. Nervous Child, 2, 217–250.
correlations were established between the Lord, C., & Corsello, C. (2005). Diagnostic instruments in
autistic spectrum disorders. In F. R. Volkmar, R. Paul,
clinicians’ rating and the total BRIAAC scores A. Klin, & D. Cohen (Eds.), Handbook of autism
(r ¼ .69) and three subscale scores (relationship to and pervasive developmental disorders (3rd ed.,
an adult, r ¼ .43; vocalization and expressive pp. 730–771). Hoboken, NJ: Wiley.
speech, r ¼ .64; sound and speech reception, Morgan, S. (1988). Diagnostic assessment of autism:
A review of objective scales. Journal of Psychoedu-
r ¼ .65). The authors viewed the examined concur- cational Assessment,6, 139–151. (ed.). (730–771).
rent validity as satisfactory and expressed the desire Hoboken, NJ: Wiley.
to examine the remaining subscales in the future. Parks, S. L. (1983). The assessment of autistic children:
Cohen et al. examined the discriminant A selective review of available instruments. Journal of
validity of the BRIAAC and found that the total Rimland, B. (1964). Infantile Autism: The Syndrome and Its
scores did not effectively discriminate among the Implications for a Neural Theory of Behavior (2nd print-
diagnostic groups of primary-childhood autism, ing). New York, NY: Appleton-Centrury-Crofts, Inc.
secondary-childhood autism, early-childhood Ruttenberg, B. A., Dratman, M. L., Fraknoi, J., & Wenar, C.
(1966). An instrument for evaluating autistic children
psychosis, developmental aphasia, and mental (BRIAC). Journal of the American Academy of Child
retardation (1978). Psychiatry, 5, 453–478.
Ruttenberg, B. A., Kalish, B. I., Wenar, C., & Wolf, E. G.
(1974). Behavior rating instrument for autistic and
other atypical children (rev. ed.). Philadelphia:
Clinical Uses Developmental Center for Autistic Children.
Wenar, C., & Ruttenberg, B. A. (1976). The use of BRIAC
The scoring system that addresses the whole range for evaluating therapeutic effectiveness. Journal of
of possible behaviors is clinically relevant because Autism and Childhood Schizophrenia, 6, 175–191.
Wenar, C., Ruttenberg, B. A., Kalish-Weiss, B., & Wolf,
it identifies both signs of progress and problem E. G. (1986). The development of normal and autistic
behaviors (Ruttenberg et al., 1966). These areas of children: A comparative study. Journal of Autism and
needed improvement can be specific for each child Developmental Disorders, 16, 317–333.
Behavior Rating Scale (BRS) 421 B
of those scores. The BRS scores can be
Behavior Rating Scale (BRS) interpreted at four different levels: total scores,
factor scores, item analysis, and comparisons
Sarah Butler and Catherine Lord with the other two tests within the Bayley. The
Center for Autism and the Developing Brain, total score compares the child with same-aged B
New York-Presbyterian Hospital/Westchester peers. Factor scores vary depending on age and
Division, White Plains, NY, USA are described by qualitative labels.
Synonyms Historical Background
BRS The BRS was previously known as the infant

behavior record (IBR) in the original version of
the Bayley Scales of Infant Development
Description (Bayley, 1969). Since its creation, the Bayley
has remained one of the most standardized and
The Behavior Rating Scale (BRS) is a subtest widely used measures for determining the devel-
within the Bayley Scales of Infants Development, opmental skills of infants and children in both
which is an assessment frequently used to assess clinical and research settings (Wolf & Lozoff,
the development of infants and children, includ- 1985; Klin, Saulnier, Tsatsanis, & Volkmar,
ing those with a diagnosis of autism. It is a norm- 2005).
referenced assessment that was first published in
1969 and later revised in 1993 and provides stan-
dard mental and motor indices and Psychometric Data
a developmental age equivalent for children
2 months to 2.5 years old. The Bayley Scales of The Bayley provides a method for obtaining age-
Infants Development consists of two subtests in equivalent scores for four facets of development,
addition to the BRS: the mental development cognitive, language, social, and motor, but empir-
index (MDI) and the psychomotor development ical evidence for their validity is limited (Bayley,
index (PDI). The BRS is a form for the evaluator 1993). The authors of the Bayley revision
to rate the child’s behavior throughout testing, (1993) found that the test has excellent statistical
including the ability to pay attention, social properties and sensitivity to high-risk childhood
engagement, affect and emotions, and the quality conditions, but its value for assessing young chil-
of movement and motor control. The BRS, pre- dren with autism is limited (Klin et al., 2005).
viously known as the infant behavior record Children with autism typically present with
(IBR), underwent many changes for the second a varied profile of skills, with higher level
edition, including a revamp in format and a new nonverbal problem-solving abilities, lower
scoring system. level expressive language, and lowest scores in
The examiner completes the BRS after the receptive language. Consequently, any compos-
other two components of the Bayley are assessed ite index score summarizing performance across
(Nellis & Gridley, 1994). The examiner also domains will misrepresent a child’s developmen-
solicits from the parent or caregiver additional tal profile, indicating that the actual profile with
information about the tasks and the session as varied skill levels is more informative than any
a whole. This includes whether the child’s behav- composite scores.
ior was typical during the session and if the The BRS contains 30 items that rate the child’s
child’s performance on the tasks reflected his or relevant test-taking behaviors and simulta-
her abilities. This information is not included in neously measures attention/arousal, orientation/
the BRS score, but aids in evaluating the accuracy engagement, emotional regulation, and motor
B 422 Behavior Rehearsal
quality (Bayley, 1993). The scoring of the BRS is Klin, A., Saulnier, C., Tsatsanis, K., & Volkmar, F.
based on rank values and has a five-point ordinal (2005). Clinical evaluation in autism spectrum disor-
ders: Psychological assessment within a transdisciplin-
scale for each behavior. There is limited psycho- ary framework. In F. R. Volkmar, R. Paul, A. Klin, &
metric data for the BRS, as most analyses have D. Cohen (Eds.), Handbook of autism and pervasive
been completed on the Bayley as a whole. The developmental disorders (3rd ed., pp. 730–771).
authors of the revised edition of the Bayley found Hoboken, NJ: Wiley.
Koseck, K. (1999). Review and evaluation of psychomet-
that total scores were more highly correlated for ric properties of the revised Bayley scales of
the older age range (r ¼ 0.88) than for the youn- infant development. Pediatric Physical Therapy,
ger age range (r ¼ 0.70), but concluded that the 11(4), 198–204.
interrater reliability for the BRS was fairly high Nellis, L., & Gridley, B. E. (1994). Review of the Bayley
Scales of Infant Development (2nd ed.). Journal of
for an observation-based measure (Bayley, 1993, School Psychology, 32(2), 201–209.
as cited in Koseck, 1999). Washington, K. (1998). The Bayley scales of infant devel-
opment-II and children with developmental delays:
A clinical perspective. Journal of developmental and
behavioral pediatrics, 19(5), 346–349.
Clinical Uses Wolf, A. W., & Lozoff, B. (1985). A clinically interpret-
able method for analyzing the Bayley infant behavior
The Bayley is particularly relevant in clinical record. Journal of Pediatric Psychology, 10(2),
settings with children suspected of having 199–214.
a developmental delay because it can both iden-
tify the presence of a developmental delay and
provide information to help the caregiver know
which services are necessary to help the child Behavior Rehearsal
(Washington, 1998). It is a relevant measure for
children demonstrating signs of autism because it Rebecca Munday
tests a wide variety of behaviors across different The Center for Children with Special Needs,
domains, but it is most informative when the Glastonbury, CT, USA
entire profile is assessed, rather than the total
scores (Klin et al., 2005). Another reason that
the Bayley is frequently used with children with Definition
developmental delays is that the testing materials
are of interest for these children and can hold Behavior rehearsal involves practicing appropri-
their attention (Nellis & Gridley, 1994). These ate behavior responses within social situations.
qualities of the Bayley and the BRS make the There are many methods for rehearsing social
measure highly informative in both clinical and behaviors. One method may include individuals
research settings. imagining or thinking about themselves
performing and responding appropriately to
others. A second method may include individuals
See Also practicing social interactions through describing
them verbally to others. A third method may
▶ Autism Screening Instrument for Educational include role-playing. With all methods, building
Planning (ASIEP-2) fluency through repeated rehearsal is vital
to achieving success and increasing appropriate
social skills.
Bailey, N. (1969). Bayley scales of infant development.

New York: Psychological Corporation.
See Also
Bayley, N. (1993). Bayley scales of infant development
(2nd ed.). San Antonio, TX: Psychological Corporation. ▶ Behavior
Behavior Summarized Evaluation-Revised (BSE-R) 423 B
References and Readings score indicates both the frequency of the behavior
disorders and the intensity of the pathology.
Morgan, R. L., & Salzberg, C. L. (1992). Effects of
video-assisted training on employment-related social
skills of adults with severe mental retardation. Journal
of Applied Behavior Analysis, 25, 365–383. Historical Background B
Sarokoff, R., & Sturney, P. (2004). Effects of behavior
skills training on staff implementation of discrete trial Professor Gilbert Lelord and his colleagues
teaching. Journal of Applied Behavior Analysis, 37,
designed the first BSE version in 1975 (Laffont,
535–538.
Jusseaume, Bruneau, Dubost, & Lelord, 1975).
The purpose of this version was to correlate
clinical variables with electrophysiological vari-
ables. The studies using this scale have demon-
Behavior Summarized strated that certain clinical characteristics such as
Evaluation-Revised (BSE-R) indifference to others or resistance to change were
related to electrophysiological signs such as the
Bernadette Rogé low amplitude of the potentials elicited in response
Clinical Psychopathology, Health Psychology to sensory stimuli. The major interest of this
and Neuroscience, Université de Toulouse Le technique is to provide a framework for observa-
Mirail, Toulouse, France tions that can be repeated in different contexts and
at different times in the child’s development.
Later, several successive versions involving
Synonyms a varying number of items were developed. The
factor analysis provided the means for the classi-
BSE; BSE-R; IBSE fication of the test items into categories.
The 1990 version involved 20 items
(Barthelemy et al., 1990). Nine items were later
Description added to the revised version (Barthelemy et al.,
1997). A specific version has been developed for
The Behavior Summarized Evaluation-Revised infancy and preschool years based on the BSE,
(BSE-R) is a psychometric instrument designed and 13 items have been added to describe early
for research and clinical purposes. manifestations of autism (The infant BSE: IBSE,
The current version includes 29 items that Adrien et al., 1992).
enable the formalization of behavior observations
in the different domains in which specifically
autistic difficulties occur. Psychometric Data
These domains are: touch, eye contact and
communication, motor behavior, perception, The BSE-R has been validated in a research led
and imitation. Coding is based on the observa- by Catherine Barthelemy and her colleagues
tions collected by a person who is regularly in (Barthelemy et al., 1997); 136 children with
touch with the child. The observations are autism were included in this study.
performed in the different situations of daily life
by all of the persons who work with the Inter-rater Reliability
child. A glossary describes briefly the content of For the inter-rater reliability study, 29 children
each item, which is rated on a 5-point scale (21 boys and 8 girls) were observed and their
ranging from 0 ¼ never to 4 ¼ continuously. behavior assessed with the BSE by two separate
The item is rated 0 if the behavior never appears, groups of nurses trained to use the instrument.
1 if it sometimes appears, 2 if often, 3 if very The total score reliability was very high (0.97).
often, and 4 if it is always present. Thus, the total Reliability measures were calculated for each
B 424 Behavior Summarized Evaluation-Revised (BSE-R)
item. Three items (1, 10, 29) also had high reli- and Rimland E2 score. A significant correlation
ability (0.75–1.0); ten items (2, 4, 5, 6, 9, 12, 14, was found between the BSE-R score for Factor 1
20, 27, 28) had good reliability (0.60–0.74); and and the Rimland score (.41). But there was no
12 items (3, 7, 8, 11, 13, 15, 16, 19, 21, 23, 24, 26) significant correlation between the BSE-R score
had fair reliability (0.40–0.59). Only four items for Factor 2 and the Rimland score. Convergent
(17, 18, 22, 25) had a low reliability and were validity was also confirmed in the study by Oneal
therefore excluded from the other analyses. and colleagues (2006), where the BSE scores
A factor analysis was performed on the BSE-R correlated highly with the CARS, a well-
results for the 136 children. Six factors were validated instrument.
extracted. Two factors accounted for more than
10% of total variance. Combined, they accounted Sensitivity and Specificity Study
for a total of 48, 6% of total variance. The two most Thanks to a ROC analysis, a cutoff of 27 was
loaded factors were labeled “interaction disorder” determined. This score permits a discrimination
(items 1, 2, 3, 4, 5, 6, 8, 9, 12, 23, 24, 26, 28) and between autistic children (AD) and nonautistic
“modulation disorder” (item 11, 13, 16). children (MR + PDDNOS) with a sensitivity of
A negative correlation was found between the 0.74 and a specificity of 0.71.
BSE-R score for Factor 1 and Development Other previously published results concern the
Quotient. This means that the higher the BSE-R first version of the BSE and can be found in
score, the lower the DQ was. No correlation was different papers (Barthelemy et al., 1990; Reeb,
found for Factor 2 and the DQ. Folger, & Oneal, 2009).
A criterion validity study was performed on
the BSE-R scores for all 136 children. The exter-
nal criterion was the Expert Severity Score Clinical Uses
(ESS). This was based on the observation of two
experienced staff psychiatrists who were blind to As already indicated, the BSE-R was designed for
the BSE-R score. The ESS ranged from 1 (mini- research and clinical purposes. As the validity and
mum) to 5 (maximum). A glossary was available, stability of the results obtained with the BSE-R
and for that reason, the ESS had an excellent were confirmed, several studies using this
reliability. Three diagnostic groups were consti- instrument were led mainly by Catherine
tuted: Autistic Disorders (AD), Pervasive Devel- Barthelemy’s team.
opmental Disorders Not Otherwise Specified
(PDDNOS), and Mental Retardation (MR). Biological Measures
A solid relation between the BSE-R score and Initially, research studies were conducted using
the ESS was found. Because BSE-R Factor 1 the first version (BSE). The objective was to
items significantly correlated with the DQ, the evaluate the severity of behavioral problems in
variance explained by the DQ was controlled. autistic children and to assess the correlations
Each BSE-R Factor Item and BSE Factor 1 with biological markers. Hameury et al. (1995)
score correlated with the ESS. However, the using the BSE and other measures distinguished
ESS did not correlate with Factor 2 of the BSE-R. four groups in a population of 202 subjects.
Group 1 included subjects with severe autistic
Convergent Validity Study behavior, profound mental retardation, and
Seventy-five children were assessed with the severe neurological symptoms. Group 2 included
Rimland E2 scale. The same subgroups were subjects presenting autistic behavior, language
selected (AD ¼ 51 children; PSSNOS ¼ 8 chil- and communication disorders, with slight or
dren; MR ¼ 16 children). Significant differences moderate intellectual impairment and mild neu-
existed between the three diagnostic subgroups rological symptoms. Group 3 included children
for the ESS. Correlations were calculated with severe intellectual impairment and neuro-
between the BSE-R score for Factor 1, Factor 2, logical symptoms with no or few autistic
Behavior Summarized Evaluation-Revised (BSE-R) 425 B
behavior patterns. In Group 4, subjects showed of 1–2 years. Different diagnostic subgroups
multiple but mild disorders. The biochemical were included (autism, mental retardation, atyp-
parameters of the four groups were compared. ical pervasive developmental disorder, develop-
The levels of HVA (homovanillic acid) measured mental delay without autism). The pre and post-
in urine samples varied significantly, and Group 3 mean BSE scores were compared. The decrease B
presented a very high level of HVA compared to in the scores is interpreted as an improvement. In
the other groups. The authors declare that this another study Barthelemy et al. (1989) assessed
approach could make possible the establishment changes in BSE scores and biochemical markers
of subgroups in which behavioral clinical profiles in 13 children with autism receiving medication.
could correspond to certain biological profiles Significant decreases were observed in a BSE
(with metabolic characteristics). item in responders who also showed significant
Other studies have been undertaken with the modifications in serotonin and dopamine levels
BSE revised version. Roux et al. (1997) examined (Barthelemy et al., 1997). In this study, the treat-
relations between electrophysiological reactivity ment lasted 9 months. A significant decrease in
and BSE-R. In a population of 73 children, they BSE-R scores was noted. Other studies (Lelord
showed that the item “bizarre responses to audi- et al., 1981; Martineau, Barthelemy, Cheliakine,
tory stimuli” was correlated with abnormalities in & Lelord, 1988) were led with the BSE as an
frontocentroparietal electrophysiological reactiv- indicator of improvement. These trials are sum-
ity, and that the item “unstable attention or easily marized in Reeb et al. (2009).
distracted” corresponded to abnormalities in All these studies suggest that the BSE and the
frontal electrophysiological reactivity. BSE-R are sensitive to treatment effects. However,
Hérault et al. (1996) also used the BSE-R in the number of children included in these trials was
a study on urinary levels of serotonin. No rela- usually small and there was no control group. Thus
tionship was found between molecular biology all these results must be considered with caution.
results and clinical scores.
Bruneau et al. (2003) studied relations Family Home Movies, Early Signs
between late auditory-evoked potentials recorded The IBSE has been used in research on early
in the temporal area and autism severity based on signs based upon family home movies (Adrien
BSE-R. They observed a negative correlation et al., 1993). The family movies of 12 autistic
between the importance of the right temporal children and 12 typically developing children
response and the BSE-R score. The greater were analyzed using the IBSE. Two diagnostic-
amplitude of the right temporal responses blind raters scored the films. The order of presen-
corresponded to lower (less severe) BSE-R tation of the videotapes was randomized.
scores on items involving verbal and nonverbal The scoring was performed for two different
communication skills. periods: the first and second year, in order to
As the BSE-R is included in the routine assess- compare the signs observed during these two
ment of patients in Catherine Barthelemy’s Child periods. The analysis of these family movies led
Psychiatry Unit, clinical data gathered are avail- to finding specific behaviors that enabled the
able for other studies in different fields such as prediction of the autism diagnosis.
genetics (Mbarek et al., 1999).
Parents’ Rating of Improvement
Sensitivity to Treatment Effects The BSE is a simple, easy-to-manage tool that
The BSE and later the BSE-R have been used to has been used for the assessment of improvement
evaluate the evolution of children receiving dif- by the parents themselves (Oneal, Reeb, Korte, &
ferent kinds of treatment. In a study published in Butter, 2006). The results show that the BSE
1989, Barthelemy et al. examined the modifica- presents acceptable psychometric qualities for
tions in the BSE scores of 27 children receiving parent usage when assessing changes in the
exchange and development therapy over a period child’s behavior.
B 426 Behavior Summarized Evaluation-Revised (BSE-R)
The BSE-R is an interesting instrument. It has Examples of Items descriptions (extracted

been validated and can be used in different contexts from the Glossary by Barthélémy et al. (1997);
by professionals from different fields as well as by with the author’s permission). The complete
parents. It can be useful to identify the symptoms of Glossary and the BSE-R scoring sheets are avail-
autism, to follow the changes in the expression of able at ECPA, 25 rue de la Plaine 75020 Paris
these symptoms across age, and measure the effects 1. Is eager for aloneness:
of treatment. – Keeps to the edges of a group or isolates
himself from it; cuts off communication
Appendix – Keeps in his world
– Seeks a familiar space
BSE-R items (from Barthelemy et al., 1997, with 2. Ignores people
the author’s permission) – Indifference to others. Pays no attention to
1. Aloneness them: can walk into them without seeing
2. Ignores people them; seems not to hear them
3. Poor social interaction – Does not respond to overtures
4. Abnormal eye contact – Is too quiet, indifferent (frozen expression)
5. Does not make an effort to communicate – In terms of general behavior, there is
using voice and/or words a turning away from others or a delayed
6. Lack of appropriate facial expression and reaction to them
gestures 3. Poor social interaction
7. Stereotyped vocal and verbal utterances, – No exchange of toys
echolalia – No spontaneous approaches; no offering of
8. Lack of initiative, poor activity objects
9. Inappropriate relating to inanimate objects or – Does not use objects as a mean of
to doll mediation
10. Irresistible and/or ritual use of objects – Uses the adult as an object
11. Intolerance of change and to frustration – Does not smile; does not seek company
12. Stereotyped sensorimotor activity – Is incapable of sustaining social exchanges,
13. Agitation, restlessness It should be noted that the child can stare at
14. Bizarre posture and gait parts of the examiner’s body or follow him
15. Auto-aggressiveness around and still remain withdrawn
16. Hetero-aggressiveness
17. Mild anxiety signs
18. Mood difficulties References and Readings
19. Disturbance of feeding behavior
20. Does not try to be clean (stools or urine), Adrien, J. L., Barthelemy, C., Perrot, A., Roux, S., Lenoir, P.,
plays with stools Hameury, L., et al. (1992). Validity and reliability of the
infant behavioral summarized evaluation (IBSE):
21. Individual bodily activities
A rating scale for the assessment of young children
22. Sleep problems with autism and developmental disorders. Journal of
23. Unstable attention, easily distracted Autism and Developmental Disorders, 22, 375–394.
24. Bizarre responses to auditory stimuli Adrien, J., Lenoir, P., Martineau, J., Perrot, A., Hameury,
L., Larmande, C., et al. (1993). Blind ratings of early
25. Variability symptoms of autism based upon family home movies.
26. Does not imitate the gestures or voices of Journal of the American Academy of Child and Ado-
others lescent Psychiatry, 32, 617–626.
27. Child too floppy, lifeless Barthelemy, C., Adrien, J. L., Roux, S., Garreau, B., Perrot,
A., & Lelord, G. (1992). Sensitivity and specificity of
28. Does not share emotion
the behavioural summarized evaluation (BSE) for the
29. Paradoxical sensitivity to touching and assessment of Autistic behaviours. Journal of Autism
contact and Developmental Disorders, 22(1), 23–31.
Behavior Therapy 427 B
Barthelemy, C., Adrien, J. L., Tangay, P., Garreau, B., in assessing symptoms of Autism. Children’s Health
Fermanian, J., Roux, S., et al. (1990). The behavioural Care, 38, 301–320.
summarized evaluation: Validity and reliability of a scale Roux, S., Adrien, J. L., Bruneau, N., Garreau, B., Coutu-
for the assessment of Autistic behaviours. Journal of rier, G., Gomot, M., et al. (1997). Classification of
Autism and Developmental Disorders, 20, 189–203. autistic syndrome using behavioural and electrophys-
Barthelemy, C., Bruneau, N., Jouve, J., et al. (1989). iological assessments. Developmental Brain Dysfunc- B
Urinary dopamine metabolites as indicators of the tion, 10, 28–39.
responsiveness to fenfluramine treatment in children
with autistic behavior. Journal of Autism and Devel-
Barthelemy, C., Roux, S., Adrien, J. L., Hameury, L.,
Guérin, P., Garreau, B., et al. (1997). Validation of the Behavior Therapy
revised behaviour summarized evaluation scale. Jour-
nal of Autism and Developmental Disorders, 27(2), Michael D. Powers
139–153. The Center for Children with Special Needs,
Bruneau, N., Bonnet-Brilhault, F., Gomot, M., Adrien,
J.-L., & Barthelemay, C. (2003). Cortical auditory Glastonbury, CT, USA
processing and communication in children with
autism: Electrophysiologicalybehavioral relations.
International Journal of Psychophysiology, 51, 17–25. Definition
Hameury, L., Roux, S., Barthelemy, C., Adrien, J. L.,
Desombre, H., Sauvage, D., et al. (1995). Quantified
multidimensional assessment of autism and other per- Behavior therapy (a term used here interchange-
vasive developmental disorders. Application for ably with behavior modification) is the applica-
bioclinical research. European Child & Adolescent tion of techniques based on empirically derived
Psychiatry, 4(2), 123–135.
Hérault, J., Petit, E., Martineau, J., Cherpi, C., Perrot, A., principles of learning theory to the treatment of
Barthelemy, C., et al. (1996). Serotonin and autism: human problems, with the goal of reducing or
Biochemical and molecular biology features. Psychiatry eliminating unwanted behavior and replacing it
Research, 65, 33–43. with behavior that is more adaptive and socially
Laffont, F., Jusseaume, P., Bruneau, N., Dubost, P., &
Lelord, G. (1975). Conditionnement des potentiels appropriate. While individual strands of behavior
évoqués chez des enfants normaux, retardés mentaux therapy differ in several important ways, all share
et autistiques. Revue d’Electroencephalographie et de an emphasis on treating behavioral symptoms,
Neurophysiologie, 5, 369–374. with little or no reliance or attention to underlying
Lelord, G., M€uh, J. P., Barthelemy, C., Martineau, J.,
Garreau, B., & Callaway, E. (1981). Effects of pyri- unconscious processes. With respect to cogni-
doxine and magnesium on autistic symptoms. Initial tions, behavior therapy proposes that by changing
observations. Journal of Autism and Developmental overt behavior (through reinforcement, extinc-
Disorders, 11, 219–230. tion, punishment, etc.), more adaptive emotional
Martineau, J., Barthelemy, C., Cheliakine, C., & Lelord, G.
(1988). Brief report: An open middle-term study of and affective thinking will follow. The under-
combined vitamin B6-magnesium in a subgroup of standing of the “here-and-now” in context, rather
autistic children selected on their sensitivity to this than underlying conflicts in a person’s past, is
treatment. Journal of Autism and Developmental a key distinction between behavior therapy and
Disorders, 18, 435–447.
Mbarek, O., Marouillat, S., Martineau, J., Barthelemy, C., other more psychodynamic or psychoanalytic
M€uh, J. P., & Andres, C. (1999). Association study of therapies.
the NF1 gene and Autistic disorder. American Journal
of Medical Genetics, 88, 729–732.
Oneal, B. J., Reeb, R. N., Korte, J. R., & Butter, E. J.
(2006). Assessment of home-based behaviour modifi- Historical Background
cation programs for autistic children: Reliability and
validity of the behavioural summarized evaluation. Behavior therapy has evolved over the past six
Journal of Prevention & Intervention in the Commu- decades from many schools of thought and phil-
nity, 32(1–2), 25–39.
Reeb, R. N., Folger, S. F., & Oneal, B. J. (2009). Behavioural osophical systems. This diversity is most evident
summarized evaluation: An assessment tool to enhance in the fact that despite the predominance of the
multidisciplinary and parent-professional collaborations discipline of psychology among practitioners of
B 428 Behavior Therapy
behavior therapy, some of the earliest pioneers Here, the extension of the work of Skinner
were from other fields, for example, the Russian and his early colleagues to Donald Baer, Sid-
physiologist Ivan Pavlov and the South African ney Bijou, Fred Keller, Brian Iwata, and many
psychiatrist Joseph Wolpe. Equally important is others has generated a powerful evidence-based
the observation that what we today consider technology of change designed to address sig-
behavior therapy generated from the confluence nificant deficiencies in learning as well as
of the work of three groups in different countries. behavioral excesses and deficits exhibited by
In the United States, the work of Skinner, those with ASD. The cornerstone of ABA is
Lindsley, and others on operant conditioning function-based assessment and treatment, with
adopted a more functional approach to assess- data-based decision-making utilizing a variety
ment and treatment and led to an emphasis on of methods. Treatment procedures are designed
the experimental analysis of behavior best to modify the relationships between antecedent
represented in the field of applied behavior and consequent stimuli that exert influence or
analysis. British psychologist Hans Eysenck and control on overt behavior. There is a clear
his colleagues at the Maudsley Hospital in emphasis on what can be observed and mea-
London emphasized that behavior problems sured; cognitive processes and other private
were the result of complex interactions between events are typically regarded as beyond the
the client’s personality features, the behavior domain of scientific analysis. Because ABA
itself, and the environment. Their work targeted directs itself toward the intensive study of the
these interrelationships through the use of tech- individual, a wide array of intervention and
niques of behavior change based on S-R learning evaluation strategies have been developed and
theory (classical conditioning) as an alternative validated scientifically (see Cooper, Heron, &
to the then-prevalent psychoanalytic models. In Heward, 2007, for a comprehensive review).
South Africa, Joseph Wolpe, Arnold Lazarus, and Neobehavioristic mediational S-R models
others were at work developing techniques that derive from classical conditioning and are most
used behavioral principles to treat more common frequently associated with the work of Pavlov,
psychological problems, leading to the develop- Hull, Mowrer, and Miller. In these therapeutic
ment of systematic desensitization and psycho- models, hypothetical constructs (e.g., anxiety)
therapy by reciprocal inhibition. At the time, are considered to be mediated by cognitive pro-
these evidence-based procedures were consid- cesses, and treatment techniques are designed to
ered both revolutionary and evolutionary and set put those processes on extinction, resulting in
the stage for the continuing development of behavior change. Systematic desensitization is a
behavior therapy as a scientific discipline with procedure most commonly associated with this
people with a wide range of psychological strand of behavior therapy and is used to effec-
problems. tively treat phobias, fears, and other behavioral
responses that are triggered by heightened
arousal. Social learning approaches are based on
Current Knowledge the work of Albert Bandura and his colleagues.
These approaches, like other behavior therapies,
Contemporary behavior therapy may arbitrarily but postulate that behavior is controlled by external
conveniently be classified under five broad strands: reinforcement, external stimulus events, and cog-
applied behavior analysis, neobehavioristic media- nitive mediational processes. Importantly, the
tional S-R models, social learning approaches, cognitive mediational processes determine
cognitive therapy and cognitive behavior ther- which environmental influences are more or less
apy, and “third-generation” approaches. By far, valued and receive more or less attention.
the most widely practiced with respect to Because the emphasis in social learning theory
understanding and treating autism are those is on the individual as the agent of change, self-
based on applied behavior analysis (ABA). control, self-management, and self-instruction
Behavior Therapy 429 B
are prominent parts of the treatment plan. Within 2012). All share the distinction of a general move
this paradigm, operant conditioning and espe- away from a more cognitive approach and toward
cially modeling are more prominent than classi- a more functional analytic model of assessment
cal conditioning, although all are considered. and treatment. In many ways, this return to the
Cognitive behavior therapy (CBT) and cogni- basics of behavior therapy is consistent with the B
tive therapy have become among the most prom- core features described by Kazdin (1978),
inent and visible of behavior therapy strands, namely, that behavior therapists share
along with applied behavior analysis, over the a common set of assumptions including a focus
past 25 years. These approaches are based on on current rather than historical determinants of
the early work of Arnold Lazarus (multimodal behavior, an emphasis on overt behavior change
therapy), Albert Ellis (rational emotive therapy), as the main criterion by which treatment is to be
and Aaron Beck (cognitive therapy for depres- evaluated, specification of dependent variables
sion). All share certain core features with con- and treatment parameters in objective terms so
temporary cognitive models, including the that replication is possible, an emphasis on the
understanding that in order to change behavioral bilateral relationship between behavior and the
responses, one must also alter the prominence or environment, a reliance on basic research
value of the cognitions or thoughts that accom- methods in psychology as a source of hypotheses
pany the response. CBT seeks to develop retriev- about treatment and specific therapeutic tech-
able memories of more adaptive responses that niques, and specificity in definition, treatment,
will then compete with and replace learned prob- and measuring target populations.
lematic responses by suppressing the memory of
those responses (Wood, Fujii, & Renno, 2011).
This is achieved through a talk-based therapy See Also
process whereby psychoeducation, teaching cop-
ing skills, and in vivo exposure are combined to ▶ Applied Behavior Analysis
produce specific skills for change, alternative and ▶ Behavioral Assessment
more adaptive cognitions regarding change, and ▶ Behaviorism
actual situations in which to practice change. ▶ Cognitive Behavioral Therapy (CBT)
CBT fosters change in behavior by identifying
and challenging irrational beliefs and misinter-
pretation of events that cause distress (and mal- References and Readings
adaptive behavioral responses). CBT has been
used with individuals with ASD exhibiting anxi- Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating
anxiety disorders in children with high functioning
ety disorders (Chalfant et al., 2007; Sofronoff
autism spectrum disorders: A controlled trial. Journal
et al., 2005), anger management problems of Autism and Developmental Disorders, 37, 1842–
(Sofronoff et al., 2007), and disruptive behavior 1857.
(Solomon et al., 2008; Wymbs et al., 2005) as Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
well as for treatment of core social symptoms of
River, NJ: Pearson.
ASD (Wood et al., 2009). Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012).
The final strand is both a combination of evi- Acceptance and commitment therapy: The process and
dence-based treatments as well as a reaction to practice of mindful change (2nd ed.). New York:
Guilford.
earlier iterations of cognitive behavioral models. Kazdin, A. E. (1978). Behavior therapy: Evolution and
These so-called third-generation approaches expansion. The Counseling Psychologist, 23, 34–37.
incorporate a broad array of specific procedures, Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic
including dialectical behavior therapy (Linehan, psychotherapy. New York: Plenum.
Linehan, M. M. (1993). Cognitive behavior therapy of
1993), functional analytic psychotherapy
borderline personality disorder. New York: Guilford.
(Kohlenberg & Tsai, 1991), and acceptance and Sofronoff, K., Attwood, T., & Hinton, S. (2005).
commitment therapy (Hayes, Strosahl, & Wilson, A randomized controlled trial of CBT intervention
B 430 Behavioral Approaches
for anxiety in children with Asperger syndrome. specific behaviors can be better understood and
Journal of Child Psychology and Psychiatry, 46, changed (Nelson & Hayes, 1979). It is pragmatic
1152–1160.
Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). in nature, in that behavioral assessment seeks to
A randomized controlled trial of a cognitive behavioral determine and describe underlying functional
intervention for anger management in children diag- relationships between behavior and the person
nosed with asperger syndrome. Journal of Autism and in their environment and then uses that under-
Solomon, M., Ono, M., Timmer, S., & Goodlin-Jones, B. standing to facilitate the development of new,
(2008). The effectiveness of parent child interaction more adaptive functional responses. By empha-
therapy for families of children on the spectrum. sizing objective identification and measurement
Journal of Autism and Developmental Disorders, 38, of environmental and organismic-dependent
1767–1776.
Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, variables that may influence behavior, behavioral
K., et al. (2009). Brief report: Effects of cognitive assessment ultimately serves treatment planning
behavioral therapy on parent-reported autism symp- and outcome evaluation.
toms in school-age children with high-functioning
autism. Journal of Autism and Developmental
Disorders, 39, 1609–1612.
Wood, J. J., Fujii, C., & Renno, P. (2011). Cognitive Historical Background
behavioral therapy in high-functioning autism:
Review and recommendations for treatment develop- Behavioral assessment has a long past but a
ment. In B. Reichow, P. Doehring, D. V. Cicchetti, &
F. R. Volkmar (Eds.), Evidence-based practices and relatively short history. With the advent of behav-
treatments for children with autism (pp. 197–230). ioral approaches to understanding and treating
New York: Springer. individuals with varying problems (e.g., fears
Wymbs, B. T., Robb, J. A., Chronis, A. M., Massetti, and phobias, depression, anxiety, self-injurious
G. M., Fabiano, G. A., et al. (2005). Long-term multi-
modal treatment of a child with asperger’s syndrome behavior) over the past sixty-plus years, behav-
and comorbid disruptive behavior problems: A case ioral assessment had been somewhat of an infor-
illustration. Cognitive and Behavioral Practice, 12, mal process until the 1970s when closer attention
338–350. to those dependent variables that contributed to
behavioral treatment success or failure began to
receive greater attention from researchers and
clinicians. As would be expected, there was an
Behavioral Approaches initial emphasis on what behavioral assessment
was not and in specifying differences between
▶ Didactic Approaches behavioral and so-called traditional or psychody-
namic assessment. Those differences were suc-
cinctly summarized by Mash (1979), who noted
that at a conceptual and applied level, behavioral
Behavioral Assessment assessment is characterized by the view that
human behavior is predominantly under the con-
Michael D. Powers trol of environmental and organismic events,
The Center for Children with Special Needs, rather than underlying intrapsychic processes,
Glastonbury, CT, USA introspection, or personality traits that are
inferred. Further, behavior must be examined in
context. While these were radical ideas at the
Definition time, particularly as regards the treatment of
mood, developmental, and conduct disorders of
Behavioral assessment is the process of objec- adults and children, this approach was prescient.
tively identifying and evaluating units of As the relationship between brain and behavior
response (behaviors) and related controlling is better understood through sophisticated neuro-
environmental and organismic variables so that imaging techniques and through advances in
Behavioral Assessment 431 B
neurobiology, genetics, and neurochemistry, it to emphasize, however, that indirect assessment
becomes clear that context is everything. These does not imply a reliance on inference. Rather,
variables, once broadly called organismic, now indirect behavioral assessment methods such as
are more precisely described and differentiated. questionnaires (e.g., Questions About Behavioral
The result is that behavioral assessment Function; Paclawsky, Matson, Rush, Smalls, & B
procedures are now better able to help pinpoint Vollmer, 2001) and rating scales (Social Respon-
functional relationships so that treatment selec- siveness Scale; Constantino & Gruber, 2005)
tion and efficacy improves, with greater general- are used in conjunction with direct observation
izability beyond the treatment setting. methods to clarify points of behavioral conver-
In practical terms, behavioral assessment gence and are themselves designed to measure
evolved initially after behavioral treatments behaviors that have been more precisely and
were devised, rather than before it. While this operationally defined so that interobserver agree-
observation helps to understand the recency of ment is high.
more sophisticated assessment strategies, it also Identification of target behavior is the first step
provides a context for understanding why in a comprehensive behavioral assessment and
so many behavioral interventions for complex requires that behavioral form and function be
psychological disorders have become evidence- described, including function, topography, dura-
based treatments of choice over the past 30 years tion, frequency, and intensity of the behavior.
(e.g., cognitive behavior therapy for individuals This is done in such a way that the description
with anxiety, depression, and anorexia and becomes an operational definition, specifying
bulimia and dialectical behavior therapy for explicit and precise response parameters. Once
those with borderline personality disorder). completed, determination of controlling vari-
Behavioral assessment is rooted in the under- ables is undertaken using indirect and direct
standing that behavior must be examined in methods. Indirect methods include third-party
context, with direct samples taken in multiple interviewing with a structured assessment format
settings, utilizing multiple methods of inquiry. such as the functional assessment interview
With these much more precise, operationalized, (O’Neill, Horner, Albin, Storey, & Sprague,
and objective formulations, the clinician is able to 1990), review of incident reports or permanent
more accurately specify what is expected or products of the behavioral episode, or more infor-
predicted to change and then to evaluate whether mal interviews with parents or caregivers. Direct
change, in fact, occurred after the introduction of assessment procedures include direct observation
treatment. It is this hypothesis-testing process of the target behavior in the natural or analog
that compliments the rejection of inferred causa- environment using any number of methods (e.g.,
tion and makes the behavioral assessment process momentary time sampling, partial interval
inherently objective, dynamic, and responsive to recording) as well as descriptive analysis of the
new evidence. Indeed, the reliance on the basics behavior using antecedent-behavior-conse-
of the scientific method permits the needed quence (ABC) analysis. In all cases, the behav-
flexibility to abandon or modify a treatment ioral assessor seeks to describe controlling
approach if it is not working as planned. variables of three types: antecedent stimuli, con-
sequent stimuli, and organismic stimuli. Anteced-
ent stimuli can be discriminative stimuli (they
Current Knowledge predict the expectation of a particular response
because the person has learned that their response
The technology of behavioral assessment is ever- is followed by a specific consequence) or elicitors
expanding but is always directed toward under- (which evoke automatic, physiological, or emo-
standing behavior functionally (see functional tional responses). These immediate “triggers”
analysis of behavior) through the use of direct help to understand the impact of a particular stim-
and indirect assessment methods. It is important ulus event on the person and their behavior.
B 432 Behavioral Assessment
An assessment of context is undertaken in the neurological status and behavioral expression.

form of analysis of setting events and establishing For example, identification of lesions in
operations. Setting events are variables that influ- a specific area of the brain (as would occur with
ence an ongoing relationship between a stimulus tuberous sclerosis) may help the clinician better
and a response, whereas establishing operations understand the context for a challenging behav-
momentarily change the reinforcing value of ior. This would not necessarily reduce the impor-
a discriminative stimulus. There are technical tance of addressing the target behavior, but it
differences between both terms, but both describe would likely support an interdisciplinary
antecedent conditions that alter response proba- approach to treatment.
bility. For example, when ill, or satiated on a Two final areas must be considered in behav-
specific reinforcing stimulus, a person might ioral assessment if the assessment results are to
respond differently than when healthy or in a fully inform treatment planning. The first is an
deprived state. These are assessed because these assessment of preferences and reinforcers, and
variables are more distant from the target behav- the second is the identification of functionally
ior (may not occur immediately before the target equivalent behavior(s) that can be taught as
behavior), but they may persist over time, or exert a replacement for the target behavior to be
a cumulative effect, and influence the target reduced or eliminated. There are a number of
behavior. Knowing them highlights a possible empirically based strategies for evaluating
point of intervention. which stimuli are preferred by a client. They (or
Target behavior can be embedded in a behav- caregivers) can be queried, observed, or placed in
ioral chain, and assessment for this is important a formal trial-based assessment environment. An
because it may provide an opportunity to inter- example of the latter is a “forced choice” or
vene at an early point in the chain, thereby paired stimulus presentation whereby two items
interrupting the variables that would normally are presented to a client, all matched randomly.
control the response. Equally important is the Preferences are determined by frequency of
assessment of high- and low-probability settings. selection of specific items (see Fisher et al.,
That is, it is important to understand where and 1992 for an example). In contrast to preferences,
when the target behavior is more or less likely to reinforcers can only be identified by a functional
occur as a method for considering stimulus test. That is, when presented, a stimulus is only
control. considered a reinforcer if it increases the likeli-
Behavioral assessment of consequences refers hood of reoccurrence of the behavior it followed.
to those stimuli that reliably occur after the target There are several ways to conduct a reinforce
behavior is emitted. These are critical to under- assessment including those based on concurrent,
stand that they represent those contingencies progressive ratio, or multiple schedules (see Coo-
maintaining (reinforcing) the behavior. For per, Heron, & Heward, 2007, for examples).
behavior change to occur, those contingencies If behavior change is to be achieved, general-
of reinforcement must me modified so that a ized, and maintained, it must gain for the client
problematic target behavior is no longer the same functional outcome, but with greater
reinforced by the stimulus maintaining it, clear- ease and efficiency, and be more socially desir-
ing the way for an alternative, more adaptive able and valid than the problem behavior that it
response to be reinforced and established to replaces. In short, the replacement behavior must
replace the problem behavior. work better, faster, and be useful and valued in a
Organismic stimuli have received somewhat large number of environments. Determining
less attention from researchers over the years, but which behavior to select as the replacement is
with the advent of more sophisticated technolo- an essential task in behavioral assessment for
gies (e.g., with neuroimaging or for genetics), several reasons. If left unaddressed, the client
a greater emphasis is being placed on the rela- may well substitute yet another (and potentially
tionship between physical, biological, and undesirable) behavior in place of the target
Behavioral Assessment 433 B
behavior that has been reduced because the Future Directions
functional need for the behavior still exists. For
example, if hitting another person has been a If advances in behavioral assessment over the
successful means of escaping from a task past four decades have emphasized anything, it
demand, and hitting is reduced without concur- is that the process is dynamic and data-driven. B
rent teaching of a replacement skill that serves the Whether through the development of more sensi-
same function, the client may substitute self- tive rating scales for problems experienced by
injury as a means of escape. If a replacement those with ASD, or use of microtechnologies to
skill is selected but it is not functionally equiva- more precisely measure small units of response,
lent, the client will not have an alternative that the likelihood that future iterations of behavioral
serves the same functional purpose. In this case, assessment will better support treatment planning
the new skill may be acquired but the target is without question. Ongoing work in several
behavior is not reduced. Finally, if the replace- areas will be especially useful. The continuing
ment skill to be taught is functionally equivalent, analysis of antecedent stimuli, and particularly
but requires more response effort, or is establishing operations, will continue to support
not reinforced on a sufficiently dense schedule precision intervention. A better understanding of
of reinforcement, then it is less likely to be the relationship between information processing
demonstrated by the client and less likely to deficits, including those that impact academic
serves as a replacement in the long run. In the performance, will support the development
final analysis, the treatment of behavior problems of more sensitive replacement skills that include
is better understood as the effective teaching of curriculum modifications and accommodations.
functionally equivalent, more adaptive replace- Recognizing that exceptional behavioral
ment skills. This component of the assessment is assessment science and technology is no guaran-
critical. tee that utilization or implementation will
The final component of behavioral assessment proceed correctly, future efforts to better under-
is a functional demonstration of the relationship stand the contingencies motivating organizations
between those antecedent, consequent, and and systems serving those with ASD will be very
organismic variables and the target behavior. valuable.
This process is termed functional behavior The availability of sophisticated technologies
assessment if done without a set of empirical to objectively evaluate small but significant units
analog conditions and functional analysis if of responding in persons presents many exciting
implemented with those analog conditions. Both opportunities. While the relationship between
components are described in detail elsewhere in exciting new findings related to eye gaze in very
the encyclopedia. young infants and toddlers with ASD (Klin, Lin,
When complete, the behavioral assessment Gorrindo, Ramsey, & Jones, 2009) and later
process informs treatment planning and deci- social development has yet to translate into inter-
sion-making. In contrast to other, more tradi- vention protocols demonstrating long-term
tional (and nonbehavioral) assessment effects, this area seems one of the top candidates
approaches, however, behavioral assessment is for a marriage of technology with behavioral
ongoing. That is, while it does serve a predictive science. Further, neuroimaging technologies
function by helping to elucidate relevant vari- (e.g., fMRI) can map specific brain responses to
ables that impact the target behavior, it also presented stimuli, and an exciting next step
serves a formative function (informing ongoing would be to evaluate whether behavioral treat-
decision-making through analysis of treatment ment effects demonstrated through overt behav-
effects) as well as a summative function (provid- ior leads to discernable change in brain
ing a framework for understanding the target functioning and whether collateral changes are
behavior from the point of first identification also noted neurologically. Finally, as basic sci-
through resolution and replacement). ence continues to articulate ways in which those
B 434 Behavioral Assessment Scale of Oral Functions in Feeding
with ASD are (and are not) different from those

who are neurotypical, the opportunity for greater Behavioral Assessment Scale of Oral
interdisciplinary behavioral assessment at the Functions in Feeding
neurological, genetic, and biological levels is
exciting. Behavioral assessment is built on the Stephanie Bendiske
science of specification, not speculation, and The Center For Children With Special Needs,
good measurement across disciplines has a Glastonbury, CT, USA
synergistic effect. The next decades will be excit-
ing ones.
Description
See Also This rating scale assists practitioners to establish

a baseline of oral functioning and feeding as well
▶ Behavior Rating Scale (BRS) as measure change over time. It should be utilized
▶ Behavior Therapy in conjunction with an assessment that measures
▶ Functional Analysis oral structure and muscle tone in children.
▶ Functional Analysis Screening Tool This scale provides visual feedback of progress
▶ Motivation Assessment Scale as well as assists to plan and justify feeding
therapy.
The rating scale includes the following oral
References and Readings motor skills:
Constantino, J. N., & Gruber, C. P. (2005). Social respon-
• Jaw closure
siveness scale (SRS). Los Angeles, CA: Western • Loop closure over a spoon
Psychological Services. • Tongue control
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). • Lip closure while swallowing
• Swallows food without excess loss
River, NJ: Pearson Merrill Prentice Hall.
Fisher, W. W., Piazza, C. C., Bowman, L. G., Hagopian, • Chews food (tongue/jaw control)
L. P., Owens, J. C., & Slevin, I. (1992). A comparison • Sips liquids
of two approaches for identifying reinforcers for • Swallows liquids without excess loss
persons with severe and profound disabilities. Journal
• Swallows food without coughing
of Applied Behavior Analysis, 25, 491–498.
Klin, A., Lin, D. J., Gorrindo, P., Ramsey, G., & Jones, W.
(2009). Two-year-olds with autism fail to orient
towards human biological motion but attend instead Historical Background
to non-social, physical contingencies. Nature, 459,
257–261.
Mash, E. J. (1979). What is behavioral assessment? This rating scale was developed by Margret
Behavioral Assessment, 1, 23–29. Stratton and published in the American Journal
Michael, J. (1993). Establishing operations. The Behavior of Occupational Therapy in November 1981.
Analyst, 16, 191–206.
The rating scale was developed for people with
Nelson, R. O., & Hayes, S. C. (1979). Some current
dimensions of behavioral assessment. Behavioral multiple handicaps and developmental disabil-
Assessment, 1, 1–16. ities. Ms. Stratton utilized this rating scale within
O’Neill, R. E., Horner, R. H., Albin, R. W., Storey, K., & the J.N. Adam Developmental Center in
Sprague, J. R. (1990). Functional analysis of problem
behavior: A practical assessment guide. Sycamore, IL:
Perrysburg, New York.
Sycamore Publishing.
Paclawsky, T. R., Matson, J. L., Rush, K., Smalls, Y., &
Vollmer, T. (2001). Assessment of the convergent Psychometric Data
validity of the questions about behavioral function
scale with analogue functional analysis and the
motivation assessment scale. Journal of Intellectual This is a criterion-based rating scale. Standard
Disability Research, 45, 484–494. scores are not calculated. The client’s oral
Behavioral Curricula 435 B
motor functioning is rated on a scale from 0 to 5 Historical Background
with 5 being normal and 0 being disordered or
passive movement. Recent decades have seen a marked increase in
the development of curricula for children with
autism (Olley, 2005). Researchers and practi- B
References and Readings tioners have created and evaluated a number of
comprehensive and focused (e.g., language,
Stratton, M. (1981). Behavioral assessment scale of social skills, or academic) curricula. Many of
oral functions in feeding. American Journal of
these have been behaviorally based curricula.
Occupational Therapy, 35(11), 719–21.
Current Knowledge
Behavioral Curricula
Like all curricula, behavioral curricula can use a
Marjorie H. Charlop1 and Catherine A. variety of instructional strategies to target lan-
Miltenberger2 guage, social, academic, adaptive, and other
1
Department of Psychology, Claremont skills (Olley, 2005). Behavioral curricula incor-
McKenna College, Claremont, CA, USA porate behavioral principles including an empha-
2
Claremont Graduate University, Claremont, sis on functional behavior, operationalizing
CA, USA behaviors and objectives, measuring behaviors,
individualizing programs to meet each child’s
needs, and targeting the acquisition of prerequisite
Definition skills and the reduction of interfering behaviors.
These components are briefly described below.
Broadly defined, curriculum refers to the content
and order of instruction, the instructional strate-
gies used to teach this content, and any assess- Functional Behavior
ment or other materials used to implement the
educational program (Olley, 1999, 2005). Behav- Behavioral curricula focus on functional behav-
ioral curricula are a specific type of curriculum iors. Functional behaviors are behaviors that are
that incorporates behavioral principles (e.g., an useful to the individual. More specifically, behav-
emphasis on functional behavior, operationalizing iors are considered functional if they allow the
behaviors and objectives, and measuring behav- individual to better navigate his or her current
ior). Behavioral curricula recognize the impor- environment, are required to learn or likely to
tance of individualizing the content, sequence, lead to the acquisition of other functional behav-
and method of instruction to best meet each indi- iors, increase the individual’s ability to navigate
vidual’s needs. They also tend to target the reduc- other beneficial environments (e.g., general edu-
tion and replacement of interfering behaviors cation classrooms), or make others more likely to
(e.g., ▶ Stereotypic Behavior, Tantrums; Olley, interact with the individual (e.g., eliminating dis-
2005). The characteristics of behavioral curricula ruptive or aggressive behaviors may make peers
are especially appropriate for children with autism more willing to initiate interactions with the indi-
for a couple reasons. First, behavioral strategies vidual; Cooper, Heron, & Heward, 2007). Many
have been found to improve the communication, individuals with autism require treatment in
social, and other skills of children with autism numerous areas. Instructors should attempt to
(Schreibman & Ingersol, 2005). Second, children identify and target behaviors that are most useful
with autism differ in their individual strengths and to the individual’s current functioning (Cooper
weaknesses and are believed to benefit from indi- et al., 2007). To determine which behaviors
vidualized educational programs (Olley, 1999). would be most useful, instructors should observe
B 436 Behavioral Curricula
the individual in his or her natural environment (Olley, 2005). This may be especially important
and include parents and others familiar with the for individuals with autism, who share common
individual (Cooper et al.; Olley, 2005). areas of impairment but demonstrate considerable
variability in their abilities and deficits. Measur-
ing the individual’s behavior allows instructors to
Operationalizing Behaviors and identify that individual’s need and focus the cur-
Objectives ricula accordingly. Regular measurement of the
individual’s progress provides instructors with
Behavioral curricula emphasize the importance information on that individual’s response to dif-
of operationalizing behaviors and objectives. All ferent instructional strategies. Again, this infor-
targeted behaviors should be objectively, clearly, mation can be used to identify instructional
and completely defined. To be objective, the strategies that are effective and less effective for
behavior should be described in observable that individual student and to update their program
terms. To be clear and complete, the definition content as necessary (Cooper et al., 2007).
should provide comprehensive criteria for behav-
iors that will be included or excluded (Cooper
et al., 2007). Defining targeted behaviors in this Targeting Prerequisite Skills and
way allows teachers and other people working Interfering Behaviors
with the individual to count the occurrence of
the behaviors and track student progress. Many individuals with autism lack basic prerequi-
Similarly, behavioral programs operationalize site skills and demonstrate interfering behaviors.
objectives or student goals. For each targeted Behavioral curricula tend to target these behaviors
behavior, there should be specific and objective early in an individual’s program. Prerequisite
criterion for mastery. This criterion should reflect skills refer to behaviors that facilitate later learn-
the level of competence that allows the individual ing. For example, behavioral programs often target
to use the behavior to successfully navigate his or compliance (i.e., following the instructor’s
her natural environments (Cooper et al., 2007). instructions), nonverbal and verbal imitation, and
attending behaviors (e.g., remaining seated, focus-
ing on presented stimuli; Olley, 2005). Consis-
Measuring Behavior tently demonstrating these and related skills
allow the individual to benefit from instruction
Behavioral curricula place a strong emphasis on and facilitates the acquisition of later skills.
measuring behavior. The previously described Interfering behaviors hinder the individual’s
clear and comprehensive operational definitions of ability to learn. These may be inappropriate behav-
targeted behaviors allow teachers and others work- iors, such as stereotypy, aggression, self-injury, or
ing with the individual to measure the individual’s other issues, including sleep disturbances or die-
demonstration of behaviors. An initial measure of tary concerns (Olley, 2005). These and related
the individual’s ability allows the instructors to behaviors and issues affect the individual’s ability
determine his or her current level of ability. Mea- to participate in and concentrate on instruction.
suring the targeted behaviors during intervention Reducing or eliminating these inappropriate
provides instructors with objective information on behaviors or concerns increases the individual’s
student progress (Cooper et al., 2007). ability to focus on and benefit from instruction.
Individualization Empirical Support
Behavioral curricula are usually designed to be The components of behavioral curricula are con-
individualized and meet each individual’s needs sistent with current best practices for autism
Behavioral Curricula 437 B
treatment. Existing empirical evidence indicates Strategies for Teaching Based on Autism
that effective programs use assessment and Research (STAR)
progress monitoring to individualize program
content and instruction to meet the individual’s The Strategies for Teaching Based on Autism
needs and facilitate his or her independence in his Research (STAR; Arick, Loos, Falco, Krug, B
or her natural environments. Therefore, it is 2004) program provides instructors with assess-
recommended that programs for individuals ment materials, lesson plans, activities, materials,
with autism include these elements (Crimmins, and data collection systems (Arick et al., 2004).
Durand, Theurer-Kaufman, & Everett, 2001; The program targets children’s receptive, expres-
National Research Council, 2001; New Jersey sive, and spontaneous language; adaptive skills;
Department of Education, 2004). Further, there academics; play; and social skills. These skills
is a large and growing body of research indicating are targeted via discrete trial training (DTT),
that behavioral strategies can improve the lan- pivotal response training (PRT), and functional
guage, social, and other skills of children with routines. All three of these are empirically
autism. Because behavioral curricula incorporate supported behavioral strategies. The STAR
these components and strategies, there is reason program also recognizes the importance of and
to believe that they may be effective. provides teachers with strategies for promoting
However, there is relatively little research skill integration and generalization.
examining the effectiveness of curricula content Research indicates that children with autism
(Olley, 1999). More specifically, there is a lack of who are exposed to the STAR program do make
research examining how specific content and progress. Special education professionals pro-
sequence of instruction affect the progress and vided teachers and other staff members with
long-term outcomes of children with autism. yearly workshops that used the STAR program
Because of the importance of individualizing materials to review DTT, PRT, functional rou-
each student’s program, the necessity of this tines, and data collection strategies. Over the next
type of research is unclear (Olley, 2005). How- 12 to 16 months, many of the teachers and staff
ever, more information could be useful in devel- members’ students with autism demonstrated sig-
oping effective programs that best facilitate nificant improvement in language, social skills,
individual’s progress. academics, and autonomy (Arick et al., 2003).
Additional research is also needed to validate Although promising, more research is needed to
different behavioral curricula. Researchers and determine the extent to which the STAR program
program personnel have conducted studies exam- caused this progress.
ining the effects of or outcomes associated with
different behavioral curricula (e.g., Arick et al.,
2003). However, no single curricula has the The Assessment of Basic Language and
empirical support required to meet the criteria Learning Skills: Revised (ABLLS-R)
for an efficacious treatment (Olley, 1999, 2005).
The Assessment of Basic Language and Learning
Skills – Revised (ABLLS-R; Partington, 2008) is
Existing Behavioral Curricula designed to measure and target the expressive and
receptive language, academic, adaptive, motor,
There are numerous behavioral curricula and other skills of children with autism or other
designed for children with autism and other dis- developmental disabilities (Gould, Dixon,
abilities. Three of these are described below. Najdowski, Smith, & Tarbox, 2011). The assess-
However, these descriptions only provide a brief ment is a criterion-referenced tool that measures
overview of the program. For more complete the child’s current abilities and actual use of the
information, please refer to the program manuals targeted and related skills. Based on the assess-
or other references. ment results, instructors can use the ABLLS-R to
B 438 Behavioral Curricula
design an individualized program with measur- current language and related abilities. The bar-
able goals. The ABLLS-R also includes a skills riers assessment is intended to identify existing
tracking system that can be used to monitor the interfering behaviors or absent prerequisite skills
child’s progress and mastery of skills (Partington, that could affect the child’s ability to learn. The
2008). transition assessment evaluates skills that the
Professionals and other adults trained to child needs to transition to and succeed in new
administer the ABLLS-R have collected longitu- and less restrictive environments. The task anal-
dinal data on the skill acquisition of neurotypical ysis and skills tracking system operationally
children. The collected data were obtained from defines over 900 skills from the different targeted
an international and diverse sample of 81 areas. This can provide more detailed data about
6-month to 5-year-old children. The children the child’s initial abilities and progress and guide
were assessed every 3 months, and their scores program development. After assessing the child,
were reported on the WebABLLS, the online instructors can consult the placement and IEP
form of the ABLLS-R. The preliminary data sug- section for recommendations for the child’s
gest that neurotypical children do display the goals and educational settings.
skills targeted by the ABLLS-R and that many The VB-MAPP has undergone field testing.
of the skills are exhibited before the children are However, more research is needed to establish
5 years old. These and future data will be used to its psychometric properties and examine its effec-
examine the typical development of the targeted tiveness (Gould et al., 2011).
skills and can be used to guide program develop-
ment (Partington, Bailey, & Pritchard, 2010).
However, more research is needed to examine Future Directions
the extent to which use of the ABLLS-R leads
to effective programs and improved child As previously discussed, there has been an
outcomes. increase in the development of and research
examining behavioral curricula for children with
autism. However, many of these studies have
The Verbal Behavior Milestones limited internal validity, small samples, and
Assessment and Placement Program examine program instruction and content
(VB-MAPP) together (Arick et al., 2003; Olley, 1999). Future
research should address these issues. Longitudi-
The Verbal Behavior Milestones Assessment and nal research should also be used to examine the
Placement Program (VB-MAPP; Sundberg, long-term effectiveness of different programs.
2008) includes an assessment, curriculum guide, In addition, many of the existing behavioral
and progress monitoring system that are used to curricula are designed for young or high-
develop language programs for young children functioning children with autism. There is
with autism and other language delays a need to develop empirically supported behav-
(Sundberg, 2008). The targeted skills, assess- ioral curricula for older and low-functioning indi-
ment, and curriculum suggestions are derived viduals with autism (Olley, 1999, 2005).
from B. F. Skinner’s work on verbal behavior, These and related areas of research will
developmental research, and empirically based provide researchers and practitioners with the
behavioral principles and strategies (Sundberg, information needed to develop effective behav-
2008). ioral curricula for individuals with autism. This
The VB-MAPP is composed of the milestone information will also help instructors to select
assessment, the barriers assessment, the transi- appropriate interventions for individuals
tion assessment, task analysis and skills tracking, with autism. Doing so will facilitate individuals’
and placement and IEP goals (Gould et al., 2011). progress and promote independent adult
The milestone assessment examines the child’s outcomes.
Behavioral Development Questionnaire 439 B
See Also Schreibman, L., & Ingersol, B. (2005). Behavioral interven-
tions to promote learning in individuals with Autism. In
F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.),
▶ Curriculum Handbook of autism and pervasive developmental disor-
▶ Pivotal Response Training ders (3rd ed., pp. 882–896). Hoboken, NJ: Wiley.
Sundberg, M. L. (2008). Verbal behavior milestones B
assessment and placement program (VB-MAPP). Con-
cord, CA: AVB Press.
Arick, J. R., Loos, L., Falco, R., & Krug, D. A. (2004). The
STAR program: Strategies for teaching based on
autism research, levels I, II, and III. Austin, TX:
Behavioral Development
PRO-ED. Questionnaire
Arick, J. R., Young, H. E., Falco, R. A., Loos, L. M.,
Krug, D. A., Gense, M. H., et al. (2003). Designing Anne Snow
an outcome study to monitor the progress of
Child Study Center, Autism Program,
students with autism spectrum disorders. Focus on
Autism and Other Developmental Disabilities, 18(2), Yale University, New Haven, CT, USA
75–88.
Synonyms
River, NJ: Merrill/Prentice Hall.
Crimmins, D. B., Durand, V. M., Theurer-Kaufman, K., &
Everett, J. (2001). Autism program quality indicators: BDQ; Wing subgroups questionnaire (WSQ)
A self review and quality improvement guide for
schools and programs serving students with autism
spectrum disorders. Retrieved May 12, 2011, from
http://www.p12.nysed.gov/specialed/autism/apqi.htm Description
Gould, E., Dixon, D. R., Najdowski, A. C., Smith, M. N.,
& Tarbox, J. (2011). A review of assessments for The Behavioral Development Questionnaire
determining the content of early intensive behavioral
(BDQ) is a measure that assesses several behav-
intervention programs for Autism spectrum disorders.
Research in Autism Spectrum Disorders, 5, 990–1002. ioral domains of autism spectrum disorders
National Research Council. (2001). Educating children (ASD) in an attempt to subclassify individuals
with Autism (Committee on Educational Interventions on the autism spectrum based on their behavioral
for Children with Autism, Division of Behavioral and
topography. It is based on the subclassification
Social Sciences and Education). Washington, DC:
National Academy Press. scheme proposed by Wing and colleagues, which
New Jersey State Department of Education. (2004). identified the four following ASD subtypes:
Autism program quality indicators: A self-review and aloof, passive, active-but-odd, and normal
quality improvement guide for programs serving
(Wing & Gould, 1979, please see section “His-
young students with autism spectrum disorder.
Retrieved May 12, 2011, from http://celebratethe- torical Background,” below).
children.org/old/Documents/Indicators.pdf The behavioral domains assessed by the BDQ
Olley, J. G. (1999). Curriculum for students with Autism. focus on quality of social interaction but also
School Psychology Review, 28(4), 595–607.
include symbolic play, motor imitation, nonver-
Olley, J. G. (2005). Curriculum and classroom structure.
In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), bal and verbal communication, daily routines,
Handbook of Autism and pervasive developmental stereotyped behavior, and motor coordination
disorders (3rd ed., pp. 863–881). Hoboken, NJ: Wiley. (Castelloe & Dawson, 1993). The BDQ consists
Partington, J. W. (2008). The assessment of basic
of 13 groups of four descriptions of behavior, each
language and learning skills-revised: Scoring instruc-
tions and IEP development guide. Pleasant Hill, CA: description corresponding to one of the four ASD
Behavior Analysts. subgroups. Parents are asked to rate each descrip-
Partington, J. W., Bailey, A., & Pritchard, J. K. (2010). tion on a 7-point Likert scale with regard to how
Data on the developmental patterns of specific lan-
well it describes their child (0 ¼ never,
guage and learning skills of typically developing chil-
dren as measured by the ABLLS-R. Retrieved June 30, 6 ¼ always). Additionally, for each group of
2011, from http://www.behavioranalysts.com/data.pdf items, parents are asked to select the one
B 440 Behavioral Development Questionnaire
description that best describes their child. Only characterized by reversal of pronouns and idiosyn-
the item-level ratings are used in scoring the BDQ. cratic phrases). Patterns of abnormal behavior were
As each description corresponds to a social also evident between the three groups. Stereotyped
subtype, the BDQ is scored by summing the rat- and repetitive behavior characterized the aloof
ings for each subtype. Missing items are prorated group, and repetitive speech and behavior patterns
based on the average score of available items. were seen more frequently in the passive and active
The child is assigned to the subtype for which but odd groups (Wing & Gould, 1979).
he or she received the highest score. Since the inception of Wing’s subclassifica-
tion system, it has been accepted by the field as
providing rich clinical descriptions of individuals
Historical Background with ASD (Volkmar & Klin, 2005). However,
subgroups have largely been assigned based on
As stated previously, the BDQ is based on the clinical impression rather than in a systematic
ASD subtyping system developed by Lorna Wing fashion. The goal of the BDQ was to create
and Judith Gould (1979). Wing and Gould’s sem- a standardized measure for subclassifying
inal paper (1979) was an epidemiological study of children according to the Wing subtyping system.
all children living in Camberwell, London, aged
under 15 years who showed ASD-like impair-
ments. The researchers found that the social Psychometric Data
impairment that characterized this group was
expressed in one of four ways. Social aloofness In the initial study of the BDQ, the questionnaire
was characterized by indifferent social behavior. was completed by parents of children with autism
Passive interaction involved the absence of spon- (n ¼ 34) or PDD-NOS (n ¼ 6) between the ages
taneous approach behavior but the acceptance of of 4 and 20 years (Castelloe & Dawson, 1993).
approaches made by other children. Active but odd Separately, clinicians assigned the children to
interaction included children who spontaneously a Wing subtype based on a 30-min observation.
approached other children but their interactions Agreement between the BDQ classification and
were one-sided and characterized by repetitive classification based on the clinical observation
preoccupation with certain phrases or topics of was good, at 73%. Further analyses revealed
conversation. The fourth group was the appropri- that subtype assignment by the clinician was the
ate interaction subtype, which included children most powerful predictor of BDQ assignment,
whose social interactions were normal for their indicating good external validity for the BDQ.
level of cognitive development. These groups The authors also examined the consistency of
were proposed to exist on a continuum, with the parents’ ratings across the 13 groups of descrip-
aloof individuals representing the most severe end tions, to assess the degree to which each subtype
of the spectrum of impairment, and the active but was rated in the same manner across behavioral
odd individuals at the mild end. domains. These analyses revealed that for all three
It was then hypothesized that individuals with subgroups, parents ranked the descriptions in
ASD could be subclassified based on these catego- a consistent manner. Correlations between the sum-
ries of social impairment. Furthermore, Wing pro- mary scores were computed to assess the extent to
posed that these social classifications would which each subtype was distinct from the others.
correlate with other patterns of behavior. Indeed, The correlation between the aloof and passive
the subtypes were examined and it was found that groups was .02, between the passive and active
patterns of behavior tended to occur together. The but odd groups it was .17, and between the aloof and
aloof group comprised the highest proportion of active but odd groups it was .70. The high nega-
children with autism and was significantly associ- tive correlation between the aloof and active but
ated with a history of Kanner’s (1943) “typical” odd groups was interpreted as evidence that these
autism (socially aloof, repetitive routines, speech subtypes do in fact fall at two ends of a continuum.
Behavioral Health Rehabilitation (BHR) Services 441 B
In terms of behavioral correlates of the Wing Kanner, L. (1943). Childhood psychosis: Initial studies
subtypes, Castelloe and Dawson (1993) found and new insights. Washington, DC: Winston.
Powers, M. D. (2005). Behavioral assessment of individ-
that subtype classification was significantly uals with autism. In F. R. Volkmar, R. Paul, A. Klin, &
related to mental age and score on the Childhood D. Cohen (Eds.), Handbook of autism and pervasive
Autism Rating Scale (CARS), a measure of ASD developmental disorders (3rd ed., pp. 817–830). B
symptoms (Schopler, Reichler, & Renner, 1986). Hoboken, NJ: Wiley & Sons.
Schopler, E., Reichler, R. J., & Renner, B. R. (1986). The
The aloof group had the lowest mean mental age, childhood autism rating scale (CARS) for diagnostic
the passive group occupied the intermediate posi- screening and classification of autism. New York:
tion, and the active but odd group had the highest Irvington.
mean mental age. CARS scores indicated Volkmar, F. R., & Klin, A. (2005). Issues in the
classification of autism and related conditions.
a similar trend: the aloof group had the most In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen
severe ASD symptomatology, the active but odd (Eds.), Handbook of autism and pervasive develop-
group had the least severe ASD symptoms, and mental disorders (3rd ed., pp. 5–41). Hoboken, NJ:
the passive group occupied the intermediate posi- Wiley & Sons.
Wing, L., & Attwood, A. (1987). Syndromes of autism and
tion. A trend in the same direction was seen for atypical development. In D. J. Cohen & A. Donnelan
IQ, but it did not reach significance. (Eds.), Handbook of autism (pp. 3–17). New York:
Overall, the data support the validity of Wiley.
the BDQ for classifying children with ASD into Wing, L., & Gould, J. (1979). Severe impairments of
social interaction and associated abnormalities in
subgroups based on Wing’s classification system. children: Epidemiology and classification. Journal of
Clinical Uses
The BDQ has been recommended as a useful Behavioral Disorder

addition to the assessment and treatment planning
process (Powers, 2005). Categorization of ▶ Conduct Disorder
individuals with ASD according to social impair-
ments allows for prediction of corresponding
behavioral and cognitive differences (Castelloe
& Dawson, 1993). It has been suggested that the Behavioral Health Rehabilitation
utility of such subtyping within ASD has (BHR) Services
the greatest clinical implications for the planning
of treatment services (Wing & Attwood, 1987). Paul Cavanagh
New York Institute of Technology, Central Islip,
NY, USA
See Also
▶ Spectrum/Continuum of Autism Definition

▶ Subtyping Autism
▶ Wing, Lorna Behavioral Health Rehabilitation Services
(BHRS) is a term used for a specific application
of a Medicaid-funded interdisciplinary approach
References and Readings for a child or adolescent diagnosed with a serious
emotional or behavioral disorder. The type
Castelloe, P., & Dawson, G. (1993). Subclassification of of approach is sometimes referred to as a “wrap-
children with autism and pervasive developmental dis-
around approach.”
order: A questionnaire based on Wing’s subgrouping
scheme. Journal of Autism and Developmental Several states, and primarily Pennsylvania,
Disorders, 23, 229–241. support the provision of Behavioral Health
B 442 Behavioral Health Rehabilitation (BHR) Services
Rehabilitation Services when a licensed psychol- ▶ wraparound services for more information on
ogist has deemed the service medically necessary the development of the wraparound philosophy.
as part of a Medicaid-funded Early and Periodic
Screening, Diagnosis and Treatment (EPSDT)
service. “The Early and Periodic Screening, Rationale or Underlying Theory
Diagnostic, and Treatment (EPSDT) service is
Medicaid’s comprehensive and preventive child The key provision in Medicaid-funded Behav-
health program for individuals under the age of ioral Health Rehabilitation Services is that a
21. EPSDT was defined by law as part of the licensed psychologist or psychiatrist has deter-
Omnibus Budget Reconciliation Act of 1989 mined that a child or adolescent has a medical
(OBRA ‘89) legislation and includes periodic need for the services in order to ensure the cor-
screening, vision, dental, and hearing services” rection or amelioration of defects and physical
(Centers for Medicare & Medicaid Services, and mental illnesses and conditions.
n.d.). The Medicaid EPSDT regulations provide Behavioral Health Rehabilitation Services are
for the provision of other necessary health care, individualized and interdisciplinary services for
when it will “correct or ameliorate defects, and a child or adolescent with a significant behavioral
physical and mental illnesses and conditions dis- health disability provided in the natural settings
covered by the screening services” (Centers for of their family or local community. An essential
Medicare & Medicaid Services, n.d.). feature of BHR services is that they are designed
and delivered at the sites where the problematic
behaviors occur. Based on a philosophy consis-
Historical Background tent with wraparound services, the goal of BHR
services is not to try to understand problematic
The United States Congress’s Omnibus Recon- behaviors in the abstract, but rather to provide
ciliation Act of 1989 created a Medicaid service direct intervention in the natural context with the
called the Early and Periodic Screening, Diagno- professionals designing the interventions able to
sis, and Treatment (EPSDT) services. During the learn and respond directly from the child’s behav-
1990s, several states, most notably the state of ioral responses to the interventions.
Pennsylvania’s Department of Public Welfare,
supported the provision of Behavioral Health
Rehabilitation Services when identified as medi- Goals and Objectives
cally necessary by a licensed psychologist or
psychiatrist as part of an EPSDT evaluation. Behavioral Health Rehabilitation (BHR) Ser-
While, in theory, Behavioral Health Rehabilita- vices are services based on a wraparound philos-
tion Services can be provided in any state as part ophy designed to provide comprehensive
of their Medicaid EPSDT services, Pennsylvania treatment to children and adolescents with a seri-
has been the most consistent at regularly provid- ous emotional or behavioral disorder who cannot
ing this service. make progress with the usual array of discreet
Behavioral Health Rehabilitation (BHR) services. An essential feature of BHR services is
Services is essentially a form of ▶ wraparound the coordination, or wraparound, of services in
services that is supported through Medicaid the child or adolescent’s natural environments of
funding. The use of Behavioral Health Rehabili- home, school, and the local community.
tation Services develops during the 1990s A primary goal of BHR services is to develop a
concurrent with the national development of natural community support network, and self-reg-
wraparound services for youth with complicated ulating behaviors on the part of the child or ado-
mental health and behavioral needs in several lescent, that can be maintained with the ordinary
discreet places throughout the country. See the array of services. Thus, a key outcome for BHR
historical section of the Encyclopedia listing for services is to eliminate the need for BHR services.
Behavioral Health Rehabilitation (BHR) Services 443 B
BHR clinicians and other clinicians in the has developed a set of ten Principles of Wrap-
child or adolescent’s natural environment, as around. These ten principles are as follows:
well as with other concerned community mem- 1. Family voice and choice: An emphasis on the
bers, work with the family of the child receiving primary importance of goals and perspective
services. Other concerned community members of the individual receiving services and their B
may include school administrators and teachers, family and advocates in the development of
members of a family’s religious congregation, the wraparound process. This principle
and civic officials, as well as staff at community, stresses the importance of intentional activi-
health, or recreation centers. BHR clinicians ties to illicit and include the perspective of
aid in developing and guiding a natural commu- the individual receiving services and their
nity support network. As a team, they develop family and advocates.
individualized goals to promote appropriate 2. Team based: This principle stresses the
behavior, activities, and academic and social importance of collaborative effort of family
skills in the child or adolescent’s natural home, members, professionals, and other stake-
school, and community environments. holders committed to the family’s well-
being over an extended period of time.
The choice of team members should be
Treatment Participants largely driven by the person receiving
services and their family and advocates.
Treatment participants for Behavioral Health 3. Natural supports: To the greatest extent
Rehabilitation (BHR) Services are children possible, a wraparound plan of service
or adolescents who have been diagnosed with should utilize the natural support systems of
a severe emotional or behavioral disorder by family members, friends, neighbors, church,
a psychiatrist or psychologist after a face-to- and community members. The plan should
face clinical evaluation. The prescribing also include the regular support structures
clinician must identify that the BHR services that exist in the community via school sys-
are necessary in order to ameliorate or correct tems, church congregations, community cen-
the identified severe emotional or behavioral ters, local government, etc.
disorder. 4. Collaboration: The decision-making process
in developing a wraparound plan of service
should be based on a consensus approach that
Treatment Procedures includes input from all team members.
5. Community based: Wraparound services
Behavioral Health Rehabilitation (BHR) Ser- should adhere to a principle of provision in
vices are not based on a single therapeutic the least-restrictive setting possible.
model addressing the therapeutic needs of the 6. Culturally competent: Team designation,
children or adolescents with severe emotional or service planning, and service delivery should
behavioral disorders identified as requiring the demonstrate “respect for the values, prefer-
BHR services. ences, beliefs, culture and identity of
BHR services are based upon a wraparound the child/youth and family, and their commu-
philosophy of an individualized treatment plan nity” (Bruns, Walker, & The National
utilizing all community resources based in and Wraparound Initiative Advisory Group,
delivered at the place (or places) where the prob- 2008, p. 7).
lematic behaviors occur. 7. Individualized: Wraparound services need to
While BHR services are not exactly the same be uniquely developed for the individual in
as wraparound services – the implementation of need and their family. The planning for ser-
BHR services is consistent with the wraparound vices should draw upon the best empirical
philosophy The National Wraparound Initiative evidence of effective treatment and upon
B 444 Behavioral Health Rehabilitation (BHR) Services
community and professional experience. the Institute for Behavior Change had a statisti-
However, the services should not be assem- cally significant association with reductions in
bled from a static list of available services. physical aggression, noncompliance with adult
8. Strengths based: A key in the development of prompts, socialization deficits and communica-
a wraparound plan of service is to identify, tion deficits. An association was also found
“build on, and enhance the capabilities, with improvements in the environmental safety
knowledge, skills, and assets of the child of the children” (Institute for Behavioral Change,
and family, their community, and other n.d. b, p. 1).
team members” (p. 8). Behavioral Health Rehabilitation (BHR) Ser-
9. Unconditional: The origins of the wrap- vices are not the exact equivalent of wraparound
around process grew out of a need to provide services; nevertheless, their implementation is
quality services to individuals with severe consistent with the basic philosophy of
and complex behaviors. It is understood at a wraparound approach to services. The National
the outset that this will be a difficult and Wraparound Initiative has published a summary
challenging process. Inherent in the develop- of nine controlled studies of wraparound services
ment of a wraparound plan of service is that had been reported in peer-reviewed journals
a commitment to see the process through as of 2010. Their conclusion of this very limited
despite setbacks and unanticipated behavior, universe of research is that “though many of these
events, or outcomes. There needs to be an studies have significant methodological weak-
unwavering commitment on the part of the nesses, the ‘weight of evidence’ of these studies
team to continually adapt the plan of service indicates superior outcomes for youth who
until progress is made and there is consensus receive wraparound compared to similar youth
that a wraparound process is no longer who receive some alternative service” (p. 5).
needed.
10. Outcome based: Wraparound plans of ser-
vice identify measurable outcomes and indi- Qualifications of Treatment Providers
cators of progress and success. The team
measures and evaluates these measures on As identified by Medicaid regulations and
an ongoing basis and modifies plans accord- implemented by various states, the primary treat-
ingly (Bruns et al., 2008). ment providers for Behavioral Rehabilitation
Services fall into three categories:
• Behavioral Specialist Consultants (BSC):
Efficacy Information Behavioral specialist consultants are clini-
cians with a Master’s or PhD level of educa-
As of the summer of 2011, there is little or no tion who work with children, family members,
published research specifically addressing the and other members of the treatment team to
efficacy of the Behavioral Health Rehabilitation develop the individualized BHR treatment
approach to service delivery. plan. These clinicians take overall responsibil-
The Institute for Behavior Change reports on ity for overseeing the development and imple-
their website information about research mentation of the treatment plan. In addition
conducted by Dr. Natasha K. Brown and Erica to developing and overseeing the treatment
Richman of the University of North Carolina at plan, they will work as advisors and mentors
Chapel Hill. As reported on their website, the to all individuals providing services under the
researchers “studied 301 treatment records of plan, including family and community
children age 3 to 17 between 2002 and 2007. members.
They found that Behavioral Health Rehabilitation • Mobile Therapist: A mobile therapist is a Mas-
Services (BHRS) as implemented by the staff of ter’s or PhD educated therapist who provides
Behavioral Momentum 445 B
child-centered, family focused, individual,
and family-level psychotherapy. Behavioral Momentum
• Therapeutic Staff Support: A therapeutic staff
support (TSS) worker is an individual with Shaunessy Egan
a Bachelors’ degree or higher level of educa- The Center for Children with Special Needs, B
tion, who provide one-on-one services Glastonbury, CT, USA
addressing treatment plan goals. TSS workers
are supervised by Behavioral Specialist Con-
sultants and/or Mobile Therapists. Definition
Behavioral momentum is derived from

See Also classical physics. In behavioral momentum, rate
of responding is analogous to velocity and largely
▶ Wraparound Services determined by the schedule of reinforcement, and
the characteristic rate or magnitude of the
obtained reinforcement in the situation deter-
mines the behavioral analogue of mass. The
References and Readings behavior momentum metaphor suggests that the
more reinforcement in a condition correlates with
Allegheny HealthChoices, Inc. (2006). Behavioral health greater resistance to change within that condition.
rehabilitation services: Brief treatment model.
Behavioral momentum describes the relation
Retrieved from http://www.ahci.org/Reports/
QualityFocusReports/BHRS%20Brief%20Treatment% between resistance to change (persistence of
20Report.pdf behavior) and the rate of reinforcement obtained
Bruns, E. J., & Suter, J. C. (2010). Summary of the wrap- in a given situation. Behavioral momentum refers
around evidence base. In E. J. Bruns & J. S. Walker
to the tendency for behavior to persist after
(Eds.), The resource guide to wraparound. National
Wraparound Initiative: Portland, OR. a change in environmental circumstances. The
Bruns, E. J., Walker, J. S., & The National Wraparound greater the rate of the reinforcement is the greater
Initiative Advisory Group. (2008). Ten principles of level of the behavioral momentum should be.
the wraparound process. In E. J. Bruns & J. S. Walker
Behavioral momentum is frequently used as an
(Eds.), The resource guide to wraparound. Portland,
OR: National Wraparound Initiative. intervention for noncompliance. Such interven-
Centers for Medicare & Medicaid Services. (n.d.). Med- tion involves issuing a sequence of instructions
icaid early & periodic screening & diagnostic treat- with which the learner is most likely to comply
ment benefit: Overview. Retreived from http://www.
(i.e., high-probability instructions) immediately
cms.gov/MedicaidEarlyPeriodicScrn/01_Overview.
asp prior to issuing a low-probability instruction.
Commonwealth of Pennsylvania Department of Public
Welfare. (2009). Health choices behavioral health pro-
gram: Program standards and requirements: Primary
contractor. Retrieved from http://www.dpw.state.pa. References and Readings
us/ucmprd/groups/public/documents/communication/
s_ 002381.pdf Dube, W. V., Ahearn, W. H., Lionello-DeNolf, K., &
Institute for Behavior Change. (n.d. a). A one-page over- McIlvane, W. J. (2009). Behavioral momentum:
view of Medicaid, EPSDT and BHRS in Pennsylvania Translational research in intellectual and developmen-
and elsewhere. Retrieved from http://www.ibc-pa.org/ tal disabilities. Behavior Analyst Today, 9, 238–253.
A%20one-page%20overview%20of%20Medicaid,%20 Mace, F. C., & Belfiore, P. (1990). Behavioral momentum
EPSDT%20and%20BHRS%20in%20Pennsylvania%20 in the treatment of escape-motivated stereotypy.
and%20elsewhere%20091009.pdf Journal of Applied Behavior Analysis, 23, 507–514.
Institute for Behavior Change (n.d. b). Promising Mace, F. C., Mauro, B. C., Boyajian, A. E., & Eckert, T. L.
treatment found for children with inappropriate behav- (1997). Effects of reinforce quality on behavioral
ior. Retrieved from http://www.ibc-pa.org/Press% momentum: Coordinated applied and basic research.
20Release%20and%20BHRS%20study%20071608.pdf Journal of Applied Behavior Analysis, 30, 1–20.
B 446 Behavioral Objective
Nevin, J. A. (1992). An integrative model for the study of

behavioral momentum. Journal of the Experimental Behavioral Specialist
Analysis of Behavior, 57, 301–316.
Nevin, J. A. (1996). The momentum of compliance.
Journal of Applied Behavior Analysis, 29, 535–547. ▶ Behavior Analysis
Behavioral Objective Behaviorism
Marina Azimova John Molteni

The Center for Children with Special Needs, Institute for Autism and Behavioral Studies,
Glastonbury, CT, USA University of Saint Joseph, West Hartford,
CT, USA
Synonyms
Definition
Instructional objective
Behaviorism is a philosophy of science where
behavior is the unit of study and several supposi-
Definition tions about the science of behavior are made.
Behaviorism focuses on the study of behavioral
A behavioral objective is a specific design and/or phenomenon that function under the same
set of measurements of a target behavior. principles of conditioning. This includes behav-
It includes the following necessary components: iors that are both public and private. Finally,
behavior itself, environmental circumstance(s) in use of mentalistic terminology (e.g., I feel,
which the behavior is to occur, and the standard I think, I believe) is not helpful in examining
criteria of satisfactory behavior performance. behavior and, in fact, ends the examination of
A behavioral objective is often expressed in the a phenomenon.
following format: Given (a set of conditions There is some confusion when discussing
or circumstances), an individual will (demonstra- behaviorism, particularly the radical behaviorist
tion of the target behavior) at (performance level position of B. F. Skinner by critics wherein peo-
determined by rate, frequency, etc.) in (specified ple assume that covert behaviors or behavior that
settings or with specific individuals). The behav- occurs “under the skin” such as thoughts and
ioral objective could be related to formal instruc- feelings are not important to the study of behav-
tion when described as an instructional objective, ior. The main impediment to using private events,
or a statement of what a student should be able to those internal to the individual, is the difficulty in
perform/achieve at the end of a learning phase. corroborating these events by another individual.
Given the need for objective measurement of
behavioral phenomenon, the inability to observe
internal events makes inclusion of private events
Vargas, J. S. (2009). Behavior analysis for effective a challenge in discussing and defining behavioral
teaching. London: Routledge/Taylor. principles.
The challenge for behaviorism is presenting
behavior as the primary unit of analysis for psy-
chology where the general public tends to support
Behavioral Objectives the idea that the “mind” or mental events are the
focus and cause of a person’s behavior. Mental-
▶ Objective istic concepts such as frustration, anxiety,
Behaviorism 447 B
depression, or anger are not helpful in our under- Associationism – Classical associationism dealt
standing of behavior and were deemed “explana- with the organization of ideas based on rela-
tory fictions” by Skinner. Such concepts do not tionships between mental states and can be
add to our understanding of behavioral phenom- seen in writings as far back as Aristotle.
ena; rather, they end the analysis. Behaviorists David Hume presented a model of associa- B
look to the behavioral manifestations of what is tionism that suggested that our understanding
termed frustration, anxiety, depression, and anger of reality was a product of three laws of asso-
and attempt to explore the environmental stimuli ciation. These included the Law of Resem-
that function to maintain and reinforce said blance, things that are similar are associated;
manifestations. the Law of Contiguity, things that occur close
Behaviorism maintains that behaviors that are in time will be associated; and the Law of
overt (observable) and private (“within the skin”) Cause and Effect, the most important aspect
can both be subjected to objective observations of associationism wherein the individual iden-
with the latter suffering from the challenges tifies causal influences on the environment.
noted above with regard to corroboration of This is the basis of scientific inquiry.
a second observer. Therefore, some behaviorists Logical Positivism – A philosophical perspective
view thinking and feeling as behavior in the same that posits the only true knowledge is knowl-
way as overt behaviors such as running, typing, edge derived from scientific endeavors. Meta-
and speaking. While there is some discussion physical explanations are to be abandoned as
about the utility of attempting to analyze these they cannot be demonstrated empirically.
covert behaviors (see discussion below), there is
no argument that individuals engage in covert Behaviorists
behavior. John Watson is considered the earliest psycholo-
Three type of behaviorism are generally gist to identify himself as a behaviorist. In his
discussed: work Psychology as the Behaviorist Views It, he
Methodological Behaviorism – The study of described the power of behavioral approaches
behavior should focus only on those behaviors and suggested that psychology should be the sci-
that are observable and that no mental states ence of behavior and not the mind. Watson’s
should be considered in the analysis. This is work was with reflexive behavior (see below)
most closely associated with John Watson. and therefore was responding to a limited amount
Psychological Behaviorism – Associated with of information on behavior and its relationship
B. F. Skinner, psychological behaviorists with the environment. His work led to significant
focus on the functional relationship between criticism and a backlash from traditional psychol-
environmental events (antecedents and conse- ogists who viewed his claims as boastful and
quences) and the behaviors produced by those whose methods generally consisted of introspec-
environmental events. tion or turning inward for causes of behavior
Analytical Behaviorism – A behaviorist position rather than to environmental influences.
that posits that mental states can be explained Pavlov – Ivan Pavlov’s classic experiments on
through consistent patterns of behavior. These classical conditioning, (see below), demonstrated
patterns can lead to predictions of an individ- a conditioning paradigm that involved reflective
ual’s behavior given a specific set of environ- behavior similar to Watson. In his classic exper-
mental stimuli. iments, Pavlov paired a neutral stimulus (NS), or
a stimulus with which the organism does not have
any learning history with, with an unconditioned
Historical Background stimulus (UCS), a stimulus that elicits an uncon-
ditioned response, a reflex response that occurs in
Behaviorism has links to several philosophical the presence of the UCS. In Pavlov’s experi-
schools including: ments, the neutral stimulus was a tone and the
B 448 Behaviorism
unconditioned stimulus was the presentation of a theory of why organisms behave in a certain
food. In response to the presentation of the food, way. Skinner presents a response-stimulus under-
the organism, a dog, salivated. Through repeated standing of behavior where the consequences that
pairings of a tone (NS) and the food (UCS), the follow a behavior are crucial to the conditioning
tone began to elicit the response of salivation of behavior. Operant conditioning is so named as
without the presence of the food. The tone had behaviors are emitted and operate on the environ-
become a conditioned stimulus (CS) that elicited ment. This is contrasted with behaviors that are
the conditioned response (salivation). The dia- elicited by environmental events and are reflex-
gram below outlines this process. ive in nature. Skinner extended his work in the
E. L. Thorndike – Thorndike’s experimental laboratory to extrapolations to the development
work led to his theory of Connectionism and the of language, social engineering, and education in
Law of Effect. He examined learning processes in his later work. All of these extensions of his work
experiments with animals. Animals, generally were based in operant conditioning methodology.
cats, were placed in a puzzle box that required
the animal to perform an action to escape the box
and receive a reward. Thorndike observed Current Knowledge
that the time animals took to perform an action
(e.g., lever press) decreased after successful Approaches
attempts to escape. Additionally, animals did Methodological behaviorism is associated with
not demonstrate the required action after observ- John Watson following the publication of Psy-
ing other animals engaging in the behavior. This chology as the Behaviorist Views It. Within this
led to Thorndike’s formulation of a cause/effect paradigm, observable behavior is the only thing that
description of learning. He tracked “learning should be studied and all things within the body
curves” in the behavior of animals to demonstrate should not be considered the realm of psychology.
that learning was a gradual process of trial and Radical behaviorism was proposed by B. F.
error. Thorndike’s Law of Effect indicates that Skinner. The term radical behaviorism referred to
behavior that is followed by positive conse- the acknowledgement that a science of human
quences is likely to be repeated in the future. behavior must account for covert behaviors (or
Hull – Clark Hull presented a theory of learn- behaviors within the skin) to be complete. The
ing termed drive-reduction theory. Drive- challenge for establishing the role of internal
reduction theory suggests that behaviors occur events into a functional analysis of behavior is
in response to internal drives of the organism. that these are not accessible to anyone other than
Drives are generally important for survival the individual being studied. This, therefore, does
including hunger, thirst, and warmth. Stress on not allow for corroboration of these internal
the organism leads to behaviors that reduce the events as they are not observable.
drive and reduce stress. Drive reduction rein-
forces the organism and those behaviors will Types of Conditioning
occur more frequently in the future. Hull’s theory Respondent conditioning or classical condition-
presents a stimulus-response form of behaviorism ing is the process of conditioning reflexes to
where the stimulus (drive) elicits the behavior. respond to environmental stimuli. This type of
Skinner – Burrhus Frederick (B. F.) Skinner conditioning is also known as stimulus-response
demonstrated operant conditioning procedures in conditioning where the stimulus (S) precedes the
laboratory settings. His work described the prin- response (R). This relationship is often
ciples of behavior that serve as the foundation for represented as S - > R. In a traditional classical
the science of the experimental analysis of behav- conditioning arrangement, a neutral stimulus
ior and applied behavior analysis. Skinner’s rad- (e.g., a flashing light) that has no previous history
ical behaviorism was borne out of his of being paired with the occurrence of the reflex
observations during experiments, not based on (e.g., an eye blink) is presented along with
Behaviorism 449 B
a stimulus that elicits the reflex (e.g., a puff of in the environment. During operant conditioning,
air). The stimulus that elicits the reflex response an organism’s behavior is subject to conse-
is known as the unconditioned stimulus as it does quences that lead to increases (reinforcement) or
not require a learning history to elicit the reflex or decreases (punishment) in the future occurrence
unconditioned response. After repeated pairings of that behavior. Along with these increases, B
of the neutral stimulus with the unconditioned antecedent stimulus events come to serve as dis-
stimulus, presentation of the neutral stimulus criminative stimuli for the likelihood of rein-
will come to elicit the unconditioned response forcement. That is, environmental events signal
without presenting the unconditioned stimulus. the availability of reinforcement if the organism
For this example, presenting the flashing light engages in a particular repertoire of behavior.
prior to the puff of air over multiple trials will Skinner’s work on shaping is instrumental to the
eventually lead to the flashing light eliciting eye development of learned repertoires of behavior.
blinking without presenting the puff of air. This Shaping involves reinforcement of closer and
arrangement is represented as: closer approximations to the target behavior.
For example, a rat in an operant chamber may
Neutral ! unconditioned ! unconditioned be required to push a lever to access food (a
stimulus stimulus response: reinforcer). As the rat moves about the cage and
orients to the lever, a click is followed by the
With continued pairing of the neutral stimulus delivery of the reinforcer. As the rat begins to
and the unconditioned stimulus, the neutral stim- orient toward the lever more frequently, rein-
ulus, now a conditioned stimulus, comes to con- forcement is delivered and then withheld. This
trol the occurrence of the unconditioned withholding is called extinction. Extinction leads
response, now called a conditioned response. to variability in responding where the rat may
This arrangement is represented as: now touch the lever which would be followed
by reinforcer delivery. This process continues
Conditioned stimulus ! conditioned response: until the rat reliably presses the lever. Shaping,
extinction, and schedules of reinforcement serve
When the conditioned stimulus is presented, as the basis for our understanding of the develop-
the response follows as if the unconditioned stim- ment of behavioral repertoires.
ulus had been presented. In this instance, behavior
is elicited, that is, behavior is caused by the occur- Molecular Versus Molar Behaviorism
rence of an external stimulus. Continued presen- The contrast of molar and molecular behaviorism
tation of the conditioned stimulus without the represents the focus of attention in a functional
presentation of the unconditioned stimulus will analysis. Those who support a molecular view of
gradually lead to reductions in the conditioned behaviorism support looking at the moment to
response. This process is termed extinction. moment changes in behavior and analyze the
Operant conditioning occurs when a behavior direct antecedents to and consequences of those
comes under the control of consequences that behaviors. This is a view that is in line with Skin-
follow it. The operant conditioning paradigm ner’s analyses of behavior in his basic experimen-
can be described in the three-term contingency: tal work. A molar perspective looks at behavior
over time and views behavior in the context of
Antecedent ! Behavior ! Consequence: other, longer sequences (chains) of behavior. That
is, when describing an event, one needs to observe
An antecedent is a stimulus event that the behavior to completion as opposed to
precedes the occurrence of behavior where as a moment in time. Lever pressing is best under-
a consequence is a stimulus event that follows stood as the duration of engaging in lever pressing
the occurrence of the behavior. A behavior is and not in the instant where the lever is pressed.
anything an organism does and results in a change The molar view contrasts with the molecular view
B 450 Behaviorist Theory
in terms of how responses are strengthened. The Future Directions

molecular view focuses on increases in response
rates as an indicator of response strength. In con- Behaviorists continue to evaluate and extend our
trast, the molar view focuses on increased alloca- understanding of the basic principles of behavior
tion of responding to one or another behavior in and application of these principles to socially
a choice paradigm. That is, all behavior requires significant behaviors. Extensions to complex
choices between responses and the selection of human behaviors continue to fields such as phar-
one behavior over another is a function of rein- macology, neuroscience, performance manage-
forcement. There is ongoing discussion among ment, gun safety, interventions for addiction and
behavior analysts as to which perspective best gambling, and treatment for individuals with
explains behavioral phenomena. neurodevelopmental disorders including autism
spectrum disorders.
Applications
Experimental Analysis of Behavior – The exper- See Also
imental analysis of behavior has a primary focus
on basic research, that is, research on human and ▶ Applied Behavior Analysis
nonhuman organisms whose purpose is to ▶ Classical Conditioning
develop greater understanding of behavioral prin- ▶ Functional Analysis
ciples. This, in turn, enhances our understanding ▶ Operant Conditioning
of conditions that reliably predict their occur- ▶ Punishment
rence. The experimental analysis of behavior is ▶ Reinforcement
responsible for our understanding of reinforce-
ment, schedules of reinforcement, and their
impact on behavior, punishment, discriminative References and Readings
stimuli, and choice. Basic behavioral principles
demonstrated in laboratory settings serve as the Baer, D., Wolf, M., & Risley, T. (1968). Some current
dimensions of applied behavior analysis. Journal of
basis for procedures used in applied settings.
Applied Behavior Analysis, 1, 91–97.
Applied Behavior Analysis – Applied behav- Baum, W. (2005). Understanding behaviorism. Malden,
ior analysis focuses on the application of behav- MA: Blackwell Publishing.
ioral principles to socially important behavior Cooper, J. O., Heron, J., & Heward, W. H. (2007). Applied
behavior analysis (2nd ed.). New York: Pearson.
(Baer, Wolf, & Risley, 1968). Applied behavior
Malone, J. C. (2004). Modern molar behaviorism and
analysis limits its scope of focus to the improve- theoretical behaviorism: Religion and science. Journal
ment of socially important behavior. This is not of the Experimental Analysis of Behavior, 82, 95–102.
a limitation of applied behavior analysis, but rather, Skinner, B. F. (1974). About behaviorism. New York: Knopf.
the need to focus on those behaviors brought to our
attention as needing improvement. Methods for
assessing the environmental variables that control Behaviorist Theory
behavior are consistent between the experimental
analysis of behavior and applied behavior analysis. Susan A. Mason
Applied behavior analysis practices include appli- Services for Students with Autism Spectrum
cation of reinforcement contingencies, stimulus Disorders, Montgomery County Public Schools,
control procedures, shaping, chaining, and task Silver Spring, MD, USA
analysis and are applied to various populations
and areas of practice. Applied behavior analysts
have formed an accrediting body and established Definition
criteria for university coursework and supervision
that leads to certification as a board-certified behav- Behaviorism is widely used to refer to the philos-
ior analyst. ophy of a science of behavior. There are various
Behaviorist Theory 451 B
forms of behaviorism: structuralism, behaviorism and operant. Respondent behavior is behavior
that uses cognition as causal factors (e.g., cogni- that is elicited by a stimulus; it is reflexive and
tive behavior modification), social learning the- essentially involuntary. Operant behavior
ory, in addition to methodological behaviorism is behavior that is influenced by stimulus changes
and radical behaviorism. In his text, About (consequences) that follow the behavior. B
Behaviorism (Skinner, 1974), B. F. Skinner Skinner argued that the uniqueness of operant
wrote: “Behaviorism is not the science behavior warranted its own field of study
of human behavior, it is the philosophy of that (see also Experimental Analysis of Behavior).
science” (Cooper, Heron, & Heward, 2007). Skinner conducted thousands of laboratory inves-
tigations that allowed him to systematically study
functional relationships of antecedent stimuli,
Historical Background responses, and reinforcement of those responses
in a controlled environment. Skinner’s method-
Prior to the introduction of behavioral science, ology resulted in the foundation of behavior anal-
the field of psychology consisted of the study of ysis as we know it today.
states of mind and mental processes. There are
four historical building blocks of behaviorism:
classical conditioning as presented by Pavlov, Current Knowledge
Thorndike’s law of effect, Watson’s experiments
with human conditioning, and Skinner’s concep- Behaviorism has evolved into many areas
tualization of operant conditioning. of study. It is most widely represented in the
The development of behaviorism is largely disciplines of experimental analysis of behavior
attributed to John B. Watson who wrote a seminal and applied behavior analysis. Within the field of
article in 1913 in which he argued that psychol- applied behavior analysis, methods of behavior-
ogy should be viewed as a purely objective exper- ism have been used to study and affect services in
imental branch of natural science. As such, the the areas of verbal behavior, public safety, orga-
goal should be to study the prediction and control nizational behavior, education, special education,
of behavior through direct observation of the habit reversal, behavioral medicine, cognitive
relationship of environmental stimuli and behavior modification and therapy, social learn-
resulting evoked responses. This relationship ing theory, functional analysis and assessment of
became known as the stimulus–response (S-R) behaviors, and more. The foundation of behav-
paradigm, and Watson proposed that it could be iorism continues as a philosophy of a science of
used to predict and control human behavior in behavior.
a way that would allow practitioners to improve
performance in areas such as education, business,
and law. Although Watson later made exagger- Future Directions
ated claims about the ability to predict and con-
trol human behavior, he is recognized for As previously noted, behaviorism has been the
providing a strong case that the study underpinning for both experimental analysis of
of behavior as a natural science is on par with behavior and applied behavior analysis. As such,
physical and biological sciences (Cooper et al., its methodology can be used to study many
2007 p. 9). The premise that the study of behavior branches of behavior as long as the behaviors
is a science was further expanded upon in a work can be operationally defined and observable.
by B.F. Skinner who was interested in providing As noted by Pear and Eldridge (1984, p. 459),
scientific accounts of all behavior. Skinner’s pub- “Several alternatives to the operant respondent
lication of The Behavior of Organisms (1938, framework have been proposed, but there is
1966) summarized his laboratory research and no indication that any of these currently has
gave rise to two kinds of behavior, respondent comparable organizing power. Until such a
B 452 Belief-Desire Psychology
paradigm is put forth, therefore, we see modifi-

cation of the operant respondent framework, Bell-Shaped Curve
rather than its elimination, as the more fruitful
approach.” ▶ Normal Curve
See Also Benadryl ® Allergy [OTC]
▶ Behavior Analysis ▶ Diphenhydramine

▶ Behavior Modification
▶ Behaviorism
Benadryl ® Allergy Quick Dissolve

References and Readings [OTC]
Cognitive behavior modification. Texas guide for effective ▶ Diphenhydramine
teaching cognitive behavior modification. Retrieved
from http://cdd.unm.edu/swan/autism_course/modules/
behavior/cbm/index.htm
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Benadryl ® Children’s Allergy [OTC]
Applied behavior analysis (2nd ed.). New Jersey: Pear-
son Merrill Prentice Hall.
▶ Diphenhydramine
Hernandez, P., & Ikkanda, Z. (2011). Applied behavior
analysis: Behavior management of children with
autism spectrum disorders in dental environments.
The Journal of the American Dental Association,
143(3), 281–287.
Methodological behaviorism. Retrieved from www.ucm.
Benadryl ® Children’s Allergy
es/info/psi/docs/journal/v6_n2_2003/art133.pdf Fastmelt ® [OTC]
Pear, J. J., & Eldridge, G. D. (1984). The operant-
respondent distinction: Future directions. Journal of ▶ Diphenhydramine
Experimental Analysis of Behavior, 42(3), 453–467.
Radical behaviorism. Retrieved from www.
behaviorology.org/pdf/PhilPaperOriginsBk.pdf
Redd, W. H., Porterfield, A. L., & Andersen, B. L. (1979). Benadryl ® Children’s Allergy Perfect
Behavior modification. New York: Random House. Measure™
Skinner, B. F. (1974). About behaviorism. New York: Knopf.
Social learning theory. Retrieved from http://teachnet.
edb.utexas.edu/Lynda_abbot/Social.html ▶ Diphenhydramine
Structuralism. Retrieved from http://web.mst.edu/
psyworld/structuralism.htm?pagewanted¼all
Sulzer-Azaroff, B., & Mayer, G. R. (1977). Applying
behavior analysis procedures with children and
youth. New York: Holt Rinehart and Winston. Benadryl ® Children’s Allergy Quick
Sulzer-Azaroff, B., & Mayer, G. R. (1991). Behavior Dissolve [OTC] [DSC]
analysis for lasting change. New York: Holt, Rinehart
and Winston.
▶ Diphenhydramine
Vargas, J. S. (2009). Behavior analysis for effective
teaching. New York: Routledge.
Benadryl ® Children’s Dye-Free

Belief-Desire Psychology Allergy [OTC]
▶ Intentional Stance ▶ Diphenhydramine

Bender Visual-Motor Gestalt Test II 453 B
Benadryl ® Dye-Free Allergy [OTC] Bender Visual-Motor Gestalt Test II
▶ Diphenhydramine Mikle South and Jessica Palilla

Departments of Psychology and Neuroscience, B
Brigham Young University, Provo, UT, USA
Benadryl ® Itch Relief Extra Strength

[OTC] Synonyms
▶ Diphenhydramine Bender; Bender-Gestalt II; BG-II
Description
Benadryl ® Itch Stopping [OTC]
The Bender Visual Gestalt II testing kit includes
▶ Diphenhydramine 16 stimulus cards that are separated into two tests.
These stimulus cards include an improved ver-
sion of the original nine designs and new cards
that were constructed to be more fitting for the
Benadryl ® Itch Stopping Extra age range covered by the test. All of the stimulus
Strength [OTC] cards have been mechanically drawn to increase
the clarity of the design.
▶ Diphenhydramine The administration of the Bender-Gestalt II is
considered to be user-friendly and relatively easy.
It occurs in two phases: the copy phase and the
recall phase. During the copy phase, the examinee
Benchmark is presented with the age-appropriate stimulus
cards one at a time and instructed to copy each
▶ Criterion design onto a blank, white sheet of paper using
a No. 2 pencil. In the recall phase, the examinee is
instructed to draw as many of the designs as they
can from memory onto a new sheet of paper.
Benchmark Data While there are no time limits for any of the
designs or phases, the examiner should begin
▶ Normative Data timing immediately following the presentation of
the first design, in order to keep track of the
amount of time needed for the examinee to com-
plete each separate design. The examiner should
Benchmarks also pay attention to behavioral and physical char-
acteristics of client. Such observation can help
▶ Objective determine if poor reproductions of a design are
the result of impaired motor or perception abilities.
To score the Bender-Gestalt II, a new Global
Scoring System has been outlined. This scoring
Bender system evaluates the examinee reproduction of
designs at the copy and recall phases and rates the
▶ Bender Visual-Motor Gestalt Test II quality on a five-point scale. A score of 0 is given to
B 454 Bender Visual-Motor Gestalt Test II
designs that have no resemblance to the design or Koppitz’s original scoring system was adapted after
are the product of random drawing or scribbling. her death by Cecil Reynolds (2007).
A score of 4 is given to those designs that are nearly Notable psychometric problems with the orig-
perfect in their resemblance to the design. This inal version limit interpretation of data from stud-
scoring system is considered to be fairly simple as ies utilizing that test. Several studies in the earliest
specific examples of the Global Scoring System are history of autism research utilized the original
provided in the manual. However, it requires rigid version of the Bender, but in the context of psy-
adherence to the scoring examples and much chometric problems with the test as well as the
stricter than previous scoring methods. lack of standardized diagnostic criteria for autism,
these studies are not considered relevant.
The test was included in Norcross, Koocher, and
Historical Background Garofalo’s (2006) list of “Discredited Psychologi-
cal Treatments and Tests” based on ratings by
The Bender Visual Motor Gestalt Test was a large expert panel, either for use in screening
first published in 1938 by the American neuropsychological impairment or personality
Orthopsychiatric Association under the title of function. This presumably referred to the original
“A Visual Motor Gestalt Test and Its Clinical version of the test and its uses, rather than to the
Use.” It evolved from Max Wertheimer’s early revised Bender-Gestalt II.
studies of a Gestalt theory of perception. Lauretta The second edition of the Bender Visual-Motor
Bender adapted nine of Wertheimer’s designs Gestalt Test was published in 2003. This new edi-
and put them on cards in order to understand the tion is a product of many years of analysis with the
gestalt experiences of psychiatric patients. first edition of the test, as well as modern research
Specifically, the test was designed as in the fields of psychological testing and test con-
a screening measure to test the ability of the struction. This comprehensive revision added four
perceptual system to organize visual stimuli into easier items and three harder items in order to
configural wholes, as a screening measure for increase the measurement scale. In other words, it
neuropsychological damage. It quickly grew in lowered the “floor” of the test and created a higher
popularity because it was brief and fairly “ceiling” so as to better describe those individuals
simple to score and administer. Since its original who score on the extremes of the spectrum.
development, the test has undergone many
revisions that have largely focused on changes
in interpretation and scoring procedures. Psychometric Data
A wide variety of scoring procedures have been
developed over the years using the original Bender- The Bender-Gestalt II was normed from
Gestalt Test. Among the most notable are the a stratified, random sampling of 4,000 subjects
Koppitz’s Developmental Bender Scoring System, that comparatively matched US census data from
published in 1964 as The Bender-Gestalt Test for the year 2000. T-sores, percentile ranks,
Young Children, and Max Hutt’s Scoring System. confidence intervals, and classification labels
Under Koppitz scoring system, 30 discrete errors are available for subjects ages 4 to 85+ years.
are scored if present, with each design ranging from The psychometric properties of the test are fairly
2 to 4 possible errors. This scoring procedure was strong. Interrater reliability is reported at a range
designed to measure neuropsychological impair- of .83 to .84 for the copy phase and .94 to .97 for
ment and the developmental maturation of children. the recall phase. A validity of .91 was found using
Hutt’s Scoring System, on the other hand, was split-half procedures. Over a 2–3 week interval,
designed to use the Bender-Gestalt Test as test-retest reliability is between .80 and .88 for the
a projective personality assessment for adults. It copy phase and .80 to .86 for the recall phase.
scored tests based on the frequency and severity Construct validity for the Bender-Gestalt II
with which an examinee deviated from protocol. has been supported by moderate correlations to
Bender, Lauretta 455 B
other measures. For example, it has moderate basic motor deficits and possibly higher order prob-
correlation of .65 with the Beery-Buktenica lems with visuomotor planning and organization.
Developmental Test of Visual-Motor Integration
and a correlation of .75 with the Perceptual Orga- See Also
nization factor on the WISC-III. B
▶ Bruininks-Oseretsky Test of Motor Proficiency
Clinical Uses References and Readings
The Bender Gestalt II is designed to assess the Allen, R. A., & Decker, S. L. (2008). Utility of the Bender
visual-motor integration abilities of children and Visual-Motor Gestalt Test-Second Edition in the
assessment of attention-deficit/hyperactivity disorder.
adults from 4 to 85+ years of age. It is also Perceptual and Motor Skills, 107, 663–675.
designed to be used as a test of motor memory Brannigan, G. G., & Decker, S. L. (2003). Bender Visual-
in children and adults ages 5 to 85+. It has been Motor Gestalt Test, Second Edition. Itasca, IL: Riverside
used to identify brain dysfunction in children and Publishing.
Brannigan, G. G., Decker, S. L., & Madsen, D. H. (2004).
adults, and discern emotional problems in chil- Innovative features of the Bender-Gestalt II and
dren. Generally, if the Bender-Gestalt II is being expanded guidelines for the use of the Global Scoring
used to assess for brain damage, it should be System. (Bender Visual-Motor Gestalt Test, Second
considered a screening device as it is limited to Edition Assessment Service Bulletin No.1). Itasca,
IL: Riverside Publishing.
severe forms of brain damage. Dowd, A. M., Rinehart, N. J., & McGinley, J. (2010). Motor
Allen and Decker (2008) found significant function in children with autism: Why is this relevant to
differences to indicate impaired performance, psychologists? Clinical Psychologist, 14, 90–96.
after controlling for IQ, in a moderately sized Norcross, J. C., Koocher, G. P., & Garofalo, A. (2006).
Discredited psychological treatments and tests:
sample of children (mean age ¼ 11) diagnosed A Delphi poll. Professional Psychology: Research
with attention-deficit/hyperactivity disorder and Practice, 37, 515–522.
compared to a healthy comparison group, Reynolds, C. R. (2007). Koppitz-2: The Koppitz develop-
suggesting possible utility as a measure of func- mental scoring system for the Bender-Gestalt Test.
Austin, TX: Pro-Ed.
tion in other disorders autism. Effect sizes were Volker, M. A., Lopata, C., Vujnovic, R. K., Smerbeck,
very small, however. One study (Volker et al., A. M., Toomey, J. A., Rodgers, J. D., et al. (2010).
2010) has used the Bender Gestalt II to analyze Comparison of the Bender Gestalt-II and the VMI-V in
the visual-motor skills of individuals with autism samples of typical children and children with high-
functioning autism spectrum disorders. Journal of
spectrum disorders. In demographically matched Psychoeducational Assessment, 28, 187–200.
subsamples of ASD and healthy children (mean
age ¼ 9.7; n ¼ 27 for each group), and after
statistical control for IQ, a high-functioning
autism spectrum disorder group scored lower Bender, Lauretta
than the comparison group on the two tests most
sensitive to motor function (the copy and supple- Fred R. Volkmar
mental motor scales). Director – Child Study Center, Irving B. Harris
There appears to be substantial justification for Professor of Child Psychiatry, Pediatrics and
continued investigation of atypical motor function Psychology, School of Medicine,
in autism. A recent review by Dowd, Rinehart, and Yale University, New Haven, CT, USA
McGinley (2010) notes the potential utility of
motor function as (a) a diagnostic marker of autism,
(b) an endophenotype of autism, and (c) a marker of Name and Degrees
severity of impairment, including social-
communicative impairment. The Bender-Gestalt Lauretta Bender MD
II could be used in future studies to characterize B.A. (1922) University of Chicago
B 456 Bender-Gestalt II
M.A. (1923) University of Chicago Short Biography

M.D. (1926) State of University of Iowa
A native of Butte, Montana, Lauretta Bender coped
with a significant learning difficulty but persevered
Major Appointments (Institution, to become the valedictorian of her high
Location, Dates) school class. She received her B.A. (1922) and
M.A. (1923) from the University of Chicago. She
Bender held positions at the Hospital of the received an M.D. from the State of University of
University of Chicago, the Boston Psychopathic Iowa (1926). Bender held positions at the Hospital
Hospital, the University of Amsterdam, the Johns of the University of Chicago, the Boston Psycho-
Hopkins University Hospital, and Bellevue pathic Hospital, the University of Amsterdam, the
Hospital in New York, as well as at the University Johns Hopkins University Hospital, and Bellevue
of Maryland. Hospital in New York as well as at the University of
Maryland. Bender was active in my ways at the
professional level. She was Director of Research of
Major Honors and Awards the new Children’s Unit at Creedmoor State Hos-
pital in the 1950s and while there conducted much
In 1955, Dr. Bender was the recipient of the of her work with severely impaired children.
Adolf Meyer Memorial Award from the Ameri- Her first husband, the psychiatrist Paul
can Psychiatric Association for her work on Schuler (1886–1940), tragically died after a few
severe psychiatric disturbance in children. years of marriage. She married Henry B. Parkes,
a professor at New York University, in 1954.
Landmark Clinical, Scientific, and

Professional Contributions See Also
Loretta Bender was an early pioneer in the study ▶ Bender Visual-Motor Gestalt Test II
of learning disabilities and severe psychiatric dis-
turbance in children. Highly active at the profes-
sional level both as a clinician and researcher, she References and Readings
was involved in development of various
approaches to treatment and to theories of child- Bender, L. (1969). A longitudinal study of schizophrenic
children with autism. Hospital & Community Psychiatry,
hood psychopathology. The Bender-Gestalt
20(8), 230–237.
test remains in use today. Her view of learning Bender, L. (1971). Alpha and omega of childhood schizo-
disabilities was based on a theory related to phrenia. Journal of Autism and Childhood Schizophre-
discrepancies in areas of maturation, and she nia, 1(2), 115–118.
Bender, L. (1973). The life course of children with schizo-
emphasized the confluence of various problems
phrenia. American Journal of Psychiatry, 130(7),
in children with learning problems that reflected 783–786.
their common origins. She also worked in Bender, L. (1974). The family patterns of 100 schizo-
the area of language difficulty and conducted phrenic children observed at Bellevue, 1935–1952.
Journal of Autism and Childhood Schizophrenia, 4(4),
some of the early work on reading disability.
279–292.
Her work was conducted at a time when
childhood schizophrenia/childhood psychosis
was used to describe all severe neuropsychiatric
disturbance, i.e., before the distinction of Bender-Gestalt II
autism as a distinctive diagnostic category was
made. ▶ Bender Visual-Motor Gestalt Test II
Bettelheim, Bruno 457 B
A beneficiary may refuse the benefits of the trust
Beneficiary by disclaiming her right to them. The disclaimer
may be implied by conduct “inconsistent with
John W. Thomas a trust for his” (Bogert, 170) ASD-related issues.
Quinnipiac University School of Law, Hamden, B
CT, USA See Also
▶ Discretionary Trust
Definition ▶ Support Trust
▶ Trust
Basic Definition
A beneficiary is a person for whose benefit prop-
erty is placed in trust. The beneficiary is the third References and Readings
of three ingredients critical to the creation of
a trust: (1) property, usually money, placed in Bogert, G. T. (1987). Trusts (6th ed.). St. Paul, MN: West
a trust administered by (2) a trustee for the benefit Publishing.
Bogert, G. T., & Bogert, G. B. (1987). The law of trusts
of (3) a beneficiary (restatement). A trust cannot and trustees (1987). St. Paul, MN: West Publishing.
exist without a beneficiary (Bogert, 121). Garner, B. A. (Ed.). (2009). Black’s law dictionary
On occasion, American courts refer to the benefi- (9th ed.). St. Paul, MN: West Publishing.
ciary by the French phrase cestui que trust. A trust Laura Dietz, L., Lindsley, W., Martin, L., Payne, A.,
Shampo, J., & Surette, E. C. (1998–2011). Trusts (Amer-
may have multiple beneficiaries. The trust docu- ican Jurisprudence). St. Paul, MN: West Publishing.
ments dictate when and how much of the trust
property a beneficiary will receive.
Who May Be a Beneficiary Benzodiazepines

Any legal entity, including individuals or corpo-
rations, may be a beneficiary (Bogert, 125). ▶ Sedative Hypnotic Drugs
But, only the entities intended by the creator of
the trust, or settlor, to benefit from the trust may
be a beneficiary. The settlor may be a beneficiary, beta-Alanyl-L-histidine
and even the trustee may be a beneficiary as long
as he or she is not the sole trustee. ▶ Carnosine
Many trusts have multiple beneficiaries who
can be named individually or can be designated
as a “class,” such as all of the children of a partic- Bettelheim, Bruno
ular person.
Fred R. Volkmar
Rights of a Beneficiary Director – Child Study Center, Irving B. Harris
A beneficiary’s interest in a trust varies according to Professor of Child Psychiatry, Pediatrics and
the type of trust created (Dietz). In a “fixed trust” in Psychology, School of Medicine,
which the benefits are spelled out precisely by the Yale University, New Haven, CT, USA
trust documents, the beneficiary has an ownership
interest in the trust proceeds. If the trust is
a “discretionary trust,” meaning that the trustee has Short Biography
discretion as to when and how much of the trust
property to give to the beneficiary, a beneficiary’s A highly controversial figure in the history of
interest is subject to the determination of the trustee. autism, Dr. Bettelheim was born in Austria and
B 458 BG-II
trained in Art History. His work in history led him

to the study of psychology. He became a refugee BIG-2
from the Nazis and moved to the United States.
He eventually moved to Chicago where he ▶ CNTN4: Contactin 4
became a professor at the University of Chicago
(teaching there from 1944 to 1973). He had some
psychoanalytic training in Vienna and served, in
Chicago, as the Director of the University of Biological Motion
Chicago’s Sonia Shankman Orthogenic School
– a center for treatment of severely disturbed Martha D. Kaiser
children. He made many claims for successful Child Neuroscience Laboratory, Yale Child
treatment but did so within the context Study Center, New Haven, CT, USA
of claiming that parents were involved in the
pathogenesis of autism (a theory now
long discredited). His early work on the topic Synonyms
was widely cited, although it is not clear exactly
how many children with autism he actually Human or animal motion
saw. The diagnoses of autism in his patients
have also been questioned. His popularization
of the concept of the “refrigerator mother” trau- Definition
matized a generation of parents who were told
they were responsible for their child’s autism. Biological motion refers to the movements of
Questions were raised about possible plagiarism humans or animals including eye, face, and full
in his scholarly writing and the validity of body motion. Typical observers exhibit robust
his work. sensitivity to biological motion cues provided
by other people. However, disrupted sensitivity
to biological motion, at the behavioral and neural
References and Readings level, is emerging as a hallmark of autism
spectrum disorders (ASD). The lack of tuning
Bettelheim, B. (1950). Love is not enough: The treatment to such socially relevant information may reflect
of emotionally disturbed children. Glencoe, IL: Free
Press.
some of the pathognomic social deficits
Bettelheim, B. (1959). Joey: A mechanical boy. Scientific associated with ASD.
American, 200, 117–126.
Pollak, R. (1997). The creation of Dr. B: A biography of
Bruno Bettelheim (Hardcover). New York: Touchstone.
Sutton, N. (1996). Bettelheim: A life and legacy. New York:
Basic Books.
Annaz, D., Cambell, R., Coleman, M., Milne, E., &
Swettenham, J. (2011). Young children with autism
spectrum disorder do not preferentially attend to
biological motion. Journal of Autism and Develop-
BG-II mental Disorders. doi:10.1007/s10803-011-1256-3.
Blake, R., & Shiffrar, M. (2007). Perception of human
motion. Annual Review of Psychology, 58, 47–73.
▶ Bender Visual-Motor Gestalt Test II
Kaiser, M. D., & Shiffrar, M. (2009). The visual percep-
tion of motion by observers with autism spectrum
disorder: A review and synthesis. Psychonomic
Bulletin & Review, 16(5), 761–777.
Bias Kaiser, M. D., Hudac, C. M., Shultz, S., Lee, S.-M.,
Cheung, C., Berkena, A. M., et al. (2010). Neural
signatures of autism. Proceedings of the National
▶ Measurement Error Academy of Sciences, 107(49), 21223–21228.
Birth Complications 459 B
Klin, A., Lin, D., Gorrindo, P., Ramsay, G., & Jones, W. color), pulse (heart rate), grimace (reflex irri-
(2009). Two-year-olds with autism orient to nonsocial tability), activity (muscle tone), and respira-
contingencies rather than biological motion. Nature,
459, 257–261. tion. The five criteria are given marks ranging
from 0 to 2. 0 is absent of highly disordered
and 2 is fair and normal. Thus, the scale ranges B
from 0 to 10. It is mostly scored 5 and 10 min
Biomedical Engineer after birth. 7–10 is considered normal, 4–7
fairly low, and under 3 critically low.
▶ Rehabilitation Engineer
Birth Complications Direct injuries following forcipes extractions or

acute termination can cause massive damage to
Jan Van der Rutger Gaag the brain of a neonate, with palsy and severe devel-
University Medical Centre St. Radboud, Karakter opmental hazards as consequences. These dramatic
Child & Adolescent Psychiatry University circumstances have not been related to the emer-
Centre, Nijmegen, Netherlands gence in later life of any form of psychopathology.
But over the years, subtle deviances at birth (low
Apgar scores, respiratory distress, hypoglycemia, or
Definition hyperbilirubinemia after 5–7 days) have been asso-
ciated with developmental disorders such as atten-
Birth is a crucial event in life. The transition from tion deficit hyperactivity disorders of autism.
the uterine status to the outside world is a very When taking the developmental history in par-
stressful occasion for parents but also for the ents of children with developmental disorders, one
newborn child. In retrospect, many parents will is often struck by the emphasis put on perinatal
impute developmental deviances to a poor start in hazards. These retrospective recollections are not
life. Thus, birth and perinatal complications and always reliable. Yet they illustrate how much
the first week of the neonate have been the focus value is given to the condition of the child just
of many research aimed to determine if factors after birth as a potential cause of later disorders.
involved with birth and start of life play a role in Thus, methodologically retrospective date must be
the etiology of autism. distrusted. In this item, the evidence for associa-
tions between birth complications and autism will
be reviewed from methodologically sound studies.
Definitions
– Birth: the transition from intrauterine life to Current Knowledge

life outside. This includes the vaginal pathway
or the extraction through a so-called caesarian Gardener et al. (2011) carried out a comprehen-
operation. sive meta-analysis to evaluate the perinatal and
– Complications: any deviance from normal neonatal risk factors for autism. After a PubMed,
physiology around the birth (perinatal period). Embase, and PsycINFO search, 60 methodologi-
– Perinatal period: an interval extending from cally sound studies (out of 124 published until
the 28th week of gestation until the 28th day 2007) could be retained for a thorough meta-
after birth. analysis of the possible causal relationship
– Apgar score: simple repetitive method intro- between the occurrence between perinatal and
duced by Virginia Apgar in 1952 to assess the neonatal complications and autism. Since then,
health of a newborn baby – appearance (skin only five studies were published to date, implying
B 460 Birth Complications
that the Gardener et al. meta-analysis gives also an autistic condition in the offspring as
a good summary of the current knowledge with a result of genetic and early embryo-environment
regard to peri- and neonatal factors that are asso- interplay early in gestation (viral infections,
ciated with an increased risk for autism. This drugs, etc.), suggest that the birth complications
formulation is of great importance because peri- are more the result of prenatal factors that are the
and neonatal factors appear to be by no means cause of autism later on. According to the classic
specific for any kind of psychopathology, thus Bolton et al. (1997) study on the “shared risk
pointing towards a multicausal heterogeneity hypothesis,” this shared risk hypothesis is also
already hypothesized by Bolton et al. (1997). supported by the Zwaigenbaum et al. studies
But the results from series of well-conducted (2002) that show more composite prenatal, peri-
studies clearly show that there are factors that natal, and neonatal adversity among both affected
have no association with autism and others that children and unaffected siblings in families with
show a positive association with the occurrence a high loading for the broader autism phenotype.
of autism later in life:
Factors that show no association with autism
are the following: premature rupture of mem- Future Directions
branes, delayed labor, loss of amnionic fluid on
the day before delivery, analgesia during labor, In order to fully understand the impact as a risk
green [meconium holding] amnionic fluid, acido- factor of birth complications on the increased risk
sis (pH < 7.2 in the umbilical cord, shoulder for autism, longitudinal studies, starting well
dystocia, near-dead baby, “blue baby,” hypogly- before birth like the ABC study in Norway of
cemia, hypocalcemia, infantile vomiting, intra- Generation R, are needed in order to get a better
cranial hemorrhage, macrocephaly, abnormal understanding of the interplay between family
fetal cardiac activity, assisted vaginal delivery, genetic-embryonic development-birth hazards
postterm birth, a high birth weight, and incubator and neonatal stress on the risk factors for autism.
use! Finally, neither preterm birth nor Cesarean
delivery reached statistical significance.
Factors that do show a significant increase of
the risk for autism are the following: abnormal
presentation in general, beech presentation, Bilder, D., Pinborough-Zimmerman, J., Miller, J., &
umbilical cord complications (prolapse, cord McMahon, W. (2009). Prenatal, perinatal, and neona-
wrapping around the neck), multiple birth, tal factors associated with autism spectrum disorders.
(very) low birth weight, small for gestational Pediatrics, 123(5), 1293–1300.
Bolton, P. F., Murphy, M., Macdonald, H., Whitlock, B.,
age, fetal distress, Apgar scores low after 5 min, Pickles, A., & Rutter, M. (1997). Obstetric
birth injury or trauma, congenital malformations, complications in autism: Consequences or causes of
meconium aspiration, neonatal anemia, ABO or the condition? Journal of the American Academy of
rhesus incompatibility, and hyperbilirubinemia. Child and Adolescent Psychiatry, 36(2), 272–281.
Brimacombe, M., Ming, X., & Lamendola, M. (2006).
There are also two factors that are not related Prenatal and birth complications in autism. Maternal
directly to the condition of the child but enhance and Child Health Journal, 11(1), 73–79.
the risk for autism and those are: maternal bleed- Burstyn, I., Sithole, F., & Zwaigenbaum, L. (2011).
ing and season of birth (with two high-risk Autism spectrum disorders, maternal characteristics
and obstetric complications among singletons born in
periods, namely, children born in March and in Alberta, Canada. Chronic Diseases in Canada, 30(4),
the late summer (August and September)). 125–134.
Yet, from the discussions around birth com- Burstyn, I., Wang, X., Yasui, Y., Sithole, F., &
plications as a risk factor for autism, it appears Zwaigenbaum, L. (2011). Autism spectrum disorders
and fetal hypoxia in a population-based cohort:
clearly that they cannot be perceived indepen- Accounting for missing exposures via estimation-
dently from earlier prenatal factors. Factors such maximization algorithm. BMC Medical Research
as advanced age of both mother and father, but Methodology, 11, 2.
Blindness 461 B
Cederlund, M., & Gillberg, C. (2004). One hundred males Stein, D., Weizman, A., Ring, A., & Barak, Y. (2006).
with Asperger syndrome: A clinical study of Obstetric complications in individuals diagnosed with
background and associated factors. Developmental autism and in healthy controls. Comprehensive
Medicine and Child Neurology, 46(10), 652–660. Psychiatry, 47(1), 69–75.
Croen, L. A., Yoshida, C. K., Odouli, R., & Newman, T. B. Stevens, M. C., Fein, D. H., & Waterhouse, L. H. (2000).
(2005). Neonatal hyperbilirubinemia and risk of autism Season of birth effects in autism. Journal of Clinical B
spectrum disorders. Pediatrics, 115(2), e135–e138. and Experimental Neuropsychology, 22(3), 399–407.
Gardener, H., Spiegelman, D., & Buka, S. L. (2009). Pre- Sugie, Y., Sugie, H., Fukuda, T., & Ito, M. (2005).
natal risk factors for autism: Comprehensive meta-anal- Neonatal factors in infants with autistic disorder and
ysis. The British Journal of Psychiatry, 195(1), 7–14. typically developing infants. Autism, 9(5), 487–494.
Gardener, H., Spiegelman, D., & Buka, S. L. (2011). Peri- Taylor, E. (2011). Antecedents of ADHD: A historical
natal and neonatal risk factors for autism: A compre- account of diagnostic concepts. Attention Deficit and
hensive meta-analysis. Pediatrics, 128(2), 344–355. Hyperactivity Disorders, 3(2), 69–75.
Glasson, E. J., Bower, C., Petterson, B., de Klerk, N., Wilkerson, D. S., Volpe, A. G., Dean, R. S., & Titus, J. B.
Chaney, G., & Hallmayer, J. F. (2004). Perinatal (2002). Perinatal complications aspredictors of infan-
factors and the development of autism: A population tile autism. International Journal of Neuroscience,
study. Archives of General Psychiatry, 61(6), 618–627. 112(9), 1085–1098.
Haglund, N. G., & K€allén, K. B. (2011). Risk factors for Yeates-Frederikx, M. H., Nijman, H., Logher, E., &
autism and Asperger syndrome. Perinatal factors and Merckelbach, H. L. (2000). Birth patterns in mentally
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Santangelo, S. L. (2012). Pregnancy complications
and obstetric suboptimality in association with autism
spectrum disorders in children of the nurses’ health Blindness
study II. Autism Research, 5(1), 21–30.
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factors and infantile autism. Acta Psychiatrica Therese R. Welch
Scandinavica, 114(4), 257–264. University of Rochester School of Medicine and
Maimburg, R. D., Vaeth, M., Schendel, D. E., Bech, B. H., Dentistry, Rochester, NY, USA
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Sivberg, B. (2003). Parents’ detection of early signs in
The relationship between autism and blindness is
their children having an autistic spectrum disorder. complex and one for which there is limited con-
Journal of Pediatric Nursing, 18(6), 433–439. sensus regarding its various aspects. Central to
B 462 Blindness
examinations of the relationship is a collection of 30%. Studies have also addressed prevalence of
behaviors that have been regarded as characteris- autism and particular autistic-like features as
tic of children who are blind, in particular chil- related to specific diagnoses, such as CHARGE
dren who are congenitally blind and children who syndrome (a genetic pattern of birth defects),
have profound visual impairment. Among the Leber’s congenital amaurosis (a form of atrophy
most frequently noted in references to blind chil- of the optic nerve), retinopathy of prematurity,
dren are stereotyped and ritualistic behaviors, and optic nerve hypoplasia (an anomaly of the
pronounced limitations of social and communi- optic nerve).
cative competence, delayed and limited symbolic The degree of vision impairment in relation to
play and language, delayed use and reversals of the manifestation of autistic-like features or
personal pronouns, echolalia and speech imita- autism in children who are blind has been
tions, and difficulties with abstract thinking. In a rather frequent focus of investigators. Some
addition, self-injurious behaviors, such as eye have claimed that more severe vision loss, espe-
poking, have been reported. Many of these cially loss of the ability to distinguish forms,
behaviors also are considered to be characteristic increases the likelihood of autistic-like behav-
of sighted children who have autism. Because of iors. Cognitive impairment reflected in low IQ
the seeming commonalities of certain behaviors scores, as well as other additional disabilities,
of children who are blind and children who are have also been associated with autistic-like
autistic, researchers and clinicians have been behaviors and autism in blind children. Other
challenged in determining whether such similar- studies have examined the roles of sensory dep-
ities are more than superficial. The ultimate chal- rivation and related environmental factors in con-
lenge may well be definitively identifying autism tributing to the presence of the behaviors and
spectrum disorder in individuals who have sig- autism. Some investigators have taken
nificant vision loss. a functional perspective of what others have con-
sidered autistic-like behaviors, countering that in
most cases such behaviors are adaptive responses
Historical Background to vision loss.
In the field of blindness, the classic writings of

Selma Fraiberg are most often recognized as the Current Knowledge
first reports of autistic-like behaviors in blind
children. In 1964, Fraiberg and Freedman As noted, findings and views differ substantially
published their observations of a group of blind regarding autistic-like behaviors evidenced by
children, stating that nearly a third of the children some blind children. Questions continue as to
had “ego deviation.” Keeler (1958), however, is how or whether these behaviors relate to autism
credited with the earliest report for his study of spectrum disorder in children with significant
young children with retrolental fibroplasia (oth- vision loss. Nonetheless, areas of agreement
erwise known as retinopathy of prematurity, exist. A neurological basis for the origins of the
a disease of the retina in preterm infants). Over behaviors is well recognized. Likewise, the role
the years, researchers seeking a better under- of a child’s sensory and psychosocial environ-
standing of the relationship of blindness and ment also is acknowledged. From this perspec-
autism have studied a range of its aspects. tive, deficits in sensory stimulation and
Determining the prevalence of autism spec- interpersonal experiences, from infancy forward,
trum disorder in children who are blind has been are contributing factors to autistic-like behaviors
a major goal of research studies. Resulting and possibly autism spectrum disorder in blind
reports, however, vary greatly regarding levels children.
of prevalence. Reported prevalence levels have In general, the diagnosis of autism spectrum
ranged from almost negligible to greater than disorder in children relies on observations of
Blindness 463 B
behavioral and developmental features. When for achieving a better understanding of the rela-
considering children with significant vision loss, tionship between blindness and autism, as well as
there is risk of misinterpreting a child’s behaviors for furthering screening efforts for autism spec-
or not providing appropriate modes and opportu- trum disorder, in general.
nities for the child to demonstrate competence. Any review of studies regarding blindness and B
The current diagnostic screening and assessment autism makes it readily apparent that efforts have
tools are heavily weighted with visually based been focused nearly exclusively on children,
tasks, as they were designed for use with sighted especially young children. A void exists regard-
children. The absence of such measures designed ing information about autism in blind adults.
for use with children who have visual impair- A broader, longitudinal perspective is called for
ments compounds the difficulties of in future studies.
distinguishing autistic-like behaviors from A very large, overriding concern is the lack of
autism spectrum disorder in blind children. In information regarding the progression of social
spite of the difficulties, some blind children development in the heterogeneous population of
have been diagnosed with autism. individuals with significant vision loss. Much is
yet to be learned; the necessary data are limited,
in part due to the small sample sizes of many of
Future Directions the most relevant studies. Normative data on
social development in children with visual
Clearly, efforts must be directed toward the impairment is necessary to inform diagnostic
development of screening and assessment tools criteria for ASD in this population.
for appropriately identifying autism in children
with significant vision loss. The tasks and com-
ponents of the tools need to be based on the See Also
modalities of sound and touch rather than vision.
Researches, clinicians, and caregivers then must ▶ Chess, Stella
be able to recognize alternative equivalents for ▶ Rubella
critical skills such as eye contact, directed gaze,
and joint attention, common to current measures
for autism spectrum disorder.
Directly tied to identification of autism spec- Andrews, R., & Wyver, S. (2005). Autistic tendencies:
trum disorder in children who are blind or who Are there different pathways for blindness and autism
have visual impairment is the need for appropri- spectrum disorder? British Journal of Visual Impair-
ment, 23(2), 52–57.
ate teaching methods, tools, and strategies for this
Brown, R., Hobson, R. P., & Lee, A. (1997). Are there
population. It has not been established whether “autistic-like” features in congenitally blind children?
the current instructional means used with sighted Journal of Child Psychology and Psychiatry, 38(6),
children who have autism spectrum disorder are 693–703.
Cass, H. (1998). Visual impairment and autism: Current
the most appropriate for children with significant
questions and future research. Autism, 2(2), 117–138.
vision loss, nor whether the various means can be Dale, N., & Salt, A. (2008). Social identity, autism and
adapted to be such. visual impairment in the early years. British Journal of
Several studies of the relationship of autism Visual Impairment, 26(2), 135–146.
Ek, U., Fernell, E., Jacobson, L., & Gilberg, C. (1998).
and blindness, including the very first, have Relation between blindness due to retinopathy of pre-
focused on children with retinopathy of prematu- maturity and autism spectrum disorders: A population-
rity. Currently, given the increasing recognition based study. Developmental Medicine and Child Neu-
of autism spectrum disorder in children who were rology, 40, 297–301.
Ek, U., Fernell, E., Jacobson, L., & Gilberg, C. (2005).
premature infants, the continued study of chil-
Cognitive and behavioural characteristics in blind chil-
dren with retinopathy of prematurity may be dren with bilateral optic nerve hypoplasia. Acta
a particularly valuable course of investigation Paediatrica, 94, 1421–1426.
B 464 Blitz-Nick-Salaam Kr€ampfe
Fazzi, E., Rossi, M., Signorini, S., Rossi, G., Bianchi, P. the calculation of Performance IQ. It is primarily
E., & Lanzi, G. (2007). Leber’s congenital amaourosis: a measure of visual-spatial and organizational
Is there an autistic component? Developmental Medi-
cine and Child Neurology, 49, 503–507. processing abilities, as well as nonverbal prob-
Fraiberg, S., & Freedman, D. (1964). Studies in the ego lem-solving skills. Because it is a timed task, it is
development of the congenitally blind. The Psychoan- also influenced by fine motor skills. The individ-
alytic Study of the Child, 19, 113–169. ual is presented with identical blocks with sur-
Gal, E., & Dyck, M. J. (2009). Stereotyped movements
among children who are visually impaired. Journal of faces of solid red, surfaces of solid white, and
Visual Impairment, 103, 754–765. surfaces that are half red and half white. Using an
Gense, M. H., & Gense, D. J. (2005). Autism spectrum increasing number of these blocks, the individual
disorders and visual impairment: Meeting students’ is required to replicate a pattern that the test
learning needs. New York: AFB Press.
Hartshorne, T. S., Grialou, T. L., & Parker, K. R. (2005). administrator presents to them – first as
Autistic-like behavior in CHARGE syndrome. a physical model, and then as a two-dimensional
American Journal of Medical Genetics, 133, 257–261. picture. The number of blocks required to match
Hobson, R. P., Lee, A., & Brown, R. (1999). Autism and the presented models increases and the patterns
congenital blindness. Journal of Autism and Develop-
mental Disorders, 29(1), 45–56. become increasingly difficult to visually dissect
Keeler, W. R. (1958). Autistic patterns and defective into components.
communication in blind children with retrolental Individuals who do well on this subtest tend to
fibroplasia. In P. H. Hoch & J. Zubin (Eds.), Psycho- have an aptitude for perceiving spatial patterns
pathology of communication (pp. 64–83). New York:
Grune & Stratton. and for flexible problem solving; performance is
Pring, L. (Ed.). (2005). Autism and blindness: Research also aided by the ability to work quickly. Con-
and reflections. London: Whurr. versely, one factor that may hinder an individ-
ual’s performance on block design is the presence
of high anxiety or perfectionistic tendencies
(Hopko, Crittendon, Grant, & Wilson, 2005), as
€mpfe
Blitz-Nick-Salaam Kra these can lead to an overly cautious approach that
causes the individual to finish after the time limit.
▶ Infantile Spasms/West Syndrome Poor performance may also be related to
a number of factors that affect an individual’s
ability to perceive spatial patterns, manipulate
objects, or integrate visual and spatial informa-
tion. Of note, individuals with autism spectrum
Block Design Subtest disorders have been observed to show superior
performance on the block design task (Shah &
Timothy Soto and Cate Kraper Frith, 1993). This relative strength is described by
Clinical Psychology, University of the hypothesis of the Weak Central Coherence
Massachusetts Boston, Boston, MA, USA Theory, which suggests individuals with autism
have difficulty seeing the “big picture,” and
instead may perceive parts of the whole with
Definition more relative skill than individuals without
autism (Happe & Frith, 2006).
Block design is a subtest that is administered as While not captured in the final score of block
part of several of the Wechsler Intelligence tests, design, it is clinically useful to observe how
including the Wechsler Preschool and Primary an individual approaches this task. One such
Scale of Intelligence (WPPSI, the Wechsler behavior that can be informative to the test
Intelligence Scale for Children-fourth edition administrator includes the above-mentioned
(WISC-IV; Wechsler, 2003) and the Wechsler perfectionistic tendency, or alternatively, the ten-
Adult Intelligence Scale-fourth edition (WAIS- dency to be impulsive or careless. An individ-
IV; Wechsler, 2008). This subtest is included in ual’s persistence may also be noted, as well as
Blood-Oxygen-Level-Dependent (BOLD) Signal 465 B
whether the individual tends to approach the pat-
tern in a piecemeal fashion, or in a more global Blood-Oxygen-Level-Dependent
fashion. (BOLD) Signal
Kevin A. Pelphrey B
See Also Child Study Center, Yale University School of
▶ Perceptual Organization Index (POI)
▶ Weak Central Coherence
▶ Wechsler Adult Intelligence Scale Synonyms
▶ Wechsler Preschool and Primary Scale of
Intelligence Blood-oxygen-level dependence
▶ Wechsler Scales of Intelligence
Definition
Blood-oxygen-level-dependent (BOLD) signal is
Happe, F., & Frith, U. (2006). The weak central coherence the magnetic resonance imaging (MRI) contrast of
account: Detail-focused cognitive style in autism spec-
trum disorders. Journal of Autism and Developmental
blood deoxyhemoglobin. Seiji Ogawa and his col-
Disorders, 36(5–25). leagues first discovered this intrinsic contrast mech-
Hopko, D. R., Crittendon, J. A., Grant, E., & Wilson, S. A. anism in 1990. Neurons do not store internal
(2005). The impact of anxiety on performance IQ. reserves of glucose and oxygen, which are essential
Anxiety, Stress, & Coping: An International Journal,
to their proper function. Increases in neuronal activ-
18, 17–35.
Shah, A., & Frith, U. (1993). Why do autistic individuals ity, typically in response to a demand for informa-
show superior performance on the block design task? tion processing, require more glucose and oxygen
Journal of Child Psychology and Psychiatry, 34, to be rapidly delivered via the blood stream. Via
1351–1364.
this hemodynamic response, blood releases glucose
Wechsler, D. (2002). The Wechsler preschool and primary
scale of intelligence-third edition. San Antonio, TX: and oxygen to active neurons at a faster rate relative
The Psychological Corporation. to inactive neurons. This results in a surplus
Wechsler, D. (2003). Wechsler intelligence scale for chil- of oxyhemoglobin localized to the active area, giv-
dren-fourth edition. San Antonio, TX: Psychological
ing rise to a measureable change in the local ration
Corporation.
Wechsler, D. (2008). Wechsler adult intelligence scale- of oxy- to deoxyhemoglobin, thus providing
fourth edition. San Antonio, TX: Pearson. a localizable marker of activity for MRI.
See Also
Blood-Oxygen-Level Dependence ▶ Event-Related Functional Magnetic
Resonance Imaging (MRI)
▶ Blood-Oxygen-Level-Dependent (BOLD)
Signal
Belliveau, J. W., Kennedy, D. N., McKinstry, R. C.,

Blood-Oxygen-Level-Dependent Buchbinder, B. R., Weisskoff, R. M., Cohen, M. S.,
(BOLD) Contrast Vevea, J. M., Brady, T. J., & Rosen, B. R. (1991).
Functional mapping of the human visual cortex by
magnetic resonance imaging. Science, 254, 716–719.
▶ Event-Related Functional Magnetic Reso- Kwong, K. W., Belliveau, J. W., Chesler, D. A., Goldberg,
nance Imaging (MRI) I. E., Weisskoff, R. M., Poncelet, B. P., Kennedy,
B 466 Board Certified Associate Behavior Analyst
D. N., Hoppel, B. E., Cohen, M. S., Turner, R., Cheng, must be supervised by a BCBA. As of 2015,
H., Brady, T. J., & Rosen, B. R. (1992). Dynamic applicants for the BCaBA credential will need
magnetic resonance imaging of human brain activity
during primary sensory stimulation. Proceedings of to have completed 180 h of specific coursework.
the National Academy of Sciences, 89, 5951–5955. Experience and training requirements at all
Ogawa, S., Lee, T. M., Nayak, A. S., & Glynn, P. (1990). levels of certification are rigorous and ensure
Oxygenation-sensitive contrast in magnetic resonance that certificants meet minimal competence levels
image of rodent brain at high magnetic fields.
Magnetic Resonance in Medicine, 14, 68–78. in their knowledge and abilities. BACB
certificants must accumulate continuing educa-
tion credit and recertify over 3 years to maintain
their credential. In addition, certificants must
Board Certified Associate Behavior annually confirm that they remain in compliance
Analyst with the BACB’s standards, including ethical
guidelines and disciplinary standards.
Mary Jane Weiss Because certification requirements periodi-
Institute for Behavioral Studies, Endicott cally change as standards are increased, readers
College, Beverly, MA, USA are encouraged to consult www.bacb.com for
updated information.
Synonyms
BCaBA; BCBA; BCBA-D Body Movements, Imitation of
Giacomo Vivanti
Definition Olga Tennison Autism Research Centre, School
of Psychological Science, La Trobe University,
The Behavior Analyst Certification Board ®, Melbourne, Victoria, Australia
Inc. (BACB ®) credentials practitioners at three
levels. The different categories denote varied
depths of training and levels of independence in Synonyms
practice.
Individuals who apply to become Board Gestural imitation; Imitation of intransitive
Certified Behavior Analysts ® (BCBA ®) must actions; Imitation of nonmeaningful gestures
possess at least a master’s degree, have 225
classroom hours of specific graduate-level
coursework, meet supervised experience require- Definition
ments, and pass the BCBA examination. In order
to use the Board Certified Behavior Analyst – Imitation of body movements involves copying
Doctoral (BCBA-D) designation, a BCBA must acts that do not involve the use of objects, do not
possess an acceptable doctoral degree and meet lead to an end state, do not carry a specific mean-
other criteria. As of 2015, applicants for the ing, and can only be described in terms of
BCBA credential will need to have completed changes of limb postures in space (e.g., a hand
270 h of specific coursework. moving across a forehead). Current models of
Persons who apply to become Board Certified imitation suggest that imitation of body move-
Assistant Behavior Analysts ® (BCaBA ®) must ments is supported by mechanisms that partially
have at least a bachelor’s degree, have 135 class- differ from those underlying the imitation of
room hours of specific coursework, meet super- actions that carry a semantic meaning (e.g., open-
vised experience requirements, and pass the ing a container or waving goodbye). While
BCaBA examination. Once certified, BCaBAs imitation of body movement is supported by
BOS 467 B
a “direct visuospatial route” in which the visual involved in imitation of body movements, includ-
input is directly mapped into a motor output, ing visual attention to the demonstration, social
imitation of actions that carry a semantic mean- motivation, motor planning, and executive pro-
ing is achieved via a “semantic route” in which cesses, it is likely that a heterogeneous vulnera-
previous knowledge on the meaning of the action bility in the components of the imitative process, B
can be recruited (Tessari & Rumiati, 2004). rather than a single cause, affects the ability to
Given that the familiarity with the demonstrator’s imitate body movements in individuals with
goals and means cannot be exploited in this type autism (Colombi, Vivanti, & Rogers, 2011).
of imitative task, imitation of body movement is
considered to provide a rigorous methodology by
which to assess “true imitation” in human and See Also
comparative research.
Early signs of the ability to imitate body ▶ Apraxia
movements are reported to be present in human ▶ Imitation
newborns since early infancy, and mutual imita- ▶ Mirror Neuron System
tion games between child and caregiver, involv- ▶ Motor Planning
ing affective mirroring and copying of body
movements, are observed throughout infancy
and toddlerhood across cultures. These early References and Readings
reciprocal exchanges are thought to promote
social bonding and to provide a foundation for Colombi, C., Vivanti, G., & Rogers, S. J. (2011).
The neuropsychology of the imitation deficit in autism.
social-cognitive development (Stern, 1985).
In D. Fein (Ed.), The neuropsychology of autism.
Difficulties in imitating body movements in New York: Oxford University Press.
individuals with autism are reported in many Rogers, S. J., & Williams, J. H. G. (2006). Imitation in
studies that used different stimuli, coding autism: Findings and controversies. In S. J. Rogers &
J. H. G. Williams (Eds.), Imitation and the social
systems, and comparison groups (including dif-
mind: Autism and typical development (pp. 277–309).
ferent clinical populations) and across a wide New York: Guilford.
range of IQ, language levels, and chronological Stern, D. (1985). The interpersonal world of the infant.
ages (see Rogers & Williams, 2006). Differences New York: Basic Books.
Tessari, A., & Rumiati, R. I. (2004). The strategic control
in the way individuals with autism imitate body
of multiple routes in imitation of actions. Journal of
movements include (1) reduced frequency of Experimental Psychology. Human Perception and
spontaneous imitation and (2) diminished Performance, 30, 1107–1116.
accuracy of imitative performance. While Williams, J. H. G., Whiten, A., & Singh, T. (2004). A
systematic review of action imitation in
autism-specific deficits are documented in
autistic spectrum disorder. Journal of Autism and
several imitative tasks, imitation of body move- Developmental Disorders, 34, 285–299.
ments appears to be more impaired than imitation
of actions carrying a semantic meaning in this
population (Williams, Whiten, & Singh, 2004).
Various explanations have been hypothesized to
account for these difficulties in autism, including Bogus Therapy
abnormalities in visual attention, a primary
deficit in the perception-action mapping ▶ Pseudoscience
implemented by the mirror neuron system,
a reduced motivation to imitate, and a primary
deficit in motor execution. However, none of this
explanation is supported by unequivocal BOS
evidence. Since children with autism have diffi-
culties in many of the neurocognitive processes ▶ Behavior Observation Scale
B 468 BOT-2
in the ABR (waves I, II, III, IV, and V); however,

BOT-2 wave V is the waveform used for threshold testing.
Individuals with autism spectrum disorders might
▶ Bruininks-Oseretsky Test of Motor Proficiency not be able to consistently respond to traditional
tests of hearing sensitivity, and therefore, the ABR
may be completed to establish hearing sensitivity.
BOTMP
See Also
▶ Bruininks-Oseretsky Test of Motor Proficiency
▶ Auditory Acuity
▶ Auditory Brainstem Response (ABR)
▶ Brainstem Auditory Evoked Potentials
Bound Morphemes ▶ Hearing
Hall, J. (1992). Handbook of auditory evoked responses.

Brainstem Audiometry Needham Heights, MA: Allyn & Bacon.
Rosenblum, S. M., Arick, J. R., Krug, D. A., Stubbs, E. G.,
Young, N. B., & Pelson, R. O. (1980). Auditory
Jennifer McCullagh brainstem evoked responses in autistic children. Journal
Department of Communication Disorders, of Autism and Developmental Disorders, 10, 215–225.
Rosenhall, U., Nordin, V., Sandstrom, M., Ahlsen, G., &
Southern Connecticut State University,
Gillberg, C. (1999). Autism and hearing loss. Journal of
New Haven, CT, USA Autism and Developmental Disorders, 29(5), 349–357.
Skoff, B. F., Fein, D., McNally, B., Lucci, D.,
Humes-Bartlo, M., & Waterhouse, L. (1986).
Brainstem auditory evoked potentials in autism.
Synonyms Psychophysiology, 23, 462.
Skoff, B. F., Mirsky, A. F., & Turner, D. (1980).
Auditory Brainstem Response (ABR) Prolonged brainstem transmission time in autism.
Psychiatry Research, 2, 157–166.
Definition
Brainstem audiometry, sometimes called a Brainstem Auditory Evoked

brainstem auditory evoked response (BAER) or Potentials
an auditory brainstem response (ABR), is an elec-
trophysiologic test that assesses the auditory sys- Kirsten O’Hearn
tem through the low brainstem. This test can Laboratory of Neurocognitive Development,
assess hearing sensitivity in individuals who can- Department of Psychiatry, University
not respond to traditional testing; thus, it is often of Pittsburgh School of Medicine,
used in newborn hearing screenings and in Pittsburgh, PA, USA
populations that are nonverbal. The ABR is com-
pleted by placing recording electrodes on the indi-
vidual’s head and ears and placing earphones in Synonyms
their ears. Responses are elicited using click and
tonal stimuli which are delivered through the Auditory brainstem response, ABR; Brainstem
earphones. Five waveforms are typically present auditory evoked response, BAER
Brainstem Auditory Evoked Potentials 469 B
Definition bilaterally; and wave V, distal lateral lemniscus
and inferior colliculus on the contralateral side.
Brainstem Auditory Evoked Potentials (BAEP) Interpretation of the BAEP is routinely done by
are low-amplitude electrical voltage potentials in examining the latency and length of these waves
the brain that are evoked by a sound, often a click, and the interpeak intervals between them (IPI), B
and recorded using electrodes on the scalp also known as interpeak latencies (IPL). The
(i.e., electroencephalography or EEG). Since the amplitudes are less frequently interpreted
potentials typically have an amplitude around 1 because they are more variable across individ-
mV, hundreds of trials are averaged together to uals, and thought to be less reliable indices of
provide data with adequate signal to noise ratio. dysfunction. The IPIs are considered particularly
BAEPs have been used as a tool to examine important, reflecting the conduction times in the
brainstem integrity and hearing ability clinically auditory pathway through the brainstem (i.e.,
since the 1970s, helping to diagnose tumors auditory nerve then cochlear nerve, cochlear
and other diseases such as multiple sclerosis. nucleus, and lateral lemniscus). Therefore, longer
BAEPs are particularly useful with patients who IPIs are thought to indicate impaired function,
are difficult to test by traditional audiometry, possibly related to the number, synchronicity, or
where feedback is required, because of integrity of the neurons firing in these regions.
compromised levels of consciousness, limited The BAEP is relatively adult-like by
communication, or behavioral noncompliance. 18 months of age, though wave V may continue
BAEPs are also useful for detecting subtle to mature until 3 or 4 years of age. They differ in
changes that may be clinically relevant, and females and males, with a slightly shorter latency
localizing the deficits. and higher amplitude in females. More recently,
The BAEP reflects the function of the auditory the BAEP has been examined in response to
nerve (eighth nerve), cochlear nucleus, superior a tone (instead of a click), which is thought
olive, and inferior colliculus, measuring the time to measure dysfunction more specific to the
it takes an aural stimulus to travel through the cochlear regions.
auditory pathway in the brainstem. They are
thought to measure action potentials and postsyn-
aptic activity propagating along the auditory See Also
nerve, and to other regions along the auditory
pathway. When measured in response to a brief ▶ Auditory Brainstem Response, ABR
stimulus (typically a click) in the ear canal via an ▶ Auditory Potentials
inserted earphone or headphone, the elicited ▶ Brainstem Auditory Evoked Response, BAER
waveform response is detected by surface elec- ▶ Evoked Potentials
trodes placed at the base of the scalp and the ear ▶ Visual Evoked Potential (VEP)
lobes. The BAEP generally includes seven ▶ Visual/Somatosensory Cognitive Potentials
waves, but it is the initial five waves that have
been the most extensively studied and are useful
for clinical applications. These five waves occur References and Readings
within 6 or 7 ms and are labeled waves I through
V. Abnormalities in specific waves are informa- Legatt, A. D., Arezzo, J. C., & Vaughan, H. G., Jr. (1988).
The anatomic and physiologic bases of brain stem
tive, as they are thought to localize the differ- auditory evoked potentials. Neurologic Clinics, 6(4),
ences to particular parts of the auditory pathway. 681–704.
Wave I is believed to reflect the distal auditory Moore, J. K., & Lithicum, F., Jr. (2007). The human
nerve on the ipsilateral side; wave II, proximal auditory system: A timeline of development. Interna-
tional Journal of Audiology, 46(9), 460–478.
auditory nerve on the ipsilateral side; wave III,
Starr, A., & Anchor, L. J. (1975). Auditory brain stem
ipsilateral cochlear nucleus; wave IV, superior responses in neurological disease. Archives of Neurol-
olivary nucleus and adjacent brainstem regions ogy, 32, 761–768.
B 470 Brainstem Auditory Evoked Response (BAER)
Stone, J. L., Calderon-Arnulphi, M., Watson, K. S., BAEPs produce seven waves of activity. The first
Patel, K., Mander, N. S., Suss, N., et al. (2009). five of these – labeled waves I through V – have
Brainstem auditory evoked potentials–a review and
modified studies in healthy subjects. Journal of Clini- been well characterized, with wave V followed
cal Neurophysiology, 26(3), 167–175. by a negative dip (Stone et al., 2009). These
initial five waves occur within about 7 ms. The
waves are thought to reflect activation
progressing as the aural stimulus moves from
Brainstem Auditory Evoked more distal regions of the auditory nerve to the
Response (BAER) more proximal regions. Examining the length of
the waves and the latencies between them (the
▶ Auditory Brainstem Response (ABR) interpeak intervals: IPIs, also known as interpeak
latencies IPL) provides insight into whether there
is dysfunction along the auditory pathway
through the brainstem and, potentially, helps to
Brainstem Auditory Evoked localize that dysfunction. Waves I, III, and
Response, BAER V have been particularly well characterized.
Wave I is thought to be generated peripherally,
▶ Brainstem Auditory Evoked Potentials at the auditory or cochlear nerve; wave III at the
cochlear nuclei; and wave V at the lateral
lemniscus. These signals go from the ipsilateral
side (waves I to III in the auditory nerve, cochlear
Brainstem Auditory Evoked nucleus, and superior olive) to bilateral brainstem
Responses in Autism (BAERs) regions (wave IV) to contralateral regions
(wave V in the lateral lemniscus and inferior
Kirsten O’Hearn colliculus). The wave structure develops
Laboratory of Neurocognitive Development, an adult-like architecture in the first few
Department of Psychiatry, University of years of life, with maturation starting in more
Pittsburgh School of Medicine, Pittsburgh, peripheral regions (with waves I and III maturing
PA, USA in the first year) and moving to more
central regions (with wave V maturing at
3–4 years of age; Fujikawa-Brooks, Isenberg,
Definition Osann, Spence, & Gage, 2010; Moore &
Lithicum, 2007).
BAERs (brainstem auditory evoked responses;
also referred to as brainstem auditory evoked
potential, BAEPs, and auditory brainstem Historical Background
response, ABR) measure the electrical voltage
potentials in the proximal auditory pathway in Since sensory modulation is disrupted in ASD,
response to a noise. This is done via electrodes with both under- and over-reactivity to sounds,
on the scalp and earlobe (see also definition: early theories posited that auditory brainstem
▶ Brainstem Auditory Evoked Potentials). The function might be affected in ASD (Ornitz, et al.,
noise is most frequently a click, but tones and 1985; modified in Ornitz, 1987). To empirically
other sounds have also been used (e.g., Russo study this possibility, BAERs were used, examin-
et al., 2008). BAERs are thought to reflect the ing the integrity of this region and the claim of
function of the auditory pathway through the atypical brainstem function in ASD. Early work
brainstem, providing insight into both the level on autism in the 1970s and early 1980s was prom-
of hearing and the integrity of brainstem function ising, suggesting that there may be abnormalities
in a given individual. When the noise is a click, in BAERs in individuals with ASD. A problem,
Brainstem Auditory Evoked Responses in Autism (BAERs) 471 B
however, was that what aspect of BAERs actually participants with ASD and, in some cases, their
differed in ASD was not consistent across studies first-degree relatives (Maziade et al., 2000). This
(Klin, 1993). In addition, BAERs do not require indicates that, while abnormal BAERs are not
attention or consciousness, making them useful causal, they may reflect a subgroup which
for testing special populations; however, this fact would be important to identify clinically (Nagy B
also led to a very heterogeneous sample being & Loveland, 2002). Thus, there is still potential
tested in many of these early studies. Some of for abnormal BAERs to be a biomarker for at
the participants had known neurological condi- least a subset of individuals with ASD, providing
tions (Klin, 1993; Minshew, 1991), and in some insight into the disorder. In addition, what is
studies, many individuals had hearing loss (e.g., atypical in the BAERs of the individuals with
Taylor, Rosenblatt, & Linschoten, 1982), which ASD has differed both within and across studies,
create an obvious confound when interpreting suggesting that there may be multiple ways to
these studies. Gender has been shown to affect disrupt the auditory pathway through the
BAERs, with shorter latencies in women. There- brainstem. These disruptions generally present
fore, gender also has to be considered since as prolongations of the waves or IPIs, when they
a greater proportion of women in the control are evident. Nagy and colleagues argue that some
group could lead to spurious group differences. of these disruptions may be specific to ASD (e.g.,
Indeed, the conclusion that BAERs were abnormal prolongation of waves III to V; on the basis of
in ASD was disputed in the mid-1980s by work Bachevalier, 1996), while others might be evi-
suggesting that the differences reported in the dent in a number of disorders (e.g., speech
early studies reflected participant characteristics impairment, ADHD: prolongation of waves I to
other than ASD (e.g., other neurological III) and are potentially related to differences in
disorder, intellectual disability). Courchesne language acquisition (Nagy & Loveland, 2002).
et al. (1985) tested a cohort of high-functioning In general, it is not clear whether even the differ-
individuals with ASD, with well-matched con- ences that have been identified in ASD are spe-
trols, and found no differences in the group with cific to this disorder. However, these differences
ASD. Once the issues discussed above were taken do not generalize to all developmental disorders.
into account – and the reliability of the measures, While individuals with Down’s syndrome also
as methods were still improving – several reviews display abnormal BAERS, the atypical patterns
argued that differences in individuals with ASD are distinct from those in autism (Sersen, Heaney,
were not evident (Minshew, 1991) or less likely Clausen, Belser, & Rainbow, 1990). Finally,
(Klin, 1993). Klin (1993) pointed out that, while abnormalities may have implications clinically,
BAERS did not provide convincing evidence of as recent work suggests that there may be some
brainstem dysfunction in ASD, they did suggest experience-dependent plasticity in the BAER
that peripheral hearing loss might be common in wave pattern that is sensitive to auditory training
ASD and such hearing loss would be important (Chandrasekaran & Kraus, 2010; Skoe & Kraus,
clinically when treating those with ASD. 2010; see Russo, Hornickel, Nicol, Zecker, &
Tables listing the results and the samples used Kraus, 2010 for training in ASD).
in these earlier studies are included in Klin (1993) The studies in recent years have shown
and Wong and Wong (1991). a prolongation of either the wave itself or –
relatedly – the IPI (Gillberg, Rosenhall, &
Johansson, 1983; Kwon, Jungmi, Choe, Ko, &
Current Knowledge Park, 2007; Maziade et al., 2000; Rosenhall,
Nordin, Brantberg, & Gillgerg, 2003; Tanguay
More work has led to further inconsistencies in et al., 1982; Tas et al., 2007; Wong & Wong,
the data, though several important themes have 1991), though a few early studies indicated
emerged. In all studies, differences in the BAERs a shortening of waves (see Table 1 in Rosenhall
of those with ASD are evident in a subset of et al., 2003 for a summary of earlier studies).
B 472 Brainstem Auditory Evoked Responses in Autism (BAERs)
Brainstem Auditory Evoked Responses in Autism (BAERs), Table 1 Recent literature on BAERs in ASD in
response to clicks (see Russo et al., 2008; Tharpe et al., 2006 for recent evidence of differences in BAERs to other
sounds, but not to clicks)
Prolongation? Prolongation? IPIs I–III,

Study N Potential confounds? Latencies I, III, V III–V
Tas et al. (2007) N ¼ 30 ASD Individuals with ASD None III–V
N ¼ 15 controls sedated controls not
M age ¼ 3 year
Rosenhall et al. N ¼ 101 ASD with Controls slightly older I, V III–V
(2003) normal hearing than individuals with
N ¼ 59 controls ASD
M age ¼ 8 year
Fujikawa-Brooks N ¼ 20 ASD V in L ear None
et al. (2010) N ¼ 20 controls
M age ¼ 10 year
Maziade et al. N ¼ 73 ASD, 251 Not reported Longer I–III and I–V in
(2000) relatives ASD and first-degree
N ¼ 521 controls relatives especially
M age ¼ 7 year siblings
Magliaro et al. N ¼ 16 ASD Many more F in control III, V I–III, I–V
(2010) N ¼ 25 controls group (16 vs. 1)
M age ¼ 12 year
Kwon et al. (2007) N ¼ 71 ASD May have had other V in L ear I–V, III–V bilateral in
(22 autism) medical issues, 2 cases larger more
N ¼ 50 controls with brainstem heterogeneous ASD
M age ¼ 3 year abnormalities group only
Other conditions, such as Down’s syndrome, may “features,” but not in those with intellectual dis-
tend to exhibit shorter IPIs (Sersen et al., 1990). ability. Later studies (summarized in Table 1)
This longer latency is evident in a subset of those reported longer IPIs I–III in both individuals
with ASD, generally not more than about 50% of with ASD and their first-degree family members
the sample. Which wave (I, III, or V) or IPI the (Maziade et al., 2000). However, 52% of the
group differences are evident differs between families with ASD had normal BAEPs in every-
studies; however, wave V appears to be most one in the family. Rosenhall and colleagues
often affected, especially in the left (L) ear. (See (2003) reported that 58% of children with ASD
Table 1 for a summary of recent results since had longer latencies in waves I and V and IPI in
2000 to click tones in BAERs.) This may reflect III–V. This study included a large sample, but
a more general slowing of auditory processing a portion of the sample had hearing loss. Kwon
that differs across this heterogeneous population. and colleagues (2007) reported longer I–V and
This pattern is also evident in many earlier stud- III–V and wave V in large group of those on the
ies. Skoff and colleagues reported prolonged III– spectrum (ASD) (N ¼ 71), but not in those with
V IPIs in the L ear in 33% of their sample (1980). autism defined more strictly (N ¼ 22). The take-
Thivierge et al. found that 80% of their home message from Kwon and colleagues was
populations had longer I–V and III–V IPIs that ASD might have a lot of physiological over-
(1990). Wong and Wong (1991) reported lap with central auditory processing disorder
increased latencies of wave V, and I–III, III–V, (CAPD), on the basis of the ABR results,
and I–V IPIs, in sedated individuals with autistic and that this comorbidity might have
Brainstem Auditory Evoked Responses in Autism (BAERs) 473 B
clinical implications. In contrast to these positive until around 3 or 4 years old. While age was
results, several studies have reported no approximately matched in many of the studies,
difference between groups to click stimuli differential development across groups may still
(Courchesne et al., 1985; Rumsey, 1984; Tharpe be influencing the results.
et al., 2006). Several studies have examined the BAER B
Most of the studies do not have a well- response to sounds other than clicks, and these
matched control group (but see Courchesne results suggest that group differences might be
et al., 1985), although many of the recent ones more likely with sounds other than with the tra-
do a test for hearing impairment before including ditional click response. Russo et al. (2008) exam-
participants in the results. In addition, since ined pitch encoding. They found that 20% of
BAERs are thought to be relatively resistant to children on the autism spectrum had difficulty
age, function level, or other potential confounds with pitch, while none showed abnormal
such as the effects of sedation, these differences BAERs to click sounds, but this result was not
may generally not affect the results or do so only correlated with language outcome. The ASD
subtly. However, in these studies, there are still group had more boys and lower IQ, but the results
issues with the control groups. One such issue is did not change when these issues were controlled
gender. Since females have shorter IPIs, includ- statistically. Tharpe et al. (2006) found differ-
ing too many in the control group could bias the ences in the BAER when the stimulus was
IPIs to be shorter in controls and therefore appear a pure tone, but not when it was a click. This
longer in ASD. For instance, Magliaro, Scheuer, difference was evident in 11 of 22 individuals
Assumpcao, and Matas (2010) found prolonga- with ASD. Fujiwaka-Brooks and colleagues
tion in III and V and IPIs I–III and I–V, but this (2010) included more clicks per second (61–91
study included a substantial proportion of instead of 11–25 used typically), a stressor that is
females in the control group. Recent studies known to lead to longer latencies typically, espe-
have attempted to control for gender (Russo cially in wave V. These investigators found dif-
et al., 2008), since there are almost always a few ferences in left ear only, with a trend for latency
more females in the control group, and have of wave I and significant results of wave V. They
found differences. Another issue is that also report a negative correlation between the
a number of subjects with serious hearing loss latency of wave V and verbal IQ, suggesting
and ASD have been identified across studies a relationship between this wave and language
(Rosenhall et al., 2003; Tas et al., 2007). This is skill. About half the sample showed the differ-
an important issue clinically, as it may not be ence in the L ear for wave V. This group points
immediately evident in children with ASD that out the importance of testing from both ears, as
they have hearing loss (Klin, 1993). So, while this some studies have only tested the right ear.
emphasizes the importance of examining hearing
in those with ASD, it also presents confounds in
the available data. For instance, Tas Future Directions
(2007) reported a longer III–V bilaterally in
young children with ASD. However, five These studies indicate that BAERs may be abnor-
children were identified as having hearing loss, mal in ASD, but this is unlikely to reflect impor-
and, while the three with severe loss were tant information about etiology across the
excluded, the two with mild hearing loss were spectrum. These abnormal BAERs may reflect
not. This study also brings up the issue of using disrupted auditory processing, possibly deep in
quite young children, around 2 years old the brainstem. There is not convincing evidence
(see also Kwon et al., 2007; Wong & Wong, that it is specific to ASD. However, that differ-
1991). While the BAER architecture is relatively ences are evident for only a subset of participants
mature by 18 months of age, there is some with ASD might prove useful for identifying sub-
evidence that wave V continues to mature groups of ASD. In addition, differences in the
B 474 Brainstem Auditory Evoked Responses in Autism (BAERs)
developmental pattern in ASD have not been Electroencephalography and Clinical Neurophysiol-
studied but may be enlightening. While TD indi- ogy, 61(6), 491–501.
Fujikawa-Brooks, S., Isenberg, A. L., Osann, K.,
viduals may show little change in the BAERs Spence, M. A., & Gage, N. M. (2010). The effect of
after age 4 or due to intellectual disability, this rate stress on the auditory brainstem response in
pattern may not be true of those with ASD. Such Autism: A preliminary report. International Journal
developmental differences could help explain the of Audiology, 49, 129–140. doi:10.3109/14992020903
289790.
discrepancy between the findings of Courchesne Gillberg, C., Rosenhall, U., & Johansson, E. (1983). Audi-
et al. (1985) with a high-functioning set of adults tory brainstem responses in childhood psychosis. Jour-
with ASD and well-matched controls and the nal of Autism and Developmental Disorders, 13(2),
more recent work that generally focuses on 181–195.
Klin, A. (1993). Auditory brainstem responses in autism:
children, often very young ones (Kwon et al., brainstem dysfunction or peripheral hearing loss. Jour-
2007; Tas et al., 2007; Wong & Wong, 1991). nal of Autism and Developmental Disorders, 23,
In addition, recent studies have begun to identify 15–35.
plasticity in the BAER in the auditory pathway in Kwon, S., Jungmi, K., Choe, B., Ko, C., & Park, S. (2007).
Electrophysiologic assessment of central auditory
the brainstem when training takes place processing by auditory brainstem responses in children
(Chandrasekaran & Kraus, 2010; Skoe & Kraus, with Autism spectrum disorders. Journal of Korean
2010; see Russo et al., 2010 for studies in ASD), Medical Science, 22, 656–659.
and high-functioning individuals with ASD Magliaro, F. C., Scheuer, C. I., Assumpcao, F. B., &
Matas, C. G. (2010). Study of auditory evoked poten-
may be able to compensate for their social and tials in Autism. Pro-Fono Revista de Atualizacao
communication issues and engage further Cientifica, 22, 31–37.
through language. This plasticity may help to Maziade, M., Merette, C., Cayer, M., Roy, M., Szatmari,
explain the variability in the BAER differences P., Cote, R., et al. (2000). Prolongation of brainstem
auditory – Evoked responses in Autistic probands and
in ASD, in addition to other differences across the their unaffected relatives. Archives of General Psychi-
spectrum, as well as help to inform potential atry, 57, 1077–1083.
interventions. Minshew, N. J. (1991). Indices of neural function in
Autism: Clinical and biological implications. Pediat-
rics, 87, 774–780.
Moore, J. K., & Linthicum, F. H. (2007). The human
See Also auditory system: A time-line of development. Interna-
tional Journal of Audiology, 46(9), 460–478.
▶ Auditory Brainstem Response, ABR Nagy, E., & Loveland, K. A. (2002). Prolonged brainstem
auditory evoked potentials: and autism specific or
▶ Auditory Potentials autism-nonspecific marker. Archives of General Psy-
▶ Brainstem Auditory Evoked Response, BAER chiatry, 59(3), 288–290.
▶ Evoked Potentials Ornitz, E. M., Atwell, C. W., Kaplan, A. R., &
▶ Visual Evoked Potential (VEP) Westlake, J. R. (1985). Brain-stem dysfunction in
autism. Results of vestibular stimulation. Archives of
▶ Visual/Somatosensory Cognitive Potentials General Psychiatry, 42(10), 1018–1025.
Rosenhall, U., Nordin, V., Brantberg, K., & Gillgerg, C.
(2003). Autism and auditory brain stem responses.
Ear and Hearing, 24, 206–214. doi:10.1097/01.
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26(2), 217–220. Kraus, N. (2010). Biological changes in auditory
Chandrasekaran, B., & Kraus, N. (2010). The scalp- function following training in children with Autism
recorded brainstem responses to speech: Neural ori- spectrum disorders. Behavioral and Brain Function,
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Courchesne, E., Courchesne, R. Y., Hicks, G., & Lincoln Russo, N. M., Skoe, E., Trommer, B., Nicol, T., Zecker, S.,
A. J. (1985). Functioning of the brain-stem auditory Brdlow, A., et al. (2008). Deficient brainstem encoding
pathway in non-retarded autistic individuals. of pitch in children with Autism spectrum disorders.
Broader Autism Phenotype 475 B
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doi:10.1016/j.clinph.2008.01.108. Broader Autism Phenotype
Russo, N., Zecker, S., Trommer, B., Chen, J., & Kraus, N.
(2009). Effects of background noise on cortical
encoding of speech in Autism spectrum disorders. Jeremy Parr1 and Ann S. Le Couteur2
B
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Sersen, E. A., Heaney, G., Clausen, J., Belser, R., &
Rainbow, S. (1990). Brainstem auditory-evoked Newcastle Upon Tyne, UK
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Down’s syndrome. Biological Psychiatry, 27, Newcastle University, Sir James Spence
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Skoe, E., & Kraus, N. (2010). Auditory brain stem
response to complex sounds: A tutorial. Ear and Newcastle upon Tyne, UK
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Stone, J. L., Calderon-Arnulphi, M., Watson, K. S.,
Patel, K., Mander, N. S., Suss, N., et al. (2009). Definition
Brainstem auditory evoked potentials – a review and
modified studies in healthy subjects. Journal of Clini-
cal Neurophysiology, 26, 167–175. Autism spectrum disorder (ASD) twin and family
Tanguay, P. E., Edwards, R. M., Buchwald, J., Schwafel, studies showed during the 1990s that the behav-
J., & Allen, V. (1982). Auditory brainstem evoked ioral phenotype extends beyond the clinical diag-
responses in autistic children. Archives of General
Psychiatry, 39(2), 174–180. noses of autism and ASD to include related
Tas, A., Yagiz, R., Tas, M., Esme, M., Uzun, C., & milder behaviors or personality traits in the rela-
Karasalihoglu, A. R. (2007). Evaluation of hearing in tives of affected individuals. These qualitatively
children with Autism by using TEOAE and ABR. similar ASD-related behaviors in relatives are
Autism, 11, 73–79. doi:10.1177/1362361307070908.
Taylor, M. J., Rosenblatt, B., & Linschoten, L. (1982). termed the broader autism phenotype (BAP)
Auditory brainstem response abnormalities in Autistic (see Losh, Adolphs, & Piven, 2011 for a review).
children. Canadian Journal of Neurological Sciences, Although several authors have reported that these
9, 429–433. symptoms and traits are continuously distributed
Tharpe, A. M., Bess, F. H., Sladen, D. P., Schissel, H.,
Couch, S., & Schery, T. (2006). Auditory characteris- in the general population, the term “BAP” has not
tics of children with Autism. Ear and Hearing, 27, been used to describe individuals with social
430–441. communication difficulties from population sam-
Tzounopoulos, T., & Kraus, N. (2009). Learning to encode ples (see Constantino, 2011 for a review of this
timing: Mechanisms of plasticity in the auditory
brainstem. Neuron, 62, 463–469. literature).
Wong, V., & Wong, S. N. (1991). Brainstem auditory Researchers have defined BAP characteristics
evoked potential study in children with Autistic disor- using interview and questionnaire methods, neu-
der. Journal of Autism and Developmental Disorders, ropsychological and neurophysiological testing,
21, 329–340.
and neuroimaging (Bailey & Parr, 2003;
Dawson et al., 2002; Losh et al., 2011). However,
there is no formal definition of the BAP due
Brainstem Evoked Response (BER) to variability in approaches and research findings
(see section “Historical Background”);
▶ Evoked Potentials indeed BAP is not a “diagnosis” recognized in
the international diagnostic classification
systems.
Thus, the best working definition of the BAP
BRIAAC would be “individuals with the BAP show behav-
ioral characteristics and personality traits similar
▶ Behavior Rating Instrument for Autistic and to, but milder than, their relative with ASD” (see
Atypical Children (BRIAAC) Current Knowledge).
B 476 Broader Autism Phenotype
Broader Autism Phenotype, Table 1 Broader autism phenotype measures

Interview/questionnaire/
Instrument observation Populations used References
Social responsiveness scale Questionnaire Twin, singleton, multiplex, Constantino and Todd
and general pop samples (2003)
BAP-Q Questionnaire Singleton and multiplex Hurley, Losh, Parlier,
families Reznick, and Piven (2007)
BPASS Interview and observation Singleton and multiplex Dawson et al. (2007)
families
Family history interview and Interview and observation Singleton and multiplex Parr et al. and the
impression of interviewee families IMGSAC, in preparation
Historical Background 2002). More recently, neurophysiological mea-

surement and neuroimaging studies of relatives
Over the last 20 years, many groups have used have been a focus (see Losh et al., 2011); the
a variety of instruments to define various character- rationale for using all these approaches to BAP
istics in relatives of people with ASD. A large body characterization is described by Bailey and Parr
of literature describes the different components of (2003). By contrast to this investigation of the
the BAP proposed following studies using a range relatives of people with ASD, other groups have
of methodologies and measures in different conceptualized and measured a range of social
populations (see Bailey, Palferman, Heavey, & Le communication and other difficulties in the con-
Couteur, 1998 and Losh et al., 2011 for reviews). text of normative trait variation in the general
Research shows that in keeping with ASD, population hypothesizing that these traits could
impaired social communication and social emo- be included on a dimension with ASD (see
tional abilities are core features of the BAP, Constantino, 2011 for a review).
together with repetitive behaviors (including obses- The BAP has been of increasing interest to
sional behaviors) and behavioral rigidity (for researchers due to its potential importance for
reviews, see Parr, Wittemeyer, & Le Couteur, understanding the neurobiological nature of
2011 and Losh et al., 2011). Of all the BAP traits, ASD (for a review, see Lainhart & Lange,
repetitive behaviors, rigidity, perfectionism, obses- 2011). From 2000, research groups began
sions, and circumscribed/special interests have collecting data from relatives in an attempt to
been the most difficult to identify and quantify. assist in the search for ASD susceptibility
Two approaches have been taken to the inves- genes, assuming that the BAP indexes
tigation of these ASD-like behavioral traits. First, a “genetic risk” that may be present in one or
researchers have focused on identifying the both parents and “unaffected” siblings – thus
BAP in families of one child with ASD relatives might carry ASD susceptibility
(singleton families) and two or more people genes and express an “ASD-like” phenotype
with ASD (multiplex families). Various groups (see Bailey & Parr, 2003 and Losh et al., 2011).
have continued this research as part of the search The most commonly used measures for the
for autism susceptibility genes (see the work of identification of BAP in affected families are
Piven, Dawson, and Parr et al. and the Interna- summarized in Table 1. In keeping with ASD
tional Molecular Genetic Study of Autism Con- itself, reliable direct observation of BAP behav-
sortium [IMGSAC]). In addition to investigating iors has been challenging. For this reason, most
the behavioral BAP within ASD families, research groups have used some form of inter-
researchers have focused on identifying neuro- view data, either exclusively or in combination
psychological components of the BAP in the with other measures. For most ASD molecular
relatives of people with ASD (Dawson et al., genetic studies, the BAP measures have been
Broader Autism Phenotype 477 B
designed to dimensionalize the social communi- degrees of insight into their difficulties and the
cation difficulties of parents and children impact of their behavior for themselves and
(e.g., quantitative trait loci studies) rather than others (Losh et al., 2011; Parr et al., 2011).
to define an affected/unaffected categorical “cut- “BAP” is a term used in research and not usu-
off score” – this means “the BAP” is less clearly ally in clinical practice. However, in clinical set- B
defined than might be expected. tings, with their knowledge of the importance of
genetic factors in autism, relatives of people with
ASD comment about their own ASD-related diffi-
Current Knowledge culties, or those of other family members. For
clinicians, the challenge is how best to “classify”
Research studies have shown that relatives of peo- these difficulties shown by people who do not have
ple with ASD have difficulties qualitatively similar ASD but who do experience some degree of social
to those seen in ASD, but milder – the individual’s communication impairment. It is important to be
profile of difficulties does not meet clinical ASD able to effectively describe these difficulties for
threshold. Generally, males are more commonly the affected individual themselves, and families
and more severely affected than females, and rela- and professionals; this leads to a better understand-
tives from multiplex families are more affected than ing of the person’s behaviors and the reason for
those from singleton families. Children and young them. This is likely to be particularly important for
people may have difficulties with developing and individuals who may benefit from specific inter-
maintaining friendships and problems relating to vention and resources – for example, mentoring in
others. Children frequently have less well- the workplace for adults with BAP and support
developed social play than their same age peers. from education and/or social care professionals for
Children and adults may be considered aloof. Lan- affected children, young people, and adults (see
guage and communication difficulties are common. Parr et al., 2011; Parr & Le Couteur, 2011).
Perfectionism, obsessions, and rigidity may be Finally, relatively little is known about the
seen. Considering mental health, the BAP has neurobiology or pathophysiology of the BAP. It
been associated with affective disorder (particularly has been hoped that better understanding the BAP
depression). Whether depression is part of the BAP will lead to improved neurobiological knowledge
or is a function of having a relative with ASD about ASD itself. However, in keeping with
remains unknown (for a detailed review, see Losh ASD, replicated neurobiological findings are
et al., 2011). scarce (comprehensively recently reviewed by
Investigation of the familial mechanisms that Lainhart & Lange, 2011). Whether BAP will
underpin ASD continue, and indeed, the finding play a significant role in advancing our under-
that parents from multiplex and simplex ASD standing of the complexity of ASD remains to be
families show the BAP at different rates is likely seen (Parr et al., 2011).
to be important for our understanding of etiology.
However, to date, the BAP has contributed only
modestly to the understanding of the neurobiology Future Directions
of ASD or the identification of genetic variants
(see Lainhart & Lange, 2011 and Parr et al., 2011). During the next decade, studies of parents and
The impact of the BAP on the functioning of other relatives of people with ASD will continue,
affected children, young people, and adults is and this will undoubtedly expand the understand-
similar to that seen in ASD itself, but milder, ing of subclinical ASD traits. Genetics research is
and usually results in less impairment in daily likely to continue to be a major “driver” of
life. However, BAP traits may lead to difficulties increased knowledge about BAP – for example,
with peer interactions, marital relationships, and there will be great interest in the extent to which
thus potentially difficulties at home, school, and the BAP is seen in the relatives of people with
in the workplace. People with BAP have varying ASD who have an identified inherited or de novo
B 478 Broader Autism Phenotype
causal variant as this will further inform our See Also

knowledge of the genetic and environmental con-
tributions to ASD. ▶ Autism
Another exciting prospect will be the findings ▶ Perfectionism
from studies of siblings of children with ASD ▶ Repetitive Behavior
(“at-risk” or “high-risk” sibling studies). These ▶ Social Communication
studies will provide insights into the developmen-
tal trajectories of children with ASD and those
without ASD who have the BAP; both groups can
be compared to siblings who develop typically,
Bailey, A., Palferman, S., Heavey, L., & Le Couteur, A.
and to controls. In the future, as “high-risk” sib- (1998). Autism: The phenotype in relatives. Journal of
lings move toward and into adolescence and Autism and Developmental Disorders, 28(5), 369–392.
adulthood, the knowledge of how early develop- Review.
Bailey, A., & Parr, J. (2003). Implications of the broader
ment and subsequent characteristics relate to indi-
phenotype for concepts of autism. Novartis Founda-
vidual progress and outcomes will improve. tion Symposium, 251, 26–35.
Finally, one new direction for BAP research Constantino, J. N. (2011). Autism as a quantitative trait.
relates to intervention. There is currently great In D. Amaral, D. Geschwind, & G. Dawson (Eds.),
Autism spectrum disorders (pp. 510–520). New York:
interest in whether intervention changes the
developmental trajectories and outcomes for Constantino, J. N., & Todd, R. D. (2003). Autistic traits in
“at-risk” siblings (e.g., the study of Green and the general population: A twin study. Archives of
colleagues in the UK). Projects evaluating the General Psychiatry, 60, 524–530.
Dawson, G., Estes, A., Munson, J., Schellenberg, G.,
effect of the BAP on the delivery of parent-
Bernier, R., & Abbott, R. J. (2007). Quantitative
mediated early intervention for ASD have com- assessment of autism symptom-related traits in pro-
menced. If research findings show that the BAP bands and parents: Broader phenotype autism symp-
has a negative impact on the effectiveness of tom scale. Journal of Autism and Developmental
Disorders, 37(3), 523–536.
parents’ interactions with their child with ASD,
Dawson, G., Webb, S., Schellenberg, G. D., Dager, S.,
identifying the most beneficial intervention strat- Friedman, S., Aylward, E., et al. (2002). Defining the
egies for BAP-affected parents will become both broader phenotype of autism: Genetic, brain, and
a research and a clinical priority to ensure better behavioral perspectives. Development and Psychopa-
thology, 14(3), 581–611.
understanding and effective targeting of evi-
Hurley, R. S., Losh, M., Parlier, M., Reznick, J. S., &
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For older children and adults with the BAP, tionnaire. Journal of Autism and Developmental Dis-
interventions and treatments need to be evalu- orders, 37(9), 1679–1690.
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ated. Researchers are, for example, beginning to
broader autism phenotype. In D. Amaral, D.
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Indeed, it could be argued that people with BAP
autism phenotype. In D. Amaral, D. Geschwind, &
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national experts answer questions on ASD. Gottingen/
may well have more insight into their difficulties. Oxford: Hogrefe.
Workplace interventions for people with BAP Parr, J. R., Wittemeyer, K., & Le Couteur, A. S. (2011).
may also be of benefit – whether mentoring or Commentary: The broader autism phenotype implica-
tions for research & clinical practice. In D. Amaral, D.
other types of workplace support gives adults
Geschwind, & G. Dawson (Eds.), Autism spectrum
a greater chance of working more productively disorders (pp. 521–524). New York: Oxford Univer-
with colleagues still remains to be seen. sity Press.
Broca’s Aphasia 479 B
spoken language skills and need to develop com-
Broca’s Aphasia pensatory strategies to manage the condition. It is
thought that recovery is enhanced depending
Elizabeth R. Eernisse upon factors such as age of onset, health, educa-
Department of Language and Literacy, Cardinal tion level, and how soon treatment takes place B
Stritch University, Milwaukee, WI, USA after brain damage has occurred.
Synonyms Clinical Expression and

Pathophysiology
Nonfluent aphasia
Broca’s aphasia is often due to damage in
the left frontal lobe of the brain, also referred
Short Description or Definition to as “Broca’s area.” Patients demonstrate
impaired, effortful speech/language output in
Broca’s aphasia is a language disorder that is the face of relatively intact comprehension skills.
characterized by limited, “telegraphic” spoken
language output in the face of intact language
comprehension skills. This condition is typically Evaluation and Differential Diagnosis
the result of damage to the left frontal lobe of the
brain, often due to stroke, but may also result Please see “▶ Aphasia.”
from traumatic brain injury or a degenerative
neurological condition.
Treatment
Categorization Treatment for Broca’s aphasia, as in other apha-

sias, is typically individualized and is based on
Broca’s aphasia is considered a “nonfluent” the patient’s profile of strengths and needs.
aphasia under larger aphasia classification Formal speech-language therapy is often
systems due to the patient’s lack of fluent speech recommended to address functional communica-
output. tion in a variety of settings in which patients are
expected to communicate. Therapy goals are
focused on maximizing the individual’s ability
Epidemiology to communicate effectively with peers and family
members, given residual strengths. For
Estimates of Broca’s aphasia in the larger popu- individuals with Broca’s aphasia, treatment
lation are largely unknown, though it has been strategies often focus on language output
estimated that 80,000 people develop aphasia in and naming as well as building sentence
the United States each year. length, building on their intact comprehension
skills. In addition, computer-assisted methods
are beginning to show promise in assisting indi-
Natural History, Prognostic Factors, and viduals with Broca’s aphasia to transmit
Outcomes messages.
Family member and patient support groups are
The prognosis for individuals who are diagnosed often a critical piece of the therapeutic process as
with Broca’s aphasia is largely dependent upon the patient and family learn to manage the
the severity of the condition. Often, people with patient’s changed mode of communication.
Broca’s aphasia do not completely recover fluent Support groups are often key to recovery.
B 480 Brodmann’s Area 4
Please see “▶ Aphasia” for a list of general

treatment strategies for aphasia. Bruininks-Oseretsky Test of Motor
Proficiency
See Also Mikle South and Jessica Palilla

Departments of Psychology and Neuroscience,
▶ Aphasia Brigham Young University, Provo, UT, USA
References and Readings Synonyms
American Speech-Language-Hearing Association (ASHA). BOT-2; BOTMP

(2008). Incidence and prevalence of speech, voice,
and language disorders in adults in the United States.
Available from, www.asha.org/research/reports/
speech_voice_language.htm. Retrieved 5 January 2011 Definition
Barresi, B., Goodglass, H., & Kaplan, E. (2001). The
assessment of aphasia and related disorders.
The original version of the Bruininks-Oseretsky
Hagerstown, MD: Lippincott Williams & Wilkins.
Chapey, R. (2008). Language intervention strategies in Test of Motor Proficiency was abbreviated as the
aphasia and related neurogenic communication BOTMP. The revised second edition is usually
disorders. Philadelphia: Wolters Kluwer/Lippincott referred to as the BOT-2.
Williams & Wilkins.
Goodglass, H., Kaplan, E., & Barresi, B. (2000). Boston
diagnostic aphasia examination third edition
(BDAE-3) (3rd ed.). Austin, TX: Pro-Ed. Description
Kaplan, E., Goodglass, H., & Weintraub, S. (1983).
The Boston naming test. Philadelphia: Lea and
Febiger.
The BOT-2 is designed to assess motor profi-
Kent, R. D. (1994). Reference manual for communicative ciency in children and adults from ages 4 to
sciences and disorders: Speech and language. Austin, 21 years and 11 months. This was intended to
TX: Pro-Ed. cover the age range for children served by the
Kertesz, A. (2006). Western Aphasia battery- revised
American Individuals with Disabilities Educa-
(WAB-R). Austin, TX: Pro-Ed.
Lapointe, L. L. (2004). Aphasia and related neurogenic tion Act (IDEA). It is individually administered,
language disorders. New York: Thieme Medical standardized, and norm referenced. It is used for
Publishers. treatment planning and evaluation in clinical and
National Institute on Deafness and Other Communication
school settings as well as for research. Physical
Disorders. (2008). Aphasia. Available from, http://
www.nidcd.nih.gov/health/voice/aphasia.htm. and occupational therapists especially may find
Retrieved 5 January 2011 the test useful.
The Complete Form version of the BOT-2
includes 53 items based on activities such as cutting
out a circle, copying a square, bouncing a ball, and
standing on one leg. Items are organized into eight
Brodmann’s Area 4 subtests and further categorized into four motor
area composites and one comprehensive score.
▶ Precentral Gyrus These composites are strength and agility (running
speed and agility + strength subtests, meant to
measure control of the musculature of body
involved in movement); manual coordination
BRS (manual dexterity and upper limb coordination
subtests, meant to measure the ability to manually
▶ Behavior Rating Scale (BRS) manipulate objects and the level of coordination in
Bruininks-Oseretsky Test of Motor Proficiency 481 B
the hands and arms); body coordination (bilateral Psychometric Data
coordination and balance subtests, to measure large
musculature control of posture, balance, as well as Criticisms of the original BOTMP included con-
the sequential and simultaneous coordination of the cerns about the normative sample being racially
lower and upper limbs); and fine manual control homogenous and functioning at normal levels B
(fine motor precision and fine motor integration both intellectually and motorically. A child’s ability
subtests, to measure the level of control and to understand and respond to instructions may have
coordination of the hand and fingers by looking at confounded motor skill development. Factor ana-
an individual’s ability to grasp, draw, and cut lyses showed that 14 of the 17 fine motor ability
with scissors). items loaded at significant levels on the general
The nature of the measure makes it fairly easy motor ability factor, implying that the BOTMP
to administer, as children tend to enjoy performing was not a good stand-alone measure for assessing
the variety of activities involved in the testing. The fine motor abilities and that the grouping of
BOT-2 revision has made it much more adaptive tests into fine and gross motor skills was
for younger children, for instance by increasing the problematic. The creators of the BOT-2 revision
number of blocks to string and adding the balance set out to address these and other issues.
beam to walk on. The entire battery of tests can The normative sample for the BOT-2 included
take an hour to administer, but a 14-item Short 1,520 individuals from ages 4 to 21, with greater
Form of the test is available which only requires age differentiation for normative comparisons in
20 min. The short form accounts for 96.3% of the younger children (in 1-year increments) up to a
variability in children ages 3–5, so it can be used as 5-year age increment for the adult sample. It was
a substitute for the complete battery when appro- targeted to US Census Data from 2001 and included
priate. The test manual provides many clear pic- about 11% of children with special education sta-
tures of the tasks being completed. However, tus. Separate clinical samples were tested for
scoring of the test is time-intensive, taking at autism/Asperger’s, developmental coordination
least 20 min according to Deitz, Kartin, and disorder, and mild-to-moderate mental retardation.
Kopp (2007). Deitz et al. note that scoring for the Interrater reliability reported by the devel-
BOT-2, although improved over the BOTMP, opers of the BOT-2 is above.90 for all but the
nonetheless is tedious, sometimes confusing, and fine motor scale (adjuster r ¼.86). Test-retest
easy to make errors. Norm lookup tables are also reliability is good for the Total Composite and
difficult to use. the Short Form totals, but generally less good
(with substantial variability) for the other scale
composites and item analyses. Deitz et al. (2007)
Historical Background therefore recommend that the Composite scores
be used wherever possible and that reliance on
The BOTMP was originally developed in Russia by subscale scores is inadvisable.
Oseretsky in 1923 (Oseretsky 1923). When it was Test developers utilized Confirmatory Factor
translated into English by Doll in 1946 (Doll 1946), Analysis to document a good fit for the four-
it was known as the “Oseretsky Test of Motor factor model of the BOT-2, better than the two-
Proficiency.” However, because the test had been factor (Fine vs. Gross Motor) structure of the
based on Oseretsky’s personal observations of chil- original BOTMP. The three clinical samples all
dren, it had many problems relating to its psycho- scored significantly lower than the normative
metric properties. Multiple revisions were made in sample on both the Complete and Short forms.
order to increase the reliability and validity of the Convergent validity was strong for the original
measure, and the BOTMP represents the culmina- BOTMP (adjusted r ¼ .80 for composite scores);
tion of these revisions. The BOT-2 was published in the Peabody Test of Developmental Motor
2005 with updated and revised materials, items, Skills – Second Edition (adjusted rs ranging
scales, and norms. from .51 to .75 for subscales); and the Test of
B 482 Bruxism
Visual Motor Skills – Revised (comparison of studies that have used the BOT-2 instead of the
relevant fine motor skills adjusted r ¼ .74). original BOTMP.
Statistical modeling by Wuang, Lin, and Su
(2009) on a sample of 446 children diagnosed See Also
with intellectual disability found that the manual
coordination and strength + agility composites fit ▶ Bender Visual-Motor Gestalt Test II
the whole sample better than the fine motor and
body coordination composites, which fit the
lower-functioning end of the sample better than References and Readings
the higher-functioning end. Their analysis
suggested elimination and/or restructuring of Beitel, P., & Mead, B. J. (1980). Bruininks-Oseretsky test of
motor proficiency: A viable measure for 3- to 5-yr-old
a number of items and scales to improve both
children. Perceptual and Motor Skills, 5, 919–923.
reliability and discriminant validity. Bruininks, R. H. (1978). Bruininks-Oseretsky test of motor
proficiency – Owner’s manual. Circle Pines, MN:
American Guidance Service.
Bruininks, R., & Bruininks, B. (2005). Bruininks-
Clinical Uses Oseretsky test of motor proficiency (2nd ed.). Minne-
apolis, MN: NCS Pearson.
Deitz et al. (2007) note that the inclusion of 11% Deitz, J. C., Kartin, D., & Kopp, K. (2007). Review of the
special education students in the normative sample Bruininks-Oseretsky test of motor proficiency, second
edition (BOT-2). Physical & Occupational Therapy in
makes the BOT-2 less likely than its BOTMP
Pediatrics, 27, 87–102.
predecessor to score children with motor disabil- Dewey, D., Cantell, M., & Crawford, S. G. (2007). Motor and
ities as significantly below average. gestural performance in children with autism spectrum
The BOTMP has been used to characterize disorders, developmental coordination disorder, and/or
attention deficit hyperactivity disorder. Journal of Inter-
motor problems in individuals diagnosed with
national Neuropsychological Society, 13, 246–256.
Autism Spectrum Disorders. One study Doll, E. A. (1946). The Oseretsky Tests of Motor Profi-
(Ghaziuddin & Butler, 1998) compared BOTMP ciency. Circle Pines, MN: American Guidance Service.
motor coordination between children diagnosed Ghaziuddin, M., & Butler, E. (1998). Clumsiness in autism
and Asperger syndrome: A further report. Journal of
with autism, Asperger’s syndrome (AS), and per-
Intellectual Disability Research, 44, 43–48.
vasive developmental disorder not otherwise spec- Hattie, J., & Edwards, H. (1987). A review of the
ified (PDDNOS). Of the three groups, those with Bruininks-Oseretsky test of motor proficiency. British
autism were the most clumsy, followed by those Journal of Educational Psychology, 57, 104–113.
Oseretsky, N. I. (1923). A metric scale for studying the
with AS and then those with PDDNOS. However,
motor capacity of children. [In Russian].
there was not a significant difference between the Wuang, Y.-P., Lin, Y.-H., & Su, C.-Y. (2009). Rasch anal-
autism group and the AS group. These results indi- ysis of the Bruininks-Oseretsky test of motor profi-
cate that caution should be used before including ciency-second edition in intellectual disabilities.
Research in Developmental Disabilities, 30, 1132–1144.
clumsiness as a diagnostic criterion for only one of
the disorders. Dewey, Cantell, and Crawford
(2007), using the BOTMP Short Form, found par-
ticular impairment in gestural performance in ASD Bruxism
relative to other clinical groups (developmental
motor coordination and ADHD). In the context of Arianne Stevens and Raphael Bernier
generally impaired motor performance for all the Psychiatry and Behavioral Sciences, University
clinical groups, Dewey et al. suggest that gestural of Washington, Seattle, WA, USA
impairments in autism are not solely attributable to
motor problems.
The test is also frequently used in studies of Synonyms
developmental coordination disorders, with a few
studies of ADHD. There are very few published Sleep bruxism
Buckhannon Versus West Virginia Department of Health and Human Resources 483 B
Definition PubMed Health. (2010, February 22). Bruxism: Teeth
grinding and clenching. Retrieved from http://www.
ncbi.nlm.nih.gov/pubmedhealth/PMH0002386/
Bruxism is the nonfunctional and involuntary US Department of Health and Human Service. (2000).
grinding, gnashing, clenching, or tapping of teeth. Oral health in America: A report of the Surgeon
Bruxism is considered to be common among indi- General. Rockville, MD: US Department of Health B
viduals with developmental delays or disabilities, and Human Services, National Institute of Health and
Human Services, National Institute of Dental and
including those diagnosed with autism spectrum Craniofacial Research, National Institute of Health.
disorders. Bruxism is classified as nocturnal
(occurring during sleep) or diurnal (occurring
while awake). Bruxism can be audible when teeth
are grinding or gnashing or inaudible when teeth BSE
are clenching. Many are not aware of their brux-
ism, but some will develop symptoms such as tooth ▶ Behavior Summarized Evaluation-Revised
sensitivity, headaches, or jaw pain. Bruxism is (BSE-R)
considered to be a psychophysiological and sleep
disorder influenced by anatomical and biological
(i.e., dental abnormalities), neurological (i.e., men-
tal retardation), and/or psychological (i.e., stress, BSE-R
trauma, anxiety) factors. Studies examining effec-
tive treatments for bruxism in individuals with ▶ Behavior Summarized Evaluation-Revised
developmental disabilities are limited to date; how- (BSE-R)
ever, dental-based approaches, biofeedback,
behavior therapy, habit reversal, and stress man-
agement appear to be common interventions.
Buckhannon Versus West Virginia
Department of Health and Human
See Also Resources: Definition of Prevailing
Party
▶ Habit Reversal
▶ Tics Regina Gilroy
Quinnipiac University School of Law,
Hamden, CT, USA
Allen, K. D., & Polaha, J. (2006). Analysis and treatment Definition

of oral-motor repetitive behavior disorders. In D. W.
Woods & R. G. Miltenberger (Eds.), Tic disorders, In General
trichotillomania, and other repetitive behavior disor-
The issue in this case was whether the prevailing
ders: Behavioral approaches to analysis and treatment
(pp. 269–296). New York: Springer. party in a claim for violating the Americans
Glaros, A. G., & Epkins, C. C. (1995). Habit disorders: with Disabilities Act (ADA) should be awarded
Bruxism, trichotillomania, and tics. In M. C. Roberts attorney’s fees under the catalyst theory. The
(Ed.), Handbook of pediatric psychology (2nd ed.,
Supreme Court, quoting Black’s Law Dictionary
pp. 558–574). New York: The Guilford Press.
Glaros, A. G., & Rao, S. M. (1977). Bruxism: A critical 1145 (7th ed. 1999), defines “prevailing party” as
review. Psychological Bulletin, 4, 767–781. “[a] party in whose favor a judgment is rendered,
Mindell, J. A., & Owen, J. A. (2010). Sleep related regardless of the amount of damages awarded (in
rhythmic movements: Bruxism. In A clinical guide to
pediatric sleep: Diagnosis and management of sleep
certain cases, the court will award attorney’s fees
problems (2nd ed., pp. 90–93). Philadelphia: to the prevailing party).” The catalyst theory pro-
Lippincott Williams and Wilkins. vides fees to a party where the case serves as
B 484 Bulimia Nervosa
a “catalyst” for legislative change. The Supreme References and Readings

Court ruled that the “catalyst theory” is not an
appropriate basis for attorney’s fees under certain Buckhannon Bd. & Care Home v. W. Va. Dep’t of Health
& Human Res., 532 U.S. 598 (U.S. 2001).
civil rights cases, including under the ADA. The
Weber, M. C. (2004). Litigation under the Individuals
prevailing party is only entitled to attorney’s fees with Disabilities Education Act After Buckhannon
when they are victorious in court and awarded Board & Care Home Inc. v. West Virginia Department
a judgment in court. of Health & Human Resources. Ohio State Law
Review, 65, 357–411.
Implications for ASD Students

Buckhannon has implications for those with
ASD. First, in the case of discrimination under Bulimia Nervosa
the ADA, parents may be less willing to bring
cases because of the expense of bringing ▶ Eating Disorders
a lawsuit. The parent would not be guaranteed
expensive attorney fees if they end up prevailing
outside of a courtroom. Only cases heard in court
would be awarded attorney’s fees. Second, IDEA Bullying
(Individuals with Disabilities Education Act) has
made fees available to parents who win in either Young-Shin Kim1, Soonjo Hwang2 and
administrative or judicial proceedings. If IDEA Bennett Leventhal3
1
follows the Buckhannon decision, then this fee Psychiatry, Yale Child Study Center,
payment for parents would become obsolete if New Haven, CT, USA
2
a case is heard in an informal proceeding or Psychiatry, Massachusetts General Hospital,
dismissed because of a change in law. Boston, MA, USA
3
Psychiatry, Nathan Kline Institute for
Litigation Strategies Psychiatric Research (NKI), Orangeburg,
Buckhannon specifically dealt with an assisted NY, USA
living facility which failed a fire inspection.
Buckhannon was ordered to be shut down, but
filed suit under the ADA. After filing suit, Synonyms
the state legislature removed the language that
created the problem. But, because of the Supreme Bullying; Peer victimization; School harassment
Court decision, Buckhannon was not entitled to an
award of attorney’s fees. Most special education
cases settle either because of the speed necessary Short Description or Definition
to allow the child to continue his/her education or
the school district changes its behavior before Bullying is an aggressive behavior perpetrated by
a decision is even made. Under Buckhannon, par- those who hold and/or try to maintain a dominant
ents would not be able to recover attorney fees. It position over others (Morita, 1985). It is intended
might be more appropriate to try to mediate to cause mental and/or physical harm or suffering
between the parents and school district, so that in to another: it is a repetitive behavior and almost
the mediation agreement the parents can be enti- always involves an imbalance of power between
tled to some reasonable attorney’s fees. victim and perpetrator in which the victim is
usually not able to defend himself/herself
(Farrington, 1993). Bullying is also the most
See Also common form of school violence.
Bullying can take various forms including:
▶ Americans with Disabilities Act exclusion, verbal abuse, physical abuse, and/or
Bullying 485 B
coercion (Kim, Koh, & Leventhal, 2004). Bullying behavior and a limited range of interests, often in
may be “direct” or “indirect.” Direct bullying unusual topics or objects that can make them stand
includes physical and verbal aggression, such as out as quite different from their peers: this often
kicking, threatening, name-calling, and insulting. puts them in the position of becoming targets for
Indirect or covert/relational bullying includes social ridicule (Cappadocia et al., 2011; Gray, 2004). B
exclusion/isolation, such as ignoring, cliques, Other challenges often facing children with ASD
rumor-mongering, insulting, and humiliating with that include unusual sensory responses such as
the spread of embarrassing information about an hyper/hyposensitivity to auditory, olfactory, tactile,
individual (van der Wal, de Wit, & Hirasing, 2003). or visual stimuli; problems in motor coordination;
Students are involved in bullying as victims, and poor performance in physical education, can
perpetrators, victim-perpetrators, or bystanders. also contribute to the risk of becoming a target of
Victims may experience many forms of bullying the peer victimization (Bejerot, Edgar, & Humble,
with considerable variability in form. Some stu- 2011; Kelly et al., 2008).
dents may be involved in bullying as both a Perpetrators of bullying intend to cause mental
victim and perpetrator; that is, they are bullied and/or physical harm or suffering on other children;
by one student or a group of students and may perpetrators identify what would cause pain to their
also individually or in a group bully other stu- victims and, then, plan and execute their actions
dents (Schwartz, 2000). accordingly. However, it is difficult for children
With recent advances in information technol- and adolescents with ASD to bully others due to
ogy, bullying has added cyberspace to the their difficulties in understanding and using the
schoolyard and neighborhood as sites for bullying. rules governing social behaviors and perspectives
In cyberspace, bullying can take place anony- of other people. Nevertheless, their behaviors may
mously, without overtly identifying the perpetra- be regarded as bullying for several reasons. First,
tors. Further, children or adolescents may not be children and adolescents with ASD may have
safe from bullying even in their homes since increased levels of aggressive behaviors (Mandell,
unkind text messages, hateful e-mails, videos, or Walrath, Manteuffel, Sgro, & Pinto-Martin, 2005;
provocatively manipulated messages and mate- van Roekel et al., 2010). Since bullying is a form of
rials can reach them 24 hours per day, 7 days aggression, those with ASD who have increased
a week (Pridgen, 2009). level of aggression may be considered to be bully-
ing other children or adolescents (van Roekel
et al.). Second, because adolescents with ASD
Epidemiology/Clinical Expression have limited insight into social processes (Frith &
Hill, 2004; van Roekel et al., 2010), they may not
Children and adolescents with Autism Spectrum be aware of the consequences of their own behavior
Disorder (ASD) have essential difficulty in or words; some of these behaviors may be regarded
reciprocal social interaction along with as bullying (van Roekel et al.). For example, chil-
impairment in communication skills (American dren with ASD may say brutally honest things or
Psychiatric Association [APA], 1994; Caronna, violate the physical space of others to the extent that
Milunsky, & Tager-Flusberg, 2008; Frith & Hill, they cause discomfort, even though it may not be
2004; Gura, Champagne, & Blood-Siegfried, 2011; intended to be bullying (Montes & Halterman,
Kelly, Garnett, Attwood, & Peterson, 2008; van 2007; van Roekel et al., 2010).
Roekel, Scholte, & Didden, 2010). These difficul- Although the severity of ASD symptoms is
ties make those with ASD especially vulnerable for negatively correlated with successful social inclu-
involvement with bullying as victims and/or perpe- sion and peer relationships, even children and
trators since bullying is a form of dynamic and adolescents with high-functioning ASD continue
complex social interactions (Cappadocia, Weiss, to struggle with social competence as they age
& Pepler, 2011; Sharp & Cowie, 1994). Children (Brauminger & Kasari, 2000; Cappadocia et al.,
with ASD also often demonstrate stereotyped 2011; Orsmond, Krauss, & Seltzer, 2004); as
B 486 Bullying
a result, even with improvement in overall func- demonstrated that children and adolescent with
tioning, individuals with ASD remain at increased high-functioning ASD recruited from those
risks for bullying experiences (Cappadocia et al., awaiting participating in social intervention study
2011). (N ¼ 62) showed increased scores for bullying
Indeed, several previous studies have reported participation when compared to a control group,
that children or adolescents with ASD showed even after being controlled for their IQs (Volker
increased involvement in bullying as victims or et al., 2010).
perpetrators (Cappadocia et al., 2011; Little, When examining the experience of school bul-
2001, 2002; Twyman et al., 2010; van Roekel lying in children and adolescents with ASD, the
et al., 2010). Little used a website survey of 411 school setting likely plays an important role: there
parents of children with Asperger’s disorder (AD) are advantages and shortcomings in different
(75% of subjects) or nonverbal learning disorder school settings for children and adolescents with
(25%); they reported that up to 75% of the children ASD (Burack, Root, & Zigler, 1997; Laugeson,
with AD were bullied within previous year. The Frankel, Mogil, & Dillon, 2009). On one hand,
younger children, boys, and children with ASD regular classroom has been associated with
had greater risk for victimization (Little, 2001). In increases in the complexity of interactions and
another study of 187 adolescents with ASD attend- decreases in nonsocial activity, in comparison to
ing a special secondary education school, van special education settings. On the other hand,
Roekel et al. also reported that 7 to 30% were these individuals report often feeling lonelier and
victimized more than once a month, and having poorer quality friendships then their typi-
19 to 46% bullied others, depending on the infor- cally developing classmates (Capps, Sigman, &
mants (teacher, peer, or self-report of bullying) Yirmiya, 1996; Laugeson et al., 2009; Sigman &
(van Roekel et al., 2010). Samson et al. showed Ruskin, 1999). Another study also implies impor-
individuals with Autistic Disorder recruited from tant feature that in a special educational setting,
clinics in Germany and Switzerland (40 with teachers report higher rates of bullying among stu-
autism and 83 control), who reported higher rates dents with ASD than those without (van Roekel
of experiencing teasing or being ridiculed, com- et al., 2010).
pared to the control group who did not have ASD In general, bullying is associated with various
diagnoses (Samson & Huber, 2010). Interestingly, psychological problems as consequences or ante-
Shtayermann measured the bullying experiences of cedents to bullying experiences (Barker,
10 adolescents or young adults with Asperger’s Arseneault, Brendgen, Fontaine, & Maughan,
Disorder using mailed or online self- or parent’s 2008; Kim, Koh, & Leventhal, 2005; Kim,
questionnaires, and reported a negative correlation Leventhal, Koh, Hubbard, & Boyce, 2006; Salmon,
between the severity of AD symptoms and victim- James, & Smith, 1998; Srabstein & Piazza, 2008);
ization. The authors considered that children and children and adolescents with ASD who are also
adolescents with milder AD symptoms received involved with bullying are not exceptions. In a study
lesser support and supervision from teachers and/ of 192 children diagnosed with ASD recruited from
or parents than those with severe symptom, leading the website for parents of children with ASD or the
to greater risks for victimization due to “under- school system, using parental report of psychopa-
surveillance” by adults (Shtayermman, 2007). thology, Cappadocia et al. reported that ASD chil-
Although there are significant limitations in his dren who were bullied once or more per week had
study, including the small number of samples and higher levels of anxiety; hyperactivity; self-injuri-
survey accuracy, this finding suggests that children ous, stereotypic behaviors; and oversensitivity when
and adolescents with ASD, irrespective of symptom compared to those not bullied or bullied less than
severity, require appropriate support from care- once per week (Cappadocia et al., 2011). Addition-
givers and teachers in order to prevent peer victim- ally, correlations between peer victimization and
ization. Additionally, Volker et al., using suicidal ideation were reported in adolescents with
a standardized behavioral rating scale, AD (Asperger’s Disorder) (Shtayermman, 2007).
Bullying 487 B
Kelly et al. reported that peer victimization was prevention, early identification, and intervention
not only directly related to severity of ASD symp- with bullying in ASD children and adolescents.
toms, but also that poor peer relationship was asso- Due to their impairments in making and
ciated with anxiety and depression symptoms recognizing social interactions, the utility of
measured by parental survey in 322 children with self-report as a tool for identifying bullying expe- B
ASD recruited from the clinics. This suggests that riences in the ASD population may be limited.
not only do ASD symptoms increased risks for peer Indeed, van Roekel et al. showed that teachers
victimization but also that victimization may reported higher prevalence of bullying compared
worsen associated symptoms in children with to peer- and self-reports which indicated much
ASD (Kelly et al., 2008). Such bidirectional lower rates of school bullying in this population:
impacts of social problems and peer victimization teachers reported 27% of adolescents frequently
on each other have been already demonstrated in involved in school bullying (more than once
a general population of adolescents in a week), whereas adolescents themselves
a longitudinal study (Kim et al., 2006). reporting only 12% in 230 adolescents with
In addition to ASD severity, cognitive function ASD (van Roekel et al., 2010). This was dis-
may play roles in the risks for the involvement in tinctly different from the findings in children
bullying and development of psychopathological and adolescents without ASD, when on average
consequences from bullying experiences. For self-report or peer nomination measurement
example, children with milder forms of ASD or report 35 to 48% of involvement in bullying as
higher cognitive function may be more accurate in victims and/or perpetrators, but teacher or parent
recognizing bullying when they are bullied while report only have 10 to 18% (Cleary, 2000;
those with more severe ASD or lower levels of Hunter, Boyle, & Warden, 2004; Ladd &
cognitive function might not; this may lead to Kochenderfer-Ladd, 2002; Nansel et al., 2001;
more serious adverse consequences from bullying Rønning et al., 2009). Such a discrepancy
experiences in the higher functioning groups may stem from the combination of two factors:
(Sofronoff, Dark, & Stone, 2011). First, teachers may have missed opportunities to
The experience of bullying in childhood and witness bullying incidences among typically
adolescence can have long-term sequelae, includ- developing children since bullying usually occur
ing in adulthood. Samson et al. recruited 40 adults in the absence of adults supervision; children and
diagnosed with ASD and 83 adults without ASD adolescents with ASD receive higher levels of
to compare their recollection of bullying experi- supervision and monitoring from teachers,
ence in their childhood and/or youth; compared to resulting in more opportunities for teachers to
the control group, the individuals with Asperger’s observe peer interactions and bullying in this
Disorder report not only higher rates of recollec- population. Second, individuals with ASD have
tions of being ridiculed or teased in their child- difficulties understanding the mental states of
hood or youth, but also fear for being ridiculed at other people, and consequently in understanding
present, indicating that the psychological damage the intentions of others (Frith & Hill, 2004; van
of school bullying persists beyond the school Roekel et al., 2010). It may be difficult for chil-
years (Samson & Huber, 2010). dren and adolescents with ASD to recognize or
identify bullying incidents due to their limited
social insights, unlike typically developing chil-
Evaluation and Differential Diagnosis dren (van Roekel et al.). Therefore, comprehen-
sive assessment with multiple informants
Given the high prevalence of bullying and its including caregivers, teachers, and peers in addi-
association with psychiatric and psychological tion to self-report is crucial for the identification
morbidities in children and adolescents of bullying experience in children and adoles-
with ASD, comprehensive and careful cents with ASD (Ladd & Kochenderfer-Ladd,
attention and assessment is required for 2002; Mandell et al., 2005).
B 488 Bullying
Treatment ASD (Cappadocia et al., 2011; Frankel, Myatt,

Whitham, Gorospe, & Laugeson, 2010; Laugeson
Screening for bullying experience and symptoms et al., 2009). This relationship scaffolding, individ-
for ASD in primary care and community setting is ualized for each child to capitalize on his or her
an important first step for early identification and strengths and support weaknesses, can help the
intervention since children and adolescents with child develop coping skills that may reduce the
ASD are at increased risks for the involvement of impact of the bullying on the victimized child and
bullying (Gura et al., 2011; Tantam, 2009). in turn reduce the likelihood of bullying. It is impor-
Careful school placement is crucial for children tant to encourage children to seek help from
and adolescents with ASD. Regular education a trusted adult and continue to seek help until they
classroom placement has resulted in mixed out- find an adult who is willing to listen and offer
comes for individuals with ASD (Burack et al., protection and support. Once the adult understands
1997; Laugeson et al., 2009). As mentioned earlier, the particulars of the bullying episodes (e.g., when
mainstream classroom placement is associated with and where), safe places and safe people can be
the increase of the complexity of interactions and discussed to minimize the risk for bullying
decrease in nonsocial activity in comparison to to occur (Cappadocia et al., 2011; Cummings
special education. On the other hand, placement in et al., 2006).
special education classroom can enhance teachers’ Finally, validated effective antibullying cam-
capacities for careful attention and intervention for paigns/interventions to decrease bullying in
those students with ASD and protection from unde- home, schools, and communities will exert
sirable social stigma and traumatization (Laugeson preventive effect on bullying not only for
et al.). Having close friends in a classroom is pro- children with ASD but for all children receiving
tective of becoming a target of bullying (Cappado- such interventions (Olweus, 1994; Olweus &
cia et al., 2011; Nansel et al., 2001; Williams, Limber, 2010; Vreeman & Carroll, 2007).
2007). Therefore, interventions such as social skill Understanding the relationships between
training to help these children have better friend- ASD and bullying has been limited due to the
ship will decrease their risks for peer victimization shortcomings of previous studies, including
(Laugeson et al., 2009). small sample size, limited sampling methods,
Children and adolescents with ASD have vari- and/or inadequate measurement of bullying
ous comorbid psychopathologies including depres- (Mandell et al., 2005). Future study should
sion, anxiety, and withdrawal, which are reported to focus on incidence/prevalence of bullying, the
be associated with increased risks for the involve- impact of bullying experiences on the natural
ment of bullying in general population (Volker course of ASD, associations between bullying
et al., 2010). Appropriate assessment and interven- experiences and other comorbid psychopathol-
tions for comorbid conditions in ASD children is ogy, and development and assessment of inter-
warranted (Volker et al.). vention programs in larger population-based
When a child is being bullied, particularly samples of children and adolescents with ASD.
a child with a disability, adult support is crucial.
Through scaffolding, adults can support children to
acquire and develop important social skills such as: Conclusion
adaptive emotional and behavioral regulation strat-
egies and coping skills, identifying and engaging Bullying is common among all children, but the
with supportive peers, problem solving, and com- children with ASD are at even greater risk of this
municating assertively (Cappadocia et al., 2011; harmful experience. And, just as is the case for
Cummings, Pepler, Mishna, & Craig, 2006). typically developing children, reduction of bully-
Recent research supports the effectiveness and ing enhances developmental prospects for all
importance of parent-assisted learning with respect children, including those with ASD. While ASD
to developing social skills among children with may not be preventable at this time, we can
Bullying 489 B
reduce or even prevent bullying experiences for Hunter, S. C., Boyle, J. M. E., & Warden, D. (2004). Help
children with ASD, as we can and must for all seeking amongst child and adolescent victims of
peer-aggression and bullying: The influence of
children. school-stage, gender, victimization, appraisal, and
emotion. British Journal of Educational Psychology,

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cism experiences in children with special health care
needs. Journal of Developmental and Behavioral
Pediatrics, 31, 1–8. ▶ Antidepressants
Buspirone 491 B
References and Readings benzodiazepine, buspirone does not directly
affect a GABA system and is not habit-forming.
Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric There is limited information on the use of
buspirone in children and only one trial in ado-
(2nd ed.). New York: Oxford.
lescents with pervasive developmental disorders. B
In that study, buspirone appeared to be only mod-
estly beneficial for disruptive and agitated
behavior.
Buspar
▶ Buspirone
See Also
▶ Anxiolytics
Buspirone

Nursing & Child Psychiatry, Yale University
Buitelaar, J. K., van der Gaag, R. J., & van der Hoeven, J.
School of Nursing, Yale Child Study Center, (1998). Buspirone in the management of anxiety and
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Synonyms psychopharmacology: Principles and practice
Buspar; Vanspar
Definition
Buspirone is an antianxiety medication that is an

agonist for the serotonin 1A receptor. Unlike the
C
CABS During the first five trials of CVLT-C, a list of

15 items consisting of three semantic categories
▶ Clancy Behavior Scale (fruit, clothing, and toys), labeled “list A” or “the
Monday list,” is read aloud to the child and he or
she is asked to recall as many items as possible
following each presentation. During the sixth
California Verbal Learning Test, trial, a second 15-item list containing new
Children’s Version (CVLT-C) words that belong to one of the categories from
the original list (fruits) as well as words from two
Beau Reilly and Raphael Bernier new categories with semantic similarities
Psychiatry and Behavioral Sciences, University (furniture and sweets) from the original list are
of Washington, Seattle, WA, USA presented as “list B” or “the Tuesday list” to the
child as an interference task. The child is then
asked to recall as many words as possible. After
Synonyms completion of the list B trial, the child is then
asked to recall words from list A without presen-
CVLTC; CVLT-C; CVLT – Children’s Version tation of the items. In the seventh trial, list cate-
gories are used as cues to elicit recall from the
original list via prompts from the examiner such
Description as “Tell me all the things to wear in the Monday
list.” Following trial 7 is a 20-min break from the
The California Verbal Learning Test-Children’s task during which time the child can complete
Version (CVLT-C; Delis, Kramer, Kaplan, & nonverbal tasks or participate in other activities
Ober, 1994) is an examination of auditory and that provide moderate distraction. Following this
verbal learning for children between the ages of “long-delay” interval, the child is asked to recall
5 years and 16 years 11 months. The test makes as many words as he or she can from list A (long-
use of familiar visual categories to generate a delay free-recall trial), asked to recall words from
measure of short- and long-term memory list A after being provided with the categorical
performance. Encoding and recall are examined cues (long-delay cued-recall trial), and finally
via the use of single words verbally presented in read a 45-item list aloud and asked to
the context of “a shopping list” over the course of indicate whether or not each word was on list
eight total trials spanning 15–20 min with an A (yes/no recognition trial). Responses are
additional 20-min period to accommodate recorded and documented by the examiner during
delayed recall testing. every trial.

C 494 California Verbal Learning Test, Children’s Version (CVLT-C)
A complete administration of the CVLT-C variable, in particular, allows for a thorough

produces data on eight recall measures, eight examination of specific learning characteristics
learning characteristics, four areas of recall that may be evident across differing presentations
errors, four recognition measures, and five of clinical populations. Deficits in areas related to
contrast measures. This includes information learning (i.e., flat learning slope across trials with
concerning encoding strategies for success over low amounts of new words learned), encoding
time as well as the characteristics of errors that (e.g., poor trial 1 performance followed by
occur. In addition to generating information on a normative learning slope), or sustaining focus
the quantity of items accurately recalled after (i.e., normative recall on initial trials with poor
each of the eight testing trials, the CVLT-C recall on later trials) can be identified with the
allows for the detailed examination of character- learning slope, allowing for the closer inspection
istics related to acquisition methods utilized dur- of learning characteristics and discrimination of
ing the learning process. Characteristics related other possible domains of learning that may be
to the learning process are examined through the affected (Spreen & Strauss, 1998). Children with
use of learning strategy variables and contrast Down syndrome, attention deficit hyperactivity
variables. disorder (ADHD), and other disorders have dem-
The learning strategy variables aid in outlining onstrated distinct and differentiated characteris-
the characteristics of acquisition and encoding tics of learning slope in clinical populations
that progress throughout the course of the (Delis et al., 1994).
examination. They include semantic clustering The CVLT-C contrast variables (Donders,
(i.e., consecutive words from the same category), 1999) aid in the identification of trial discrepan-
serial clustering (i.e., words recalled in the same cies and learning differences that occur through-
order in which they were presented), primacy out the learning process. These include aspects
recall (i.e., percentage of words recalled from of encoding related to proactive interference
the first five items of the list), middle recall (i.e., the contrast between list B recall and list
(i.e., percentage of words recalled from the mid- A trial 1 recall), retroactive interference (i.e., the
dle five items of the list), recency recall contrast between list A short-delay free recall and
(i.e., percentage of words recalled from the last list A trial 5), rapid forgetting (i.e., contrast
five items of the list), learning slope (i.e., the between list A long-delay free recall and list
average number of new words recalled per learn- A short-delay recall), and retrieval problems
ing trial), consistency (i.e., percentage of words (i.e., contrast between discrimination trial and
recalled once that were also recalled on the fol- list A long-delay free recall).
lowing trial), recognition hits (i.e., number of
words correctly identified as belonging to list
A during the recognition trial), and discrimina- Historical Background
bility (i.e., accuracy of distinguishing target
words in list A from distraction words in list B). Delis et al. (2000) observed that while there are
Characteristics of errors are also calculated with a variety of verbal learning instruments that
regard to perseveration (i.e., words repeated in measure the amount of material that is recalled,
a trial), free intrusions (i.e., extra-list intrusions far fewer examine the processes by which the
on all free-recall trials), cued intrusions information is learned and retrieved. Construc-
(i.e., extra-list intrusions on the cued-recall tion of CVLT-C in 1994 followed the same pro-
trials), total intrusions (i.e., extra-list intrusions cess-oriented approach of the original California
on all trials), false-positives (i.e., words incor- Verbal Learning Test (CVLT) for adults (Delis
rectly identified as list A items during the recog- et al., 1987). For construction of the task, selec-
nition trials), and response bias (i.e., the tendency tion of the target words themselves was chosen
to identify words as belonging on the target list based on their frequency of occurrence in the
during recognition trials). The learning slope English language as well as the frequency of
California Verbal Learning Test, Children’s Version (CVLT-C) 495 C
reported words by children in the sample. The of adolescent populations, with girls
three most common words in each semantic cat- outperforming boys (Beebe, Ris, & Dietrich,
egory were removed to avoid recall confounds 2000). Low correlations with measures of execu-
associated with item familiarity (Miller, Bigler, tive functioning and moderate associations with
& Adams, 2003). The context of a shopping list intelligence measures such as the Wechsler block
was selected for its consistent familiarity with design and vocabulary subtests have been
children across a wide range of cultural and reported (Beebe et al., 2000). Donders (1999) C
demographic variables and mapped closely with also identified a significant link between parental
the CVLT with regard to presentation, timing, education levels and test performance in the stan-
and scoring. dardized sample, with children of parents with
higher education consisting of 22% of the highest
performing children and children of parents with
Psychometric Data lower rates of education accounting for 30% of
the children in the below-average range
The normative sample for the CVLT-C consists of of performance.
stratified data taken from the 1988 US census Predictably, age effects were observed among
findings and is comprised of 920 children in 12 the standardization sample, with steeper learning
age ranges from 5 years to 16 years 11 months. slopes being present in children as age increased
Standardized scores were derived from accumu- and development progressed. Consistency of
lative raw score performance per age group, dis- recalled items and immediate recall scores were
tribution normalization, and elimination of also observed to have developmental trends
outliers and skewing effects. The remaining learn- across the sample. The use of semantic clustering
ing score components of the CVLT-C were devel- strategy as a learning strategy was first emergent
oped via regression analyses (Delis et al., 1987). among 9–12-year-old participants. Adolescents
Investigations of test-retest reliability in the sample exhibited higher degrees of serial
among 106 school-age children ranged clustering strategy use compared to other age
from.17 (cued-recall intrusions, for 12-year- groups (Delis et al., 1994). Investigations of
olds) to .90 (perseverations, for 8-year-olds) executive functioning and CVLT-C process
(Delis, Kramer, Kaplan, & Ober, 1987, 1994; scores further indicate that perseverative errors
Spreen & Strauss, 1998). Alternate forms evidence strong consistency throughout develop-
reliability was reported at .84 (Delis et al., 1987, ment with minimal improvement, while rates of
1994; Spreen & Strauss, 1998), indicating appro- intrusions and false-positives exhibit consider-
priate reliability for multiple administrations able improvement as development progresses
with children and tracking results and learning into adolescence (Beebe et al., 2002;
characteristics over time. Delis et al., 1994).
Gender effects were reported by the authors to Donders (1999) provided maximum likeli-
be minimal in the initial standardization sample, hood confirmatory factor analysis on 13 qualita-
and significant differences were not found for tive and quantitative variables from the original
gender in the 4-year-old sample norms provided standardized sample to identify the most salient
by Goodman, Delis, and Mattson (1999) for nor- factors of learning and memory tapped by the
mative populations. However, differences in gen- CVLT-C. A five-factor model consisting of atten-
der have been reported in follow-up examinations tion span, learning efficiency, free delayed recall,
of the standardization sample (Kramer et al., cued delayed recall, and inaccurate recall showed
1997) and have been evidenced in clinical the greatest fit and was proposed to be a valid and
populations of children with ADHD (Cutting clinically useful predictor of performance on the
et al., 2003) and significant head injury measure.
(Warschausky, Kay, Chi, & Donders, 2005). The CVLT-C has been co-normed with the
Gender effects were also evident in examinations children’s category test (CCT; Boll, 1993),
C 496 California Verbal Learning Test, Children’s Version (CVLT-C)
allowing examiners to compare a child’s memory endorsement of distracter items during the recog-
and learning performance with other forms of nition trial. Semantic and serial clustering char-
higher order cognitive functioning. Combining acteristics were also consistent with
the results of both tasks to generate the learning developmental trends, providing evidence for
profile of a child can be clinically valuable as the utility in identifying early memory and learning
CCT provides explicit feedback on a nonverbal characteristics with the younger population.
task, while the CVLT-C provides non-explicit
feedback on a verbal task through repetition. By
taking advantage of the co-normed scores, clini- Clinical Uses
cians are able to tap a wider range of learning
areas and skills for characterizing the cognitive The CVLT-C has been used to assess memory
capabilities of the child. Donders (1999) exam- and learning in a wide variety of clinical child-
ined the psychometric comparisons of the two hood populations and has been used to examine
measures including the magnitude of difference verbal learning in children with ASD. Early stud-
necessary for statistical significance in scores. ies of memory and list learning among children
Standardized sample data from both measures with ASD highlighted specific deficits in recall co
were used to evaluate covariances and statisti- mpared to control groups. Boucher and Warring-
cally significant discrepancies between the ton (1976) used memory tests that employed pic-
T scores of those instruments as well as the base tures, lists, and spoken words with 29 children
rate of specific discrepancies among 920 children with ASD and compared recall scores against
ranging in age from 5 to 16 years. Results age-matched controls. During trials of forced-
suggested that the CCT and CVLT-C share choice recall, children with autism showed sig-
a small degree of common variance. Statistically nificantly lower rates of recall than controls but
significant score discrepancies between the two demonstrated considerable improvement when
measures (T-score difference greater than 18 provided with semantic descriptive cues of list
among 5–8-year-olds and greater than 16 among items and pictures.
9–16-year-olds) were common, indicating Initial investigations of verbal recall among
that evaluation of the potential clinical signifi- children with autism spectrum disorder (ASD)
cance of a discrepancy between the obtained utilizing the CVLT also suggested distinct differ-
results should also include consideration of base ences in learning and memory profiles when com-
rate statistics when evaluating individual pared to typically developing peers. Minshew
children. and Goldstein (1993) compared the performance
While the standardization sample focused on of high-functioning children and adults with ASD
children ages 5 years through 16 years 11 months, ranging in age from 12 to 40 years old to age-
Goodman et al. (1999) provided normative data matched normal controls using the CVLT. The
for 4-year-old participants on the CVLT-C for comparison group significantly outperformed the
potential administration with younger ASD group. Specific scores indicated that while
populations to aid in early identification and individuals with ASD showed comparable recall
intervention. Each month of the 4-year-old and recognition scores when presented with list
range was represented among the stratified sam- A of CVLT, they showed significantly more
ple of 80 (40 males and 40 females). Performance intrusion errors on both list A and list B items
characteristics of the younger population were and considerably lower recall scores on list B.
considerably similar to that of the normative The authors concluded that the overall character-
sample data, apart from a few learning characteristics of the ASD scores were indicative of a
istics. The 4-year-old participants had a tendency “subtle inefficiency of verbal memory” that was
for higher extra-list intrusions relative to their more suggestive of deficits in mechanisms for
correct responses on cued recall that were not effectively organizing information than a reflec-
present on free recall as well as a higher tion of comprehensive memory impairment.
California Verbal Learning Test, Children’s Version (CVLT-C) 497 C
More recent investigations into learning strat- stability coefficients of many of the variables
egies and encoding profiles of children with ASD examined in the CVLT-C fall below acceptable
lend support for this theory and suggest that the standards, cautioning against the use of single
CVLT-C may be effective in highlighting variables as valid examination of cognitive fac-
specific characteristics of verbal learning in chil- tors (Spreen & Strauss, 1998). Overall, the test has
dren with ASD that differ from those of typical shown to be an efficient and informative instru-
developing peers. Phelan, Filliter, and Johnson ment of memory and verbal learning among chil- C
(2010) compared performance and verbal learn- dren that serves as a valuable asset to clinicians
ing characteristics on the CVLT-C between 15 involved in diagnostic assessment, treatment plan-
high-functioning children with ASD and typical ning, service enrollment, and needs assessment.
developing controls. Although the learning pro-
files and performance characteristics of both
groups were comparable, children with ASD
demonstrated considerable improvement in their
cued-recall scores compared to their free-recall Beebe, D. W., Ris, M. D., & Dietrich, K. N. (2000). The
scores, suggesting the need for external supports relationship between CVLT-C process scores and mea-
and cueing opportunities to facilitate verbal sures of executive functioning: Lack of support among
community-dwelling adolescents. Journal of Clinical
memory performance among ASD youth.
and Experimental Neuropsychology, 22(6), 779–792.
Key clinical strengths of the CVLT-C include Boll, T. (1993). Children’s category test. San Antonio,
its relative ease of use and excellent internal TX: The Psychological Corporation.
consistency. Considerable research and psycho- Boucher, J., & Warrington, E. K. (1976). Memory deficits
in early infantile autism: Some similarities to the
metric data have been gathered with CVLT-C,
amnesic syndrome. British Journal of Psychology,
and it has proven useful in predicting a variety of 67(1), 73–87.
difficulties and deficits that can inform decision Cutting, L. E., Koth, C. W., Mahone, E. M., & Denckla,
making concerning placements in groups such as M. B. (2003). Evidence for unexpected weaknesses in
learning in children with attention-deficit/hyperactiv-
head trauma patients and other neurodeve-
ity disorder without reading disabilities. Journal of
lopmental disorders (Nagel et al., 2006; Nichols Learning Disabilities, 36(3), 257–267.
et al., 2004). As previously noted, the test pro- Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A.
vides a considerable amount of information about (1987). California verbal learning test manual
(CVLT). San Antonio, TX: The Psychological
the verbal learning process and learning strate-
Corporation.
gies across a relatively short period of time in Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A.
such a way that recall and cueing effects can be (1994). California verbal learning test-children’s ver-
examined efficiently and reliably. Scores on the sion (CVLT-C). San Antonio, TX: The Psychological
Corporation.
CVLT-C have been shown to account for
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A.
a considerable amount of the variance in the (2000). The California verbal learning test manual
prediction of special education services and (2nd ed.). San Antonio, TX: The Psychological
long-term educational outcome among children Corporation.
Donders, J. (1999). Structural equation analysis of the
with severe head injury that could translate to
California Verbal Learning Test-Children’s Version
other clinical populations (Miller & Donders, in the standardization sample. Developmental Neuro-
2003). The CVLT-C’s implementation across psychology, 15(3), 395–406.
a wide range of childhood populations illustrates Goodman, A. M., Delis, D. C., & Mattson, S. N. (1999).
Normative data for 4-year-old children on the Califor-
its breadth in utility and efficiency across several
nia Verbal Learning Test-Children’s Version. The
domains of care. The provision of normative data Clinical Neuropsychologist, 13(3), 274–282.
for 4-year-olds additionally provides valuable Kramer, J. H., Delis, D. C., Kaplan, E., O’Donnell, L., &
opportunities for early screening, intervention, Prifitera, A. (1997). Developmental sex differences in
verbal learning. Neuropsychology, 11(4), 577–584.
and tracking among children early in develop-
Miller, M. J., Bigler, E. D., & Adams, W. V. (2003).
ment. While the internal consistency of the test Comprehensive assessment of child & adolescent
has been thoroughly investigated and validated, memory: The wide range assessment of memory and
C 498 Callosotomy (Surgical Severing)
learning, the test of memory and learning, and the Description

California verbal learning test-children’s version. In
C. R. Reynolds & R. W. Kamphaus (Eds.), Handbook
of psychological assessment of children: Intelligence, The CANTAB ® tests are simple, computerised,
aptitude, and achievement (pp. 275–304). New York: non-linguistic, and culturally blind. They can be
Guilford Press. administered by a trained assistant. Importantly,
Miller, J. J., & Donders, J. (2003). Prediction of educa- interpretation of a patient’s condition can be eas-
tional outcome after pediatric traumatic brain injury.
Rehabilitation Psychology, 48, 237–241. ily understood by a clinician. Below is a complete
Minshew, N. J., & Goldstein, G. (1993). Is autism an list of all tests, correct at time of publication. The
amnesic disorder? Evidence from the California verbal tests are categorised as assessing the following
learning test. Neuropsychology, 7(2), 209–216. cognitive domains:
Nagel, B. J., Delis, D. C., Palmer, S. L., Reeves, C., Gajjar,
A., & Mulhern, R. K. (2006). Early patterns of verbal 1. Induction
memory impairment in children treated for medullo- 2. Visual Memory
blastoma. Neuropsychology, 20(1), 105–112. 3. Executive function
Nichols, S., Jones, W., Roman, M. J., Wulfeck, B., Delis, 4. Attention
D. C., Reilly, J., et al. (2004). Mechanisms of verbal
memory impairment in four neurodevelopmental 5. Verbal/Semantic Memory
disorders. Brain and Language, 88(2), 180–189. 6. Decision Making and Response Control
Phelan, H. L., Filliter, J. H., & Johnson, S. A. (2010). Brief 7. Social Cognition
report: Memory performance on the California verbal 8. Other tests
learning test – children’s version in autism spectrum
disorder. Journal of Autism and Developmental Disor-
ders, 41(4), 518–523.
Spreen, O., & Strauss, E. (1998). A compendium of neuro- CANTAB – Induction
psychological tests: Administration, norms, & com-
mentary (2nd ed.). New York: Oxford University Press.
Warschausky, S., Kay, J. B., Chi, P., & Donders, J. (2005). These very short tests can be used to familiarize
Hierarchical linear modeling of California verbal participants with the general idea of responding
learning test–children’s version learning curve charac- in a task by touching the screen. They can also be
teristics following childhood traumatic head injury. regarded as warm-up tasks, getting the partici-
Neuropsychology, 19(2), 193–198.
pant used to the general testing situation.
They consist of: Motor Screening Task and
Big/Little Circle
Motor Screening (MOT)
Callosotomy (Surgical Severing) See Fig. 1
▶ Agenesis of Corpus Callosum Overview

The Motor Screening test is typically administered
at the beginning of a test battery, and serves as
a simple introduction to the touch screen for the
Cambridge Neuropsychological Test participant. If a participant is unable to comply
Automated Battery with the simple requirements of this test, it is
unlikely that they will be able to complete other
Aditya Sharma tests successfully. This test therefore screens for
Academic Child and Adolescent Mental Health, visual, movement, and comprehension difficulties.
Sir James Spence Institute Newcastle University,
Newcastle upon Tyne, UK Administration Time
Around 2 minutes
Synonyms Task
Participants must touch the flashing cross which
CANTAB is shown in different locations on the screen.
Cambridge Neuropsychological Test Automated Battery 499 C
Cambridge Neuropsychological Test Automated Cambridge Neuropsychological Test Automated

Battery, Fig. 1 Motor screening task Battery, Fig. 2 Big/Little circle (BLC)
Outcome Measures Test Modes

This test has two outcome measures which One mode – clinical
measure the participant’s speed of response and
the accuracy of the participant’s pointing.
Visual Memory
Test Modes
Two modes are available – clinical and high vis- These tests allow investigation of visual and spa-
ibility. In high visibility the crosses are drawn tial aspects of memory and consist of: Delayed
using thicker lines and are easier to see. Matching to Sample, Paired Associates Learning,
Pattern Recognition Memory and Spatial Recog-
Big/Little Circle (BLC) nition Memory.
See Fig. 2
Delayed Matching to Sample
Overview See Fig. 3
The Big/Little Circle test assesses comprehen-
sion, learning, and reversal. It is also intended to Overview
train participants in the general idea of following Delayed Matching to Sample (DMS) assesses
and reversing a rule, before proceeding to the forced choice recognition memory for novel
Intra-Extra dimensional Shift test (IED), so it non-verbalisable patterns, and tests both simulta-
should ideally precede the IED task in a battery. neous and short-term visual memory. This test is
primarily sensitive to damage in the medial tem-
Administration Time
poral lobe area, with some input from the frontal
Around 2 minutes
lobes.
Task
Participants must first touch the smaller of the Administration Time
two circles displayed, then, after 20 trials, touch Around 10 min
the larger circle for 20 further trials.
Task
Outcome Measures The participant is shown a complex visual pattern
This test has five outcome measures, covering (the sample) and then, after a brief delay, four
latency (speed of response) and the participant’s similar patterns. The participant must touch the
ability to touch the correct circle. pattern which exactly matches the sample.
C 500 Cambridge Neuropsychological Test Automated Battery

Battery, Fig. 3 Delayed matching to sample Battery, Fig. 4 Paired associates learning (PAL)
Outcome Measures was originally located. If the participant makes an

This test has 19 outcome measures, assessing error, the patterns are re-presented to remind the
latency (the participant’s speed of response), the participant of their locations. The difficulty level
number of correct patterns selected, and statisti- increases through the test. In the clinical mode,
cal analysis measuring the probability of an error the number of patterns increases from one to
after a correct or incorrect response. eight, which challenges even very able
participants.
Test Modes
Clinical mode (for testing once); five parallel Outcome Measures
modes (for repeated testing), and child mode This test has 21 outcome measures, covering the
(a simplified version for testing children) errors made by the participant, the number of
trials required to locate the pattern(s) correctly,
Paired Associates Learning (PAL) memory scores, and stages completed.
See Fig. 4
Test Modes
Overview Clinical mode (for testing once); five parallel
This challenging test assesses visual memory and modes (for repeated testing)
new learning, and is a useful tool for assessing
patients with questionable dementia, Mild Pattern Recognition Memory (PRM)
Cognitive Impairment, Alzheimer’s disease, and See Fig. 5
age-related memory loss.
Overview
Administration Time This is a test of visual pattern recognition mem-
Around 10 min, depending on level of ory in a two-choice forced discrimination para-
impairment digm. This test is often used, in conjunction with
Spatial Recognition Memory (SRM), before the
Task Paired Associates Learning (PAL) test, as both
Boxes are displayed on the screen and are opened these tests help to train the participant for PAL.
in a randomized order. One or more of them will PRM and SRM contain different elements of
contain a pattern. The patterns are then displayed PAL and the results considered together help to
in the middle of the screen, one at a time, and the decide on the exact nature of the cognitive deficit
participant must touch the box where the pattern being considered.

Battery, Fig. 5 Pattern recognition memory Battery, Fig. 6 Spatial recognition memory
Overview
Administration Time This is a test of visual spatial recognition memory
Around 5 min, depending on level of impairment in a two-choice forced discrimination paradigm.
This test is often used, in conjunction with
Task Pattern Recognition Memory (PRM), before the
The participant is presented with a series of 12 Paired Associates Learning (PAL) test, as both
visual patterns, 1 at a time, in the center of the these tests help to train the participant for PAL.
screen. These patterns are designed so that they PRM and SRM contain different elements of
cannot easily be given verbal labels. In the rec- PAL and the results considered together help to
ognition phase, the participant is required to decide on the exact nature of the cognitive deficit
choose between a pattern they have already seen being considered.
and a novel pattern. In this phase, the test patterns
are presented in the reverse order to the original Administration Time
order of presentation. Around 5 min, depending on level of impairment
This is then repeated, with 12 new patterns.
The second recognition phase can be given either Task
immediately or after a 20 min delay. The participant is presented with a white square,
which appears in sequence at five different loca-
Outcome Measures tions on the screen. In the recognition phase, the
This test has three outcome measures, including participant sees a series of five pairs of squares,
the number and percentage of correct trials and one of which is in a place previously seen in the
latency (speed of participant’s response). presentation phase. The other square is in a loca-
tion not seen in the presentation phase. As with the
Test Modes PRM test, locations are tested in the reverse of the
Clinical mode (for testing once); four parallel presentation order. This subtest is repeated three
modes (for repeated testing). Each of these more times, each time with five new locations.
modes also has separate immediate and delayed
versions available. Outcome Measures
This test has three outcome measures, including
Spatial Recognition Memory (SRM) the number and percentage of correct trials and
See Fig. 6 latency (speed of subject’s response).
Test Modes
Clinical mode (for testing once); four parallel
modes (for repeated testing)
CANTAB – Executive Function, Working

Memory, and Planning Tests
These tests address executive function, working

memory, and planning; all are associated with the
frontal area of the brain.
Attention Switching Task (AST)

Overview Cambridge Neuropsychological Test Automated
AST is a test of the participant’s ability to switch Battery, Fig. 7 Intra-extra dimensional set shift
attention between the direction or location of an
arrow on screen. This test is a sensitive measure
of frontal lobe and ‘executive’ dysfunction. Intra-Extra Dimensional Set Shift (IED)
See Fig. 7
Administration Time
Around 8 minutes, depending on level of Overview
impairment Intra-Extra Dimensional Set Shift is a test of rule
acquisition and reversal. It features:
Task • Visual discrimination and attentional set
The test begins with an arrow in the centre of the formation
screen which points either to the left or to the • Maintenance, shifting, and flexibility of
right. The participant is introduced to two but- attention
tons, one on the left and one on the right, and is This test is primarily sensitive to changes to
asked to press a button corresponding to the the fronto-striatal areas of the brain.
direction in which the arrow is pointing. This test is a computerized analogue of the
After this initial training, the participant is then Wisconsin Card Sorting test, and is sensitive to
told that the arrow might appear on the left or the cognitive changes associated with schizophrenia,
right side of the screen, and depending on the cue Parkinson’s Disease, and dopaminergic-
given at the top of the screen, the participant must dependent processes.
either press the left or right button to indicate on
which side of the screen the arrow is displayed, or Administration Time
else press the left or right button to correspond Around 7 min, depending on level of impairment
with the direction in which the arrow is pointing.
Task
Outcome Measures Two artificial dimensions are used in the test:
AST has 7 outcome measures, each of which can • Color-filled shapes
have various options applied to it. The AST mea- • White lines
sures cover latency, correct and incorrect Simple stimuli are made up of just one of these
responses, commission errors, omission errors, dimensions, whereas compound stimuli are made
switch cost and congruency cost. up of both, namely white lines overlying color-
filled shapes. The participant starts by seeing two
Test Modes simple color-filled shapes, and must learn which
AST has one mode: Clinical one is correct by touching it.
Administration Time
Around 10 min, depending on level of
impairment
Task
As for SOC (Stockings of Cambridge), the sub-
ject is shown two displays containing three col- C
ored balls. The displays are presented in such a
way that they can easily be perceived as stacks of
colored balls held in stockings or socks
suspended from a beam. This arrangement
makes the 3-D concepts involved apparent to the
participant, and fits with the verbal instructions.
Cambridge Neuropsychological Test Automated There is a row of numbered boxes along the
Battery, Fig. 8 One touch stockings of cambridge
bottom of the screen. The test administrator first
demonstrates to the participant how to use the
balls in the lower display to copy the pattern in
Feedback teaches the participant which stim- the upper display, and completes one demonstra-
ulus is correct, and after six correct responses, the tion problem, where the solution requires one
stimuli and/or rules are changed. These shifts are move. The participant must then complete three
initially intra dimensional (e.g., color-filled further problems, one each of two moves, three
shapes remain the only relevant dimension), moves, and four moves.
then later extra dimensional (white lines become Next the participant is shown further prob-
the only relevant dimension). lems, and must work out in their head how
Participants progress through the test by satis- many moves the solutions to these problems
fying a set criterion of learning at each stage (six require, then touch the appropriate box at the
consecutive correct responses). If at any stage, bottom of the screen to indicate their response.
the participant fails to reach this criterion after 50
trials, the test terminates. Outcome Measures
OTS has four outcome measures – problems
Outcome Measures solved on first choice, mean choices to correct,
This test has 18 outcome measures, assessing mean latency to first choice, and mean latency to
errors, and number of trials and stages completed. correct. Each of these measures may be calcu-
lated for all problems, or for problems with a
Test Modes specified number of moves (one move to five or
Clinical mode (for testing once); seven parallel six moves).
modes (for repeated testing)
Test Modes
One Touch Stockings of Cambridge (OTS) OTS has four modes, with varying numbers of
See Fig. 8 problems and boxes.
Overview Spatial Span (SSP)

One Touch Stockings of Cambridge is a spatial See Fig. 9
planning task which gives a measure of frontal
lobe function. OTS is a variant of the Stockings of Overview
Cambridge test (see below) and places greater Spatial Span assesses working memory capacity,
demands on working memory as the participant and is a visuospatial analogue of the Digit Span
has to visualize the solution. test.

Battery, Fig. 9 Spatial span Battery, Fig. 10 Spatial working memory
Administration Time lobe and “executive” dysfunction. It has been

Around 5 min, depending on level of impairment shown in recent studies that impaired perfor-
mance on SWM emerges as a common factor in
Task prepsychosis.
White squares are shown, some of which briefly
change color in a variable sequence. The partic- Administration Time
ipant must then touch the boxes which changed Around 8 min, depending on level of impairment
color in the same order that they were displayed
by the computer (for clinical mode) or in the Task
reverse order (for reverse mode). The number of The test begins with a number of colored squares
boxes increases from two at the start of the test to (boxes) being shown on the screen. The aim of
nine at the end, and the sequence and color are this test is that, by touching the boxes and using
varied through the test. a process of elimination, the participant should
find one blue “token” in each of a number of
Outcome Measures boxes and use them to fill up an empty column
This test has six outcome measures, covering on the right hand side of the screen. The number
span length (the longest sequence successfully of boxes is gradually increased, until it is neces-
recalled), errors, number of attempts, and latency. sary to search a total of eight boxes. The color and
position of the boxes used are changed from trial
Test Modes to trial to discourage the use of stereotyped search
Two modes: clinical mode and reverse mode. strategies.
Spatial Working Memory (SWM) Outcome Measures

See Fig. 10 The 24 outcome measures for SWM include
errors (touching boxes that have been found to
Overview be empty, and revisiting boxes which have
SWM is a test of the participant’s ability to retain already been found to contain a token),
spatial information and to manipulate remem- a measure of strategy, and latency measures.
bered items in working memory. It is a self-
ordered task, which also assesses heuristic Test Modes
strategy. This test is a sensitive measure of frontal Clinical mode

Battery, Fig. 11 Stockings of Cambridge Battery, Fig. 12 Choice reaction time
Stockings of Cambridge (SOC) Test Modes

See Fig. 11 Clinical mode
Overview
SOC is a spatial planning test which gives a CANTAB Attention Tests
measure of frontal lobe function
These tests measure different aspects of attention
Administration Time and reaction time. Choice Reaction Time (CRT),
Around 10 minutes, depending on level of Rapid Visual Information Processing (RVP), and
impairment. Simple Reaction Time (SRT) use the press pad
exclusively as an input device; Match to Sample
Task Visual Search (MTS) and Reaction Time (RTI)
The participant is shown two displays containing use both the press pad and the touch screen.
three coloured balls. The displays are presented
in such a way that they can easily be perceived as Choice Reaction Time
stacks of coloured balls held in stockings or socks See Fig. 12
suspended from a beam. This arrangement makes
the 3-D concepts involved apparent to the partic- Overview
ipant, and fits with the verbal instructions. Choice Reaction Time (CRT) is a two-choice
The participant must use the balls in the lower Reaction Time test which is similar to the Simple
display to copy the pattern shown in the upper Reaction Time (SRT) test, except that stimulus
display. The balls may be moved one at a time by and response uncertainty are introduced by hav-
touching the required ball, then touching the posi- ing two possible stimuli and two possible
tion to which it should be moved. The time taken responses. It is useful for testing general alertness
to complete the pattern and the number of moves and motor speed.
required are taken as measures of the partici-
pant’s planning ability. Administration Time
Around 7 min, depending on level of impairment
Outcome Measures
This test has three outcome measures, including Task
the number and percentage of correct trials and An arrow-shaped stimulus is displayed on either
latency (speed of participant’s response). the left or the right side of the screen.

Battery, Fig. 13 Match to sample visual search Battery, Fig. 14 Rapid visual information processing
The participant must press the left hand Administration Time

button on the press pad if the stimulus is Around 9 min, depending on level of impairment
displayed on the left hand side of the screen,
and the right hand button on the press pad if the Task
stimulus is displayed on the right hand side of the The participant is shown a complex visual pattern
screen. (the sample) in the middle of the screen, and then,
after a brief delay, a varying number of similar
Outcome Measures patterns are shown in a circle of boxes around the
This test has 13 outcome measures, assessing edge of the screen. Only one of these boxes
correct and incorrect responses, errors of com- matches the pattern in the center of the screen,
mission and omission (late and early responses), and the participant must indicate which it is by
and latency (response speed). touching it. Reaction time is measured on the
basis of the release of the press pad, which allows
Test Modes for its more accurate measurement.
Clinical mode
Outcome Measures
Match to Sample Visual Search (MTS) The 12 outcome measures for SOC cover the
See Fig. 13 number of problems solved with minimum
moves, the mean number of moves for n-move
Overview problems, mean initial thinking time for n-move
Match to Sample Visual Search (MTS) is problems, and mean subsequent thinking time for
a matching test, with a speed/accuracy trade- n-move problems.
off. It is a simultaneous visual search task with
response latency dissociated from movement Test Modes
time. Efficient performance on this task Clinical mode
requires the ability to search among the targets
and ignore the distractor patterns which have Rapid Visual Information Processing (RVP)
elements in common with the target. This test See Fig. 14
can help to differentiate between Parkinson’s
disease and Alzheimer’s disease, and also Overview
between Lewy Body dementia and Alzheimer’s Rapid Visual Information Processing (RVP) is
disease. a test of sustained attention (similar to the
Continuous Performance Task) and has proved
useful in many studies in which drugs are used to
help develop a disease model. It is sensitive to
dysfunction in the parietal and frontal lobe areas
of the brain and is also a sensitive measure of
general performance.
C
Administration Time
Around 7 min
Task
A white box appears in the center of the computer
screen, inside which digits, from 2 to 9, appear in
a pseudo-random order, at the rate of 100 digits per Cambridge Neuropsychological Test Automated
minute. Participants are requested to detect target Battery, Fig. 15 Reaction time
sequences of digits (e.g., 2–4–6, 3–5–7, 4–6–8)
and to register responses using the press pad. subject must sometimes respond by using the
press pad, sometimes by touching the screen,
Outcome Measures and sometimes both.
The nine RVP outcome measures cover latency,
Outcome Measures
probabilities, and sensitivity (calculated using
The four outcome measures in RTI are divided
Signal Detection Theory), and hits, misses, false
into Reaction Time (simple and five-choice) and
alarms, and rejections.
movement time (simple and five-choice)
Test Modes Test Modes
Clinical mode, plus 123 mode (for children aged Clinical mode, parallel mode, and child mode
4–8) and 357 mode (for children aged 7–14)
Simple Reaction Time (SRT)
Reaction Time (RTI) See Fig. 16
See Fig. 15
Overview
Overview Simple Reaction Time (SRT) is a test which
Reaction Time (RTI) is a latency task with measures simple Reaction Time through delivery
a comparative history (the five choice task) and of a known stimulus to a known location to elicit
uses a procedure to separate response latency a known response. The only uncertainty is with
from movement time. It is more useful than regard to when the stimulus will occur, by having
CRT or SRT where it is necessary to control for a variable interval between the trial response and
tremor. the onset of the stimulus for the next trial. Like
Choice Reaction Time (CRT), it is useful for
Administration Time testing general alertness and motor speed, and is
Around 5 min, depending on level of impairment often sensitive to medication effects.
Task Administration Time

The task is divided into five stages, which require Around 6 min, depending on level of impairment
increasingly complex chains of responses. In
each case, the subject must react as soon as Task
a yellow dot appears. In some stages, the dot As soon as the participant sees the square on the
may appear in one of five locations, and the screen, they must press the button on the press pad.
Cambridge Neuropsychological Test Automated

Battery, Fig. 16 Simple reaction time
Outcome Measures
The 11 outcome measures for SRT cover latency
(response speed), correct responses, and errors of
commission and omission.
Test Modes
Clinical mode
Cambridge Neuropsychological Test Automated
Battery, Fig. 17 Graded naming test
CANTAB – Semantic/Verbal Memory

Tests in addition graded in difficulty to allow for indi-
vidual differences. This means that it may be able
These tests, which address semantic and/or ver- to detect any word-finding difficulty even in those
bal memory, are relatively new additions to the with an extensive naming vocabulary.
CANTAB battery consisting of: Graded Naming
Test (GNT) and Verbal Recognition Memory Administration Time
(VRM). Around 10 min, depending on level of impairment
Graded Naming Test (GNT) Task

See Fig. 17 Thirty different line drawings are displayed on
the screen, 1 at a time. The participant must
Overview identify the object depicted in each drawing.
The Graded Naming Test has been used exten-
sively in cognitive neuropsychology. The Graded Outcome Measures
Naming Test (GNT) avoids the problem of ceil- This test has six outcome measures, which
ing effects in previous naming tests by having include total correct, total errors, and normative
participants name drawings of objects in ascend- z-score and percentile.
ing difficulty. Reduced efficiency in retrieving
the name of an object can be the first and only Notes
indication of impaired language functioning. Currently available in UK English only (this test
This test assesses object-naming ability, but is is culturally biased and there are no alternative
• Following a delay of 20 min, recognize the
words they have seen before from another
list of 24 words containing the original list
and 12 new distractors
Outcome Measures
The five outcome measures for VRM cover cor- C
rect and incorrect responses for the recognition
and free recall parts of the test.
Notes
Currently available in UK English only
Cambridge Neuropsychological Test Automated Test Modes

Battery, Fig. 18 Verbal recognition memory Clinical mode and four parallel modes for
repeated testing. Each mode has immediate and
delayed parts.
versions at present). A pencil and paper version
of this test is also available.
CANTAB – Decision Making and
Test Modes Response Control Tests
Clinical mode
These tests add another dimension to cognitive
Verbal Recognition Memory (VRM) profiling and investigation of frontal lobe func-
See Fig. 18 tion. Most decisions in life have an emotional or
risk-related component, and many clinical condi-
Overview tions are associated with inappropriate risk
Despite the general desirability of nonverbal tests models/strategies.
because of their culture free applicability, They consist of Affective Go/No-go (AGN),
researchers and clinical studies sometimes Information Sampling Task (IST), Cambridge
require verbal tests, perhaps because of need to Gambling Task (CGT) and Stop Signal Task
explore questions relating to language or left (SST).
hemisphere function. Other verbal tests have
a long history of use in psychiatric assessment Affective Go/No-go (AGN)
and clinical studies. The Verbal Recognition See Fig. 19
Memory test, which assesses immediate and
delayed memory of verbal information under Overview
free recall and forced choice recognition condi- This test assesses information processing biases
tions, should provide comparable results. for positive and negative stimuli.
Affective cognitive functions are thought to be
Task related to the ventral and medial-prefrontal cor-
In the VRM test, the participant is shown a list of tex areas of the brain because of the limbic con-
12 words, 1 at a time, and then asked to: nections with this region. As such, the Affective
• Produce as many of the words as possible Go/No-go test represents a powerful research
immediately following the presentation assessment tool for current studies on the neural
• Recognize the words they have seen before substrates of depression, bipolar disorder, Post-
from a list of 24 words containing the original Traumatic Stress Disorder (PTSD), and many
12 words and 12 distractors other affective conditions.

Battery, Fig. 19 Affective Go/No-Go Battery, Fig. 20 Cambridge gambling task
Administration Time
Around 10 min, depending on level of is presented to the participants “up-front” and
impairment there is no need to learn or retrieve information
over consecutive trials.
Task Unlike other “Gambling” tasks, CGT dissoci-
The test consists of several blocks, each of ates risk taking from impulsivity, because in the
which presents a series of words from two of ascending bet condition, the participant who
three different affective categories: Positive wants to make a risky bet has to wait patiently
(e.g., joyful), Negative (e.g., hopeless), and for it to appear. The likely neural substrate for
Neutral (e.g., element). The participant is given this task is the orbitofrontal prefrontal cortex.
a target category, and is asked to press the press Traumatic Brain Injury, Alcoholism, and Drug
pad when they see a word matching this category. abuse are all conditions sensitive to this test.
Outcome Measures Administration Time

Twelve outcome measures covering latency and Up to 30 min
errors of commission and omission
Task
Note On each trial, the participant is presented with
Currently available in English only. a row of ten boxes across the top of the screen,
some of which are red and some of which are
Test Modes blue. At the bottom of the screen are rectangles
Six modes, four using positive and negative stim- containing the words “Red” and “Blue.” The
uli only, and two using positive, negative, and participant must guess whether a yellow token is
neutral stimuli hidden in a red box or a blue box.
In the gambling stages, participants start with
Cambridge Gambling Task (CGT) a number of points, displayed on the screen, and
See Fig. 20 can select a proportion of these points, displayed
in either rising or falling order, in a second box on
Overview the screen, to gamble on their confidence in this
The Cambridge Gambling Task was developed to judgment. A stake box on the screen displays the
assess decision making and risk-taking behavior current amount of the bet. The participant must
outside a learning context. Relevant information try to accumulate as many points as possible.
at a time, which open up to reveal one of the two
colors shown at the bottom of the screen. Once
a box has been touched, it remains open. When
the subject has made their decision about which
color is in the majority, they must touch the panel
of that color at the bottom of the screen to indicate
their choice. After the subject has indicated their C
choice, all the remaining gray boxes on the screen
reveal their colors and a message is displayed to
inform the subject whether or not they were cor-
rect. The colors change from trial to trial.
There are two conditions – the fixed win con-
dition, in which the subject is awarded 100 points
Cambridge Neuropsychological Test Automated for a correct decision regardless of the number of
Battery, Fig. 21 Information sampling task boxes opened, and the decreasing win condition,
in which the number of points that can be won for
Outcome Measures a correct decision starts at 250 and decreases by
The six CGT outcome measures cover risk tak- 10 points for every box touched. In either condi-
ing, quality of decision making, deliberation tion, an incorrect decision costs 100 points.
time, risk adjustment, delay aversion, and overall
proportion bet. Outcome Measures
The eight IST outcome measures cover errors,
Test Modes latency, total correct trials, mean number of
Ascending first (where stakes are displayed in boxes opened per trial, and probability of the
ascending order for two stages, then in subject’s decision being correct based on the
descending order for two stages) and Descending available evidence at the time of the decision.
first (where stakes are displayed in descending
order for two stages, then in ascending order for Test Modes
two stages). IST has two modes:
• Fixed win-decreasing win (after practice tri-
Information Sampling Task (IST) als, the fixed win stage precedes the decreas-
See Fig. 21 ing win stage)
• Decreasing win-fixed win (after practice trials,
Overview the decreasing win stage precedes the fixed
The Information Sampling Task (IST) tests win stage)
impulsivity and decision making.
Stop Signal Task (SST)
Administration Time See Fig. 22
Up to 15 min
Overview
Task SST is a classic stop signal response inhibition
The subject is presented with a 5 5 array of gray test, which uses staircase functions to generate an
boxes on the screen, and two larger colored estimate of stop signal reaction time.
panels below these boxes. The subject is This test gives a measure of an individual’s
instructed that they are playing a game for points, ability to inhibit a prepotent response.
which they can win by making a correct decision
about which color is in the majority under the Administration Time
gray boxes. They must touch the gray boxes one Up to 20 min
Emotion Recognition Task (ERT)

Overview
ERT measures the ability to identify emotions in
facial expressions. The participant is shown a
series of faces which appear on the screen briefly
and asked to identify the emotion (happiness,
sadness, anger, disgust, surprise and fear).
Administration Time
Around 10 minutes, depending on level of
impairment.
Task
Cambridge Neuropsychological Test Automated One hundred and eighty stimuli, which are com-
Battery, Fig. 22 Stop signal task puter morphed images derived from the facial
features of real individuals each showing a specific
Task emotion, are displayed on the screen, one at a time,
This test consists of two parts. in two blocks of ninety. Each face is displayed for
In the first part, the participant is introduced to a short while (200 ms) and then immediately cov-
the press pad, and told to press the left hand ered up, and then six buttons are displayed, each
button when they see a left-pointing arrow, and describing an emotion which could be portrayed in
the right hand button when they see a right- the photograph. The participant must decide which
pointing arrow. There is 1 block of 16 trials for is the appropriate button to describe the emotion
the participant to practice this. and touch the button. There are fifteen different
In the second part, the participant is told to photographs for each of the six emotions, each
continue pressing the buttons on the press pad showing different levels of intensity.
when they see the arrows, as before, but, if they
hear an auditory signal (a beep), they should Outcome Measures
withhold their response and not press the button. The outcome measures for ERT cover percentages
and numbers correct or incorrect, and overall
Outcome Measures response latencies. Results can be looked at across
SST has five outcome measures, each of which can individual emotions, or across all emotions at once.
have various options applied to it. The SST mea-
sures cover direction errors, proportion of success- Test Modes
ful stops, RT on GO trials, SSD (50%), SSRT. ERT is available for clinical trials immediately,
and will be available for academic research in
Test Modes CANTABeclipse 5. Please contact Cambridge
SST has one mode: clinical. Cognition for further information.
ERT takes around ten minutes to administer in
healthy individuals.
Social Cognition
A range of disorders are known to affect social Other Tests

cognition and there is an expanding research field
examining how such conditions may bias cogni- Visual Analogue Scales (VAS)
tive processes involved in social interaction. This Overview
domain is assessed by: Emotion Recognition Visual Analogue Scales are psychometric
Task (ERT). response scales which can be used as a
measurement instrument for subjective states. versions of the Wisconsin Card Sorting Test and
The CANTAB VAS assess subjective measure- the Tower of London and also the Delayed
ments of drug effect, energy levels, sickness, Matching to Sample test, widely used in monkeys
alertness and mood. for visual recognition memory. The tests are
constructed in such a way that they may be
Administration Time given to animals (monkeys) with minimal
Around 5 minutes, depending on level of change. The nonverbal nature of the CANTAB C
impairment. tests makes them largely language independent
and culture free. CANTAB has been standardized
Task on a large, predominantly elderly, population and
The participant must respond to sixteen questions validated in neurosurgical patients as well as in
as they appear on the screen by touching the on- patients with basal ganglia disorders,
screen slider and moving it to the appropriate Alzheimer’s disease, depression, and schizophre-
position on the scale. nia. In addition, CANTAB has been used to eval-
uate: (a) the therapeutic effects of dopaminergic
Outcome Measures and cholinergic medication in neurodegenerative
The outcome measures for this test allow you disease; (b) cognition in 5–11-year old normal,
to look at the data on a question-by-question learning-disabled, and autistic children; (c) defi-
basis. cits in patients with HIV infection; and (d) early,
asymptomatic Huntington’s disease. The latter
Test Modes illustrate its usefulness in early identification of
Please contact Cambridge Cognition for informa- progressive disorders. It is suggested that the
tion about availability for academic research. battery should have particular utility across
a wide range of age and intelligence in longitudi-
nal assessment after exposure to toxicants, and
Historical Background allow meaningful comparison with experimental
studies of toxic effects in other species.
Grounded in the neurosciences, the CANTAB ® There is emerging evidence to support
neuropsychological tests were developed more the involvement of frontal cortex in autism.
than 21 years ago at the University of Cambridge CANTAB is particularly useful in helping study
by Professors Robbins and Sahakian, to enable the cognitive profile of children who have autism
detailed translational assessment and evaluation and related disorders.
of cognitive function. Lesion, neuroimaging,
clinical and psychopharmacological studies
have enabled a unique understanding of the struc- Psychometric Data
tural, clinical and biochemical sensitivities of
each of the tests. (CANTAB) CANTAB tests are sensitive to cognitive changes
The CANTAB battery was developed for the caused by a wide range of CNS disorders and
assessment of cognitive deficits in humans with medication effects.
neurodegenerative diseases or brain damage Where error scores are a key outcome mea-
(Fray and Robbins 1999). It consists of a series sure, CANTAB tests are graded in difficulty to
of interrelated computerized tests of memory, avoid ceiling effects.
attention, and executive function, administered Where accurate measurement of latency is
via a touch-sensitive screen. It allows important, responses are made via a press pad.
a decomposition of complex tasks commonly Elsewhere, engaging touch-screen technology
used in clinical assessment into their cognitive maximizes compliance.
components and enables the extrapolation of The majority of CANTAB tests are indepen-
findings from the animal literature. Tests include dent of language and culture.
Clinical Uses Frontal lobe excision Roifman syndrome

Frontal variant frontotemporal Schizoaffective disorder
The following cognitive and other disorders have dementia
been investigated using CANTAB ®: Gluten ataxia Schizophrenia
Hallucinosis Seasonal affective
AD/HD – Attention deficit Lesion in orbitofrontal disorder
hyperactivity disorder cortex Head injury Self harm
AIDS dementia complex Liver failure Hearing loss Semantic dementia
Alcoholism Long-term health effects Heart disease Specific language
of diving impairment
Amphetamine addiction Machado-Joseph disease Heart failure Social withdrawal in
Amygdalo-hippocampectomy Mad Hatter’s disease Schizophrenia
Anorexia nervosa Manic depression Heavy social drinking Solvent encephalopathy
Anterior parietal damage Melancholia Hepatic encephalopathy Spina bifida
Antisocial behavior Mercury poisoning Heroin addiction Steele-Richardson-
Antisocial personality disorder Mild cognitive Olzsewski syndrome
impairment (MCI) Herpes encephalitis Stiff Person syndrome
Anxiety Motor neuron disease Hippocampal atrophy Striatocapsular infarct
Attention deficit-hyperkinetic Multiple sclerosis HIV/AIDS Subarachnoid
disorder hemorrhage
Autism Multiple system atrophy Huntington’s disease Substance abuse
Basal ganglia lesions Narcolepsy Hydrocephalus Tardive dyskinesia
Bipolar disorder Neuronal migration Hypercortisolemia Temporal lobe excision
disorders Hyperostosis frontalis interna Temporal lobe lesion
Borderline personality Normal pressure Hypertension Tinnitus
disorder hydrocephalus Insomnia Tourette’s syndrome
Camptocormia Obsessive compulsive Korsakoff syndrome Traumatic brain injury
disorder
Late paraphrenia Trichotillomania
Capgras syndrome Organophosphate
Lead exposure Tuberous sclerosis
pesticide exposure
Left ventricular systolic White matter lesions
Carcinoid syndrome Panic disorder
dysfunction
Chronic drug misuse Paraphrenia
Chronic fatigue syndrome Parkinson’s disease Drugs
Chronic occupational solvent Periventricular brain
Pharmacological studies (academic research)
encephalopathy insult
Critical illness requiring Personality disorder
have been carried out on the following drugs
intensive care using CANTAB:
Dementia Alzheimer-type Petrol (gasoline) sniffing
(DAT) Alcohol Flumazenil Modafinil
Dementia lewy body type Phenylketonuria Amisulphiride Fluoxetine Neuroleptic
Dementia of frontal type Post-concussion Amphetamine Galantamine Nicotine
syndrome Antipsychotic Ginkgo biloba Olanzapine
Developmental dyslexia Premature birth needing medication
intensive care Antiretroviral Glyburide Opiates
Diabetes Premenstrual dysphoric therapy
disorder Atomoxetine Guanfacine Paroxetine
Dorsolateral frontal cortical Progressive supranuclear Branch chain amino Highly active Pergolide
compression palsy acid drink antiretroviral
Down’s syndrome Psychopathy therapy (HAART)
Drug abuse Psychosis Bromocryptine Haloperidol Perindopril
Dysexecutive syndrome Questionable Dementia Buspirone Heroin Petrol/
Gasoline
Frontal lobe damage Renal Cancer
(continued)
(continued)
Can’t Versus Won’t Dilemma 515 C
Caffeine Hydrocortisone Phenserine understanding when a behavioral difficulty is
Cannabis Idazoxan Quetiapine due to a skill deficit (“can’t”), rather than due to
Chlorpromazine Idazoxan plus Risperidone deliberate noncompliance (“won’t”). Caregivers
Clonidine who attribute behavior problems to deliberate
Clonidine Interferon Ritalin noncompliance often see the behavior as rooted
Clozapine Interleukin-2 Rivastigmine in laziness, stubbornness, or defiance. This attri-
Cocaine Kava Rosiglitazone bution has multiple negative consequences, C
delta-9 Ketamine RU-486 including increased frustration and stress for the
tetrahydrocannabinol
caregiver, as well as use of ineffective or con-
Dexamphetamine L-Dopa Scopolamine
frontational behavior management strategies.
Diazepam Lecithin SGS742
Donepezil MDMA Sulpiride
Even caregivers who have some understand-
Dopaminergic Metamphetamine Tacrine ing of autism may believe that the individual with
medication autism is purposely engaging in misbehavior,
Ecstasy Methylphenidate Tryptophan and consequently become embroiled in an
Endozepines Mifepristone Tyrosine unproductive power struggle. The confusing
#2011 Cambridge Cognition – All rights reserved behavioral picture presented by individuals with
autism contributes to this misunderstanding. For
example, individuals with autism often have
See Also a very typical physical appearance, so the care-
givers’ natural inclination is to expect age-
▶ CANTAB appropriate skills and behavior. In addition,
many individuals with autism, including those
References and Readings with language impairments, can repeat back ver-
bal directions even when they have not fully
Cambridge Cognition Ltd. Cambridge automated neuro- understood the content of what was said, giving
psychological test automated battery. www.cantab.com a misimpression about their level of understand-
Fray, P. J., & Robbins, T. W. (1999). CANTAB battery: ing. Furthermore, poor social insight and com-
Proposed utility in neurotoxicology. Neurotoxicology
and Teratology, 18, 499–504. munication deficits may mean that individuals
Ozonoff, S., Cook, I., Coon, H., Dawson, G., Joseph, with autism are unable to recognize and commu-
R. M., Klin, A., et al. (2004). Performance on Cam- nicate their own lack of skill or need for assis-
bridge Neuropsychological Test Automated Battery tance, or may cause them to question directions
subtests sensitive to frontal lobe function in people
with autistic disorder: Evidence from the Collaborative from others in a manner that is perceived as
Programs of Excellence in Autism network. Journal of argumentative or disrespectful. Perhaps most
Autism and Developmental Disorders, 34, 139–150. confusing for caregivers is the unusual scatter of
strengths and weaknesses shown by individuals
with autism, as well as their difficulty in general-
Can’t Versus Won’t Dilemma izing the use of skills from one context to another.
For example, parents of a bright 14 year old with
Elaine Coonrod autism may simply have difficulty understanding
Department of Psychiatry, School of Medicine, how their son can have extensive working knowl-
TEACCH The University of North Carolina at edge of his computer, yet not be able to success-
Chapel Hill, Chapel Hill, NC, USA fully operate the microwave. A teacher of a more
impaired 7 year old may be confused as to why
the student can independently use the toilet at
Definition home but repeatedly soils her clothing at school.
In general, when faced with a “can’t versus
One common issue faced by parents, teachers, won’t” dilemma, it is more productive to begin by
and caregivers of individuals with autism is assuming that the individual with autism “can’t”
C 516 Canadian Certified Rehabilitation Counselor (CCRC)
and then conduct a behavioral assessment focused autism, its specific genetic etiology remains
on the symptoms of autism that may be impeding largely unknown. A candidate gene is one for
his or her behavioral success. The caregiver should which there is some evidence of contribution to
consider the ways in which the individual’s unique the etiology of a disorder but for which this has not
profile of strengths and weaknesses in communica- yet been definitively demonstrated. These genes
tion, socialization, flexibility and interests, sensory are identified by a variety of techniques including
responses, and learning style may be contributing to linkage analysis, association studies, cytogenetic
the behavioral difficulty. That information can then analysis, studies of copy number variation, and
be used to generate positive, proactive strategies to next-generation sequencing. Typically, once a
help support desired behaviors in the future. candidate gene has been identified, it is
reinvestigated via analysis in independent patients’
samples. Particularly for studies that rely on case–
References and Readings control comparisons, replication is essential to ele-
vating a candidate gene to a “risk” gene.
Marcus, L. M., Kunce, L. J., & Schopler, E. (2005).
Working with families. In F. R. Volkmar, A. Klin, R.
Paul, & D. J. Cohen (Eds.), Handbook of autism
and pervasive developmental disorders (Vol. II, Historical Background
Marcus, L. M., & Palmer, A. (2010). Families of children Over the past decade, many studies have shown
with autism: What educational professionals should
know. In F. A. Karnes & K. R. Stephens (Eds.), The that autism is not a simple Mendelian disorder
practical strategies series in autism education. Austin, caused by a single gene at the population level.
TX: Prufrock. In the early phase of autism gene discovery, the
Notbohm, E. (2005). Ten things every child with autism majority of candidate genes were selected for
wishes you knew. Arlington, TX: Future Horizons.
Schopler, E. (1995). Parent survival manual: A guide to study based on biological plausibility; that is,
crisis resolution in autism and related developmental they were involved in some biological process
disorders. New York: Plenum. that could conceivably play a role in ASD. These
genes were then typically evaluated in candidate
gene association studies in which one or a small
Canadian Certified Rehabilitation number of common genetic polymorphisms in or
Counselor (CCRC) near one or a small number of genes were evalu-
ated in cases versus controls. If an overrepresenta-
▶ Certified Rehabilitation Counselor tion of a particular allele or alleles was identified,
the gene was considered a candidate ASD gene.
These studies were based on the hypothesis that
Candidate Genes in Autism common alleles were responsible for the disorder.
Across all of medicine, the majority of such
Youeun Song1 and Abha R. Gupta2 studies proved difficult to replicate. In retrospect,
1
Child Study Center, Yale University School of it is clear that approach had some significant
Medicine, New Haven, CT, USA limitations. Among these, the chances of choos-
2
Developmental-Behavioral Pediatrics, Child ing correctly among millions of genetic varia-
Study Center, Yale University, New Haven, tions were low, the effect sizes carried by
CT, USA common alleles for most common medical con-
ditions were much smaller than anticipated
(resulting in studies that were in retrospect often
Definition markedly underpowered), and there were multi-
ple potential confounds, including ancestral
Although twin and family studies show that genes mismatching of cases and controls, that were
play a critical role in determining the risk for difficult to control for. More recently, the
Candidate Genes in Autism 517 C
approach has been replaced for the most part odds that the locus is linked to the phenotype.
by genome-wide association studies, typically When the LOD score is more than 2.2, linkage is
of large patient cohorts, that eliminate many of considered suggestive; 3.6 is considered signifi-
these difficulties. This approach has led to the cant (Lander & Kruglyak, 1995). Linkage peaks
identification of replicated risk alleles in many have been found on almost every chromosome.
common medical conditions, including schizo- As reviewed by Gupta and State (2007), loci with
phrenia and bipolar disorder. To date, this among the highest LOD scores are 3q26.32 (LOD C
approach has led to the identification of several 4.81), 2q31.1 (LOD 4.80), 17q11.2 (LOD 4.3),
new candidate genes in ASD, but these have not 17q21.32 (LOD 4.1), and 7q36.1 (LOD 3.7). For
yet replicated in well-powered studies. the most part, linkage studies in autism have
Over the last several years, the identification of failed to replicate each other, probably due to
candidate genes through studies of common vari- a number of reasons, such as nonuniform criteria
ation has been complemented by studies of rare for patient selection, differing sets of polymor-
variation. Here again, it is common practice to phisms, and differing statistical methodologies.
pursue an initial observation with an attempted A few loci, such as 17q11-q21 and along 7q, have
independent replication. With rare variations, the been highlighted by more than one study (Abra-
infrequency of individual mutations and the over- hams & Geschwind, 2008). Some of the genes
all genetic heterogeneity of autism may make such implicated are CNTNAP2 (contactin-associated
studies difficult to mount. A variety of approaches protein-like 2), EN2 (engrailed homeobox 2),
are being developed in an effort to provide a path RELN (reelin), MET (MET proto-oncogene),
to confirm candidate loci: these include assessing CADPS2 (Ca2+-dependent activator protein for
the total amount of rare variation in a gene in cases secretion 2), ITGB3 (integrin beta3), and
versus controls (as opposed to asking questions SLC6A4 (solute carrier family 6) (Abrahams &
about one particular rare allele). This approach is Geschwind).
often called a mutation burden analysis. In addi- Linkage studies have also been conducted in
tion, there are ongoing efforts to take advantage of consanguineous families using homozygosity
particular types of variation, including de novo mapping. Homozygous regions are parts of the
mutations, to increase the power to detect and genome where the identical chromosomal seg-
confirm the association of a gene or locus with ment is inherited from both parents due to
ASD risk (Sanders et al., 2011). a recent common ancestor. In homozygosity
mapping, it is hypothesized that the disorder is
inherited as a recessive trait. Candidate genes
Current Knowledge found by this method include DIA1 (deleted in
autism-1), NHE9 (sodium/proton exchanger 9),
Genome-Wide Linkage Studies PCDH10 (protocadherin 10), and CNTN3
Linkage studies identify chromosomal loci (contactin 3) (Morrow et al., 2008).
inherited by affected individuals more frequently
than expected by chance. These studies most Candidate Gene and Genome-Wide
often investigate multiplex families in which Association Studies
there is more than one affected person. DNA Association studies determine whether there is
polymorphisms are used as markers of chromo- a statistically significant relationship between
somal loci throughout the genome. The closer the exposure to the variant and increased (or
marker is to a disease gene, the more likely there decreased) population risk for the phenotype.
is cosegregation between the marker and the phe- Numerous genetic association studies have inves-
notype under study. The likelihood that a locus is tigated common variants in one or a small num-
linked to the phenotype is represented as the LOD ber of candidate genes, often selected due to
score (logarithm of the odds). For example, hypothesis-driven disease models. Since these
a LOD score of 3 means that there is 1,000 to 1 studies are relatively inexpensive, many genes
C 518 Candidate Genes in Autism
have been evaluated for association with autism, analysis include NLGN4X (neuroligin 4X),
with multiple positive results. However, very few UBE3A (ubiquitin protein ligase E3A),
of them have been replicated (Gupta & State, GABRB3, CENTG2 (centaurin gamma 2),
2007). Some genes identified by this method are SHANK3 (SH3 and multiple ankyrin repeat
GABRB3 (gamma-aminobutyric acid A receptor domains 3), and CNTNAP2 (Abrahams &
beta3), GRIK2 (glutamate receptor ionotropic Geschwind; State, 2010).
kainite 2 precursor), SLC25A12 (solute carrier More recently, copy number variations
family 25 member 12), MET, RELN, EN2, (CNVs) have been investigated using
SLC6A4, and CNTNAP2 (Abrahams & microarrays. Genome-wide CNV analyses have
Geschwind, 2008; State, 2010). Rare variants found that CNVs are significantly enriched in
can also be investigated by association studies, neuronal cell adhesion molecules and the
but this method requires comprehensive ubiquitin pathway (Glessner et al., 2009) and
resequencing of candidate genes in large cohorts that recurrent de novo copy number variations
and is expensive. In addition to common variants, (CNVs) at 7q11.23, 15q11.2-13.1, 16p11.2, and
rare variants in CNTNAP2 have been associated the NXRN1 (neurexin 1) locus are strongly asso-
with autism (Bakkaloglu et al., 2008). ciated with autism (Sanders et al., 2011). The
More recently, high-resolution SNP arrays 7q11.23 region, the duplication of which is asso-
have enabled genome-wide association studies ciated with autism in this study, is previously
(GWAS), which query all genes rather than known to be deleted in Williams-Beuren syn-
investigating a few candidate genes at a time. drome, which features a highly social personality,
Three loci which have been associated with suggesting an intriguing correlation between
autism are chromosome 5p14.1, between the copy number at this locus and sociability.
genes CDH9 (cadherin 9) and CDH10 (cadherin
10), chromosome 5p15, near the gene SEMA5A Whole-Exome Sequencing
(semaphoring 5A), and chromosome 20p12.1, With the development of high-throughput technol-
near the gene MACROD2 (MACRO domain ogies which have been steadily decreasing in cost, it
containing 2) (reviewed by State, 2010). CDH9 has become possible to obtain the DNA sequence
and CDH10 are interesting candidate genes since for the entire coding region (exome) of the human
they are involved in neuronal cell adhesion. genome. This has a profound influence on gene
SEMA5A has been implicated in axonal guidance. discovery in complex genetic disorders such as
ASD. So far, most common variants appear to
Cytogenetic Analysis have small effects on disease risk. Even when
Cytogenetic analysis is the study of chromosomal large studies have been performed, the vast majority
abnormalities such as inversions, translocations, of the genetic contribution to disease risk remains
duplications, deletions, and aneuploidies. Tradi- unexplained. These findings suggest that rare vari-
tionally, these abnormalities have been detected ants with relatively large effects may account for
via karyotype analysis (microscopic examination a larger fraction of this missing risk than previously
of chromosomes). A review by Veenstra- anticipated. Whole-exome sequencing enables the
VanderWeele et al. (2004) calculated that 4.3% identification of rare variants. It can be applied to
of the 1826 karyotypes published in the ASD both large-scale case–control studies and pedigree-
literature are abnormal. Abnormalities have based linkage studies.
been found on every chromosome, indicating There are several large whole-exome sequenc-
that no one rearrangement is responsible for any ing studies in progress. Studying simplex families
substantial fraction of cases. The most common with one affected child, O’Roak et al. (2011)
chromosomal abnormality found in ASD is identified de novo mutations in a number of can-
maternally inherited duplications at 15q11-q13 didate genes: FOXP1 (forkhead box P1),
(Abrahams & Geschwind, 2008). Some genes GRIN2B (glutamate receptor, ionotropic,
which have been implicated by cytogenetic N-methyl D-aspartate 2B), SCN1A (sodium
CANTAB 519 C
channel, voltage-gated, type I, alpha subunit), Choi, M., Scholl, U. I., Ji, W., Liu, T., Tikhonova, I. R., &
and LAMC3 (laminin, gamma3). Zumbo, P. (2009). Genetic diagnosis by whole exome
capture and massively parallel DNA sequencing. Proc
Natl Acad Sci USA, 106, 19096–19101.
Expression Arrays El-Fishawy, P., & State, M. W. (2010). The genetics of
This method aims at studying alterations in gene autism: Key issues, recent findings, and clinical impli-
expression in autism using postmortem brain tis- cations. The Psychiatric Clinics of North America, 33,
sues or peripheral blood. Some genes implicated
83–105.
Glessner, J. T., Wang, K., Cai, G., Korvatska, O., Kim, C. E.,
C
include the EPB41L3 (erythrocyte membrane & Wood, S. (2009). Autism genome-wide copy number
protein band 4.1-like 3), which interacts with variation reveals ubiquitin and neuronal genes. Nature,
CNTNAP2, and the genes relating glutamatergic 459, 569–573.
Gupta, A. R., & State, M. W. (2007). Recent advances in
neurotransmission (Abrahams & Geschwind, the genetics of autism. Biological Psychiatry, 61,
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▶ Functional Analysis
▶ Genome-Wide Association
CANTAB
References and Readings Melissa C. Goldberg
Kennedy Krieger Institute, Baltimore, MD, USA
Abrahams, B. S., & Geschwind, D. H. (2008). Advances in
ogy. Nature Reviews Genetics, 9, 341–355.
Bakkaloglu, B., O’Roak, B. J., Louvi, A., Gupta, A. R., Synonyms
Abelson, J. F., & Morgan, T. M. (2008). Molecular
cytogenetic analysis and resequencing of contactin
associated protein-like 2 in autism spectrum disorders. Cambridge Neuropsychological Test Automated
American Journal of Human Genetics, 82, 165–173. Battery
C 520 CANTAB
Description Historical Background
CANTAB is a computerized battery of cognitive- Information about the CANTAB can be found on
neuropsychological tests that is marketed by the CANTAB website at www.cantab.com. The
Cambridge Cognition. The CANTAB website is CANTAB is currently produced and marketed by
www.cantab.com. Cambridge Cognition. The CANTAB was
CANTAB is promoted as having some of the founded by Dr. Trevor W. Robbins at the Univer-
following features that can be beneficial for use in sity of Cambridge and Dr. Barbara J. Sahakian at
research (see http://www.cantab.com/cantab-for- the Section of Old Age Psychiatry, Institute of
academic-research.asp): Psychiatry, in the United Kingdom and their col-
• Computer touch-screen administration leagues (Robbins & Sahakian, 2002). The devel-
• Independent of culture opment of the CANTAB was based from
• Normative data available across age (4–90 cognitive neuropsychological paradigms in ani-
years) and IQ levels mals in order to examine components of cogni-
• Test-retest reliability data available on many tive function in humans (beginning with the
of the tests elderly) and deficits in patients with dementia
The tests that make up the CANTAB are (Alzheimer’s disease); performance on the
grouped into some of the following general catego- CANTAB has been linked to the frontal and
ries (see http://www.cantab.com/cantab-tests.asp): temporal lobes of the brain (Robbins et al., 1998).
• Screening The CANTAB has been used to examine
• Executive function, planning, and spatial aspects of cognitive function in over 100 psychi-
working memory atric and neurologic diseases and disorders
• Attention and reaction time including Alzheimer’s dementia, anxiety disor-
• Visual memory and learning ders, attention deficit hyperactivity disorder,
• Decision making and response control autism spectrum disorder, Parkinson’s disease,
• Semantic/verbal memory and schizophrenia. Please see http://www.can-
• Social cognition (emotion recognition) tab.com/disorders.asp for a full listing of disor-
The CANTAB has been used to measure ders that have been examined using the
aspects of executive function in individuals with CANTAB.
autism including set shifting, planning, and spa- The CANTAB was first used in research
tial working memory. A brief description of these studies involving individuals with autism in the
tasks is as follows (also see http://www.cantab. mid-1990s. Publications on the CANTAB in
com/cantab-tests.asp for more details): individuals with autism can be found in the
• Intradimensional/extradimensional (ID/ED) “References and Readings Section.” Results on
set-shifting task. Assesses the ability to attend the CANTAB in autism show that the
to characteristics of simple and compound intradimensional/extradimensional (ID/ED) set-
stimuli, use feedback to learn a rule, and to shifting task, the Stockings of Cambridge (SOC)
shift attention within and across dimensions of task, and the spatial working memory task from
a stimulus. the CANTAB have been useful in detecting
• Stockings of Cambridge (SOC) task. Is impairments in executive functioning in individ-
a spatial planning task based on the Tower of uals with autism; however, there is some incon-
Hanoi task. The SOC task examines the ability sistency in the literature on whether deficits are
to rearrange colored balls in a lower display to always found in all of these tasks. In addition,
match a goal arrangement in an upper display performance on the ID/ED, SOC, and SWM tasks
in the least number of moves possible. from the CANTAB has been examined in siblings
• Spatial working memory (SWM) task. Examines as well as in parents of children with autism. The
the ability to retain spatial information in work- results in siblings showed while there were no
ing memory and also assesses search strategy. group differences in overall means, a subset of
CANTAB 521 C
the siblings showed deficits at the ED stage on the References and Readings
ID/ED task and difficulty in passing the higher-
level planning problems on the SOC task Berger, H. J. C., Aerts, F. H. T. M., van Spaendonck,
K. P. M., Cools, A. R., & Teunisse, J.-P. (2003).
(Hughes et al., 1999). Parents of children with
Central coherence and cognitive shifting in relation
autism showed impairment on all three of the to social improvement in high-functioning young
CANTAB tasks of executive function (fathers in adults with autism. Journal of Clinical and Experimen-
particular, were more impaired on the SOC plan- tal Neuropsychology, 25(4), 502–511. C
Cambridge Cognition (2008). CANTAB Topic: Test-
ning task, Hughes et al., 1997).
retest reliabilities and detecting reliable change.
CANTAB Resources. http://www.cantab.com/cantab-
for-academic-research.asp, http://www.cantab.com/
Psychometric Data cantab-tests.asp, http://www.cantab.com/disorders.asp
CANTAB Website: www.cantab.com
DeLuca, C. R., Wood, S. J., Anderson, V., Buchanan, J.,
Normative data on the CANTAB are available for Profitt, T. M., Mahony, K., & Pantelis, C. (2003).
individuals 4–90 years of age in four IQ ranges. Normative data from the Cantab. I: Development of
(See CANTAB website www.cantab.com for executive function over the lifespan. Journal of Clin-
ical and Experimental Neuropsychology, 242–254.
information about norms; also see DeLuca
Garcia-Villamisar, D., & Hughes, C. (2007). Supported
et al., 2003; Luciana & Nelson, 2002; Robbins employment improves cognitive performance in adults
et al., 1994, 1998). with Autism. Journal of Intellectual Disability
Test-retest reliability data for CANTAB tasks Research, 51(2), 142–150.
Goldberg, M. C., Mostofsky, S. H., Cutting, L. E.,
are also available (Cambridge Cognition, 2008;
Mahone, E. M., Astor, B. C., Denckla, M. B., et al.
Lowe & Rabbitt, 1998). Data on the Standard (2005). Subtle executive impairment in children with
Error of Prediction (SEP) are also available on autism and children with ADHD. Journal of Autism
CANTAB tasks in order to be able to calculate a and Developmental Disorders, 35(3), 279–293.
Happé, F., Booth, R., Charlton, R., & Hughes, C. (2006).
confidence interval for determining whether a
Executive function deficits in autism spectrum disor-
retest score is due to a real effect or a measure- ders and attention-deficit/hyperactivity disorder:
ment error (Cambridge Cognition, 2008). Examining profiles across domains and ages. Brain
and Cognition, 61, 25–39.
Hill, E. (2004a). Evaluating the theory of executive dysfunc-
tion in autism. Developmental Review, 24, 189–233.
Clinical Uses Hill, E. (2004b). Executive dysfunction in autism. Trends
in Cognitive Sciences, 8(1), 26–32.
In autism, the CANTAB has generally been used Hughes, C., & Graham, A. (2002). Measuring executive
functions in childhood: Problems and solutions? Child
as a research tool rather than for clinical use.
and Adolescent Mental Health, 3, 131–142.
There is one publication in the literature that Hughes, C., Leboyer, M., & Bouvard, M. (1997). Execu-
has used the CANTAB to examine changes fol- tive function in parents of children with autism.
lowing rehabilitation in autism. The study Psychological Medicine, 27, 209–220.
Hughes, C., Plumet, M.-H., & Leboyer, M. (1999). Towards
reported changes in executive function abilities
a cognitive phenotype for autism: Increased prevalence
on the Stockings of Cambridge planning task and of executive dysfunction and superior spatial span
the Spatial Working Memory task in adults with amongst siblings of children with autism. Journal of
autism following participation in a vocational Child Psychology and Psychiatry, 40(5), 1–14.
Hughes, C., Russell, J., & Robbins, T. W. (1994). Evi-
rehabilitation program compared to prior to
dence for executive dysfunction in autism. Neuropsy-
enrolling the program (Garcia-Villamisar & chologia, 32(4), 477–492.
Hughes, 2007). Luciana, M., & Nelson, C. A. (2002). Assessment of
neuropsychological function through use of the
Cambridge Neuropsychological Testing Automated
See Also Battery: Performance in 4- to 12-year-old children.
Developmental Neuropsychology, 22, 595–624.
Ozonoff, S., Cook, I., Coon, H., Dawson, G.,
▶ Cambridge Neuropsychological Test Joseph, R. M., Klin, A., et al. (2004). Performance on
Automated Battery Cambridge Neuropsychological Test Automated
C 522 Capgras Delusion
Battery subtests sensitive to frontal lobe function in

people with autistic disorder: Evidence from the col- Capgras Syndrome
laborative programs of excellence in autism network.
34(2), 139–150. Adriano Rodrigues1, Claudio Banzato2, Clarissa
Ozonoff, S., South, M., & Miller, J. N. (2000). DSM-IV- Dantas3 and Paulo Dalgalarrondo4
defined Asperger syndrome: Cognitive, behavioral and 1
Health Sciences Center, Federal University of
early history differentiation from high-functioning
autism. Autism, 4, 29–46. Piaui – UFPI, Teresina, Brazil
2
Robbins, T. W., James, T., Owen, A. M., Sahakian, B. J., Psychiatry, University of Campinas – Unicamp,
McInnes, L., & Rabbitt, P. M. (1994). CANTAB: A Campinas, São Paulo, Brazil
factor analytic study of a large sample of normal 3
Department of Psychiatry, Faculty of Medical
elderly volunteers. Dementia, 5, 266–281.
Robbins, T. W., James, M., Owen, A. M., Sahakian, B. J., Sciences, University of Campinas (Unicamp),
Lawrence, A. D., McInnes, L., & Rabbitt, P. M. A. Campinas, São Paulo, Brazil
4
(1998). A study of performance on tests from University of Campinas Cidade Universitária
the CANTAB battery sensitive to frontal lobe “Zeferino Vaz”, São Paulo, Brazil
dysfunction in a large number of normal volunteers:
implications for theories of executive functioning
and cognitive aging. Journal of the International
Neuropsychological Society, 474–90. Synonyms
Robbins, T. W., & Sahakian, B. J. (2002). Computer
methods of assessment of cognitive function. In
J. R. M. Copeland, M. T. Abou-Saleh, & D. G. Blazer Capgras delusion; Capgras delusion syndrome;
(Eds.), Principles and practice of geriatric psychiatry Delusion of doubles; Delusion of duplicates;
(2nd ed.). Chichester: John Wiley & Sons. Delusion of negative doubles; Delusion of
Sinzig, J., Morsch, D., Bruning, N., Schmidt, M. H., & substitution; Delusional hypoidentification;
Lehmkuhl, G. (2008). Inhibition, flexibility, working
memory and planning in autism spectrum disorders Illusion des sosies
with and without comorbid ADHD-symptoms. Child
and Adolescent Psychiatry and Mental Health, 2(1),
1–12. Short Description or Definition
Steele, S. D., Minshew, N., Luna, B., & Sweeney, J. A.
(2007). Spatial working memory deficits in autism.
Journal of Autism and Developmental Disorders, Capgras syndrome is a particular type of delu-
37(4), 605–612. sional misidentification characterized by the
Teunisse, J.-P., Cools, A. R., van Spaendonck, K. P. M., inability of recognizing someone (usually
Aerts, F. H. T. M., & Berger, H. J. C. (2001). Cognitive
styles in high-functioning adolescents with autistic a loved one, a close relative, or friend) as the
disorder. Journal of Autism and Developmental Disor- person they claim to be. In this monothematic
ders, 31(1), 55–66. delusion, the individual recognizes overtly and
straightforwardly who that person is meant to
be, upholding however a firm belief to the con-
trary, which is anchored in subjective cues such
as an eerie feeling that something is not quite
Capgras Delusion right about that person, complete lack of a sense
of familiarity, and missing the proper affective
▶ Capgras Syndrome response. Individuals with Capgras syndrome
cling to the unshakeable belief that the original
person in question was replaced by an impostor,
who cunningly is trying to fool them – with no
success at all because, of course, they know bet-
Capgras Delusion Syndrome ter. The nature of this alleged impostor, an almost
exact double, usually is human, but in some
▶ Capgras Syndrome cases, it may turn out to be ghostly, alien, or
Capgras Syndrome 523 C
robot. As a consequence of the puzzling disso- Even though the classic form of the Capgras
nance between “looking familiar” and “feeling syndrome involves the replacement of persons,
familiar,” this is often referred as a most extraor- there are interesting variations in which pets,
dinary and uncanny experience (Young, 2009). objects, or even places (such as one’s own
There is no emotional connectedness whatsoever house) are replaced by copies or duplicates.
to the putative impostor, and so a sense of suspi- Thus, the syndrome could be further specified
cious estrangement ends up prevailing. There- by adding the indication of whom or what has C
fore, the overall clinical picture is dominated by allegedly been replaced; there would be then
an intense paranoid tint. A combination of deper- Capgras syndrome for persons, for animals, for
sonalization (an alteration in the experience of objects, for places, etc. The Capgras syndrome is
self in which the individual experiences his/her one of the four main delusional misidentification
own body or mental activity as changed in quality syndromes described in the psychiatric literature,
to become unreal, detached, or automatized) and and unlike the other three (Frégoli syndrome,
derealization (an alteration in which it is the intermetamorphosis syndrome, and the syndrome
individual’s surroundings that are experienced of Subjective Doubles) where false and positive
as remote, lacking immediacy, and oddly unreal) identification (hyperidentification) phenomena
is not unusual in the earlier stages of the syn- occur, it is marked by false and negative identifi-
drome (Munro, 2009). Sometimes, individuals cation (hypoidentification). The Frégoli syn-
with Capgras syndrome become enraged and act drome is characterized by a delusional false
on their delusion, attacking the “impostor” with recognition; in short, the individual identifies
violence. But it may also happen that their familiar persons in strangers. The body may be
relationship with the impostor follows the same different, but there is no doubt about the presence
pattern of the one with the original person. of the psychological identity of a familiar person.
The latter has changed completely his/her physi-
cal appearance or taken over someone else’s
Categorization body, a most radical form of disguise (usually
with malevolent intentions). In intermeta-
The eponym “Capgras syndrome” was proposed morphosis, the individual comes to believe that
by the French psychiatrist Joseph Levy-Valensi, people around have exchanged their identities, so
in 1929 (Blom, 2010). The name refers to Jean each person involved in this delusional plot
Marie Joseph Capgras, who described in 1923, in becomes somebody else. In the syndrome of the
collaboration with Jean Reboul-Lachaux, the subjective doubles, the individual is convinced of
case of a psychotic patient who believed that her the existence of exact doubles of him/herself
husband, her children, other inmates, and hospital (Munro, 2009). It has also been described reverse
staff had been replaced by successive and numer- forms of both Capgras and Frégoli syndromes. In
ous “doubles” or physically identical impostors the reverse Capgras, the own self of the individ-
(Capgras & Reboul-Lachaux, 1923). Capgras and ual is taken as a sort of psychological impostor,
Reboul-Lachaux themselves referred to this phe- inhabiting a body that does not belong to him/her.
nomenon by the French term illusion des sosies In the reverse Frégoli, the psychological identity
(illusion of doubles). The patient they described of one’s own self is preserved alongside with
also believed that she herself had many doubles radical changes in his/her physical makeup
and, in addition to the “delusion of doubles,” she (Rodrigues & Banzato, 2006). Delusional
had persecutory and grandiose delusions. How- misidentification may be a symptom of several
ever, a narrower connotation for the Capgras psychiatric (most frequently) and neurologic ill-
syndrome, referring only to the delusional nesses, or a separate syndrome on its own right.
misidentification, gradually evolved (Rodrigues When misidentification takes place in the context
& Banzato, 2006). of schizophrenia, severe mood disorder, or
C 524 Capgras Syndrome
dementia, it is regarded as a feature of that illness or, more frequently, appear later on, after years
and it should be referred to as a misidentification of evolution. Remission of this delusion may
phenomenon rather than the syndrome in ques- precede the overall clinical improvement, be
tion. But when a delusion such as the ones afore- simultaneous with it or only be achieved after
mentioned is the principal and most conspicuous the abatement of other symptoms. The delusional
aspect of a psychosis and other conditions can be misidentification may also persist in the long run.
ruled out (see differential diagnosis below), it When patients with schizophrenia and mood dis-
should be assigned as a subcategory within per- orders are compared to each other, the latter are
sistent delusional disorder (ICD-10) or delusional seemingly less prone to have unremitting mis-
disorder (DSM-IV) (Munro, 2009). Some clas- identifications and to hold them for longer than
sify Capgras phenomenon into either “primary,” the acute phase of the illness (Christodoulou,
when associated with psychiatric illnesses, or 1977).
“secondary,” when the phenomenon occurs in
the context of a neurologic disorder (Barton,
2003). Clinical Expression and
Pathophysiology
Epidemiology Several theories have been formulated in order to

explain the Capgras syndrome, and among them,
Estimates of the prevalence rate of Capgras syn- we have both the psychological comprehensive
drome vary, depending on the settings and facil- (in the sense of taking into account meaningful
ities where the investigations are carried out. connections within the individual’s life and cir-
Currently, the syndrome is claimed to be more cumstances) and the cognitive neuropsychiatric
common than previously assumed, ranging from ones. As they typically share the view that the
1.3% up to 4% of psychiatric inpatients – with core emergent phenomenon in Capgras syndrome
lower frequencies being reported in emergency is the puzzling dissociation between the proper
rooms and in private psychiatric practice. Special objective recognition of a given percept and
populations seem to be particularly at risk to a distorted sense of familiarity towards it, it
develop Capgras syndrome at some point in the should be recognized that these theories may
course of their illnesses. Prevalence rates as high not be mutually exclusive. Instead, they can
as 15–40% in patients with schizophrenia and even be seen as complementary to each other in
2–30% in patients with Alzheimer’s disease some cases, however, with different emphasis,
have been reported. Data regarding sex ratio are which is placed either on the psychological
conflicting, showing either an even distribution dynamic aspects or on the neural underpinnings
of cases or an increased frequency among of the phenomena.
women – up to twice the frequency found
among men (Tamam, Karatas, Zeren &
Ozpoyraz, 2003; Henriet et al., 2008). Psychodynamic and Other
Psychologically Comprehensive
Theories
Natural History, Prognostic Factors, and
Outcomes The fact that patients with Capgras syndrome
sometimes report feelings of strangeness in respect
The age of onset, course, and outcomes of to both their surroundings and themselves has fos-
Capgras syndrome vary, depending on the under- tered the hypothesis that experiences of derealiza-
lying neuropsychiatric condition. Among psychi- tion and depersonalization could play a role in the
atric patients, Capgras delusion may either be emergence of the Capgras syndrome and other
present at the clinical onset of the mental disorder delusional misidentification syndromes. According
to this hypothesis, derealization and depersonaliza- well-established or still hypothetical, paves the
tion might be conceived as roots to the distorted way for putting forward testable hypothesis,
feelings of familiarity usually held by patients improving thus the empirical anchorage of such
towards their acquainted ones. Whether this distor- theories. As these approaches heavily rely on
tion is a direct consequence of derealization and analogies with other conditions where disrupted
depersonalization, or a response to these symp- face recognition processes definitely or presum-
toms, the delusion of substitution is often thought ably occur, such as prosopagnosia, reduplicative C
of as having a somewhat appeasing effect on the paramnesia, autistic disorder, and Asperger syn-
individual by explaining away the rather uncom- drome, heuristic gains should be expected.
fortable and perplexing experience of unreality Several models of this sort have already been
(Christodoulou, 1991). proposed, each one of them positing different
Another comprehensive hypothesis about the hypothetical mechanisms that would lead to
genesis of this curious phenomenon revolves these diverse, though correlated, phenomena.
around the alleged presence of unacceptable or One of these models was first presented by
ambivalent feelings toward a close person. Joseph (1986). According to it, putative cortical
A split on such person’s identity would then interhemispheric disconnections would respond
take place in the patient’s mind as a means to for the distortions on the familiarity feelings
circumvent the conflict. For example, someone experienced by patients towards known persons.
holding unconscious aversive feelings towards Dissociation between cerebral hemispheres
his parents would be allowed, by means of the would lead to two different and segregated
Capgras delusion, to experience unambiguous images of the percept – one of them produced
love and respect towards them, while, at the by analytic strategies in the left hemisphere and
same time, directing the otherwise unacceptable another one produced through more global
feelings of despise, hate, distrust, or fear to the processing in the right hemisphere. These two
“impostors” (Enoch, 1986). Similarly, the syn- images would suffice for the patient to recognize
drome could possibly develop in the context of the physical features of known people, but their
changing interpersonal relationships, when dissociation would also engender a very strange
experiences of strangeness and unconscious twofold experience of the percept, suitable to
negative feelings towards a given person might delusional interpretation. Nevertheless, individ-
emerge more easily. The ultimate consequence uals with corpus callosum agenesia or those who
would be the belief that this close person is not suffered section of this commissure for treatment
who he or she seems to be but an impostor of severe epilepsy do not seem to be particularly
(Berson, 1983). prone to develop Capgras syndrome, which
Additionally, the syndrome has also been weakens Joseph’s hypothesis.
thought to result from a pathological regression A more elaborated and highly regarded
to archaic models of thinking, arguably common hypothesis to explain Capgras syndrome was
in primeval stages of human evolution, possibly articulated by Ellis and Young (1990),
inherited by all of us, when the idea of doubles underpinned by Bauer’s (1984) postulation of
and the theme of dualities in general were usual distinct pathways for overt and covert face rec-
(Todd, 1957). ognition. According to Bauer, face recognition
would involve two different processes and neu-
roanatomic pathways. A ventral route connecting
Cognitive Neuropsychiatric Theories the visual associative cortex to temporal lobes
(especially amygdala) via inferior longitudinal
In contrast to purely psychological and psycho- fasciculus would be critical for overt or conscious
dynamic theories, the emphasis given by cogni- face recognition. On the other hand, a dorsal
tive neuropsychiatric approaches to the neural route connecting visual associative cortex to cin-
underpinnings of Capgras syndrome, whether gulate gyrus and hypothalamus via superior
temporal lobe and inferior parietal lobule would little evidence that the dorsal visual pathway play
function as a kind of covert system for the recog- any role in visual recognition – either in animals
nition of faces. The latter would not in fact allow or in humans – and even less in ascribing emo-
someone to know whose is the face seen in tional significance to visual percepts. In contrast,
a given moment, nor determining whether it is they state that inferotemporal area and amygdala,
familiar or not. Instead, the authors argue that this relevant structures in the ventral visual pathway,
route would be relevant in assigning affective are respectively regarded as critical in matching
significance to faces. Bauer’s proposal follows seen faces to stored representations and to the
from the observation that one of his patients emotional responses these faces might evoke.
with bilateral occipito-temporal damage and suf- They propose that malfunctioning of the ventral
fering from severe prosopagnosia – the impaired visual pathway alone may explain both
ability to recognize previously known faces and prosopagnosia and Capgras syndrome. As to
learn new ones – could still show distinctive skin Capgras syndrome specifically, their suggested
conductance responses when pictures of known explanation is that the activity of ventral visual
faces presented to him were paired with their recognition structures in the ventral temporal
correct names or wrong ones. Although incapable lobe would be normal, but it somehow fails to
of telling if those faces were known to him, or trigger the activity of ventral limbic structures.
even guessing the correct face/name pairing, this This would happen due to either a disconnection
patient’s autonomic responses were taken as between these structures or to impairments within
indicative that covert recognition was present the ventral limbic structures.
and, probably, provided by a mechanism inde- Perceptual abnormalities engendered by inad-
pendent from the one responsible for overt rec- equate visual processing of facial features had
ognition. This surprising integrity of autonomic been also posited as the fundamental dysfunction
responses to unrecognized known faces in in Capgras syndrome. Together with clinical
prosopagnosic patients has been confirmed by and test-generated evidence that patients with
other authors (Tranel & Damasio, 1985). Capgras syndrome often present sub-
Based on Bauer’s distinction, Capgras syn- prosopagnosic face recognition defects, the fact
drome, according to Ellis and Young (1990), that some of them have been reported to show
could be conceived as a clinical and anatomo- full-blown prosopagnosia and brain damages that
functional mirror image of prosopagnosia. While include those seen in prosopagnosic patients has
in prosopagnosia, overt recognition pathways are led to the so-called prosopagnosia hypothesis for
supposedly disrupted and covert recognition Capgras syndrome. However, each of these
route is claimed to be intact, the inverse would alleged links between the two conditions must
arguably happen in Capgras syndrome. In the be taken cautiously. Accumulated evidence indi-
latter, adequate appraisal of structural and cates that if there is some sort of relationship
dynamic facial features, as well as correct evoca- between prosopagnosia and Capgras syndrome,
tion of related semantic information, would be it is unlikely to be a straightforward one. It seems
guaranteed by ventral route proper functioning. that at best, there is a heuristically fruitful anal-
At the same time, dorsal route malfunctioning ogy, such as the one rendered by the models
would prevent the patient to ascribe the expected proposed by Ellis and Young (1990) and by
affective tone to familiar faces. Such a strange Breen et al. (2000).
mismatch would then stimulate rationalization Two other hypotheses are worth mentioning,
and support the delusional belief that an impostor as they depart from the emphasis usually given to
has replaced an acquainted person. experiences of depersonalization/derealization,
Departing from Bauer’s two-route model of perceptual dysfunctions, or to a primarily
face recognition, as well as from its use by Ellis disrupted ability to attach familiarity feelings to
and Young (1990) to explain Capgras syndrome, known faces. One of them, originated from the
Breen et al. (2000) point out that there is very observation of delusional misidentifications in
schizophrenic patients, postulates that in order to Structural and Functional Brain Findings
be identified and evoke familiarity feelings,
a given percept must be subjected to a process Structural abnormalities in brain CT and MRI
of integration of its various perceived features scans, as well as EEG and functional brain imag-
and stored representations. Such integration ing alterations, have been found not only in cases
would be critical for ascribing percepts with of neurologic Capgras syndrome but, very often,
a sense of “uniqueness,” a key element for their also in those considered to be primary psychiatric C
identification (Margariti & Kontaxakis, 2006). cases. These injuries have been shown to be either
This hypothesis had been explored by Cutting diffuse or localized (often numerous) and not
(1991), to whom the loss of that sense of “unique- rarely a superposition of both. In most cases, the
ness” would be related to right hemisphere dys- findings are located in the frontal lobes, some-
function (allegedly present in schizophrenic times exclusively, but frequently in association
patients) and subsequent failure in perceiving with abnormalities affecting other brain areas.
and processing information globally. A second Right hemisphere is significantly most often
theory has postulated that Capgras syndrome, as affected, as compared to the left hemisphere.
well as reduplicative paramnesia, would be pos- This pattern is consistent with the role postulated
sibly related to a failure in updating stored repre- for the frontal lobes in the genesis of reasoning
sentations of an object, thus leading to a and decision-making biases that may give a delu-
mismatch between its currently seen characteris- sional status to abnormal familiarity feelings.
tics and those remembered by the patient (Staton A variety of conditions has been found to be
& Brumback, 1982). causes of the structural and functional abnormal-
Finally, it must be stressed that the delusional ities mentioned, including tumors, head trauma,
character of Capgras syndrome cannot be strokes, infections, EEG paroxystic discharges,
explained by the dysfunctions postulated at the and metabolic and neurodegenerative disorders
core of any of the enlisted theories alone, and this (Barton, 2003; Gainotti, 2007; Devinsky, 2009).
is sometimes acknowledged by their very propo-
nents. Indeed, derealization, depersonalization,
and perceptual abnormalities often occur in the Evaluation and Differential Diagnosis
absence of impaired reality testing. Likewise, it is
argued that even the puzzling experience of miss- The assessment of individuals with Capgras syn-
ing the affective overtones expected in the sight of drome is basically clinical, as it happens with
a close person should not be so promptly taken as delusions in general. Phenomenal experience,
a sufficient condition for a delusion. Accordingly, i.e., the way a particular content is subjectively
the fact that patients with Capgras syndrome fail to experienced by the individual (in this case, the
conceive less unreasonable explanations to their certainty that a replacement has occurred), is the
experiences than the existence of an impostor, as key domain of the clinical evaluation. Compared
well as to revise their odd beliefs despite evidence to other types of delusions (such as persecutory
in contrary, is sometimes suggested to indicate that and mystic or religious), it is easier to have
altered reasoning and disrupted monitoring of Capgras syndrome’s delusional character
decisional processes play a significant role in the promptly acknowledged by everyone around, due
clinical picture. If there is actually an altered expe- to the clear impossibility of content (hence its
rience in the encounter with a close person, then classification as a “bizarre delusion”). It is also
a two-stage model for Capgras syndrome may be important to ascertain how broad and systematic
needed, one accounting for the odd experience the delusion in question is if it is really
itself and another accounting for the creation and a monothematic one or just a small part of an
maintenance of a delusional explanation for such overarching delusion. Furthermore, full assess-
experience (Barton, 2003; Gainotti, 2007; ment of all other areas of psychopathology, includ-
Coltheart et al., 2011). ing consciousness, attention, memory, perception,
thinking, language and speech, mood, and motor part of a delusional disorder (typically regarded as
activity, is required for the sake of differential and having poor therapeutic response) (Munro, 2009).
precise diagnosis.
It is relevant to identify if Capgras phenome- See Also
non occurs in the context of schizophrenia (or
schizophrenia spectrum disorders), in other ▶ Face Perception
kinds of delusional disorders (where pure ▶ Face Recognition
Capgras delusion should be included), or in ▶ Psychosis
major mood disorders with delusion (Berson,
1983). Moreover, Capgras phenomenon is often References and Readings
associated with organic brain disorders (about
one fourth to one third of the cases), such as Barton, J. J. (2003). Disorders of face perception and
recognition. Neurologic Clinics of North America,
brain tumors and infarcts, head trauma, subarach- 21, 521–548.
noid hemorrhage, and basilar migraine, so Bauer, R. M. (1984). Autonomic recognition of names and
a complete neurological investigation should be faces: A neuropsychological application of the guilty
carried out in all cases (Barton, 2003). Substance- knowledge test. Neuropsychologia, 22, 457–469.
Berson, R. J. (1983). Capgras’ syndrome. The American
related disorders must be suspected as well, and Journal of Psychiatry, 140(8), 969–978.
the history of substance use needs to be properly Blom, J. D. (2010). Capgras’ syndrome. In J. D. Blom
checked out; laboratory screening tests for drugs (Ed.), A dictionary of hallucinations (pp. 84–85).
may be run as a supplementary measure. Regard- New York: Springer.
Breen, N., Caine, D., & Coltheart, M. (2000). Models of
less the final diagnosis reached, a careful and face recognition and delusional misidentification: A
comprehensive assessment must be performed critical review. Cognitive Neuropsychology, 17, 55–72.
to estimate the actual risk of the individual with Capgras, J., & Reboul-Lachaux, J. (1923). L’illusion des
Capgras syndrome (or more broadly, Capgras “sosies” dans un délire systématisé. Bulletin de la
Societe´ Clinique de Me´decine Mentale, 11, 6–16.
phenomenon) acting on such delusion, as, under- Christodoulou, G. N. (1978). Course and prognosis of the
standably, the putative impostor constitutes an syndrome of doubles. The Journal of Nervous and
obvious target for violence. Mental Disease, 166(1), 68–72.
Christodoulou, G. N. (1991). The delusional misidenti-
fication syndromes. The British Journal of Psychiatry,
159(suppl. 14), 65–69.
Treatment Coltheart, M., Langdon, R., & McKay, R. (2010). Delusional
belief. Annual Review of Psychology, 62, 271–298.
To date, no specific treatment is available to Cutting, J. (1991). Delusional misidentification and the
role of the right hemisphere in the appreciation of
Capgras syndrome. When it is part of the clinical identity. The British Journal of Psychiatry, 159
picture of some particular medical condition, (Suppl. 14), 70–75.
interventions aiming at the basic disorder should Devinsky, O. (2009). Delusional misidentifications and
be the first choice. The delusional character of the duplications: Right brain lesions, left brain delusions.
Neurology, 72(1), 80–87.
syndrome prompts the use of antipsychotics. Psy- Ellis, H. D., & Young, A. W. (1990). Accounting for
chological approaches are unlikely to make the delusional misidentifications. The British Journal of
delusion disappear but may be useful to make Psychiatry, 157(2), 239–248.
patients less concerned, isolated, and dysfunc- Enoch, M. D. (1986). Whose double? The psychopathol-
ogy of the delusional misidentification syndromes,
tional because of their pathological beliefs. Good especially the Capgras syndrome. Bibliotheca
estimates of treatment response in Capgras syn- Psychiatrica, 164, 22–29.
drome are not available. Although it is reasonable Gainotti, G. (2007). Face familiarity feelings, the right
to assume that prognosis of delusional misidenti- temporal lobe and the possible underlying neural mech-
anisms. Brain Research Reviews, 56(1), 214–235.
fication will depend on the underlying medical or Henriet, K., Haouzir, S., & Petit, M. (2008). L’illusion des
psychiatric condition, it must be kept in mind that sosies de Capgras: une interpretation délirante d’un
high response rates may be achieved in the treat- trouble spécifique de la reconnaissance affective des
ment of delusions in general, even when they are visages. Revue de la littérature et proposition d’un
CARS, Second Edition, Questionnaire for Parents or Caregivers 529 C
modele séquentiel. Annales Me´dico-psychologiques, Definition
166(2), 147–156.
Joseph, A. B. (1986). Focal central nervous system abnor-
malities in patients with misidentification syndromes. Carnosine is a compound formed from two amino
Bibliotheca Psychiatrica, 164, 68–79. acids (histidine and alanine) and is found in sev-
Margariti, M. M., & Kontaxakis, V. P. (2006). eral organ systems including muscle and brain.
Approaching delusional misidentification syndromes A number of possible biological roles for this
as a disorder of the sense of uniqueness. Psychopa-
thology, 39, 261–268. compound have been suggested including antiox- C
Munro, A. (2009). Persistent delusional symptoms and idant properties. It has been used experimentally
disorders. In M. G. Gelder, N. C. Andreasen, J. J. in several disorders. One small double-blind study
López-Ibor Jr., & J. R. Geddes (Eds.), New Oxford in 2002 by Chez and colleagues reported positive
textbook of psychiatry (2nd ed., Vol. 1, pp. 609–628).
New York: Oxford University Press. initial findings, although the study was criticized
Rodrigues, A. C. T., & Banzato, C. E. M. (2006). on various grounds and the results have not yet
Delusional misidentification syndrome: Why such been well replicated in the scientific literature.
nosologic challenge remains intractable. Psychopa-
thology, 39, 296–302.
Staton, R. D., & Brumback, R. A. (1982). Wilson H. See Also
Reduplicative paramnesia: A disconnection syndrome
of memory. Cortex, 18, 23–26.
▶ Neurochemistry
Tamam, L., Karatas, G., Zeren, T., & Ozpoyraz, N. (2003).
The prevalence of Capgras syndrome in a university hos-
pital setting. Acta Neuropsychiatrica, 15(5), 290–295.
Todd, J. (1957). The syndrome of Capgras. Psychiatric References and Readings
Quarterly, 31, 250–265.
Tranel, D., & Damasio, A. R. (1985). Knowledge without Chez, M. G., Buchanan, C. P., Aimonovitch, M. C.,
awareness: An autonomic index of facial recognition Becker, M., Schaefer, K., Black, C., & Komen, J.
by prosopagnosics. Science, 228, 1453–1454. (2002). Double-blind, placebo-controlled study of
Young, G. (2009). In what sense “familiar”? Examining L-carnosine supplementation in children with autistic
experiential differences within pathologies of facial rec- spectrum disorders. Journal of Child Neurology,
ognition. Consciousness and Cognition, 18, 628–638. 17(11), 833–837.
Levy, S. E., & Hyman, S. L. (2005). Novel treatments for
autistic spectrum disorders. Mental Retardation and
Developmental Disabilities Research Reviews, 11(2),
131–142.
Capute Scales (along with Cognitive
Adaptive Test)
CARS
▶ Clinical Linguistic and Auditory Milestone Scale
▶ Childhood Autism Rating Scale
Carnosine
CARS, Second Edition, High-
Fred R. Volkmar Functioning Version
Professor of Child Psychiatry, Pediatrics and ▶ Childhood Autism Rating Scale
Psychology, School of Medicine,
CARS, Second Edition, Questionnaire

Synonyms for Parents or Caregivers
beta-Alanyl-L-histidine ▶ Childhood Autism Rating Scale

C 530 CARS, Second Edition, Standard Version
study (sometimes referred to as case report) pro-

CARS, Second Edition, Standard vides a focused report of an individual or series of
Version individuals to illustrate some important issue rel-
evant to clinical work or research. Many of the
▶ Childhood Autism Rating Scale conditions now recognized as significant causes
of developmental disability first appeared as case
reports, e.g., Down syndrome and childhood
CARS2-HF autism. Sometimes case reports are used to draw
attention to other relevant issues, e.g., new
▶ Childhood Autism Rating Scale approaches to treatment. Case studies from the
behavioral literature may be used to illustrate the
possible effectiveness of a new intervention, e.g.,
the subject is used as his/her own control with
CARS2-QPC data collected pre-, during, and post-intervention.
In other fields such as business or law, case stud-
▶ Childhood Autism Rating Scale ies take other formats.
Case studies may be primarily descriptive or
may be more theoretical in nature. Sometimes, as
in the case of Down syndrome (trisomy 21), the
CARS2-ST underlying theory may prove profoundly wrong
but the observation is very robust (in the case of
▶ Childhood Autism Rating Scale Down syndrome, the report from Dr. Down
appeared well before there was any awareness
of the importance of human chromosomes in
Case Report development and disease). Case studies can
bring attention to new phenomena, can serve as
▶ Case Study a vehicle for teaching or documenting a poten-
tially important clinical issue, and may, over
time, lead to more focused hypothesis-based
research. As noted, single-subject research
Case Study methods provide possibilities for statistically
based evaluation within a report focused on
Fred R. Volkmar a single case.
Director – Child Study Center, Irving B. Harris While case studies have importance in focusing
Professor of Child Psychiatry, Pediatrics and attention on new observations and stimulating
Psychology, School of Medicine, hypothesis testing and theory building, they also
Yale University, New Haven, CT, USA have some important limitations. Various factors
can go into the selection of the case that is reported,
and generalization is therefore difficult. There is an
Synonyms obvious tendency on the part of editors and
reviewers to support positive association reports
Case report (rather than negative ones) in case studies and
again generalization can be limited. Cases may
also be reported with these multiple publications
Definition of the same case contributing to a perception of
greater significance than actually is apparent.
Case studies are frequent in both biomedical and As a result, many journals now have limited
behavioral psychological research. A typical case publication of case reports.
Casein 531 C
One example in the autism research is pro-
vided by the many case reports of autism associ- Casein
ated with a host of medical conditions ranging
from congenital infections, inborn errors of Madison Pilato
metabolism, obstetrical risk, and so forth. As Neurodevelopmental and Behavioral Pediatrics,
noted by Rutter, Bailey, Bolton, and Le Couteur University of Rochester Medical Center,
(1994) in the 1970s and early 1980s, there were Rochester, NY, USA C
frequent reports of such associations, but the
value of such reports was limited given a lack of
relevant controls for issues of diagnosis, dupli- Synonyms
cate reporting, issues in assessment, and lack of
comparison groups. Rutter and colleagues Milk protein
emphasized the importance of controlling for
these factors and adopting a more epidemiologi-
cally based approach in evaluating reports of Definition
comorbid associations of autism with these
conditions. When this was done, the strongest Casein is a milk protein. One type of casein found
associations were with a handful of genetic in human and cow milk, beta-casein, is digested
conditions (fragile X and tuberous sclerosis) and into beta-casomorphins (BCMs). Sun, Cade,
with seizure disorder. Fregly, and Privette (1999) demonstrated that
BCMs affect many regions in the rat brain (i.e.,
nucleus accumbens, caudate, putamen, ventral
See Also tegmental and median raphe nucleus, and
orbitofrontal, prefrontal, parietal, temporal,
▶ Comorbidity occipital, and entorhinal cortices). These effects
▶ Fragile X Syndrome are partially blocked by opiate receptor antago-
▶ Qualitative Versus Quantitative Approaches nists, indicating that BCMs act like opioids in the
▶ Seizure Disorder mammalian nervous system. Additionally, infu-
▶ Tuberous Sclerosis Complex sion of BCM has been shown to cause behavioral
changes in rats including restlessness followed by
inactivity, reduced response to sound, and
References and Readings reduced social interaction (Sun & Cade, 1999).
These results are used to support to the opioid-
Bailey, D. B., Jr., Mesibov, G. B., Hatton, D. D., Clark,
R. D., Roberts, J. E., & Mayhew, L. (1998). Autistic
excess theory (Panksepp, 1979) to explain the
behavior in young boys with fragile X syndrome. Jour- symptoms of autism. According to this theory,
nal of Autism and Developmental Disorders, 28(6), BCMs become excessive because of an enzyme
499–508. deficiency (Trygstad et al., 1980; Reichelt et al.,
Down, J. L. H. (1866). Observations on an ethnic classifica-
tion of idiots. Clinical Lecture Reports of London
1981) or a leaky gut (Wakefield et al., 1998), and
Hospital, 3, 259–262. the opioid effects in the human nervous system
Kanner, L. (1943). Autistic disturbances of affective contact. contribute to the symptoms of autism. However,
The Nervous Child, 2, 217–250. well-designed studies have not found abnormal
Rutter, M., Bailey, A., Bolton, P., & Le Couteur, A. (1994).
Autism and known medical conditions: Myth and sub-
opioid concentrations (Cass et al., 2008) or evi-
stance. Journal of Child Psychology and Psychiatry, dence for GI abnormalities in individuals with
35(2), 311–322. autism (Buie et al., 2010; Fernell, Fagerberg, &
Volkmar, F. R., & Nelson, D. S. (1990). Seizure disorders Hellstrom, 2007; Sandhu et al., 2009).
in autism. Journal of the American Academy of Child
and Adolescent Psychiatry, 29(1), 127–129.
Despite a lack of support for either the enzyme
Wiznitzer, M. (2004). Autism and tuberous sclerosis. deficiency or leaky gut theory, the opioid-excess
Journal of Child Neurology, 19(9), 675–679. theory has led to a focus on eliminating casein,
C 532 CASL
and often gluten, from the diets of children with Lucarelli, S., Frediani, T., Zingoni, A. M., Ferruzzi, F.,
autism. Most studies have examined a combined Giardini, O., Quinteri, F., et al. (1995). Food allergy
and infantile autism. Panminerva Medica, 37,
gluten-free, casein-free diet. Therefore, it is dif- 137–141.
ficult to assess the effect of eliminating casein Millward, C., Ferriter, M., Calver, S. J., & Connell-Jones,
alone. However, one study (Lucarelli et al., G. G. (2009). Gluten- and casein-free diets for autistic
1995) did find improvement on five out of seven spectrum disorder. Cochrane Database of Systematic
Reviews, 2, 1–28.
behavioral scales in children adhering to an only Panksepp, J. (1979). A neurochemical theory of autism.
casein-free diet compared to a control group with Trends in Neurosciences, 2, 174–177.
no dietary restrictions. Worsening on two out of Reichelt, K. L., Hole, K., Hamberger, A., Saelid, G.,
seven of the scales was also observed after Edminson, P. D., Braestrup, C. B., et al. (1981).
Biologically active peptide-containing fractions in
a casein challenge. However, the study design schizophrenia and childhood autism. Advances in Bio-
had many limitations. Notably, a small sample chemical Psychopharmacology, 28, 627–643.
was studied and it is unclear if the behavior Sandhu, B., Steer, C., Golding, J., & Emond, A. (2009).
evaluators were blinded to the diet status of the The early stool patterns of young children with autistic
spectrum disorder. Archives of Disease in Childhood,
participants. In addition, no other studies have 94, 497–500.
eliminated only casein. More research and repli- Sun, Z., & Cade, J. R. (1999). A peptide found in schizo-
cations are needed before casein-free diets can be phrenia and autism causes behavioural changes in rats.
considered efficacious. Gluten-free, casein-free Autism, 3, 85–95.
Sun, Z., Cade, J. R., Fredly, M. J., & Privette, R. M.
diets also lack scientific support. In a 2008 (1999). Beta-casomorphin induces Fos-like immuno-
review, Millward, Ferriter, Calver, and reactivity in discrete brain regions relevant to schizo-
Connell-Jones reported mixed results for gluten- phrenia and autism. Autism, 3, 67–83.
free, casein-free diets, with most studies having Trygstad, O. E., Reichelt, K. L., Foss, I., Edminson, P. D.,
Selid, G., Bremer, J., et al. (1980). Patterns of peptides
major methodological limitations and the better and protein-associated-peptide complexes in psychiat-
designed studies reporting mostly negative ric disorders. British Journal of Psychiatry, 136, 59–72.
findings. Without adequate data, elimination Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J.,
diets are currently not recommended (Buie et al.). Casson, D. M., Malik, M., et al. (1998). Illeal-lym-
phoid-nodular hyperplasia, non-speficic colitis, and
pervasive developmental disorder in children. The
See Also Lancet, 351, 637–641.
▶ Antigluten Therapy
▶ Gluten-Free Diet
▶ Nutritional Interventions CASL
▶ Comprehensive Assessment of Spoken

References and Readings Language
Buie, T., Campbell, D. B., Fuchs, G. J., III, Furuta, G. T.,

Levy, J., Van de Water, J., et al. (2010). Evaluation,
in individuals with ASDs: A consensus report. Pediat- CAT/CLAMS
rics, 125, S1–S18.
Cass, H., Gringras, P., March, J., McKendrick, I., ▶ Clinical Linguistic and Auditory Milestone
O’Hare, A. E., Owen, L., et al. (2008). Absence of
urinary opioid peptides in children with autism. Scale
Archives of Disease in Childhood, 93, 745–749.
Fernell, E., Fagerberg, U. L., & Hellstrom, P. M. (2007).
No evidence for a clear link between active intestinal
inflammation and autism based on analyses of faecal
Catapres
calprotectin and rectal nitric oxide. Acta Paediatrica,
96, 1076–1079. ▶ Clonidine
Catatonia 533 C
There can also be a marked increase in repetitive
Catatonia and ritualistic behaviors.
There is very little research evidence to guide
Amitta Shah medical treatment of catatonia in people with
Leading Edge Psychology Clinical Psychology autism spectrum disorder. The few papers that
Consultancy Centre, Purley, Surrey, UK have been published on the medical treatment
have reported individual case studies of individ- C
uals with acute catatonic stupor who have
Definition responded to medication and/or electroconvul-
sive therapy (ECT) (summarized in Dhossche,
Catatonia is a complex neuropsychological Shah & Wing, 2006; Ghaziuddin et al., 2005).
disorder which can affect individuals with autism Guidelines for medical and psychological man-
spectrum disorder, including those agement, based on clinical experience, are given
with high-functioning autism and Asperger for mild, moderate, and severe catatonia in the
syndrome. Clinicians do not generally chapter by Dhossche, Shah, and Wing (2006). It
associate catatonia with autism, and thus the is recommended that ECT and/or lorazepam
condition is often misdiagnosed and wrongly challenge test should be tried only as a last resort
treated and hardly ever picked up at an early in cases of severe catatonia which is life-
stage. threatening.
Catatonia affects individuals with autism The general first-line treatment approach in
spectrum disorder in different ways and can be mild and moderate catatonia and catatonia-like
a progressive condition. It can occur gradually as deterioration is the psychological treatment
catatonia-like deterioration or less commonly as developed by Shah and Wing which is referred
an acute full-blown catatonia with catatonic to as the Shah-Wing Approach. The main aspects
stupor. The diagnosis of catatonia should be of this approach include the following:
considered in any individual with autism Timely diagnosis of catatonia-like deterioration
spectrum disorder when there is obvious and at an early stage.
marked deterioration in any aspect of functioning Detailed psychological assessment of the per-
compared to previous levels (Wing & Shah, son’s underlying autism and possible stress
2000). factors.
In individuals with autism spectrum disorder, Eliminating possible culprits such as antipsy-
catatonia is shown by the onset of any of the chotic medication.
following signs of deterioration: Designing a person-centered multidimensional
Increased slowness affecting movements and plan of management which reduces the stress
speech and motivates the individual. This includes
Marked reduction in the amount of speech or looking at the individual’s program, environ-
complete mutism ment, occupation, lifestyle, and activities and
Difficulty in initiating and inhibiting actions making changes as needed.
Increased reliance on physical or verbal prompts Providing 1:1 support and verbal and physical
Increased passivity and increased social prompts.
withdrawal Providing external stimulation and increasing
Apparent lack of motivation and volition participation with support.
Other manifestations and associated behaviors Clinical application of this approach has been
include freezing during actions, difficulty found to be extremely effective in significantly
crossing thresholds, to and fro movements and reducing the effects of catatonia and in enabling
hesitations, odd stiff posture, Parkinsonian fea- parents/carers to understand and manage the con-
tures, and episodes of excitement and agitation. dition effectively.
C 534 CATCH 22 (Chromosome 22q11 Deletion Syndrome)
References and Readings Categorization
Dhossche, D. M., Shah, A., & Wing, L. (2006). Blueprints The acronym CATCH22 was suggested in the
for the assessment, treatment and future study
1990s to encompass the variable features
of catatonia in autism spectrum disorders. In
D. M. Dhossche (Ed.), Catatonia in autism spectrum that accompany 22q11 deletion (Wilson 1993).
disorders. USA: Elsevier. Clinical diagnoses associated with 22q11 dele-
Dhossche, D. M., Wing, L., Ohta, M., & Neum€arker, K.-J. tion include DiGeorge syndrome, Shprintzen
(2006). Catatonia in autism spectrum disorders. USA:
(velocardiofacial) syndrome, and Takao
Elsevier.
Ghaziuddin, M., et al. (2005). Catatonia in autism: (conotruncal anomaly face) syndrome. These
A distinct subtype? Journal of Intellectual Disabilities phenotypes were recognized independently due
Research, 49, 102–105. to the prominence of particular clinical features.
Shah, A., & Wing, L. (2006). Psychological approaches
Identification of a common 22q11 deletion
to chronic catatonia-like deterioration in autism spec-
trum disorders. In D. Dhossche (Ed.), Catatonia in among patients with any of these diagnoses pro-
autism spectrum disorders. USA: Elsevier. vided the clear unifying factor for these clinically
Wing, L., & Shah, A. (2000). Catatonia in autism spec- defined syndromes.
trum disorders. British Journal of Psychiatry, 176,
An absent thymus and hypocalcemia due to a
357–362.
small parathyroid were the first recognized fea-
tures of DiGeorge syndrome, establishing the
diagnosis in the 1960s (Kirkpatrick and DiGeorge
1968). Additional characteristics including facial
features and heart defects were noted as reports of
CATCH 22 (Chromosome 22q11 the syndrome accumulated. DiGeorge syndrome
Deletion Syndrome) is now recognized by a pattern of structural or
functional deficits of the thymus, reduced para-
Kimberly Aldinger thyroid function, decreased serum calcium, and
Department of Cell and Neurobiology, congenital heart defects.
Keck School of Medicine, University Shprintzen, or velocardiofacial syndrome
of Southern California, Los Angeles, (VCFS), includes palate abnormalities, a character-
CA, USA istic facial appearance, and, in some cases, heart
disease (Shprintzen et al. 1978, 1981). Additional
features of VCFS include learning disabilities,
Synonyms developmental delay, and a wide array of psychiat-
ric disorders (Motzkin et al. 1993).
DiGeorge syndrome; Takao syndrome; Takao, or conotruncal anomaly face syn-
Velocardiofacial syndrome drome, is identical to DiGeorge syndrome, but
the Japanese group was the first to recognize the
major contribution of outflow tract defects of the
Short Description or Definition heart (Takao et al. 1980).
In 1981, de la Chappelle and colleagues reported
CATCH22 is an acronym for cardiac defect, that an unbalanced translocation between chromo-
abnormal facies, T-cell deficit, cleft palate, and some 22 and another chromosome was associated
hypocalcemia due to chromosome 22q11 dele- with features of DiGeorge syndrome. The small
tion. These are variable features associated with deletion created by the chromosome rearrangement
several clinically defined syndromes, including led to the hypothesis that genes in this region of
DiGeorge, velocardiofacial, and Takao. This chromosome 22 were responsible for DiGeorge
term excludes the DiGeorge phenotype that syndrome (Augusseau et al. 1986). Further
may have other chromosomal or environmental prospective analysis of patients with DiGeorge
causes. syndrome confirmed the importance of 22q11
CATCH 22 (Chromosome 22q11 Deletion Syndrome) 535 C
deletion in this population, though additional Clinical Expression and
chromosomal abnormalities were found in a few Pathophysiology
cases (Greenberg et al. 1988). Targeted chromo-
some studies in patients with VCFS (Driscoll et al. CATCH22 is characterized by infant hypocalce-
1992, 1993; Kelly et al. 1993; Scambler et al. 1992) mia, which can manifest seizures, and suscepti-
or Takao syndrome (Burn 1993) revealed bility to infection, due to deficient T cells.
a similar proportion of 22q11 deletion in these Associated cardiac malformations typically C
phenotypes as well. A 1.5- or 3-Mb piece of affect the outflow tract. These include tetralogy of
22q11 is typically lost (Cohen et al. 1999; Jerome Fallot, type B interrupted aortic arch, truncus
and Papaioannou 2001). arteriosus, right aortic arch, and aberrant right
In a more recent discussion of the CATCH22 subclavian artery.
acronym, Burns suggested using DiGeorge Facial features include a small mouth, square
syndrome for the severe presentation at birth, nose tip with pinched nostrils, unusual earlobe
VCFS for children with a prominent craniofacial folding, short upper lip folds, and slanting eyes
presentation, and Takao syndrome when cardiovas- (Wilson et al. 1993).
cular features are prominent, with the CATCH VCFS is usually seen in the older child,
phenotype encompassing all of the three diagnoses presenting with a bulbous nose, square nasal tip,
(Burns 1999). and hypernasal speech associated with submucous
or obvious cleft palate. Cardiac defects tend to be
less severe in these children with ventricular septal
Epidemiology defect being common.
Short stature and mild to moderate learning
22q11 deletion occurs in about 1 in 5,000 chil- difficulties are common. Various psychiatric dis-
dren and accounts for 2 % of all heart defects orders, including paranoid schizophrenia and
(Liling et al. 1999). This is the second most major depressive illness, have also been described
frequent cause of congenital heart disease after in adult cases of VCFS (Motzkin et al. 1993).
Down syndrome. In the United States, as many as Hearing loss, cleft lip, kidney abnormalities,
700 infants may be affected annually, with and low-functioning thyroid can also occur,
a slightly higher prevalence in Hispanics (Botto though these features are less common (Wilson
et al. 2003). et al. 1993).
Natural History, Prognostic Factors, and Evaluation and Differential Diagnosis

Outcomes
Distinctive facial features together with a heart
Infants with successful correction of their heart defect affecting the major outflow tract defect or a
defects have typical life spans. Immunological fea- history of recurrent infection should raise suspicion.
tures often resolve over time. Speech difficulties Hypocalcemia often occurs in affected infants,
abate with therapy and surgery to correct palate though it frequently resolves within the first year
abnormalities. (Wilson et al. 1993).
Identification of 22q11 deletion as a major cause A chest X-ray is necessary for immunological
of DiGeorge and VCSF has provided a major con- assessment. However, identifying a small thymus
tribution to the diagnosis of these clinically defined by radiography can be challenging in stressed
disorders. However, this advance is relatively infants. Children with CATCH22 may have nor-
recent, with few CATCH22 patients followed mal white blood cell counts, while sick infants
throughout their lifetime. Further study of adults may instead have a normal thymus and reduced
with CATCH22 is required to evaluate disease white blood cell counts. To resolve these differ-
progression (Shprintzen, 2008). ences, assess the number of CD4-positive
C 536 CATCH 22 (Chromosome 22q11 Deletion Syndrome)
T lymphocytes. Sick infants should be treated as Wong, L. Y., Elixson, E. M., Mahle, W. T., & Campbell,
if they have compromised cellular immunity, R. M. (2003). A population-based study of the 22q11.2
deletion: phenotype, incidence, and contribution to major
with transfusion using irradiated blood to avoid birth defects in the population. Pediatrics, 112, 101–107.
graft-versus-host disease until diagnosis is con- Burn, J. (1999). Closing time for CATCH22. Journal of
firmed (Wilson et al. 1993). Medical Genetics, 36, 737–738.
Suspicion of 22q11 deletion syndrome should be Burn, J., Takao, A., Wilson, D., Cross, I., Momma, K.,
Wadey, R., Scambler, P., & Goodship, J. (1993).
confirmed using a molecular genetics test. Karyotype Conotruncal anomaly face syndrome is associated
can exclude major chromosomal rearrangements, with a deletion within chromosome 22q11. Journal of
while fluorescent in situ hybridization or copy num- Medical Genetics, 30(10), 822–824.
ber variation analyses can more precisely determine Cohen, E., Chow, E. W., Weksberg, R., & Bassett, A. S.
(1999). Phenotype of adults with the 22q11 deletion
deletion size and location. Parents should be syndrome: a review. American Journal of Medical
screened for carrier status; 10–25 % of parents may Genetics, 86, 359–365.
be asymptomatic carriers (Levy et al. 1997). De la Chapelle, A., Herva, R., Koivisto, M., & Aula, P.
(1981). A deletion in chromosome 22 can cause
DiGeorge syndrome. Human Genetics, 57, 253–256.
Driscoll, D. A., Salvin, J., Sellinger, B., Budarf, M. L.,
Treatment McDonald-McGinn, D. M., Zackai, E. H., & Emanuel,
B. S. (1993). Prevalance of 22q11 microdeletions in
Clinical management is complex due to the array DiGeorge and velocardiofacial syndromes: implica-
tions for genetic counseling and prenatal diagnosis.
of phenotypes associated with CATCH22. Heart Journal of Medical Genetics, 30(10), 813–817.
defects are usually the focus of treatment, though Driscoll, D. A., Spinner, N. B., Budarf, M. L., McDonald-
this treatment does not differ from that for other McGinn, D. M., Zackai, E. H., Goldberg, R. B.,
similar heart defects. Early echocardiography is Shprintzen, R. J., Saal, H. M., Zonana, J., Jones,
M. C., Mascarello, J. T., & Emanuel, B. S. (1992).
critical in any child with suspected CATCH22. Deletions and microdeletions of 22q11.2 in velo-car-
Hypocalcemia can be treated using calcium dio-facial syndrome. American Journal of Medical
supplements and 1,25-cholecalciferol. Genetics, 44(2), 261–268.
The child should be examined for the presence Greenberg, F., Elder, F. F., Haffner, P., Northrup, H., &
Ledbetter, D. H. (1988). Cytogenetic findings in
of a submucous cleft, which can elude detection a prospective series of patients with DiGeorge anomaly.
and often requires surgical intervention. American Journal of Human Genetics, 43(5), 606–611.
Immunological features manifest as frequent Jerome, L. A., & Papaioannou, V. E. (2001). DiGeorge
respiratory infections in early childhood with few syndrome phenotype in mice mutant for the T-box
gene, Tbx1. Nature Genetics, 27, 286–291.
occurrences of severe immunodeficiency. Kelly, D., Goldberg, R., Wilson, D., Lindsay, E., Carey,
Early thymus transplantation has been performed A., Goodship, J., Burn, J., Cross, I., Shprintzen, R. J.,
to alleviate immunological features, though these & Scambler, P. J. (1993). Conformation that the velo-
features may resolve on their own over time cardio-facial syndrome is associated with haplo-
insufficiency of genes at chromosome 22q11. Ameri-
(Markert et al. 1999). can Journal of Medical Genetics, 45(3), 308–312.
Kirkpatrick, J. A., Jr., & DiGeorge, A. M. (1968). Congen-
ital absence of the thymus. American Journal of Roent-
See Also genology, Radium Therapy, and Nuclear Medicine, 103,
32–37.
▶ Velocardiofacial Syndrome Levy, A., Michel, G., Lemerer, M., & Philip, N. (1997).
Idiopathic thrombocytopenia pupura in two mothers of
children with DiGeorge sequence: A new component
manifestation of deletion 22q11? American Journal of
References and Readings Medical Genetics, 69, 356–359.
Liling, J., Cross, I., Burn, J., Daniel, C. P., Tawn, E. J., &
Augusseau, S., Jouk, S., Jalbert, P., & Prieur, M. (1986). Parker, L. (1999). Frequency and predictive value of
DiGeorge syndrome and 22q11 rearrangements. 22q11 deletion. Journal of Medical Genetics, 36(10),
Human Genetics, 74, 206. 794–795.
Botto, L. D., May, K., Fernhoff, P. M., Correa, A., Coleman, Markert, M. L., Boeck, A., Hale, L. P., kloster, A. L.,
K., Rasmussen, S. A., Merritt, R. K., O’Leary, L. A., McLaughlin, T. M., Batchvarova, M. N., Doued,
Catecholamine System 537 C
D. C., Koup, R. A., Kostyu, D. D., Ward, F. E., Rice, Dopaminergic System
H. E., & Mahaffey, S. M. (1999). Transplantation Dopamine is produced by neurons in the
of thymus tissue in complete DiGeorge
syndrome. New England Journal of Medicine, 341, substantia nigra, the ventral tegmental area, and
1180–1189. hypothalamus. These neurons project to many
Motzkin, B., Marion, R., Goldberg, R., Shprintzen, R., & areas of the brain, including the prefrontal cortex,
Saenger, P. (1993). Variable phenotypes in the amygdala, the hippocampus, and striatum.
velocardiofacial syndrome with chromosomal dele-
tion. Journal of Pediatrics, 123(3), 406–410. Dopamine released by the hypothalamus also C
Scambler, P., Kelly, D., Lindsay, E., Williamson, R., acts as a neurohormone, inhibiting the release of
Goldberg, R., Shprintzen, R., Wilson, D. I., Goodship, prolactin from the anterior lobe of the pituitary.
J. A., Cross, I. E., & Burn, J. (1992). Velo-cardio-facial In the periphery, dopamine is also produced in the
syndrome associated with chromosome 22 deletions
encompassing the DiGeorge locus. Lancet, 339(8802), adrenal medulla. Dopamine activates five known
1138–1139. types of receptors (D1–D5).
Shprintzen, R. J. (2008). Velo-cardio-facial syndrome:
30 years of study. Developmental Disability Research
Reviews, 14(1), 3–10.
Shprintzen, R. J., Goldberg, R. B., Lewin, M. L., Sidoti, Function
E. J., Berkman, M. D., Argamaso, R. V., & Young, D.
(1978). A new syndrome involving cleft palate, car- Norepinephrine and dopamine act as
diac anomalies, typical facies, and learning disabil- neuromodulators in the brain and also as periph-
ities: velo-cardio-facial syndrome. The Cleft Palate
Journal, 15(1), 56–62. eral hormones in the blood circulation. Norepi-
Shprintzen, R. J., Goldberg, R. B., Young, D., & Wolford, nephrine is a neuromodulator of the peripheral
L. (1981). The velo-cardio-facial syndrome: sympathetic nervous system.
A clinical and genetic analysis. Pediatrics, 67, Central catecholamine function is important
167–172.
Takao, A., Ando, M., Cho, K., Kinouchi, A., & Murakami, for regulating many behaviors, e.g., cognition,
Y. (1980). Etiologic categorization of common con- movement, sleep, mood, attention, and learning.
genital heart disease. In R. Van Praagh & A. Takao In the periphery, catecholamine release
(Eds.), Etiology and morphogenesis of congenital increases heart rate, blood pressure, and blood
heart disease (pp. 253–269). Mount Kisco, NY: Futura
Publishing. glucose, generally associated with the response
Wilson, D. I., Burn, J., Scambler, P., & Goodship, J. to an environmental stressor.
(1993). DiGeorge syndrome, part of CATCH 22. Jour-
nal of Medical Genetics, 30, 852–856.
Pathophysiology
Abnormally high levels of central and peripheral

catecholamines can be caused by trauma
Catecholamine System (brainstem), neuroendocrine tumors (e.g., for
the periphery in the adrenal medulla – a condition
Alex Bonnin known as pheochromocytoma). Monoamine
Keck School of Medicine, University of oxidase A (MAO-A) deficiency can also lead to
Southern California, Los Angeles, elevated levels of central and peripheral
CA, USA catecholamines.
Structure See Also
The most abundant catecholamines are epineph- ▶ Catechol-O-methyltransferase

rine (adrenaline), norepinephrine (noradrena- ▶ Dopamine
line), and dopamine. Catecholamines are ▶ Epinephrine
produced from phenylalanine and tyrosine. ▶ Norepinephrine
C 538 Catechol-O-Methyltransferase
Structure
Catechol-O-Methyltransferase
Anatomical Structure
Alex Bonnin The caudate nucleus, along with the putamen,
Keck School of Medicine, University of Southern globus pallidus (GP), subthalamic nuclei, and
California, Los Angeles, CA, USA substantia nigra (SN), makes up a larger
collection of nuclei called the basal ganglia. The
two caudate nuclei, each residing within
Synonyms a hemisphere, sit alongside the lateral ventricles,
superior to the thalamus, and laterally bound by
COMT the internal capsules. Its C-shaped structure con-
sists of three identifiable regions: (1) the bulbous
“head” lying ventral to the putamen and forming
Definition the anterior horn of the lateral ventricle, which
tapers to (2) the long, curved “body” which
Enzyme that catalyzes the O-methylation of cat- moves posteriorly forming the floor of the lateral
echolamine neurotransmitters and catechol hor- ventricle and then curves anteriorly to end at
mones, leading to their inactivation. (3) the thinner “tail” near the posterior end of
There are two known isoforms: the thalamus and forming the roof of the temporal
A membrane-bound isoform (MB-COMT) horn of the lateral ventricle. The tail, or cauda in
and a soluble cytoplasmic isoform (S-COMT). Latin, is the namesake for this structure.
The caudate nucleus and putamen together
See Also form the striatum (or neostriatum). Although
these two structures share embryonic origin,
▶ Catecholamine System starting as a single nuclear mass, they develope
▶ Epinephrine into anatomically distinct structures divided by
the internal capsule. Yet, the internal capsule
does not completely separate the caudate nucleus
Category Fluency from the putamen. At the head of the caudate
nucleus, a striated cell bridge, made up of gray
▶ Verbal Fluency matter extensions, joins the caudate nucleus to
the putamen, thus giving its name “striatum.”
The striatum (caudate nucleus and putamen) and
Caudate the GP comprise the corpus striatum.
Furthermore, the ventral portion of the caudate
▶ Caudate Nucleus nucleus, the putamen, nucleus accumbens, and
anterior perforated substance make up the ventral
striatum. These classifications are used to
Caudate Nucleus differentiate structure, afferent and efferent pro-
jections, associated neurotransmitters, and
Lauren Schmitt functions.
Psychiatry, UT Southwestern Medical Center,
Dallas, TX, USA Histology
The majority (90%) of the neurons that make up
the caudate nucleus are efferent spiny dendrites
Synonyms which release gamma-aminobutyric acid
(GABA), an inhibitory neurotransmitter. The
Caudate; Neostriatum; Striatum remaining neurons, those without spines, connect
Caudate Nucleus 539 C
internally and use the excitatory neurotransmit- (originating in the SNr and projecting to the stri-
ter, acetylcholine (ACh). atum) are dopaminergic may have either excit-
atory or inhibitory effects, depending on which
Neural Connections type of receptor the neurotransmitter binds.
Like the other basal ganglia nuclei, the caudate
nucleus has a multitude of nerve connections, Pathways
serving important and widespread functions, The afferent and efferent neurons of the caudate C
which will be discussed in greater detail in the nucleus (and putamen too) participate in the
next section. Here, the major afferent (excitatory) direct and indirect feedback loop pathways of
and efferent (inhibitory) projections will be the thalamus, having either excitatory or inhibi-
discussed. tory effects, respectively. In the direct pathway,
Afferent (or Input) Nuclei: The major afferent the inhibitory GABAergic effect of the efferent
connections are from the cerebral cortex and neurons releases the GPint from inhibition, thus
substantia nigra. The corticostriatal connection creating a net excitatory reaction. Alternatively,
(from the cerebral cortex to the caudate nucleus) in the indirect pathway, GABA from the striatum
originates primarily from the frontal and associ- inhibits the GPext and has downstream effects in
ation cortices, in particular the prefrontal and the subthalamic nulcei and the GPint, ultimately
parietal regions. (The putamen in comparison leading to a net inhibitory effect. Thus, whether
receives its projections from the primary motor, the caudate nucleus is involved in engaging or
premotor, supplementary motor, and somatosen- inhibiting an action depends on which pathway
sory cortices.) All afferent connections are wins out (DeLong, 2000).
excitatory and glutaminergic. Additionally, Furthermore, the caudate nucleus may also
these afferent connections are ipsilaterally and have excitatory or inhibitory effect in the cortex
topographically organized, such that within the via dopaminergic neurons within the nigrostriatal
same hemisphere, the frontal lobe inputs onto the pathway. The depolarization (stimulation) or
head of the caudate nucleus, the parietal and hyperpolarization (inhibition) of a cell is highly
occipital lobes onto the body, and the temporal dependent on the dopamine receptor on the post-
lobe onto the tail. synaptic terminal.
Efferent (or Output) Nuclei: The major effer-
ent connections of the caudate nucleus are to the
internal and external segment of the globus Function
pallidus (GPint and GPext, respectively) and the
substantia nigra pars reticulata and compata Most of our knowledge of the functionality of the
(SNr and SNc, respectively). The striatopallidus caudate nucleus come from a variety of animal
(from the striatum to the globus pallidus) studies, human lesion studies, and more recently,
and striatonigral (from the striatum to the functional magnetic resonance imaging (fMRI).
substantia nigra) efferents are inhibitory and The caudate nucleus, which was once thought to
GABAergic. The GPint efferents then project to have its influences limited to the sensorimotor
the thalamus, enervating the dorsomedial system, is now known to be heavily involved in
nucleus, intralaminar nuclei, and parts of the ven- executive function, memory, and even some
tral anterior nuclei. The SNr efferents project to aspects of social communication. Consequently,
the superior colliculus (SC) of the eye and the most of the caudate’s role in sensorimotor func-
ventral anterior and ventral lateral thalamic tioning, except for that of higher-level control,
nuclei. has since be re-established as being the role of the
Intrinsic (or Internal) Nuclei: The GABAergic putamen (for review, see Middleton & Strick,
inhibitory striatopallidal and striatonigral con- 2000).
nections are not the only intrinsic connections From a cognitive perspective, convincing
within the striatum. Nigrostriatum connections evidence points toward the caudate nucleus
C 540 Caudate Nucleus
contributing to goal-oriented behavior (Grahn, regions via its multiple neural pathways to exe-
Parkinson & Owen, 2008). Goal-oriented behav- cute a response which will provide further feed-
ior is the appropriate stimulation of action and the back to the caudate nucleus.
selection of goals (and subgoals) based upon the Social/Language Processing: It is difficult to
expected outcome of the specific action. Thus, completely differentiate the caudate nucleus’ role
cognitive flexibility and set-switching between in social aspects and language processing from its
goals become very important in goal-oriented role in the higher-order cognitive functions
behavior. In animal lesion and neurochemical discussed above. For instance, it is not surprising
studies, the caudate nucleus has been directly that neuroimaging and lesion studies have found
linked to the rats’ ability to change or switch that social rewards activate the caudate nucleus,
between choices, as it seen in reversal learning given the fact that this structure responds simi-
tasks (Ragazzino, 2003; Ragazzino & Choi, larly to monetary, and even expected (but not
2004), and strategies (Ragazzino, Jih, & Tzavos, necessarily received), rewards (Izuma, Saito, &
2002; Yin, Ostlund, Knowlton, & Balleine, 2005) Sadato, 2008; Montague et al., 2002; Villablanca,
when task contingencies change (e.g., which item 2010). Involvement in social behavior is likely
is rewarded, the value of the reward, schedule of limited to and selectively involved in behavior
reward). Furthermore, the caudate nucleus has associated with action-outcomes but may have
been found to be selectively responsible for important implications in social motivation
adapting to these new task contingencies and which is reliant on assessing social reward.
executing the appropriate switch rather than In terms of language, evidence shows that the
inhibiting the proponent response as the prefron- caudate nucleus plays may pay a role in the
tal cortex does (Dias, Robbins, & Roberts, 1996). higher-level language processing involved in
In primates, single-unit recording from the cau- bilingualism and deciphering phonemes and
date nucleus revealed different patterns meaning of words in ambiguous situations
depending on whether the expected outcomes of (Crinion et al., 2006). This finding was left-side
the action are positive or negative (Ravel, unilateral which is to be expected as language
Legallet, & Apicella, 2003). Similarly, human function as a whole is predominately localized
neuroimaging evidence has found stronger acti- to the left hemisphere. Although its contribution
vation responses in the caudate nucleus to posi- to language processing is not directly related to
tive reinforcement. In addition, greater activation action-outcome or goal-directed behavior, the
was seen within the caudate nucleus when sub- caudate nucleus continues to have a critical role
jects thought they had subjective control over the in situations which require an active selecting
outcome (Grahn et al., 2008). Thus, the caudate process to yield the best outcome. Here, the cau-
nucleus is necessary for both the behavior date nucleus helps determine which phonemes
(the process of selection) and the evaluation of and/or definitions make the most sense given
the outcome (choice). previous knowledge and current context.
This role in goal-oriented behavior and In conclusion, the caudate nucleus is highly
reward-based learning is not surprising given involved in higher-order cognitive functioning,
the caudate nucleus’ modulation of dopamine, especially in learning and memory tasks that are
which is known to be heavily involved in the highly dependent on reinforcement. Its predomi-
reward systems (Cools et al., 2009), abundance nant role in goal-oriented behavior has been
of dopamine receptors, and influence in updating shown in rodent, primate, and human studies.
information during working memory tasks
(Frank & O’Reilly, 2006). Essentially, the cau-
date nucleus is active in a constant loop of eval- Pathophysiology
uating feedback, deciding what to do based upon
that feedback (e.g., maintaining vs. switching Given the structural and functional significance
response), and stimulating (or inhibiting) other of the caudate nucleus, and the known executive
dysfunction in autism, it is not surprising that this Although they argue that this supports an auto-
structure has been implicated in the pathophysi- immune theory of autism, more importantly, it
ology of the disorder. Morphological, genetic, illustrates an additional abnormality within the
and neuroimaging studies have found evidence caudate nucleus as well as the heterogeneity of
of abnormalities within the caudate nucleus of these abnormalities.
individuals with autism and its associated disor- Additional atypical physiology has been found
ders. Although not all results are consistent with in the functional connectivity between the cau- C
each other, especially in relation to the behavioral date nuclei and cerebral cortex (Turner et al.,
and clinical correlates of autism, abnormalities 2006). In a functional connectivity MRI
within the caudate nucleus have been repeatedly (fcMRI) study, age-matched males with autism
found and likely contribute in some way to the showed decreased connectivity between the right
aberrant functioning of individuals with autism caudate nucleus and occipital-temporal regions
and its associated disorders. but increased connectivity between bilateral cau-
Morphological data has shown a bilateral date nuclei and contralateral motor cortices com-
enlargement of the caudate nucleus in individuals pared to controls within (Turner et al., 2006).
with autism when compared to healthy control Taken all together, individuals with autism
groups (Cody Hazlett et al., 2009; Holllander show an aberrant neural organization, which
et al., 2005; Langen et al., 2007; 2009; Sears likely contributes to autism’s phenotypic expres-
et al., 1999), which remains significant even sion given the caudate nucleus’ role in initiating
when total brain volume is taken into account. direct and indirect pathways.
The volumetric increase (Langen et al., 2009) as Given the caudate nucleus’ diffuse connec-
well as outward deformation (Qiu et al., 2010) of tions throughout the brain via the direct and indi-
the caudate nucleus has been localized to the head rect pathways, this disrupted functional
of the structure. Only one study (Langen et al., connectivity may have important implications in
2009) found unilateral malformation, with the executive dysfunction of autism, yet fMRI
a significantly greater volumetric increase in the studies implicating the caudate nucleus have
right caudate nucleus. Langen and colleagues been relatively sparse and inconsistent. Silk and
additionally found that caudate volume has an colleagues found reduced activation of the cau-
atypical developmental trajectory (2009). Cau- date nucleus in individuals with autism compared
date volume increased with age in individuals to controls during a mental rotation task,
with high-functioning autism compared to the a paradigm known to rely heavily on executive
inverted U-shape trajectory in typical develop- functioning and working memory (2006). This
ment, peaking between the ages 7 and 8. Due to finding, however, has not been replicated in
this atypical development, the greatest differ- other tasks relying on visuospatial skills and
ences in caudate volume were seen at later ages working memory (Luna et al., 2002). Alterna-
(Langen et al., 2007, 2009). It should be noted, tively, this group found the caudate nucleus to
however, that not all studies have documented be involved in sensorimotor control associated
this increase in caudate volume (Langen et al., with saccadic eye movements in individuals
2011). Age, specific diagnosis, intellectual func- with autism but not healthy control individuals.
tioning, and the current or previous usage of They suggest that the caudate nucleus, as well as
medication may have contributed to these non- other structures within the frontal-striatal circuit,
significant findings. is recruited during saccadic eye movements as
At a microscopic level, Singh and Rivas a compensatory mechanism due to a defective
documented that serum antibodies, which were sensorimotor system (Takarae, Minshew, Luna,
not present in healthy controls, were most com- & Sweeney, 2007). If individuals with autism use
monly present in the cauduate nucleus (49%) of the caudate nucleus for lower-level functions,
children with autism, compared to the cerebral like saccadic eye movements, then there may be
cortex (18%) and cerebellum (9%; 2004). less resources available for the caudate nucleus to
C 542 Caudate Nucleus
perform higher-level cognitive tasks, like those Rett syndrome and not to autistic behavior, how-
associated with goal-oriented behavior. ever this has been be examined.
Some of the most intriguing findings are not Although the above studies contribute signif-
from those found in individuals with autism but icantly to the autism literature and begin to delin-
those found in individuals with the genetic disor- eate the neurophysiological abnormalities in
ders associated with autism (see fragile autism, only a few have examined how these
X syndrome and Rett syndrome). Individuals structural differences may express themselves
with fragile X syndrome (FXS) not only have an phenotypically. Langen and colleagues found
increased caudate nucleus size when compared to significant negative correlations between caudate
controls (Cody Hazlett et al., 2009; Gothelf et al., volume and insistence on sameness (IS) on the
2007; Hoeft et al., 2008; Reiss et al., 1995) but ADI-R (or difficulty changing minor routines;
also when compared to individuals with non-FXS 2009). This is consistent with Sears and col-
autism (Cody Hazlett et al., 2009). The Cody leagues finding negative correlations between
Hazlett study further broke down their results to caudate volume and higher-order repetitive
analyze the subgroups of FXS individuals with behaviors (ADI-R C2 algorithm items), including
and without autism compared to autism non-FXS the same IS factor as Langen et al. (2009). Inter-
individuals and controls. Their results showed estingly, a significant positive correlation was
that both FXS groups (those with and without found between low-order repetitive behaviors
autism) had significantly enlarged caudate (stereotyped movements) and caudate volume
nucleus volumes compared to the autism and (Sears et al., 2009). These correlations with repet-
control groups, and there was no significant dif- itive behaviors, however, are not consistent. Two
ference in the caudate volume between the two groups (Holllander et al., 2005; Rojas et al., 2006)
FXS groups (Cody Hazlett et al., 2009). This found positive correlations between caudate vol-
latter finding suggests that although both FXS ume and higher-order repetitive behaviors. These
and autism have been linked to enlargement of inconsistencies as well the nonsignificant find-
the caudate nucleus, this is effect is not additive. ings make discussion of this literature. Examin-
Such that individuals with both FXS and autism ing all the results together reveals, at least, some
do not have a greater increase in volume of the relationship between caudate nucleus enlarge-
caudate nucleus. Alternatively, it may mean that ment and phenotypic behavior in individuals
individuals with both an autism and a FXS diag- with autism.
nosis have a greater probability of having an In conclusion, although the caudate nucleus
enlarged caudate nucleus compared to those indi- has been implicated in the pathophysiology of
viduals with a sinlge diagnosis. Yet, since not all autism and its associated genetic disorders,
individuals with FXS have autism nor do all results are relatively inconsistent. Morphological
individuals with FXS or FXS with autism have data supporting an enlargement of the caudate
enlargements of the caudate nucleus, it is hard to nucleus in individuals with autism remains the
determine how these physiological abnormalities most replicated, but even these results are not
behaviorally manifest themselves in each always in agreement, especially when in relation
disorder. to diagnostic criteria. Findings from the FXS and
In comparison, age- and gender-matched girls Rett syndrome studies may have important impli-
with Rett syndrome showed smaller volumes of cations in the genetic pathophysiology of autism
the caudate nucleus when compared to controls and should be examined in greater detail. Addi-
(Subramaniam, Naidu, & Reiss, 1997). It should tionally, given the known functional importance
be noted, however, that although Rett syndrome of caudate nucleus in behavioral flexibility and
is characterized by autistic-like behavior, the reversal learning, known to be affected in autism,
study did not indicate whether these individuals more studies should aim to identify where the
had a diagnosis of autism or not. Thus, a functional abnormalities of the caudate nucleus
decreased caudate volume may be specific to are in individuals with autism. At this time
though, despite inconsistencies in the literature, Holllander, E., Anagnostou, E., Chaplin, W., Esposito, K.,
the caudate nucleus remains an important struc- Haznedar, M., LiCalzi, E., Wasserman, S., Soorya, L.,
& Buchsbaum, M. (2005). Striatal volume on magnetic
ture when examining the etiology of autism due resonance imaging and repetitive behaviors in autism.
to its significant structural, neurochemical, and Biological Psychiatry, 58, 226–232.
functional connections. Izuma, K., Saito, D. N., & Sadato, N. (2010). Processing of
the incentive for social approval in the ventral striatum
during charitable donation. Journal of Cognitive Neu-
roscience, 22, 621–631.
C
See Also Langen, M., Durston, S., Staal, W., Palmen, S., & van
Engeland, H. (2007). Caudate nucleus is enlarged in
▶ Executive Function (EF) high-functioning medication-naive subjects with
autism. Biological Psychiatry, 62, 262–266.
Langen, M., Leemans, A., Johnston, P., Ecker, C., Daly,
E., Murphy, C. M., dell’Acqua, F., Durston, S., The
References and Readings AIMS Consortium, & Murphy, D. G. M. (2011).
Fronto-striatal circuitry and inhibitory control in
Anagnostou, E., & Taylor, M. J. (2011). Review of neu- autism: Findings from diffusion tensor imaging
roimaging in autism spectrum disorders: What we tractography. Cortex, 30, 1–11.
have learned and where we go from here. Molecular Langen, M., Schnack, H., Nederveen, H., Bos, D., Lahuis,
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▶ Qualitative Versus Quantitative Approaches ▶ Communicative Development Inventories

Center-Based Programs 545 C
typically focus their interventions exclusively on
CDIs this population of learners and are often based in
universities although some are freestanding
▶ Communicative Development Inventories private programs. Center-based programs include
▶ MacArthur-Bates Communicative Develop- research on intervention with ASD as an
ment Inventories, Second Edition important aspect of their work.
C
CDT Historical Background
▶ Clock Drawing In the late 1960s, shortly after Lovaas et al.

(1965, 1973) demonstrated that children with
autism living on a hospital inpatient unit could
learn adaptive skills, interest in the science of
Ceiling Effect Applied Behavior Analysis (ABA) as a treatment
approach for autism increased in universities
Domenic V. Cicchetti around the United States. For example, the Koegel
Departments of Psychiatry and Biometry, Autism Center at UC, Santa Barbara, was opened
Yale Child Study Center, Yale University, in 1971 with an outpatient clinic and an experi-
New Haven, CT, USA mental classroom. The research on pivotal
response treatment coming from that center over
the years has been highly influential to the field of
Definition ABA (e.g., Koegel, O’Dell, & Koegel, 1987).
The Douglass Developmental Disabilities
This phenomenon occurs when a test item is so easy Center opened in 1972 at Rutgers University in
that a large number of test takers achieve the highest New Jersey as a research-based day program for
score possible on that item. Another way of viewing school-age children with autism (Harris &
the phenomenon would be to describe such easy Handleman, 2000). That program is noted for
items as ones that fail to distinguish between levels research on teaching parents to use ABA methods
of ability of the test takers. If nearly all or all testees (Harris, 1983), for research on the assessment of
get the Vineland adaptive behavior item right, then children with ASD (e.g., Delmolino, 2006), and
it is a useless item, from a psychometric perspective for developing new ABA methods to teach skill
and must never see the light of clinical brightness. acquisition and behavior management (e.g.,
Jennett, Harris, & Delmolino, 2007). In 1975,
Raymond Romanczyk established the Institute
for Child Development at the State University
Center-Based Programs of NY at Binghamton. The work on computer-
based curricula coming from that center has been
Sandra Harris adopted in many places (Romanczyk &
Douglass Developmental Disabilities Center, Lockshin, 1982). The Walden Early Childhood
Rutgers, The State University of New Jersey, program was opened on the campus of University
New Brunswick, NJ, USA of Massachusetts in 1985 and has since relocated
to the Emory University School of Medicine
(McGee, Morrier, & Daly, 2001). Their emphasis
Definition on incidental teaching with preschool-age chil-
dren has had an important impact on preschool
Center-based programs for children, adolescents, programs for children with ASD (McGee,
and adults with autism spectrum disorders (ASD) Morrier, & Daly, 1999).
C 546 Center-Based Programs
Not all centers are university based. For exam- programs, another goal is teaching undergraduate
ple, the Princeton Child Development Institute in and graduate students how to implement these
New Jersey (McClannahan & Krantz, 2001) is methods. After they leave the university, these
a freestanding private program that has an students can bring the ABA treatment methods
affiliation with the University of Kansas, but is into the wider community and help disseminate
physically far removed from that campus. cutting edge techniques in public and private
They have made major contributions to the schools. Some center-based programs have staff
understanding of the treatment of ASD including members who consult to schools and families
a competency-based staff training program, and about the most effective ways to educate students
the use of activity schedules to help students with with ASD and share their knowledge through that
ASD function independently (McClannahan & consultation.
Krantz, 1999). Another freestanding program There are significant advantages to providing
located in New Jersey that has a research focus treatment in a center-based program. One of these
is the Alpine Learning Group which was founded is that the entire staff is focused on the treatment
in 1989 and contributes research findings in of ASD and this depth of talent ensures that if
several areas of ABA (e.g., Meyer, Taylor, a teacher is on jury duty or an assistant teacher is
Levin, & Fisher, 2000). on medical leave, there will be other experienced
staff members able to step in and maintain
a high-quality program for a learner. Public
Rationale or Underlying Theory schools rarely have the resources to ensure that
kind of coverage, and parents running their own
Many center-based programs are at universities home-based program may find themselves
in which innovative research in the treatment of overwhelmed when there are not enough staff
autism spectrum disorders can most efficiently be members to cover the teaching hours in the day.
done, and others are private programs that place Another advantage is that center-based programs
a high value on doing research as part of their typically use cutting edge teaching methods.
mission. Once new ABA teaching techniques These data-based methods offer the learner
have been developed in these environments, a major advantage in terms of the likelihood of
they are fine-tuned to work in school-based and making progress over time.
home-based settings. Instructional methods One potential disadvantage of a center-based
developed in research settings have very limited program is that there may not be easy access to
value if they can only be applied in the center typically developing peers. By contrast, the pub-
where they were created. It is essential that the lic schools are primarily comprised of youngsters
methods be shown to be effective when used by in regular education classes who can be invited to
well-trained staff members in community set- serve as role models. To compensate for the lack
tings as well. The Princeton Child Development of neurotypical peers, some center-based pro-
Institute, for example, has consulted to several grams, especially at the preschool level, include
replication sites that adopted their approach. a classroom of typically developing preschool
These sites are located in College Point, NY; children who can be role models and friends for
New Milford, NJ; Bedminster, NJ; Maplewood, young children with ASD. This provides an inclu-
NJ; Gdansk, Poland; and Istanbul, Turkey. sive experience for the child who is getting ready
to go to kindergarten in a public school. In addi-
tion, when children in a center-based program are
Goals and Objectives ready to be transitioned to their home districts,
they will make many visits over an extended
One goal of center-based programs is developing period of time to help them feel comfortable
effective treatments for learners with an autism when they are fully included in the public school.
spectrum disorder (ASD). For university-based This transition process allows the center-based
Center-Based Programs 547 C
staff to identify skill deficits that need to be Treatment Procedures
addressed for the child to fit into the new place-
ment. Older learners who still require intensive Many center-based programs are at universities
services of a center-based program often with a commitment to developing empirically
spend significant amounts of time in community supported treatments, and others are private pro-
settings where they are exposed to children or grams which share that research goal. Because
adults of their own age. Applied Behavior Analysis (ABA) has the best C
The extent of parental control varies by track record of providing rigorous evidence, most
instructional setting. In home-based programs, center-based programs employ a broad array of
parents are typically present for much of the ABA methods. They range from naturalistic
instructional time and are active in making day- teaching in a playful setting with a young child
by-day decisions. Some parents value this role or helping a teenager with ASD take public trans-
and expect to be very active in their young child’s portation to using more structured methods
education. However, in families where both including discrete trial teaching to help students
parents must work or in single parent families, it learn factual knowledge that forms the basis for
is not feasible for parents to be at home oversee- effective communication and improved cognitive
ing the teaching programs and still earn a living to skills. Among the many behaviors that children
support their family. Under these conditions, with ASD have learned with ABA techniques are
a center-based program or a school-based empathy skills (Schrandt, Townsend, & Poulson,
program has the advantage of allowing parents 2009), using a greater diversity of responses
to leave much of the daily decision making to the (Napolitano, Smith, Zarcone, Goodkin, &
educational team. By law, parents must have McAdam, 2010), and requesting answers to
a voice in planning their child’s education, but novel questions (Ingvarsson & Hollobaugh,
when the program is not home based, they do not 2010). Rogers and Dawson (2010) have devel-
have the intensive control of daily decision oped ABA techniques that are developmentally
making that is possible in their own home. informed to work with very young children
starting at 1 year of age and continuing to age 5
years.
Treatment Participants For difficult to manage behavior such as self-
injury, aggression, or tantrums, ABA offers
Children of all ages, adolescents, and adults may sophisticated functional assessment/analysis
be served by center-based programs. The centers techniques followed by the development of
vary in how they select learners. They may recruit a treatment intervention to teach the student
students with specific educational needs, for positive alternatives to disruptive behavior (e.g.,
example, significant speech delays or problems Hanley, Iwata, & McCord, 2003). For example,
with forming important visual or auditory dis- a child who is motivated to slide to the floor
criminations, to test a new intervention. Alterna- because it gains her teacher’s attention might
tively they may admit students who cannot be learn to raise her hand or give the teacher a card
accommodated in the public schools because of that says “Talk to me please.” Similarly,
the complexity of their learning needs, the lack of a teenager who is motivated to avoid a task
trained staff with a knowledge of ASD in the might learn to ask for a “break please” or give
district, or seriously challenging behaviors on the teacher a “break card.”
the part of the learner. Although inclusion in
a regular education class is a goal for every
child, there are some learners with autism Efficacy Information
spectrum disorders whose behavioral challenges
make that goal difficult, if not impossible, to As reflected in this encyclopedia, there is
achieve. a substantial body of empirical data
C 548 Center-Based Programs
demonstrating that techniques based on the prin- a group that receives the usual services available
ciples of ABA can be highly effective in teaching in the community (called treatment as usual,
new skills in multiple domains including commu- TAU). Data from these studies are analyzed
nication, social behavior, adaptive behaviors, using statistical methods to compare differences
vocational skills, and the self-control of maladap- between groups (e.g., Harris & Handleman,
tive behaviors. Much of this research comes from 2000; Rogers & Dawson, 2010; Sallows &
center-based programs (e.g., Charania, LeBlanc, Graupner, 2005; Smith, Groen, & Wynn, 2000).
Sabanathan, Ktaech, Carr, & Gunby, 2010;
Koegel, Camarata, Valdez-Menchaca, & Koegel,
1997; Miguel, Clark, Terwshko, & Ahearn, Qualifications of Treatment Providers
2009).
Treatment providers in many center-based pro-
grams include assistant teachers with high school
Outcome Measurement diplomas or who are university undergraduates.
They are supervised by special education
Starting with the pioneering work of Lovaas, teachers who have, or are working toward, their
much of the published outcome research has eval- Board Certification as Behavior Analysts. Some
uated home-based treatment. Center-based center-based programs also have speech and lan-
research often results in research articles focused guage therapists who, in addition to their speech
on changes in specific behaviors. For example, credentials, hold the BCBA certificate. Senior
R. L. Koegel and L. K. Koegel (2006) use single supervisors typically have the BCBA credential,
subject designs to illustrate changes in communi- have many years of experience, and are often
cation, social and academic skills when children faculty members engaged in research and staff
are taught skills using pivotal response treat- training. This creates an environment that can be
ments. Single subject designs include a multiple quite dynamic in ensuring that services remain
baseline design across individuals where two or state of the art.
more people have baseline (untrained) data col-
lected on a target behavior and then one person
enters treatment while the others continue in See Also
baseline. When the first person reaches criterion,
the next person enters treatment and so forth. ▶ Educational Interventions
Multiple baseline designs can also be used for ▶ School to Work Transition Process
one participant across three or more tasks.
Another single subject design is called
a reversal design, and in using this intervention, References and Readings
baseline data are first collected, then the treat-
ment is introduced, and after changes have been Charania, S. M., LeBlanc, L. A., Sabanathan, N.,
Ktaech, I. A., Carr, J. E., & Gunby, K. (2010).
observed, there is return to baseline for a brief
Teaching effective hand raising to children with
period, and finally the treatment, if demonstrated autism during group instruction. Journal of Applied
to be effective, is put in place. Single subject Behavior Analysis, 43, 493–497.
designs are especially useful for the in-depth Delmolino, L. (2006). Brief report: Use of DQ for
estimating cognitive ability in young children with
study of the influence of teaching methods on autism. Journal of Autism and Developmental
individual participants. Disorders, 36(7), 959–963.
In addition to single subject designs, some Hanley, G. P., Iwata, B. A., & McCord, B. E. (2003).
longer term follow-up studies of the effectiveness Functional analysis of problem behavior: A review.
Journal of Applied Behavior Analysis, 36, 147–185.
of ABA treatments employ group designs in
Harris, S. L. (1983). Families of the developmentally
which participants are assigned randomly to dif- disabled: A guide to behavioral intervention.
ferent conditions including a treatment group and Elmsford, NY: Pergamon.
Central Auditory Processing Disorder 549 C
Harris, S. L., & Handleman, J. S. (2000). Age and IQ at and redirection and sertraline on vocal stereotypy.
intake as predictors of placement for young Journal of Applied Behavior Analysis, 42, 883–888.
children with autism: A four to six year follow-up. Napolitano, D. A., Smith, T., Zarcone, J. R., Goodkin, K.,
Journal of Autism and Developmental Disorders, 30, & McAdam, D. B. (2010). Increasing response
137–142. diversity in children with autism. Journal of Applied
Ingvarsson, F. T., & Hollobaugh, T. (2010). Acquisition of Behavior Analysis, 43, 265–271.
intraverbal behavior: teaching children with autism to Rogers, S. J., & Dawson, G. (2010). Early start Denver
mand for answers to questions. Journal of Applied
model for young children with autism. New York:
Guilford Press.
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Jennett, H. K., Harris, S. L., & Delmolino, L. (2007). Romanczyk, R. G., & Lockshin, S. B. (1982). The IGS
Discrete trial instruction vs. mand training for teaching curriculum. Vestal, NY: CBTA.
children with autism to make requests. The Analysis of Sallows, G. O., & Graupner, T. D. (2005). Intensive
Verbal Behavior, 24, 69–85. behavioral treatment for children with autism:
Koegel, L. K., Camarata, S. M., Valdez-Menchaca, M., & Four-year outcome and predictors. American Journal
Koegel, R. L. (1997). Setting generalization of on Mental Retardation, 110, 417–438.
question-asking by children with autism. American Schrandt, J. A., Townsend, D. B., & Poulson, C. L.
Journal on Mental Retardation, 102, 346–357. (2009). Teaching empathy skills to children with
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response autism. Journal of Applied Behavior Analysis, 42,
treatments for autism. Communication, social 17–32.
and academic development. Baltimore, MD: Paul Smith, T., Groen, A. D., & Wynn, J. W. (2000).
Brookes Randomized trial of intensive early intervention for
Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987). children with pervasive developmental disorders.
A natural language teaching paradigm for nonverbal American Journal on Mental Retardation, 105,
autistic children. Journal of Autism and Developmen- 269–285.
tal Disorders, 17, 187–200.
Lovaas, O. I., Koegel, R. L., Simmons, J. Q., & Long, J. S.
(1973). Some generalization follow-up measures on
autistic children in behavior therapy. Journal of
Applied behavior Analysis, 6, 131–166. Central Auditory Processing
Lovaas, O. I., Schaeffer, B., & Simons, J. Q. (1965). Disorder
Experimental studies in childhood schizophrenia.
Building social behavior in autistic children by the
use of electric shock. Journal of Experimental Shannon Palmer
Research in Personality, 1, 99–109. Central Michigan University, Mount Pleasant,
McClannahan, L. E., & Krantz, P. (1999). Activity sched- MI, USA
ules for children with autism: Teaching independent
behavior. Bethesda, MD: Woodbine House.
McClannahan, L. E., & Krantz, P. (2001). Behavior anal-
ysis and intervention for preschoolers at the Princeton Synonyms
Child Development Institute. In J. S. Handleman &
S. L. Harris (Eds.), Preschool education programs for
Auditory perceptual disorder; Auditory processing
children with autism (2nd ed., pp. 191–214). Austin,
TX: ProEd. disorder
McGee, G. G., Morrier, M. J., & Daly, T. (1999).
An incidental teaching approach to early
intervention for toddlers with autism. Journal of the
Association for Persons with Severe Handicaps, 24,
133–146.
McGee, G. G., Morrier, M. J., & Daly, T. (2001). The A central auditory processing disorder (CAPD) is
Walden early childhood programs. In J. S. Handleman defined as difficulty with “processing auditory
& S. L. Harris (Eds.), Preschool education programs
information in the central nervous system and
for children with autism (2nd ed., pp. 157–190).
Austin, TX: ProEd. neurobiological activity that underlies and gives
Meyer, L. S., Taylor, B., Levin, L., & Fisher, J. (2000). rise to the electrophysiologic auditory potentials”
Alpine Learning Group. In S. L. Harris & J. S. (American Academy of Audiology [AAA],
Handleman (Eds.), Preschool Programs in Autism
2010). This processing difficulty results in poor
(1st ed., pp. 135–155). Austin, TX: Pro-Ed.
Miguel, C. E., Clark, K. M., Tereshko, L., & Ahearn, performance in localization and lateralization,
W. H. (2009). The effects of response interruption auditory discrimination, auditory pattern
C 550 Central Auditory Processing Disorder
perception, and temporal processing (American Clinical Expression and

Speech-Language-Hearing Association [ASHA], Pathophysiology
2005). Individuals diagnosed with CAPD often
exhibit trouble following oral instructions, diffi- For most children with CAPD, the exact cause of
culty in background noise, problems with read- the disorder is unknown. However, inefficient
ing, spelling and language, and academic interhemispheric information transfer and impre-
difficulties (Bamiou, Musiek, & Luxon, 2001; cise neural synchrony, among other things, may
Chermak, Tucker, & Seikel, 2002). be involved (Jerger et al., 2002). Neurological
disorders, damage, or abnormalities may also
be the cause of CAPD if the auditory areas of
Categorization the brain are affected (Musiek, Baran, &
Pinheiro, 1994).
Currently, there is no consensus on the categori-
zation of CAPD. There are two proposed models
of CAPD in children: the Buffalo model Evaluation and Differential Diagnosis
(Katz, 1992) and the Bellis-Ferre model
(Bellis, 2003; Ferre, 1997). Both of these models Currently, there is no gold standard test for
attempt to categorize CAPD based on the types of evaluating and diagnosing auditory processing
difficulty the individual exhibits. However, nei- disorders. Rather, as the definition of CAPD
ther of these models is based on peer reviewed includes disorders of multiple auditory skills,
data, and neither model is able to categorize the evaluation of CAPD should also include
all children diagnosed with CAPD (Jutras et al., tests of multiple auditory skills (AAA, 2010;
2007). ASHA, 2005). This is done using a test battery
approach. A typical CAPD evaluation will begin
with a test of hearing sensitivity to rule out any
Epidemiology type of peripheral hearing loss. Individuals
exhibit difficulty with one or more auditory func-
The epidemiology of CAPD is not well tions as a result of poor processing of auditory
documented at this point in time. There is one information beyond the ear. This represents
estimate that 2–3% of children have an auditory a problem with the auditory system beyond the
processing disorder (Chermak & Musiek, 1997). inner ear. Therefore, an individual who is seeking
In adults, it is estimated that 10–20% of elderly a diagnosis of CAPD should not have peripheral
adults demonstrate an auditory processing hearing loss on a pure tone audiogram test.
disorder (Cooper & Gates, 1991). The current recommendations from the American
Academy of Audiology state that a diagnosis of
CAPD should be given if a person
Natural History, Prognostic Factors, performs below the age-established norms on
Outcomes two or more tests of central auditory function
(AAA, 2010). Tests that may be included in
There are no longitudinal studies following indi- a CAPD test battery can be divided into two
viduals with CAPD, therefore, prognostic factors main categories: behavioral tests and electro-
and outcomes cannot be estimated at this point in physiological tests.
time. Some risk factors for CAPD have been Behavioral tests are designed to assess one of
identified, including neurological dysfunction or the many areas of auditory processing. These
disorders, severe jaundice during infancy, tests require individuals to participate in the test-
chronic otitis media during preschool years, ing process in some way. This includes pressing
and family history of CAPD, hearing loss, or a button, raising their hand, or repeating what
academic underachievement. they hear. The main processes evaluated by
Central Auditory Processing Disorder 551 C
behavioral tests are binaural integration, binaural understanding speech in the presence of back-
separation, auditory closure, temporal resolution, ground noise, many CAPD test batteries include
temporal ordering, and understanding speech in a speech in noise test. These tests present words
noise. Some tests currently available to evaluate or sentences with some type of background noise.
binaural integration include the Dichotic Digits This noise may be broadband or multi-talker bab-
Test, Staggered Spondaic Words Test, and the ble. The difference in loudness between the sig-
binaural integration subtest of the SCAN (Katz, nal that the individual must repeat (words or C
Basil, & Smith, 1963; Keith, 2000a; Musiek, noise), and the background noise may vary.
1983). These tests involve having different infor- Some of these tests include the Words in Noise
mation presented to the left and right ear simul- (WIN) test, the QuickSIN, the Hearing in
taneously (dichotic testing). Individuals are Noise Test (HINT), and the Speech Perception
asked to listen to what is being presented to in Noise (SPIN) Test.
both ears and repeat back everything they hear. The difficulty with all of these CAPD tests for
Binaural separation is also tested using a dichotic use with individuals diagnosed with autism is that
test procedure; however, they are asked to focus they require the individual to actively and
on the sounds presented to one ear while ignoring cooperatively participate in the test procedures.
what they hear in the other ear. Some tests of These tests also use varying amounts of speech
binaural separation include the competing words materials for testing and/or instruction.
and competing sentences subtests of the SCAN This requires each individual tested to have nor-
and the competing sentences test (Keith, 2000a). mal or near normal speech and language abilities
Auditory closure is the brain’s ability to fill in and normal cognitive function in order to
missing information. This is tested by presenting complete the tests. These requirements would
words or sentences that have had some informa- disqualify most individuals with autism
tion removed and asking individuals to repeat from being able to reliably complete the test pro-
what they hear. Some examples of auditory cedures. Therefore, testing and diagnosis of
closure tests include low-pass filtered speech CAPD is not typically done on individuals with
and compressed speech. autism.
Temporal processing is related to the timing Electrophysiological (evoked potential) tests
aspects of sound. Temporal resolution is the involve placing small recording electrodes on the
ability to hear changes in a sound over time surface of the scalp, forehead, and ears. For this
(Moore, 2003). This is often evaluated type of testing, the individual is asked to sit
using a gap detection task, in which individuals quietly while listening to various sounds.
are asked to press a button when they hear The electrodes record responses from groups of
a small piece of silence embedded in static neurons in the brainstem and brain when a sound
noise. Clinically applicable tests of temporal resis presented. Individuals with CAPD may have
olution include the Gaps in Noise (GIN) Test abnormalities in the size or timing of their evoked
(Musiek et al., 2005) and the Random Gap Detec- potentials responses. Some studies have also
tion Test (Keith, 2000b). Temporal ordering is found abnormalities on some electrophysiologi-
the skill of determining the order in which multi- cal tests of individuals with autism, although the
ple stimuli were presented. This is evaluated by research findings tend to be mixed (Marco,
presenting two to three sounds that vary in some Hinkley, Hill, & Nagarajan, 2011). These tests
aspect (frequency or duration) and asking indi- allow the evaluation of the function of auditory
viduals to report in what order they heard the areas of the central nervous system without active
sounds. These tests are the Frequency participation on the part of the individual. How-
Pattern Test and the Duration Pattern Test ever, electrophysiological tests alone cannot
(Musiek, 1994). diagnose CAPD. The results of these tests should
Because one of the most common complaints be combined with behavioral test measures to
of someone with CAPD is difficulty diagnose CAPD.
C 552 Central Auditory Processing Disorder
Treatment American Speech-Language-Hearing Association.

(2005). (Central) Auditory processing disorders-the
role of the audiologist. Bethesda, MD.
Treatment options for CAPD fall into four general Bamiou, D. E., Musiek, F. E., & Luxon, L. M. (2001).
categories: environmental modifications, infor- Aetiology and clinical presentations of auditory
mal auditory training, formal auditory training, processing disorders – A review. Archives of Disease
and computer-based training. Environmental in Childhood, 85, 361–365.
Bellis, T. J. (2003). Assessment and management of cen-
modifications are designed to improve the sig- tral auditory processing disorders in the educational
nal-to-noise ratio (SNR) for the child with setting: From science to practice (2nd ed.). Toronto,
CAPD. SNR is the intensity of the signal the ON: Thomson Delmar Learning.
listener is meant to attend compared to the inten- Chermak, G., & Musiek, F. (1997). Central auditory
processing disorders: New perspectives. San Diego,
sity of the background noise that should be CA: Singular.
ignored. Some of these modifications may include Chermak, G., Tucker, E., & Seikel, J. A. (2002). Behav-
offering preferential seating in the classroom, ioral characteristics of auditory processing disorder
reducing background noise, providing written and attention-deficit hyperactivity disorder: Predomi-
nantly inattentive type. Journal of the American
instructions for assignments and projects, Academy of Audiology, 13, 332–338.
previewing or pre-teaching classroom materials, Cooper, J. C., Jr., & Gates, G. A. (1991). Hearing in the
and some form of assistive listening technology. elderly – The Framingham cohort, 1983–1985: Part II.
The goal of these strategies is to improve the Prevalence of central auditory processing disorders.
Ear and Hearing, 12, 304–311.
individual’s functioning in difficult listening situ- Ferre, J. (1997). Processing power: A guide to CAPD
ations, not to remediate the CAPD directly. assessment and management. San Antonio, TX:
Informal auditory training and formal auditory Communication Skills Builders.
training are activities created for each individual Jerger, J., Thibodeau, L., Martin, J., Mehta, J., Tillman, G.,
Greenwald, R., et al. (2002). Behavioral and electro-
that are designed to improve the specific auditory physiologic evidence of auditory processing disorder:
skills with which the child has difficulty. These A twin study. Journal of the American Academy of
activities are either completed at home (informal Audiology, 13, 903–912.
training) or during scheduled rehabilitation sessions Jutras, B., Loubert, M., Dupuis, J. L., Marcoux, C.,
Dumont, V., & Baril, M. (2007). Applicability of cen-
(formal training) with a speech-language patholo- tral auditory processing disorder models. American
gist or audiologist. The exact activities will be Journal of Audiology, 16, 100–106.
individualized for each individual and may include Katz, J. (1992). A classification of auditory processing dis-
auditory skills similar to those used during the test orders. In J. Katz, N. Stecker, & N. Henderson (Eds.),
Central auditory processing: A transdisciplinary view.
procedures. These activities begin with easier tasks Baltimore: Mosby-Yearbook.
and progress to more difficult assignments. Katz, J., Basil, R. A., & Smith, J. M. (1963). A staggered
spondaic word test for detecting central auditory
lesions. The Annals of Otology, Rhinology, and
See Also Laryngology, 72, 908–917.
Keith, R. W. (2000a). Development and standardization of
▶ American Speech-Language-Hearing SCAN-C test for auditory processing disorders in chil-
dren. Journal of the American Academy of Audiology, 11,
Association Functional Assessment of
438–445.
Communication Skills Keith, R. W. (2000b) Random gap detection test. St.
▶ Auditory Processing Louis, MO: Auditec of St Louis Ltd.
▶ Dichotic Listening Loo, J. H., Bamiou, D. E., Campbell, N., & Luxon, L. M.
(2010). Computer-Based Auditory Training
(CBAT): benefits for children with language-
and reading-related learning difficulties.
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American Academy of Audiology. (2010). Clinical Marco, E. J., Hinkley, L. B. N., Hill, S. S., & Nagarajan,
Practice Guidelines: Diagnosis, treatment and man- S. S. (2011). Sensory processing in autism: A review of
agement of children and adults with central auditory neurophysiologic findings. Pediatric Research, 69,
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Cerebellar Abnormalities in Autism 553 C
Moore, B. (2003). An introduction to the psychology ▶ Cerebellum). More precisely, recent research
of hearing (5th ed., pp. 163–194). San Diego, CA: has provided clear evidence supporting
Academic Press.
Musiek, F. (1983). Assessment of central auditory the involvement of the cerebellum in emotion
dysfunction: The dichotic digits test revisited. Ear processing and cognition (Schmahmann &
and Hearing, 4, 79–83. Sherman, 1998) which are commonly impaired
Musiek, F. (1994). Frequency (pitch) and duration pattern in individuals with ASD.
tests. Journal of the American Academy of Audiology,
5, 165–168. This entry briefly summarizes the research C
Musiek, F. E., Baran, J., & Pinheiro, M. (1994). literature on the cerebellum as it applies
Neuroaudiology: Case studies. San Diego, CA: Singu- to ASD. Ovid MEDLINE search of the entire
lar Publishing Group. medical literature (1948–2010) revealed that
Musiek, F., Shinn, J., Jirsa, R., Bamiou, D., Baran, J., &
Zaidan, E. (2005). The GIN (Gaps in Noise) Test this covers approximately 25 years of research.
performance in subjects with and without confirmed The earliest studies (1985–1999) are briefly sum-
central auditory nervous system involvement. Ear & marized in the Historical Background section as
Hearing, 26, 608–618. there are already many published reviews on this
earlier work. In the Current Knowledge section,
a more detailed review is provided on research
published in the past decade which consists of the
Central Auditory Processing majority of published work on cerebellar abnor-
Disorder (CAPD) malities in ASD.
▶ Auditory Processing
The earliest studies describing cerebellar abnor-

Cerebellar Abnormalities in Autism malities in ASD were published in the mid-
1980s. These studies were of two general types:
Antonio Hardan1 and Roger J. Jou2 neuropathology and structural neuroimaging.
1
Department of Psychiatry and Behavioral The first neuropathological investigations
Sciences, Stanford University, Stanford, consisted of case reports or series which reported
CA, USA (Frazier & Hardan, 2009) various cerebellar
2
Child Study Center, Yale University School abnormalities, including the well-known finding
of Medicine, New Haven, CT, USA of decreased Purkinje cell number (Bauman &
Kemper, 1985; Ritvo et al., 1986) which are
distinctive inhibitory output neurons arising
Definition from the cerebellar cortex (see entry: ▶ Purkinje
Cells). This finding was replicated a decade later
Cerebellar abnormalities consist of some of the by another group using a different sample,
earliest neurobiological findings to be described reporting Purkinje cells reduction in postmortem
in autism spectrum disorders (ASD). Like other cerebellar tissue (Bailey et al., 1998). These ini-
brain anomalies reported in this disorder, cere- tial neuropathological reports implicating the
bellar abnormalities are diverse with varying cerebellum sparked a large number of confirma-
levels of inconsistency and specificity. Therefore, tory studies with structural MRI being the most
the contribution of the cerebellum to the patho- commonly used modality. These investigations
physiology of ASD remains unclear. Neverthe- produced mixed results with respect to cerebel-
less, this structure continues to be of great interest lum size and one of its major subdivisions, the
to the autism research community in light vermis, which includes 10 lobules (i.e., anterior
of growing evidence suggesting a role that vermis, lobules I–V; posterior superior vermis,
goes beyond motor coordination (see entry: lobules VI–VII; and posterior inferior vermis,
C 554 Cerebellar Abnormalities in Autism
lobules VIII–X). Some reports described smaller examination, this group of studies continues to
cerebellar vermis (Courchesne, Yeung- represent only a small minority of autism-related
Courchesne, Press, Hesselink, & Jernigan, 1988) published studies. Nevertheless, recent research
while others found normal (Garber & Ritvo, has provided new and informative insights. The
1992) or even larger size (Piven, Saliba, Bailey, well-known observation of reduced Purkinje cell
& Arndt, 1997). It should be noted, however, that counts was reported to be an inconsistent finding
the initial MRI studies had significant limitations, and may only be found in a subpopulation of
partially owing to the novelty of this technology individuals with ASD (Whitney, Kemper,
in neuropsychiatric research during this time Bauman, Rosene, & Blatt, 2008). Moreover,
period. For example, many studies reporting on in a recent neuropathological study, cerebellar
size of the cerebellum refer to area as measured in pathology was commonly observed, but reduc-
midsagittal slices and not volume. Finally, tion in Purkinje cells was not consistently found
a series of studies using clinical assessments to (Wegiel et al., 2010). However, this does not
indirectly test for underlying cerebellar neuropa- necessarily diminish the importance of Purkinje
thology were also published in the 1980s and cells as part of the neuropathology of ASD.
1990s. These investigations assessed a number Abnormalities in this population of cells may be
of abilities believed to depend on the cerebellum, expressed in other ways such as size reduction
including gait (Hallett et al., 1993), attention which has also been reported (Fatemi et al.,
(Courchesne et al., 1994), and eye movements 2002). In addition to Purkinje cells, basket and
(Minshew, Luna, & Sweeney, 1999). These find- stellate cells (key cerebellar inhibitory interneu-
ings were also mixed, though most reports cited rons) have been studied, and no abnormalities
abnormalities suggestive of cerebellar pathology. have been observed in their number or shape,
suggesting that Purkinje cell loss is related to
a late developmental event (Whitney, Kemper,
Current Knowledge Rosene, Bauman, & Blatt, 2009).
In the past decade, there has been a surge in the Molecular/Cellular Neurobiology
number of autism-related published studies. This This category includes human experiments done
large body of research was accompanied by on the molecular and cellular level, usually
major technological advances which enabled cli- involving the use of postmortem neural tissue or
nicians/scientists to study new questions and clar- blood serum from living participants. As a broad
ify existing ones. These advances have led to an category, these studies represent much of the
increase in our understanding of the role of the research in ASD reporting on cerebellar anoma-
cerebellum in ASD; however, there is still much lies; however, this grouping is quite diverse and
to be learned. Inconsistent findings remain represents mainly preliminary work which needs
a challenge, and the implications of new findings replication and further investigation. Neverthe-
are not entirely clear and/or need replication. This less, the resulting research has provided signifi-
portion of the review is organized by research cant leads into the molecular basis of ASD.
modality which includes the following: neuropa- One way to conceptualize this body of literature
thology, molecular/cellular neurobiology, neuro- is by predicted aberrations in the following:
imaging, and clinical testing. The neuroimaging neurotransmission, immune function, apoptosis
literature represents the majority of the published (programmed cell death), and cell signaling.
work, and this section will be divided further by With respect to neurotransmission, abnormalities
imaging modality. have been reported in the gamma-aminobutyric
acid (GABA), nicotine, and glutamate neuro-
Neuropathology transmitter systems. There are now
While some of the most informative research has many studies reporting abnormalities in the
come from postmortem neuropathological GABAergic system which mainly includes
abnormal expression of GABA receptors gray and white matter volumes. These new soft-
(Fatemi, Folsom, Reutiman, & Thuras, 2009) ware programs allow the examination of increas-
and the rate-limiting, GABA-synthesizing ingly larger sample sizes, enhancing statistical
enzyme, glutamic acid decarboxylase (Fatemi power and facilitating important group stratifica-
et al., 2002; Yip, Soghomonian, & Blatt, 2007). tion (i.e., by age, gender, etc.). However, the
Studies have also been published, although lim- inconsistencies present in the earlier structural
ited in number, to support abnormalities in the MRI literature persisted in the newer studies. In C
nicotinic (Lee et al., 2002) and glutaminergic fact, the results have become even more mixed.
systems (Purcell, Jeon, Zimmerman, Blue, & There are several reports documenting increases
Pevsner, 2001). in cerebellar size, including total volume
Immune dysfunction has also been implicated (Hardan, Minshew, Harenski, & Keshavan,
as part of the pathobiology of ASD. There 2001), gray matter (Ke et al., 2008), white matter
are several studies reporting on the presence of (Bloss & Courchesne, 2007), and/or vermal lob-
antibodies to cerebellar proteins in the serum of ules (Akshoomoff et al., 2004). In contrast, find-
individuals with ASD (Singer et al., 2006; Wills ings from several other studies revealed
et al., 2009). A recent investigation specifically reductions in cerebellar size, including total vol-
identified a neuroinflammatory process in post- ume (Hallahan et al., 2009), gray matter (Toal
mortem cerebellum tissue of individuals with et al., 2010), white matter (Courchesne et al.,
ASD (Vargas, Nascimbene, Krishnan, 2001), and vermal lobules (Carper &
Zimmerman, & Pardo, 2005) which was subse- Courchesne, 2000). Finally, reports documenting
quently supported by a similar study (Laurence & normal cerebellar volumes have also been
Fatemi, 2005). Additionally, there are also sev- published (Hazlett et al., 2005). It is worth noting
eral studies that support the presence of aberrant that most of these newer studies do not restrict
apoptosis in the cerebellum of individuals with their analysis to the cerebellum, and most con-
ASD. These investigations reported the reduction duct a whole-brain analysis also reporting on
of antiapoptotic protein Bcl-2 (Fatemi, Halt, extracerebellar anomalies while examining dif-
Stary, Realmuto, & Jalali-Mousavi, 2001) and ferent age groups. Therefore, future studies
increase in proapoptotic proteins, cathepsin should focus on the cerebellum solely while
D and caspase-3 (Sheikh et al., 2010). Finally, including a large sample of participants and
many studies have found abnormal levels of one a narrow age range.
or more of the numerous proteins involved in
various cell signaling processes. Those proteins Functional MRI
found to be abnormal in the cerebellum of indi- Functional MRI studies are also among the most
viduals with ASD include reelin (Fatemi et al., commonly used neuroimaging modality to study
2005), phosphodiesterase (Braun, Reutiman, Lee, the neurobiology of ASD (see entries: ▶ Func-
Folsom, & Fatemi, 2007), and neurotrophin-3 tional MRI and ▶ Magnetic Resonance Imaging).
(Sajdel-Sulkowska, Xu, & Koibuchi, 2009). While some studies reported on the cerebellum in
their analyses, a limited number of investigations
Neuroimaging focused primarily on this structure. Studies have
Structural MRI applied motor tasks and paradigms, probing cog-
Structural MRI is one of the most commonly used nitive and emotional processing (Schmahmann &
neuroimaging modalities to study the neurobiol- Sherman, 1998). Motor tasks commonly involved
ogy of ASD (see entry: ▶ Magnetic Resonance finger tapping or button pressing, and some inves-
Imaging). Major advances in recent structural tigations have reported reduced (Mostofsky et al.,
MRI methodologies or technologies include the 2009; Muller, Pierce, Ambrose, Allen, &
use of novel semiautomatic morphometric soft- Courchesne, 2001) while others found increased
ware that led to improved ability to perform vol- cerebellar activation (Allen & Courchesne,
umetric measurements and separately measure 2003; Allen, Muller, & Courchesne, 2004)
in individuals with ASD when compared to con- as a putative marker of neuronal viability, and
trols. Abnormal cerebellar activation has also glutamate + glutamine being related to excitatory
been reported in nonmotor probes of attention pathways (see entry: ▶ Magnetic Resonance
(Allen & Courchesne, 2003), executive function Spectroscopy). Finally, there is one study using
(Gilbert, Bird, Brindley, Frith, & Burgess, 2008), single-photon emission computed tomography
and face processing (Critchley et al., 2000). which did not find any significant differences in
Abnormalities of how the cerebellum connects the cerebellum (Hashimoto et al., 2000).
to other brain areas have also been observed in
a recent investigation examining functional con- Clinical Testing
nectivity with evidence indicating a lack of syn- Thus far, this review has focused on studies mak-
chronization between this structure and several ing direct assessments of the cerebellum via
brain regions during task performance imaging or postmortem tissue. An indirect way
(Belmonte, Gomot, & Baron-Cohen, 2010; to assess cerebellar abnormalities is through clin-
Mostofsky et al., 2009). Finally, decreased cere- ical evaluation. This is analogous to a neurologist
bellar activation has been demonstrated in studies determining the location of a stroke by examining
examining resting state activity where no tasks the pattern of neurological impairments and clin-
are used (Paakki et al., 2010). ical symptoms. Many different assessments have
been used, and the choice depends on the system
Other Neuroimaging Modalities or brain region that is being tested. For the cere-
The remaining neuroimaging modalities, diffu- bellum, motor and nonmotor deficits are usually
sion tensor imaging, magnetic resonance spec- evaluated. Most, but not all, investigations prob-
troscopy, and single-photon emission computed ing the former have reported alterations sugges-
tomography, are less commonly used (see tive of cerebellar pathology (Goldberg, Landa,
entries: ▶ Magnetic Resonance Spectroscopy Lasker, Cooper, & Zee, 2000). Specifically,
and ▶ Magnetic Resonance Imaging). Diffusion abnormalities have been reported in postural con-
tensor imaging has grown tremendously in pop- trol (Dowell, Mahone, & Mostofsky, 2009;
ularity over the past 5 years, and there are now Minshew, Sung, Jones, & Furaman, 2004), gait
more than 30 published studies conducted in (Rinehart et al., 2006), eye movements (Takarae,
autism research. However, only a minority of Minshew, Luna, Krisky, & Sweeney, 2004), and
these investigations reported cerebellar abnor- hand-eye coordination (Gowen & Miall, 2005).
malities including impaired white matter integ- Similarly, probing various cognitive functions,
rity as measured by fractional anisotropy. These thought to depend on cerebellar integrity, have
abnormalities are found in the middle (Cheng also yielded evidence of alterations in perceptual
et al., 2010) and superior cerebellar peduncles abilities (Davis, Bockbrader, Murphy, Hetrick, &
(Catani et al., 2008) which are the major fiber O’Donnell, 2006) and learning (Mostofsky,
tracts going into and coming out of the cerebel- Goldberg, Landa, & Denckla, 2000).
lum, respectively.
Most magnetic resonance spectroscopy stud-
ies, but not all (Endo et al., 2007), have also Future Directions
described abnormal cerebellar metabolite levels
in ASD. Increased myoinositol and choline The investigations reviewed here support the
levels have been observed (Gabis et al., 2008), integral role that the cerebellum plays in the
as well as decreased N-acetylaspartate and pathophysiology of ASD. However, the exact
glutamate + glutamine (DeVito et al., 2007). involvement of this structure in the development
These metabolites reflect different functions of this disorder remains unclear despite 25 years
with myoinositol being essential for cell growth, of intensive research. From the information
choline being considered as a measure of mem- discussed above, the prevailing evidence in the
brane synthesis and turnover, N-acetylaspartate field is that cerebellar abnormalities do not occur
in isolation and do not appear to be specific to Carper, R. A., & Courchesne, E. (2000). Inverse correla-
ASD. Nevertheless, it remains an important goal tion between frontal lobe and cerebellum sizes in chil-
dren with autism. Brain, 123(4), 836–844.
to continue investigating the contribution of the Catani, M., Jones, D. K., Daly, E., Embiricos, N., Deeley,
cerebellum to the clinical and biological abnor- Q., Pugliese, L., et al. (2008). Altered cerebellar
malities observed in ASD. Studies should be feedback projections in Asperger syndrome.
comprehensive, applying multimodal imaging NeuroImage, 41(4), 1184–1191.
and biological techniques, to increase both our
Cheng, Y., Chou, K. H., Chen, I. Y., Fan, Y. T., Decety, J.,
& Lin, C. P. (2010). Atypical development of white
C
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of cerebellar vermal lobules VI and VII in autism.
The New England Journal of Medicine, 318(21),
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Neurology, 23(5), 416–420. subjects: Initial findings of the UCLA-NSAC Autopsy
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Sheikh, A. M., Li, X., Wen, G., Tauqeer, Z., Brown, W. T.,
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proteins are elevated in the brain of autistic subjects. brain located in the posterior fossa behind
Neuroscience, 165(2), 363–370. the brainstem and underneath the cerebrum. It is
Singer, H. S., Morris, C. M., Williams, P. N., Yoon, D. Y., attached or connected via three pairs of large fiber
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antibodies in children with autism and their unaffected bundles (superior, middle, and inferior cerebellar C
siblings. Journal of Neuroimmunology, 178(1–2), peduncles) and is subdivided by two transverse
149–155. fissures into three lobes (flocculonodular,
Takarae, Y., Minshew, N. J., Luna, B., Krisky, C. M., & anterior, and posterior lobes). Additionally, the
Sweeney, J. A. (2004). Pursuit eye movement deficits
in autism. Brain, 127(12), 2584–2594. cerebellum is divided into longitudinal zones
Toal, F., Daly, E. M., Page, L., Deeley, Q., Hallahan, B., which cut across the three lobes, resulting in
Bloemen, O., et al. (2010). Clinical and anatomical two hemispheres (left and right) which flank
heterogeneity in autistic spectrum disorder: A structural a narrow midline zone called the vermis.
MRI study. Psychological Medicine, 40(7), 1171–1181.
Vargas, D. L., Nascimbene, C., Krishnan, C., Zimmerman, Cerebellar circuitry has a uniform organization:
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and neuroinflammation in the brain of patients with middle/inferior peduncles. Neurons in the cere-
autism. Annals of Neurology, 57(1), 67–81. bellar cortex project to a series of deep cerebellar
Whitney, E. R., Kemper, T. L., Bauman, M. L., Rosene,
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A stereological experiment using calbindin-D28k. the superior peduncle. Traditionally, the cerebel-
Cerebellum, 7(3), 406–416. lum’s primary role is in motor control/learning
Whitney, E. R., Kemper, T. L., Rosene, D. L., Bauman,
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Decreased GAD67 mRNA levels in cerebellar in posture and gait. Lateral damage (hemi-
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reflexes, abnormal speech, tremor, and incoordi-
nation. Deficits in these functions have been
Cerebellum reported in autism. However, studies of postural
control in autism have linked impaired balance to
Antonio Hardan1 and Roger J. Jou2 reduced integration of multisensory information
1
Department of Psychiatry and Behavioral (joint-muscle position sense, visual, and vestibu-
Sciences, Stanford University, Stanford, lar) and not to cerebellar dysfunction. FMRI
CA, USA studies of motor movements have demonstrated
2
Child Study Center, Yale University School of deficits in cerebral connectivity rather than the
Medicine, New Haven, CT, USA cerebellum as the basis for coordination impair-
ments in autism. The reduction of Purkinje cell
number in the cerebellum has been widely found
Synonyms at autopsy brain examination in autism. Purkinje
cells are inhibitory neurons which contain the neu-
Little brain rotransmitter gamma-aminobutyric acid (GABA)
C 560 Cerebral Cortex
to modulate neuronal transmission. Oculomotor cortex is divided into four lobes: occipital, tem-
studies in autism have also demonstrated subtle poral, parietal, and frontal. At a microscopic
differences related to posterior fossa circuitry. scale, the cortex is organized horizontally into
Their implications for the pathophysiology of up to six layers and vertically into interconnected
autism are unknown. columns. Based on the thickness of the layers and
the predominance of different neuron types, dis-
tinct regions of the cortex, called Brodmann’s
See Also areas, can be identified under a microscope. The
cortex largely consists of cell bodies of neurons,
▶ Cerebellar Abnormalities in Autism their dendrites, and short range unmyelinated
▶ Motor Control axons, hence the term “gray matter.” Regions of
▶ Purkinje Cells the cortex are connected to one another by mye-
linated axons that run through the “white matter”
underneath the cortex.
Functional Organization
Manto, M. U., & Pandolfo, M. (Eds.). (2002). The At the grossest functional level, the cortex can be
cerebellum and its disorders. New York: Cambridge
divided into sensory cortex that takes in basic
University Press.
sensory information (auditory, visual, and
somatosensory), motor cortex which plans and
executes body motions, and association cortex
that organizes input from sensory cortex into
Cerebral Cortex a unified perceptual world and performs the
abstract thought and planning needed to guide
Brent Vander Wyk the actions of the motor cortex.
Yale Child study center, New Haven, CT, USA Smaller units of function have been reliably
localized in human brains using neuropsycholog-
ical investigations of function after brain injury
Synonyms and in healthy populations using functional
magnetic resonance imaging or positron emission
Cortex; Gray matter tomography. For example, portions of the
left temporal (Wernicke’s area) and frontal
cortex (Broca’s area) participate in language
Definition function.
The cerebral cortex is the outermost sheet of

neural tissue in the brain and plays a critical role See Also
in “higher level” cognitive functions, such as
perception, attention, memory, language, execu- ▶ Auditory Cortex
tive functions, and consciousness. ▶ Visual Cortex
Anatomical Organization
The most visually apparent features of the human References and Readings
brain are the folds (gyri and sulci), which are
necessary products of packing a large cortical Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (2000).
Principles of neural science (4th ed., p. 324).
sheet into a limited space (i.e., the skull). As
New York: McGraw-Hill.
such, the folding pattern is most prominent in Rakic, P. (1988). Specification of cerebral cortical areas.
humans and primates. At the grossest level, the Science, 241(4862), 170–176.
Cerebral Palsy 561 C
infants. Prematurity increases the risk of CP.
Cerebral Palsy However, half of the cerebral palsy occurs in
term infants.
Itxaso Marti
Neuropediatrics, Hospital Universitario
Donostia, San Sebastian, Spain Natural History, Prognostic Factors,
Outcomes C
Synonyms Natural History

By definition, cerebral palsy is secondary to a
CP; Little’s disease; Spastic diplegia; Spastic static lesion in the developing fetal or infant
paralysis brain. However, the motor symptoms are
progressive and they first appear between the
ages of 6 months to 2 years, depending on the
Short Description or Definition subtype of CP.
Functionally, with rehabilitation and physical
Cerebral palsy (CP) describes a group of disor- care, these children can acquire new motor mile-
ders of the development of movement and stones during the first decade of life, remaining
posture, causing activity limitation attributed to stable thereafter. A deterioration in walking
nonprogressive disturbances that occur in ability in adulthood would be expected due
the developing fetal or infant brain. The motor to pain, fatigue, or lack of adapted physical activ-
disorders of cerebral palsy are often accompanied ity, but the few studies that have followed CP
by disturbances of sensation, cognition, commu- patients through adulthood, report motor stability
nication, perception, and/or behavior, and/or during this period for one third to half of the
by a seizure disorder. patients.
Prognostic Factors and Outcome

Categorization The most important prognostic factor is the type
of CP. Most children with spastic diplegia or
Classification can be helpful in understanding the hemiplegia will acquire independent ambulation.
etiology, choosing a treatment, and even knowing Life span in this group is not shortened. However,
the prognosis. children with spastic tetraplegia usually will not
CP is classified by the type of motor impair- walk independently, being the prognosis for the
ment and its distribution: dyskinetic group intermediate. Usually, if the
1. Spastic CP: child arrives to sit independently for the age of
(a) Spastic diplegia 2 years, he will arrive to walk alone.
(b) Spastic quadriplegia For the quadriplegic group, survival is usually
(c) Spastic hemiplegia low. Most die from malnutrition, infections, or
2. Dyskinetic and dystonic CP respiratory problems before they reach adoles-
3. Hypotonic CP cence. Those having feeding tubes and inability
to support their head, the median survival is
17 years.
Epidemiology The presence of mental retardation, a
severe degree of disability, poor socialization,
It is estimated that 2–3 per 1,000 live newborns overprotection of parents, and denial of the
have CP. Despite improved obstetric conditions, problem of disability negatively affect a good
prevalence remains stable in the last decades, prognosis for independent living in the adult
probably related to increase survival of premature with cerebral palsy.
C 562 Cerebral Palsy
Clinical Expression and at term. It is produced by damage to one

Pathophysiology hemisphere, such as prenatal strokes or head
trauma. Independent ambulation and normal
Spastic Syndromes intelligence are commonly seen. There is no
The symptoms are those of the pyramidal greater language impairment if the dominant
syndrome: hypertonia of the affected body region, hemisphere is affected. There is an increased
spasticity, hyperreflexia, and persistence of archaic risk of seizures, growth asymmetry, and sensory
reflexes. They are also present with difficulty in impairment of the hemiplegic side. Diagnosis is
fine, rapid, and alternating movements. They are usually evoked by the end of the first year of life.
usually associated with some degree of dystonia.
Dyskinetic-Dystonic
Spastic Diplegia In children with extrapyramidal syndromes,
Spastic diplegia is a clinical syndrome with clinical involvement is characteristically greater
a greater spasticity in legs than arms, seen most in the arms than the legs. Extrapyramidal
commonly in children born prematurely. It is syndromes are often associated with a marked
primarily a disorder of developing white matter reduction in speech production, but the child
and it is nearly always associated with neuro- may have relatively preserved intelligence.
pathological and neuroimaging findings There is usually involvement of basal ganglia
of periventricular leukomalacia. Patients with (BG): selective necrosis of neurons in BG,
spastic diplegia are often identified during the thalamus, reticular formation, and cerebellum. It
first 6–12 months of life with signs of delayed is typical of term infants with perinatal injuries:
motor development. Associated symptoms may hypoxic-ischemic encephalopathy, hyperbilir-
include strabismus, orthopedic deformities, and ubinemia, etc.
oromotor dysfunction. There may be some It is usually presented with lethargy, hypoto-
degree of cognitive dysfunction. nia, and multisystem involvement. Then psycho-
motor retardation and hypotonia occurs, whereas
Spastic Quadriplegia abnormal movements may appear much later, at
Spastic quadriplegia is presented with bilateral about 2 years of age.
spasticity affecting all extremities, with signifi-
cant limitations in both mobility and hand Hypotonia and Ataxia
use. Associated deficits may be more severe, These children present with hypotonia with
including intellectual disability, seizures, ortho- delayed motor milestones. These patients are
pedic deformities including scoliosis and hip distinguished by the preservation of strength
dislocation, and visual impairment. Spastic and reflexes, suggesting a disorder of the upper
quadriplegia is the result of a broader range of motor neurons. This is a heterogeneous group of
pathological insults, including genetic and disorders.
developmental brain malformations, severe
periventricular leukomalacia, pre- and postnatal Associated Impairments
infections, asphyxia, and trauma. As with other Although characterized by their motor dysfunc-
cerebral palsy syndromes, low birth weight, tion, children with cerebral palsy frequently have
prematurity, and complicated neonatal course other associated impairments.
are important risk factors. Delayed motor devel-
opment in the first year is usually more prominent Intellectual Disability (ID) Present in 50–75%
than in spastic diplegia. of patients with CP. Usually more severe in
patients with spastic quadriplegia.
Spastic Hemiplegia
Spastic hemiplegia represents unilateral spastic- Epilepsy Present in 30–50% of cases. More
ity, excluding the face. It often affects children frequent if the lesion affects the cerebral cortex:
Cerebral Palsy 563 C
usually in spastic hemiplegia and quadriplegia. In ENT evaluation
this group, there is a greater prevalence of ID. Orthopedic evaluation
Visual Disturbances Strabismus (50%),

retinopathy (10%), cortical deficit (10%), and Treatment
ocular motility disorders.
Effective management of cerebral palsy requires C
Digestive Disorders Malnutrition, dysphagia, a team with medical and rehabilitation specialists
gastroesophageal reflux, dental anomalies, and to provide careful, coordinated treatment to
constipation. maximize functional capabilities.
Management should aim to achieve maximal
Orthopedic Disorders Hip subluxation, potential in all areas of development and to
Osteopenia. encourage independence. Realistic, functional
goals must be set and periodically reevaluated
Urinary Disorders Incontinence, urgency, by the rehabilitative team.
enuresis, detrusor dyssynergia, bladder hyperto- Rehabilitative goals will vary from patient to
nia, etc. patient depending on the clinical situation,
including ease of care, prevention of orthopedic
deformity, or facilitating function.
Evaluation and Differential Diagnosis A range of pharmacological agents are used to
treat spasticity:
Diagnosis usually requires several consecutive For localized or segmental spasticity, recommen-
explorations: spasticity does not usually appear dations support the use of intramuscular
until 6 months of age, dyskinetic movements at botulinum toxin A.
18 months and ataxia at age 2 years. For generalized spasticity, oral diazepam and
The initial symptoms are delayed tizanidine should be considered for short-term
acquisition of motor milestones, altered tone treatment.
(hyper- or hypotonia) and persistence of archaic Surgical procedures are common for orthopedic
reflexes. deformities that arise in spastic patients.
These operations have advanced from solo,
Investigations sequential procedures to simultaneous,
MRI collective procedures including both soft tis-
It is recommended in all cases of suspected CP. sue and bone.
Ninety percent of children with CP have an For children with severe cerebral palsy, refrac-
altered MRI. tory to standard interventions, neurosurgical
It helps to know the time and etiology of the CP. procedures including intrathecal baclofen,
selective dorsal rhizotomy, and deep brain
Metabolic Investigations stimulation should be considered.
Less than 5% of the cases are secondary to Physical, occupational, and speech therapies
metabolic disease. are employed as initial therapies or used in con-
Metabolic tests are only indicated in cases junction with medical and surgical treatments,
where the history is not typical: for example, no focusing on improving the strength and motion
typical MRI, family history of consanguinity, of affected muscles. Occupational and physical
mutiorganic symptoms. therapy play a fundamental role in children. Tech-
niques serve to lessen the effects of inhibitory
Other Investigations reflexes, facilitate the acquisition of gross and
EEG if suspected seizures fine motor skills, and to encourage language and
Ophthalmologic examination the promotion of confidence and self-esteem.
C 564 Cerebroatrophic Hyperammonemia
See Also Shaw, B. N. J. (1996). The respiratory consequences of

neurological deficit. In P. B. Sullivan & L.
Rosenbloom (Eds.), Feeding the disabled child
▶ Developmental Coordination Disorder (Clinics in developmental medicine no. 140,
▶ Chronic Dyskinesia pp. 40–46). New York, NY: Cambridge University
▶ Hypotonia Press.
Sullivan, P. B., Lambert, B., Rose, M., et al. (2000).
Prevalence and severity of feeding and nutritional
problems in children with neurological impairment:
Oxford Feeding Study. Developmental Medicine and
References and Readings Child Neurology, 42, 674–680.
Surveillance of Cerebral Palsy in Europe (SCPE). (2002).
A healthdirect Australia health information service. Sum- Prevalence and characteristics of children with
maries of systematic reviews of the evidence for the cerebral palsy in Europe. Developmental medicine
effectiveness of treatments for cerebral palsy. http:// and child neurology, 44, 633–640.
www.healthinsite.gov.au/topics/Systematic_Reviews_ Taylor, F., & National Institute of Neurological Disorders
of_Treatments_for_Cerebral_Palsy and Stroke (U.S.), Office of Science and Health
Ashwal, S., Russman, B. S., Blasco, P. A., Miller, G., Reports. (2001). Cerebral palsy: Hope through
Sandler, A., Shevell, M., & Stevenson, R. (2004). research. Bethesda, MD: The Institute. Accessed
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Keith A. Coffman1 and Miya Asato2
1
American Family Physician, 73(1), 91–100. www. Department of Pediatrics, School of Medicine,
aafp.org/afp/2006/0101/p91.html. Pittsburgh, PA, USA
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Pediatrics and Psychiatry, University of
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Pittsburgh School of Medicine Children’s
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Synonyms
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(Suppl 2), S3–S7. CSF; Spinal fluid
Cerebrospinal Fluid 565 C
Definition The normal concentration of protein in CSF is
15–50 mg/dL.
Cerebrospinal Fluid (CSF) is a clear, colorless Additional specific assays are performed
liquid with the consistency of water that fills the depending on the differential diagnosis.
ventricular system and subarachnoid spaces
around the brain and spinal cord. It is produced CSF Functions
primarily by the ependymal cells in the choroid 1. Physical support – The brain and spinal cord C
plexus and is absorbed via vesicular transport in essentially “float” in the CSF within the skull
the arachnoid villi. The production and absorp- and spinal column.
tion of CSF are continuous processes that 2. Protection – CSF prevents the brain from
normally occur at equal rates. These processes colliding with the bony skull in cases of head
lead to the complete replacement of the total injury. Additionally, the volume of CSF can
volume of CSF approximately three times a day. redistribute in order to maintain normal intra-
The circulation of CSF is also continuous. The cranial pressure when volume changes occur
direction of flow is from the lateral ventricles in the other intracranial contents.
through the cerebral aqueduct, out either the 3. Metabolism – CSF aids in the excretion, elim-
foramina of Luschka or the foramen of ination, and transport of centrally acting hor-
Magendie, and downward posterior to the spinal mones and brain metabolites.
cord. It then flows upward, anterior to the spinal
cord and over the cerebral cortex. Relevance of CSF to Autism
A lumbar puncture is not a part of the standard
CSF Composition workup or evaluation of children with ASD.
The CSF is sampled via lumbar puncture and is Studies of CSF have been pursued in ASD as
assayed to provide information relevant to diag- part of research seeking evidence related to
nosis, pathophysiology, and treatment. A blood various theories about the pathophysiology of
sample is drawn at the same time as the lumbar autism. It is important to remember that CSF
puncture in order to compare CSF levels with levels are not necessarily representative of brain
plasma levels of the elements below. The norms levels and certainly not of regional or localized
for the following can vary with age from prema- brain levels.
ture infant to adult: 1. Neurotransmitters – There are scattered
1. Osmolality and solute concentrations – CSF is reports of altered neurotransmitter levels and
iso-osmolar to blood plasma with normal CSF function, including levels of tetrahydro-
osmolality being 289 mOSM/L. The concen- biopterin (sapropterin), serotonin, norepi-
trations of sodium, magnesium, and bicarbon- nephrine, and dopamine. While pervasive
ate are similar to plasma; however, evidence of neurotransmitter abnormalities is
the concentrations of potassium, calcium, lacking, alterations or nutritional deficiencies
and amino acids are lower in CSF than in important for neurotransmitter formation and
plasma. function (e.g., folate) may account for a very
2. Cells – CSF is rather acellular with the normal small subset of individuals with ASD (Frye,
density of white blood cells being less than 2010).
five per high-powered field. Red blood cells 2. Mitochondrial disease – Elevated CSF lactate
are not normally present in the CSF. may be an important biomarker for individuals
3. Glucose – The normal concentration of glu- with ASD who have an underlying
cose in CSF is 45–80 mg/dL, approximately mitochondrial disease. It is unclear whether
two-thirds of the level of the normal serum mitochondrial dysfunction contributes to
glucose. the pathogenesis of ASD, or whether this is
4. Protein – There is a rostral to caudal concen- an epiphenomenon (Palmieri & Persico,
tration of protein within the nervous system. 2010).
C 566 Cerebrospinal Fluid 5-hydroxyindoleacetic Acid
3. Inflammatory markers in CSF – There are

limited reports of elevated inflammatory Certified Rehabilitation Counselor
markers in the CSF in individuals with
ASD. While immune-based therapy for Beth Garrison
autism has received recent attention, there Hartford Hospital Pain Treatment Center
is a lack of control data to determine the spec- Bristol, CT, USA
ificity of this finding (Zimmerman et al.,
2005).
Synonyms
References and Readings Canadian Certified Rehabilitation Counselor

(CCRC); Certified Rehabilitation Counselor
Fishman, R. A. (2005). Lumbar puncture and cerebrospi- (CRC)
nal fluid examination. In L. P. Rowland (Ed.),
Merritt’s neurology (Vol. 11, pp. 123–126).
Philadelphia: Lippincott, Williams and Wilkins.
Frye, R. E. (2010). Central tetrahydrobiopterin concentra- Definition
tion in neurodevelopmental disorders. Frontiers in
Neuroscience, 4, 52.
The Commission on Rehabilitation Counselor
Michaelson, D. J. (2006). Spinal fluid examination.
In K. F. Swaiman, S. Ashwal, & D. M. Ferriero Certification (CRCC) sets the standard for
(Eds.), Pediatric neurology, principles and practice quality rehabilitation counseling services in the
IV (Vol. 1, pp. 153–165). Philadelphia: Mosby USA and Canada. It is an independent, not-
Elsevier.
for-profit organization. It is this agency that
Palmieri, L., & Persico, A. M. (2010). Mitochondrial
dysfunction in autism spectrum disorders: Cause gives the certified designation to a rehabilitation
or effect? Biochmica et Biophysica Acta, 1797, counselor. The CRCC is accredited by the
1130–1137. National Commission for Certifying Agencies
Rossingnol, D. A., & Frye, R. E. (2010). Mitochondrial
(NCCA).
dysfunction in autism spectrum disorders: A system-
atic review and meta-analysis. Molecular Psychiatry, According to the Commission on Rehabilita-
17, 290–314. Online before print Jan 2011. tion Counselor Certification (CRCC) agency, this
Zimmerman, A. W., Jyonuchi, H., Comi, A. M., certification designation indicates a “higher level
Connors, S. L., Milstien, S., Varsou, A., et al. (2005).
of specialized education and training, a thorough
Cerebrospinal fluid and serum markers of inflamma-
tion in autism. Pediatric Neurology, 33, 195–201. understanding of key competency standards
based on current practices in the field, adherence
to the Code of Professional Ethics for Rehabili-
tation Counselors, and an ongoing commitment
to continuing education.”
Cerebrospinal Fluid The CRCC mandates that to receive this
5-hydroxyindoleacetic Acid designation a person must be of good moral char-
acter, meet acceptable standards of quality of
▶ CSF 5-HIAA practice, and have the requisite education and
professional background. There are stringent
eligibility requirements requiring a minimum of
a Masters degree in Counseling or Rehabilitation
Cerebrospinal Fluid Homovanillic Counseling together with specified work experi-
Acid ence qualifications. The person must take and
achieve a passing score on the CRC examination
▶ CSF HVA and renew their certification every 5 years via
Chaining 567 C
at least 100 h of continuing education or
re-examination. Certified Rehabilitation Counselor
With one exception, Masters and Doctoral (CRC)
degree candidates must have received their edu-
cation from a program accredited by the Counsel ▶ Certified Rehabilitation Counselor
on Rehabilitation Education (CORE) or from
a college or university accredited by the Council C
for Higher Education Accreditation (CHEA).
CORE accredits graduate programs which Chaining
provide academic preparation for a variety
of professional rehabilitation counseling Mary Jane Weiss
positions. CHEA is the largest institutional Institute for Behavioral Studies, Endicott
higher education membership organization College, Beverly, MA, USA
in the USA. It is governed by a 20-person
board of college and university presidents,
institutional representatives, and public Definition
members.
If a candidate receives a Masters in Rehabili- Chaining refers to a variety of procedures for
tation Counseling from a non-CORE program, teaching behavior chains. A behavior chain is
then they must complete a rehabilitation counsel- a series of responses in which each step serves
ing internship of 600 clock hours supervised by both as a reinforcer for the previous step and as
a CRC plus 12 months of acceptable employment a discriminative stimulus for the next step (e.g.,
experience supervised by a CRC, or 24 months of Cooper, Heron, & Heward, 2007). The reinforcer
acceptable employment experience including delivered at the end of the chain maintains all of
12 months supervised by a CRC. the previous responses in the chain.
Certification, unlike state licensure, It is important to teach behavior chains for
is a voluntary process and is not government complex sequences of responses that must be
regulated. It is not mandated by any state or maintained at independent levels. Chaining pro-
federal laws; however, eligibility to sit for the cedures are used to teach many multistep skills,
certification exam is federally mandated if including self-help and daily living skills.
a person wishes to work in a state or federal The most common variations of chaining are
vocational rehabilitation system. forward and backward chaining. Task analysis
is an essential component of chaining. The deter-
mination of steps in a chain that will be taught
See Also sequentially is complex and must be done
competently.
▶ American Congress of Rehabilitation In forward chaining, the sequence of actions is
Medicine taught in temporal order. The learner is prompted
and taught to perform the first step in the chain;
the trainer completes the remaining steps. When
References and Readings the learner masters the first step, he or she is
taught to do the first two steps. This continues
http://innerbody.com/careers-in-health/how-to-become- until the entire chain is taught in sequence to
a-certified-rehab-counselor.htlm
independence.
http://www.chea.org/pdf/chea_glance_2006.pdf
http://www.core-rehab.org A variation of forward chaining is total task
http://www.crccertification.com/ chaining, which is also referred to as whole task
C 568 Challenging Behavior
or total task presentation. In this variation, the See Also

learner receives instruction in every step of the
chain in every session. The trainer provides assis- ▶ Chaining
tance for every step on which it is needed, and ▶ Task Analysis
training continues until all steps are performed to
criterion.
In backward chaining, the sequence is taught References and Readings
in reverse order, from the completion of the task
to the start of the task. At the initiation of training, Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
the trainer completes all but the last step
River, NJ: Pearson.
of a chain, which is performed by the learner. Miltenberger, R. G. (2001). Behavior modification: Prin-
Upon completion of this last step, the learner ciples and procedures. Belmont, CA: Wadsworth
receives reinforcement. When competence is Thomson Learning.
Test, D. W., Spooner, F., Kevl, P. K., & Grossi, T. (1990).
achieved on this final step, the trainer then does
Teaching adolescents with severe disability to use
all but the last two steps of the chain. To receive the public telephone. Behavior Modification, 14,
reinforcement, the learner must complete the last 157–171.
two steps of the chain. This sequence is continued
until the learner completes all steps of the chain
independently. A backward chain is sometimes
taught in a modified way, known as leaps ahead.
In this variation, some steps may be skipped if Challenging Behavior
there is sufficient evidence that the learner pos-
sesses those components. Allowing skipping of Rebecca DeAquair
steps increases the efficiency of instruction. The Center for Children with Special Needs,
Using a limited hold can target the speed of Glastonbury, CT, USA
responding within a chain. In a behavior chain
with a limited hold, the sequence of responses
must be performed correctly and within a spec- Definition
ified period of time. The use of a limited hold
targets proficiency in addition to accuracy. This Challenging behavior refers to certain behaviors
can be used to speed slower responders and to that a person engages in which negatively affect
ensure that the individual can engage in the his/her daily functioning. These behaviors are
targeted responses in a normative duration. often recognized as being culturally abnormal
All chaining procedures are associated with and occur at such an intensity, frequency, or dura-
positive results and are effective in teaching tion that the safety of the person and/or others is
skills. There may be individual differences placed in jeopardy. Challenging behaviors may
among learners, and an assessment may yield be related to social, academic, communicative,
a best choice for that person. Furthermore, it has cognitive, vocational, or physical domains, may
been suggested that total task presentation may serve various functions, and should be examined
make sense for learners who are more disabled systematically in order to identify these func-
(Test, Spooner, Kevl, & Grossi, 1990) and who tions. If challenging behavior is to be decreased,
have good imitative repertoires. It may also be it is important to implement functionally and
a good match for tasks that are not too complex empirically validated interventions. Common
(Miltenberger, 2001) and for circumstances in challenging behaviors are self-injurious behav-
which learners know the steps but need to master ior, aggression, property destruction, stereotypic
them sequentially. or repetitive behaviors, and sexualized behaviors.
CHARGE Syndrome 569 C
See Also by a constellation of abnormalities, which may
include but is not limited to the following:
▶ Conduct Disorder coloboma, or a hole-shaped malformation, of
▶ Target Behavior the eye, resulting in visual impairments; heart
defects; atresia of the choanae, or blockage of
the nasal passages; retardation of growth and
References and Readings development; genital abnormalities; and ear C
abnormalities, such as a cup-shaped ear, and
Cooper, J., Heron, T., & Heward, W. (2007). Applied deafness (Nussbaum, McInnes, & Willard,
behavior analysis (2nd ed.). Hoboken, NJ: Pearson
2007). The co-occurrence of these features was
Education.
Durand, V., & Carr, E. (1991). Functional communication previously referred to as CHARGE association.
training to reduce challenging behavior: Maintenance However, with the identification of the gene
and application in new settings. Journal of Applied responsible for the majority of cases, the term
“syndrome” is now preferred (Nussbaum et al.,
Lindauer, S., Zarcone, J., Richmond, D., & Shroeder, S.
(2002). A comparison of multiple reinforcement 2007). Additional features of CHARGE syn-
assessment to identify function or maladaptive drome include abnormalities of the cranial nerves
behavior. Journal of Applied Behavior Analysis, 35, leading to deafness, swallowing difficulties, and
299–303.
facial weakness; cleft palate; and fistulae, or
Thomason, R., & Iwata, B. (2007). A comparison of
outcomes from descriptive and functional analyses abnormal conduits between the trachea and
of problem behavior. Journal of Applied Behavior esophagus (Nussbaum et al.). Behavioral difficul-
Analysis, 40, 333–338. ties have also been described, such as hyperac-
tivity and obsessive-compulsive behaviors
(Nussbaum et al.).
CHARGE syndrome is one of the rare genetic
CHARGE Association syndromes that has been associated with autism
(Filipek, 2005). The first report of this association
▶ CHARGE Syndrome described three children with CHARGE syn-
drome, two of whom also had intellectual disabil-
ity, and clinical features of autism, according to
the Autism Diagnostic Interview-Revised, Child-
CHARGE Syndrome hood Autism Rating Scale, and the Diagnostic
and Statistical Manual of Mental Disorders
Ellen J. Hoffman (DSM-IV) (Fernell et al., 1999). The prevalence
Albert J. Solnit Integrated Training Program, of autism in CHARGE syndrome has been esti-
Yale Child Study Center, New Haven, CT, USA mated to be between 15% and 50%
(Grafodatskaya, Chung, Szatmari, & Weksberg,
2010). However, the diagnosis of autism in
Synonyms CHARGE syndrome is complicated by the chal-
lenge of quantifying social and communication
CHARGE association deficits in a syndrome characterized by visual and
hearing impairments and, in some cases, intellec-
tual disability as well (Grafodatskaya et al.,
Definition 2010).
More than half of all individuals with
CHARGE syndrome is a rare genetic syndrome CHARGE syndrome carry mutations in the
(prevalence of 1:3,000–1:12,000) characterized gene, chromodomain helicase DNA binding
C 570 Charter Schools
protein 7 (CHD7), which is located on chromo-

some 8q12. In most cases, this is a de novo, or Charter Schools
new, mutation such that the recurrence risk of
CHARGE syndrome is typically low, less than Lucy Volkmar
5% if the mutation is not present in either parent Achievement First East New York Elementary
(Nussbaum et al., 2007). Because the CHD7 gene School, Brooklyn, NY, USA
encodes a protein that is involved in altering the
structure of chromosomes, it likely functions in
an epigenetic manner, regulating the expression Definition
of genes that serve critical functions in early
development. This accounts for the observation In the United States and other countries, a charter
that not all cases of CHARGE syndrome are due school is a publicly funded but privately run
to mutations in CHD7, indicating that mutations school. These schools differ from traditional pub-
in other genes can result in a similar clinical lic schools because their existence is contingent
presentation. Moreover, as with other rare genetic upon meeting certain outcomes. When granted
syndromes associated with an increased risk of a charter, the school sets certain student achieve-
autism, studies of the genetic etiology of ment goals that must be met at the time of charter
CHARGE syndrome may provide insight into renewal. The charters are renewed every 3–5
the genetics of autism. years, depending on the district or state. School
leaders at charters have increased autonomy to
meet these goals. When the number of applicants
for a charter school exceeds available seats,
students are admitted based on a lottery.
References and Readings Charter schools can be primary or secondary
schools. They do not charge admission and typi-
Fernell, E., Olsson, V. A., Karlgren-Leitner, C., Norlin,
B., Hagberg, B., & Gillberg, C. (1999). Autistic disor-
cally are exempt from some requirements of pub-
ders in children with CHARGE association. Develop- lic (state-run) schools. Students in these schools
mental Medicine and Child Neurology, 41(4), do participate in state-mandated testing.
270–272.
Filipek, P. A. (2005). Medical aspects of autism. In F. R.
Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Hand-
book of autism and pervasive developmental disorders References and Readings
(3rd ed., Vol. 1, pp. 534–578). Hoboken, NJ: John
Wiley & Sons. Lubienski, C. A., & Weitzel, P. C. (Eds.). (2010). The
Grafodatskaya, D., Chung, B., Szatmari, P., & Weksberg, charter school experiment. Cambridge, MA: Harvard
R. (2010). Autism spectrum disorders and epigenetics. Educational Press.
Journal of the American Academy of Child and Ado-
lescent Psychiatry, 49(8), 794–809.
Lalani, S. R., Safiullah, A. M., Fernbach, S. D.,
Harutyunyan, K. G., Thaller, C., Peterson, L. E.,
et al. (2006). Spectrum of CHD7 mutations in 110
CHAT
individuals with CHARGE syndrome and genotype-
phenotype correlation. American Journal of Human ▶ Checklist for Autism in Toddlers (CHAT)
Genetics, 78(2), 303–314. ▶ Modified Checklist for Autism in Toddlers
Nussbaum, R. L., McInnes, R. R., & Willard, H. F.
(2007). Nussbaum: Thompson & Thompson
(M-CHAT)
genetics in medicine (7th ed.). Philadelphia: Saunders
Elsevier.
Vissers, L. E., van Ravenswaaij, C. M., Admiraal, R., Checklist for Autism in Toddlers
Hurst, J. A., de Vries, B. B., Janssen, I. M., et al.
(2004). Mutations in a new member of the
chromodomain gene family cause CHARGE syn- ▶ Modified Checklist for Autism in Toddlers
drome. Nature Genetics, 36(9), 955–957. (M-CHAT)
Checklist for Autism in Toddlers (CHAT) 571 C
a yes/no format and administration time is
Checklist for Autism in Toddlers approximately 15 min.
(CHAT) A high-risk score is obtained if a child fails all
five items addressing protodeclarative pointing,
Meena Khowaja and Diana Robins pretend play, and gaze monitoring across parent-
Georgia State University, Atlanta, report and clinician observation. A medium-risk
GA, USA score results from failing both items on C
protodeclarative pointing. All other children are
considered to be at low risk for autism. Addition-
Synonyms ally, a two-stage screening method is
recommended in which a child screens positive
CHAT on the original CHAT administration, as well as
upon re-administration 1 month later in attempts
to reduce the likelihood of false-positive cases
Abbreviations (Baron-Cohen et al., 2000).
ASD Autism spectrum disorder

PDD-NOS Pervasive developmental disorder- Historical Background
not otherwise specified
PPV Positive predictive value The CHAT was developed in Great Britain by
Baron-Cohen and colleagues as a way for pri-
mary care physicians or home visitor nurses to
Description screen for autism in young children. It is the first
screening tool to identify autism risk in
The CHecklist for Autism in Toddlers (CHAT; 18-month-olds. The pilot version of the question-
Baron-Cohen, Allen, & Gillberg, 1992; Baron- naire included several parent-report items for
Cohen et al., 1996) is a screening tool designed to each of 10 areas of development. In efforts
capture early signs of autism in 18-month-olds by toward quicker administration, items in the imi-
inquiring about milestones related to early social tation domain were dropped, as these behaviors
and communicative development. The CHAT were determined to not be reliably present among
consists of nine parent-report items and five most 18-month-olds (more than 20% did not),
child observation items completed by the child’s resulting in the current nine areas of develop-
general physician or health visitor. The parent ment. Subsequently, only the most frequently
questions (part A) assess abnormal behaviors passed question for each domain was kept and
commonly associated with autism spectrum dis- the rest of the questions were dropped, resulting
orders (i.e., reduced social interest, social play, in the current version of one question for each of
pretend play, protodeclarative pointing, and joint the nine areas.
attention), as well as developmental behaviors In their initial study, Baron-Cohen, Allen, and
that are more likely to be intact in children with Gillberg (1992) screened 50 randomly selected
autism (i.e., rough and tumble play, motor devel- toddlers from the pediatric setting and 41 high-
opment, protoimperative pointing, and functional risk toddlers (younger siblings of children with
play). The second set of questions (part B) was autism). More than 80% of the randomly selected
created to supplement the parent’s report of the toddlers passed all items on the CHAT. Among
child’s behavior. A trained professional adminis- the high-risk group, four toddlers failed at least
ters five items measuring pretend play, two of five target ASD items and later had
protodeclarative pointing (both initiating and a diagnosis of ASD at follow-up. This first
responding to another person’s point), eye con- study, although a small sample, suggested its
tact, and functional play. All questions are in utility as an ASD screening instrument within
C 572 Checklist for Autism in Toddlers (CHAT)
a population that had been identified as being at rather than just Autistic Disorder. It consists of
risk. In a subsequent validation study screening 23-item “yes or no” questions; a positive screen
16,000 children using the CHAT, Baron-Cohen, (i.e., risk for ASD) is indicated by a total score of
Cox, Baird, Swettenham, and Nightingale (1996) three or more or a score of two or more on six
identified three critical content areas for identify- critical items. Initial data demonstrated strong
ing autism, which include pretend play (parent- specificity and negative predictive value, but
report and observation), eye gaze (observation), poor positive predictive value (Robins, Fein,
and pointing (parent-report and observation), Barton, & Green, 2001). The M-CHAT Follow-
totaling five critical items. Twelve of the 16,000 Up Interview (FUI; Robins, Fein, & Barton,
children among the general population were iden- 1999b) was developed to reduce the false-
tified as at risk for autism; risk status was based positive rate, which has increased the positive
on a two-stage screening approach in which the predictive value (Kleinman et al., 2008; Robins,
high-risk score cutoff of failing all five critical 2008; Robins et al., 2001). See ▶ M-CHAT entry
items was met both at the original administration for additional information and psychometric
of the CHAT as well as at retest approximately data.
1 month later. The two-stage method was adopted Data on the CHAT-23, a version of the CHAT
to help reduce false-positive cases. Ten of these applicable for Chinese children, was published
children received a diagnosis of autism and two by Wong and colleagues (2004). This version is
had other developmental delays, suggesting that a combination of both the M-CHAT and CHAT
the measure had adequate utility for use in the in that it consists of a Chinese translation of the
general population. Follow-up diagnostic evalu- 23-item M-CHAT (part A) plus the five clinical
ations at 3½ years of age indicated stability of observation items from the CHAT (part B). Initial
diagnosis. In a follow-up study of the 16,000 data on 18 and 24 month olds identified seven
children at age 7 years, the effectiveness of one- critical items from part A, and four key items in
stage screening was compared to two-stage part B. The fifth item in part B assessed general
screening (Baird et al., 2000); see psychometric developmental ability (i.e., functional play),
data section. In an article summarizing published which is thought to develop normally in autism
research on the CHAT, Baron-Cohen and col- and was not included in the statistical analysis.
leagues (2000) recommended using two-stage Screen positives on part A include failing two of
screening so as to ensure that failing items on seven items determined to be critical in this trans-
the first CHAT are significant developmental lation or any 6 of the 23 items overall; screen
concerns rather than situational concerns on the positives on part B include failing at least two of
day of administration (i.e., having a “bad day”) or the four key items. Based on their results, the
milder developmental delays. authors suggest a two-stage algorithm for screen-
Several different scoring systems and versions ing. This includes universal screening using part
have been developed since the original CHAT. A, followed by part B screening only for those
Scambler, Rogers, and Wehner (2001) published children who screen positive on part A. See psy-
data on a modified scoring system for the CHAT, chometric data section.
called the Denver criteria. The Denver scoring Most recently, Allison and colleagues
criteria differed in that they included failing published the Quantitative Checklist for Autism
a parent-report item of pretend play or pointing in Toddlers (Q-CHAT; Allison et al., 2008),
to show an object, as well as clinical observation which takes the form of a parent-report scale.
of pointing impairment. The Q-CHAT is different in that responders are
Additionally, the Modified Checklist for able to quantify behaviors based on a 5-point
Autism in Toddlers (M-CHAT; Robins, Fein, & Likert rating scale. Likert scale response items
Barton, 1999a) is a parent-report screening mea- vary depending on the question and range from,
sure that was adapted from the original CHAT in for example, “always” to “never,” “many times a
order to capture the whole spectrum of disorders, day” to “never,” “very easy” to “impossible,” etc.
This allows for demonstration of reduced fre- specificity remaining high, and sensitivity some-
quency of particular behaviors that children with what decreasing to .11 and .21 for high-risk and
an ASD might exhibit, rather than requiring par- medium-risk cutoffs, respectively. Overall, two-
ents to judge absolute absence of these behaviors. stage screening increases the CHAT’s PPV,
In addition to the three key items identified by which increases the likelihood that a screen pos-
Baron-Cohen et al. (1996), which are pretend itive case will receive an ASD diagnosis;
play, eye gaze, and protodeclarative pointing, the however, the false-positive rate is greater in the C
Q-CHAT includes other domains, such as lan- two-stage approach compared to screening at
guage development and repetitive behaviors. a single time point, thus reducing the measure’s
sensitivity (Baird et al., 2000; Baron-Cohen et al.,
2000). See Table 1 for a summary of psychomet-
Psychometric Data ric data.
In 2001, Scambler, Rogers, and Wehner
The entire screening sample of 16,000 screened published data on the CHAT using their Denver
at age 18 months (Baron-Cohen et al., 1996) was modifications. These criteria were based on post
later followed up when the children turned hoc analysis as part of their study on the CHAT as
7 years old (Baird et al., 2000) in order to calcu- a Level 2 screener. These scoring criteria were
late complete psychometric data, which requires compared to original scoring criteria on a sample
ascertainment of missed cases or false negatives. of 2- to 3-year-old children with ASD (n ¼ 26)
Based on their results, there were 50 cases of and other developmental disorders (DD; n ¼ 18)
autism and 44 cases of PDD-NOS in the sample. to determine how well the CHAT distinguishes
The authors compared psychometric data of the between the two groups. The Denver scoring
CHAT when using one-stage screening versus criteria yielded .85 sensitivity and 1.00 specific-
two-stage screening (two administrations 1 ity, whereas the sensitivity dropped to .65 when
month apart). Based on one-stage screening, 10 using the original CHAT scoring criteria, with
of the 50 autism cases were identified by the high- specificity remaining at 1.00. A subset of these
risk score, and an additional nine cases were children (ASD n ¼ 19; DD n ¼ 11) participated in
identified using the medium-risk score. This a follow-up study 2 years later to assess stability
yielded a sensitivity of .20, specificity of .998, of diagnosis (Scambler, Hepburn, & Rogers,
and positive predictive value (PPV) of .26 using 2006). Original CHAT scoring at Time 1 cor-
the high-risk score, and sensitivity of .38, speci- rectly classified 83% of the sample at Time 2
ficity of .98, and PPV of .05 for the medium-risk (five missed cases of ASD); 93% of the sample
score. Of all 94 ASD cases, medium-risk scoring was correctly identified at Time 2 based on the
criteria identified 33 cases whereas high-risk cut- Denver scoring criteria of the CHAT at Time 1
off scores captured 11 cases. The high-risk cut- (two missed cases of ASD). The CHAT’s original
offs demonstrated a sensitivity of .12, specificity scoring and Denver scoring have been assessed
of .998, and PPV of .29; medium-risk scores for utility in detecting autism in Fragile
yielded a sensitivity of .35, specificity of .98, X syndrome cases (Scambler, Hepburn,
and PPV of .08. When using the two-stage Hagerman, & Rogers, 2007). On a sample of 17
screening in identifying cases of Autistic Disor- children (mean age ¼ 34 months), results yielded
der, PPV increased to .75 and .29 for the high-risk sensitivity of .50 and specificity of 1.00 using
and medium-risk cutoffs, respectively. Specific- CHAT scoring criteria and sensitivity of .75 and
ity remained high, whereas sensitivity somewhat specificity of .92 using the Denver scoring
dropped to .18 and .20 for the high-risk and criteria.
medium-risk cutoffs, respectively. For all ASD The utility of the CHAT as a tool to detect
cases, there was a similar pattern with PPV again autism in children younger than 3 years was also
increasing to .83 and .59 based on the high-risk investigated in a Swedish population (Carlsson,
and medium-risk scores, respectively, with Gillberg, Lannero, & Blennow, 2010). Nurses
C 574 Checklist for Autism in Toddlers (CHAT)
Checklist for Autism in Toddlers (CHAT), Table 1 Psychometric data for the CHAT
Study Sample Sensitivity Specificity PPV
Baird et al. (2000) n ¼ 16,000, Level 1
Mean age ¼ 18.7 months
One-stage screening Autistic disorder
High-risk score .20 .998 .26
Medium-risk score .38 .98 .05
ASD
Two-stage screening Autistic disorder
ASD
Scambler et al. (2001) Autism n ¼ 26; mean age ¼ 33 months, Level 2
DD n ¼ 18; mean age ¼ 34 months
Denver scoring criteria .85 1.00
CHAT scoring criteria .65 1.00
Scambler et al. (2006) Fragile X n ¼ 17, Level 2
Mean age ¼ 34 months
Denver scoring criteria .75 .92
CHAT scoring criteria .50 1.00
Wong et al. (2004) (CHAT-23) ASD n ¼ 87; mean age ¼ 51 months, Level 2
DD n ¼ 125; mean age ¼ 29 months
Part A: Fail 2/7 key items .93 .77 .74
Part A: Fail 6/23 total items .84 .85 .79
Part B: Fail 2/4 key items .74 .91 .85
were instructed to administer the CHAT if the procedures used in the study differed from those
child was identified to be at risk based on devel- used in previous studies. Specifically, the CHAT
opmental surveillance; those who screened posi- was not uniformly administered to the entire sam-
tive on the CHAT were administered ple; in addition, 63% of the nurses reported hav-
a subsequent CHAT. In a population of 35,990 ing deviated from the study protocol. Therefore,
18-month-olds, 6,822 screened positive on devel- one might interpret these results to indicate that
opmental surveillance; however, only 18% of when providers select a subset of cases for
these cases were administered a CHAT screening, the use of standardized screening
(n ¼ 1,230), which was primarily a decision tools may not improve detection of autism.
made by the nurses who reported that most The psychometric properties of the CHAT-23
often the children in those cases seemed to be (Wong et al., 2004) in a sample of 212 toddlers
non-autistic. Compared to a control study area in aged 13–86 months yielded a sensitivity of .93,
which developmental surveillance as usual was specificity of .77, and positive predictive value of
being conducted, an equal number of children .74 when failing two of the seven key items in
were referred for an ASD evaluation. The authors part A. Failing any 6 from the 23 parent items
concluded that the use of the CHAT did not help resulted in a sensitivity of .84, specificity of .85,
increase the number of children who received an and positive predictive value of .79. Failing two
ASD diagnosis before age three. However, the of four key items in part B produced a sensitivity
of .74, specificity of .91, and positive predictive Baird, G., Charman, T., Baron-Cohen, S., Cox, A.,
value of .85. Given the sensitivity-specificity Swettenham, J., Wheelwright, S., et al. (2000). A screen-
ing instrument for autism at 18 months of age: A 6-year
tradeoff between using the key items for screen- follow-up study. Journal of the American Academy of
ing in part A compared to part B, the authors Child & Adolescent Psychiatry, 39(6), 694–702.
proposed two-level screening approach in which Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can
part B is only administered to those who initially autism be detected at 18 months? The needle, the
screen positive on part A. Limitations of the study
haystack, and the CHAT. British Journal of Psychia-
try, 161, 839–843.
C
included the small sample size, and that screening Baron-Cohen, S., Cox, A., Baird, G., Sweettenham, J., &
was administered after children had already been Nightingale, N. (1996). Psychological markers in the
evaluated and diagnosed. detection of autism in infancy in a large population.
British Journal of Psychiatry, 168(2), 158–163.
Initial publication of Q-CHAT (Allison et al., Baron-Cohen, S., Wheelwright, S., Cox, A., Baird, G.,
2008) data compared total scores within an unse- Charman, T., Swettenham, J., et al. (2000). Early iden-
lected sample (n ¼ 779; mean age ¼ 21 months) tification of autism by the CHecklist for autism in
to total scores among an ASD sample (n ¼ 160; Toddlers. Journal of the Royal Society of Medicine,
93, 521–525.
mean age ¼ 45 months). Results demonstrated a Carlsson, L. H., Gillberg, C., Lannero, E., & Blennow, M.
significantly higher mean score for the ASD (2010). Autism: Screening toddlers with CHAT in
group relative to the control group, whose range a child health care programme did not improve early
of scores approximated a normal distribution. identification. Acta Paediatrica, 99, 1897–1899.
Kleinman, J., Ventola, P., Pandey, J., Verbalis, A., Barton,
Also, the Q-CHAT demonstrated good test-retest M., Hodgson, S., et al. (2008). Diagnostic stability in
reliability of .82 and discrimination between very young children with autism spectrum disorders.
ASD and control groups. Similar to the CHAT- Journal of Autism and Developmental Disorders,
23, interpretation of findings is preliminary, given 38(4), 606–615.
Robins, D. L. (2008). Screening for autism spectrum dis-
the small sample size and screening after children orders in primary care settings. Autism, 12(5), 537–556.
have already been evaluated and diagnosed. Robins, D. L., Fein, D., & Barton, M. (1999a). Modified
checklist for autism in toddlers. Self-published.
Robins, D. L., Fein, D., & Barton, M. (1999b). Modified
checklist for autism in toddlers (M-CHAT). Follow-up
Clinical Uses interview. Self-published.
Robins, D. L., Fein, D., Barton, M. L., & Green, J. A.
The CHAT is designed for use at 18-month (2001). The modified checklist for autism in toddlers:
checkups in the pediatric setting to identify chil- An initial study investigating the early detection of
autism and pervasive developmental disorders.
dren at risk for an autism spectrum disorder. Journal of Autism and Developmental Disorders,
31(2), 131–44.
Scambler, D. J., Hepburn, S. L., Hagerman, R. J., &
See Also Rogers, S. J. (2007). A preliminary study of screening
for risk of autism in children with fragile X syndrome:
Testing two risk cut-offs for the CHecklist for Autism
▶ M-CHAT in Toddlers. Journal of Intellectual Disability
▶ Pervasive Developmental Disorder Not Research, 51, 269–276.
Otherwise Specified Scambler, D. J., Hepburn, S. L., & Rogers, S. J. (2006).
A two-year follow-up on risk status identified by the
Checklist for Autism in Toddlers. Developmental and
Behavioral Pediatrics, 27(2), S104–S110.
References and Readings Scambler, D., Rogers, S. J., & Wehner, E. A. (2001). Can
the Checklist for Autism in Toddlers differentiate
Allison, C., Baron-Cohen, S., Wheelwright, S., Charman, young children with autism from those with develop-
T., Richler, J., Pasco, G., et al. (2008). The Q-CHAT mental delays? Journal of the American Academy of
(Quantitative CHecklist for Autism in Toddlers): Child & Adolescent Psychiatry, 40(12), 1457–1463.
A normally distributed quantitative measure of autistic Wong, V., Hui, L. H., Lee, W. C., Leung, L. S., Ho, P. K.,
traits at 18–24-months of age: Preliminary report. Lau, W. L., et al. (2004). A modified screening tool for
Journal of Autism and Developmental Disorders, autism (Checklist for Autism in Toddlers [CHAT-23])
38(8), 1414–1425. for Chinese children. Pediatrics, 114, e166–e176.
C 576 Chelation
Volkmar, F., & Wiesner, L. (2009). A practical guide to

Chelation autism. Hoboken, NJ: Wiley.
Weber, W., & Newmark, S. (2007). Complementary and
alternative medical therapies for attention-deficit/
Fred R. Volkmar hyperactivity disorder and autism. Pediatric Clinics
Director – Child Study Center, Irving B. Harris of North America, 54(6), 983–1006.
Psychology, School of Medicine, Yale
Chess, Stella
Definition Fred R. Volkmar

Chelation is the use of various agents to remove Professor of Child Psychiatry, Pediatrics and
heavy metals from the body – typically lead but Psychology, School of Medicine, Yale
sometimes arsenic, mercury, or other metals are the University, New Haven, CT, USA
targets. Various agents can be used for this process.
These agents were first developed in the treatment
of poison gas inhalation during World War I and Name and Degrees
have been substantially modified and refined over
the years to increase efficiency while minimizing Stella Chess
side effects. Various routes of administration are B.A., 1935, Smith College, Northampton, MA
used for these chelating agents. There are occa- M.D., 1939, New York University College of
sional uses in treatment of other diseases, e.g., Medicine, New York, NY
those that involve excess iron storage.
As an alternative treatment many claims have
been made, but not scientifically substantiated Major Appointments (Institution,
for a range of conditions ranging from atheroscle- Location, Dates)
rosis to autism. The use in autism rested, in part,
on the unproven suggestion that high mercury Psychiatry Residency, Grasslands Hospital in
levels were involved in the production of autism. Eastview, N.Y.
There is no scientific justification for this process 1954–1966 Assistant Professor, New York
in autism. Medical College
There can be significant risks to chelation – 1966–2007 Associate and Full Professor,
including hypocalcemia, anemia, kidney prob- New York University School of Medicine
lems, and cardiac difficulties. There are reports
of deaths including one child with autism.
Deaths may relate to hypocalcemia. As with all Major Honors and Awards
nonproven treatments, particularly when some
substantial risk is concerned, parents should be Smith College Medal, 1999
careful to make informed treatment choices.

References and Readings Professional Contributions
Beauchamp, R. A., Willis, T. M., Betz, T. G., & Stella Chess made many important scientific con-
Villanacci, J. (2006). Deaths associated with hypocal-
cemia from chelation therapy – Texas, Pennsylvania,
tributions. She began her New York Longitudinal
and Oregon, 2003–2005. Morbidity, Mortality Weekly Study in 1956. This body of work, focused on
Review (MMWR), 55(8), 204–207. careful observation of styles of behavior and
Child Abuse in Autism 577 C
personality, led to the development of Chess’s See Also
concept of varying temperament. Her work
helped shift the field from a sole reliance on ▶ Bender, Lauretta
intrapsychic conflict and anxiety (as exemplified ▶ Rutter, Michael
in then popular psychoanalytic work) but instead
suggested the importance of understanding indi-
vidual differences. Chess also elaborated the References and Readings C
notion of “goodness of fit,” e.g., relative to poten-
tial matches and mismatches in parental style and Chess, S. (1971). Autism in children with congenital rubella.
Journal of Autism and Childhood Schizophrenia, 1(1),
child temperament. This work led to a growing
33–47.
body of work on the basis of individual differ- Chess, S. (1977). Follow-up report on autism in congenital
ences, their stability, and relationship to child- rubella. Journal of Autism and Childhood Schizophrenia,
hood problems. In 1971, she reported on 7(1), 69–81.
Chess, S. (1979). Discussion: Language, cognition, and
a possible observation of an association between
autism by Rutter, Studies of the autistic syndromes by
congenital rubella. In retrospect, the develop- Coleman. Research Publications: Association for
mental course of many of the patients she first Research in Nervous and Mental Disease, 57, 277–280.
reported seemed less typical of autism, but her Chess, S., Fernandez, P., & Korn, S. (1978). Behavioral
consequences of congenital rubella. Journal of Pediat-
work focused attention on a possible biological
rics, 93(4), 699–703.
mechanism in the condition. Chess also was Chess, S., & Thomas, A. (1999). Goodness of fit. Phila-
noted for her pioneering work in psychiatric- delphia: Brunner/Mazel.
pediatric liaison work and also edited an influen- Rutter, M., Birch, H. G., Thomas, A., & Chess, S. (1964).
Temperamental characteristics in infancy and the later
tial book series, Annual Progress in Child
development of behavioural disorders. British Journal
Psychiatry and Child Development, that con- of Psychiatry, 110(468), 651–661. Royal College of
tinues to be published. She founded the first Psychiatrists, United Kingdom.
pediatric psychiatry unit at Bellevue Hospital
and was a professor at NYU.
Child Abuse in Autism

Short Biography
Hillary Hurst
Born in New York to immigrant parents from Rus- Department of Psychology, University of
sia, Chess studied at the Ethical Culture School and Massachusett Boston, Boston, MA, USA
then Smith College before entering NYU Medical
School in 1935. She met her husband, and research
collaborator, Alexander Thomas while they both Definition
were in medical school. They married in 1938.
While in medical school, she worked with Lauretta Children with autism spectrum disorders are
Bender. Chess began, in collaboration with her significantly more likely than typically develop-
husband, the New York Longitudinal Study of ing children to be the victims of abuse, which
Child Development that followed several hundred encompasses emotional abuse, physical abuse,
youth. During the course of their work, they iden- sexual abuse, and neglect.
tified a series of basic temperaments and parenting
styles and also began to emphasize the importance
of “goodness of fit” with parents. Many trainees Historical Background
worked with her. She continued to teach at NYU
into her 90s. She was involved in training many of Child abuse, which includes physical abuse,
the leaders in the field and collaborated with emotional abuse, sexual abuse, and neglect, is
Michael Rutter among others. less studied among children with autism
C 578 Child Abuse in Autism
spectrum disorders (ASD) than it is among typi- reporting include communication impairments,
cally developing children, despite their elevated social knowledge deficits (e.g., not understanding
risk for exposure. However, abuse among ASD that the interaction was inappropriate), and
and intellectual disability (ID) populations is greater likelihood of attributing blame for
a growing area of research and awareness, and a negative interaction to oneself due to a history
a specific focus on sexual abuse has emerged. of difficult social interactions. The constellation
While previous attitudes held that individuals of research documenting greater exposure
with disabilities were asexual and could not be coupled with reduced likelihood of reporting is
negatively impacted by others’ sexual behaviors, very concerning and highlights the importance of
current research is more respectful of the human- protecting the safety and well-being of children
ity and sexuality of individuals with disabilities, with ASD, ID, and other disabilities.
including ASD. Individuals with ASD who A great deal of what is currently understood
have extremely limited or impaired functional about abuse among children with ASD comes
communication skills may be particularly at from a landmark study by Mandell et al. (2005).
risk, as perpetrators may believe that the individ- This study is unique in that it looks specifically at
ual with ASD will not be able to disclose their the experiences of children with ASD, instead of
role in the abusive incidents to family members ID more broadly, and considers experiences
or authorities. of both sexual and physical abuse. Unlike previ-
ous studies, which drew heavily from institution-
alized populations, Mandell et al. recruited
Current Knowledge participants who received treatment in commu-
nity settings, much like the majority of children
The Centers for Disease Control and Prevention diagnosed with ASD today. This was an impor-
(CDC) reported that in 2008, approximately tant distinction because children who live in hos-
772,000 children in the USA were victims of pital and institutional settings are at a greater risk
maltreatment. Of these children, the majority for abuse, and it is problematic to generalize
(71%) experienced maltreatment, 16% experi- findings from this population to children who
enced physical abuse, 9% experienced sexual live at home with their families. The results of
abuse, and 7% experienced emotional abuse. this study revealed high rates of abuse – 18.5%
The rates of child sexual abuse are particularly of the 156 children in the sample were reported
high: recent studies by the CDC suggest that by their parents to have experienced physical
16.67% of boys and 25% of girls in the general abuse, and16.6% were reported to have experi-
population experience some form of sexual abuse enced sexual abuse – among children with ASD.
before the age of 18. It is likely that the actual rate While these rates are lower than the ones put forth
of sexual abuse is even higher than reported by by the CDC of all children, it is important to
the CDC, given the multiple reasons that victims consider that the average age of participants in
might be reluctant to disclose or report abuse this study was 11 years and the CDC reports their
when it has happened. Also, it is important to statistics through age 18. Mandell et al. found that
keep in mind that the CDC reports statistics for children who had experienced physical abuse
the greater population, and does not compare were more likely than non-abused children to
rates of maltreatment based on children’s disabil- act out sexually, to engage in abusive behavior
ity status. However, research has consistently themselves, to attempt suicide, and to have
suggested that children with ID are at greater conduct and/or academic problems. Similarly,
risk than typically developing children to be the children who had experienced sexual abuse
victims of all forms of maltreatment (Sobsey, were more likely than non-abused children to
1994). Children with ID are also less likely than act out sexually, to engage in abusive behavior
typically developing children to report abuse themselves, and to attempt suicide. Additionally,
when it has occurred. Reasons for more limited these children were also more likely to engage in
Child Abuse in Autism 579 C
self-injurious behavior in addition to suicidal Also, the social deficits associated with ASD
behavior, to run away from home, and to have may also make children on the spectrum appeal-
had a psychiatric hospitalization. Contrary to the ing to perpetrators. For example, the perpetrator
previous belief that children with ASD were not may believe that a child with ASD can be
susceptible to the effects of abuse, the findings of manipulated more easily and be less likely to
this study suggest quite the opposite. “fight back” against advances than a typically
In considering recent research about child developing child. Unfortunately, perpetrators C
abuse and ASD, it is important to consider that may take advantage of children with social
the rate of abuse is likely even higher than difficulties by presenting themselves as a
reported since communication deficits associated “friend.” Also, children with ASD are encour-
with ASD may make it more challenging for aged to cooperate with teachers, clinicians, and
victims to report abuse, and for these reports to other professionals from a very early age, and this
be taken seriously, when it does occur. Some learned compliance may lead them to follow and
research has been conducted on victims’ reac- not to question the motives or advances of
tions following sexual abuse, and these findings a perpetrator.
suggest that children with ASD may respond Both large-scale and small-scale studies have
differently from typically developing children. suggested that children with ASD are at a greater
For example, a child with ASD who has low risk for abuse and maltreatment than typically
language abilities may engage in self-injurious developing children. There are multiple possible
or self-stimulatory behavior to try to communi- explanations for this phenomenon, some of which
cate or cope with the abuse that he or she experi- are related to the nature of ASD symptoms. There
enced. Or, a child with ASD who demonstrates is compelling evidence that parents raising chil-
echolalia may recount what a perpetrator said dren with ASD experience much higher levels of
during an abusive episode. However, this may parenting stress and depression than parents rais-
not be recognized for what it is by parents or ing typically developing children or children with
caretakers, who could dismiss the behavior sim- other intellectual and developmental disabilities.
ply as nonfunctional communication or meaning- Parenting stress and depression have each been
less jargon. In the absence of recognizing that linked as risk factors for abuse (Holden & Banez,
abuse has occurred and taking appropriate steps 1996; McPherson et al., 2009). Because of the
to intervene, the abuse could continue. Therefore, unpredictability of behavior among children with
the current literature suggests that parents and ASD, parents and caregivers may at times
caretakers of children with ASD should take become frustrated with their children’s ASD-
note of any changes in behavior (including an associated traits and instead of coping with this
increase in intensity or frequency of an existing frustration in constructive ways, they may direct
behavior, or the appearance of a new one), as it it aggressively and abusively toward their child.
could indicate abuse. This is not to say that The frustrations that lead some parents to abuse
changes in behavior always signal that abuse their children with ASD may lead others to
has occurred – it is prudent, however, to consider neglect them. Algood et al. (2011) examine sys-
the possibility that individuals with ASD may tems-level factors to see which characteristics
have been exposed to abuse. might contribute to the neglect of children with
The same language impairments that may pre- developmental disabilities more broadly.
vent children with ASD from communicating that When examining the rates and types of
abuse has occurred may be part of the reason why maltreatment among children with ASD, it is
they are victimized more often than typically important to consider who the most common
developing children in the first place. Perpetra- perpetrators are. Current research suggests that
tors may believe that children with ASD would be the most likely perpetrator differs depending on
less likely to report the abuse to others and, in the type of abuse. In the general population, par-
turn, the perpetrator would not be discovered. ents are the most common perpetrators of child
C 580 Child Abuse in Autism
neglect. However, when it comes to the other ASD often prefer familiar routines, environ-
forms of child maltreatment, perpetrators fre- ments, and settings, and to be interviewed by
quently fall into one of these four categories: a new clinician when abuse is suspected could
disability service providers, acquaintances and be an upsetting and off-putting experience. Also,
neighbors, family members, and peers with dis- some of the current tools for assessing abuse
abilities (Sobsey, 1994). This information is require a level of verbal expression that many
helpful to consider when assessing whether an children with ASD do not possess. Therefore,
individual with ASD has experienced abuse; it instruments for detecting abuse must be devel-
can also help in the development of preventative oped specifically for the needs and capabilities of
programs, which are discussed in the section children with ASD.
below. Overall, more research is needed to under-
stand the rates and types of abuse experienced
specifically by children with ASD, and who is
Future Directions perpetrating this abuse. Additionally, more
research is needed on the short- and long-term
Given what is known about the heightened risk of effects of abuse on children with ASD. Taken
sexual abuse among children with ASD, it is together, this information could be useful in
important to provide age- and developmentally preventative, educational programs for both
appropriate sexuality training to all individuals, children with ASD and the adults in their lives.
regardless of their disability status (Edelson, Also, this information could help in the interven-
2010) and to ensure that parents understand the tions and treatments for children who have been
heightened risk and have supportive resources victimized.
and respite available. While sexuality education
is associated with multiple positive outcomes, it
serves a particular function for individuals, such See Also
as children with ASD, who are susceptible to
abuse. Sexuality education can empower individ- ▶ Parent Training
uals so that they may be proactive and take steps ▶ Sex Education
to prevent being victimized (although it is impor- ▶ Sexuality in Autism
tant to note here that sexual abuse is never the
fault of the victim). Sexuality education is also
important because it can help individuals to rec- References and Readings
ognize and report sexual abuse when it has
Algood, C. L., Hong, J., Gourdine, R. M., &
occurred. Especially for children with ASD, Williams, A. B. (2011). Maltreatment of children
who may have difficulty navigating social situa- with developmental disabilities: An ecological sys-
tions and understanding the intentions of others, tems analysis. Children and Youth Services Review,
social skills training can serve a similarly valu- 33(7), 1142–1148.
Baladerian, N. (2004). An overview of violence against
able function in protecting against sexual or children with disabilities. Presentation at the Best
emotional abuse. Practice II Conference on Child Abuse & Neglect,
In light of the heightened rates of abuse among Mobile, AL.
children with ASD and its associated detrimental Edelson, M. G. (2010). Sexual abuse of children with
autism: factors that increase risk and interfere with
outcomes, it is very important to have valid and recognition of abuse. Disability Studies Quarterly,
reliable instruments that can determine whether 30(1). Retrieved from http://dsq-sds.org/article/view/
a child with ASD has experienced abuse. Edelson 1058/1228
(2010) points out that some tools that are used Gammicchia, C., & Johnson, C. Living with autism: Infor-
mation for domestic violence and sexual assault coun-
with typically developing children, such as inter- selors. Retrieved from http://www.leanonus.org/
views and anatomically detailed dolls, are inap- images/Domestic_Violence_and_Sexual_Assault_
propriate for children with ASD. Children with Counselors.pdf
Child Behavior Checklist in Autism 581 C
Holden, E., & Banez, G. A. (1996). Child abuse potential
and parenting stress within maltreating families. Child Behavior Checklist for
Journal of Family Violence, 11(1), 1–12.
Mahoney, A., & Poling, A. (2011). Sexual abuse preven- Ages 6–18
tion for people with severe developmental disabilities.
Journal of Developmental and Physical Disabilities, ▶ Achenbach System of Empirically Based
23(4), 369–376. Assessment
Mandell, D. S., Walrath, C. M., Manteuffel, B., Sgro, G.,
& Pinto-Martin, J. A. (2005). The prevalence and
C
correlates of abuse among young children with
autism served in comprehensive community-based
mental health settings. Child Abuse & Neglect, 29, Child Behavior Checklist in Autism
1359–1372.
Marge, D. K. (Ed.). (2003). A call to action: Ending
crimes of violence against children and adults with Vincent Pandolfi1 and Caroline I. Magyar2
1
disabilities: A report to the nation. Syracuse, NY: Psychology Department, Rochester Institute of
SUNY Upstate Medical University. Technology, Rochester, NY, USA
McPherson, A. V., Lewis, K. M., Lynn, A. E., Haskett, 2
M. E., & Behrend, T. S. (2009). Predictors of parenting Department of Pediatrics, University of
stress for abusive and nonabusive mothers. Journal of Rochester Medical Center, Rochester, NY, USA
Child and Family Studies, 18(1), 61–69.
Sexual Abuse. Autism Speaks. Retrieved from http://
www.autismspeaks.org/family-services/autism-safety-
project/abuse Synonyms
Sobsey, D. (1994). Violence and abuse in the lives of
people with disabilities: The end of silent acceptance? CBCL 1.5–5; CBCL 6–18; Child Behavior
Baltimore: Paul H. Brookes. Checklist 1.5–5; Child Behavior Checklist 6–18
Child and Family-Centered Abbreviations

Intervention
ADHD Attention-Deficit/Hyperactivity
▶ Role Release Disorder
ODD Oppositional Defiant Disorder
TRF Teacher Report Form
YSR Youth Self-Report
Child Behavior Checklist 1.5–5
▶ Child Behavior Checklist in Autism Description
Introduction
The Achenbach System of Empirically Based
Child Behavior Checklist 6–18 Assessment (ASEBA) consists of several norm-
referenced paper and pencil rating scales that were
▶ Child Behavior Checklist in Autism developed to assess for adaptive competencies and
a broad range of emotional and behavioral disorders
(EBDs) in children and adolescents. Two forms are
available for parents that cover the 1.5–5
Child Behavior Checklist for and 6–18 year age ranges: the Child Behavior
Ages 1½–5 Checklist 1.5–5 (CBCL 1.5–5; Achenbach &
Rescorla, 2000) and the Child Behavior Checklist
▶ Achenbach System of Empirically Based 6–18 (CBCL 6–18; Achenbach & Rescorla,
Assessment 2001). A Caregiver/Teacher Report Form
C 582 Child Behavior Checklist in Autism
for 1.5–5-year-olds, a teacher measure for DSM-oriented scales were conceptually derived
6–18-year-olds (Teacher Report Form, TRF), and and were meant to correspond to broad diagnostic
a youth self-report form (Youth Self-Report, YSR) categories in the Diagnostic and Statistical Man-
are also available. These rating scales assess for the ual of Mental Disorders-Fourth Edition (DSM-
types of EBDs most often observed in youth with IV; American Psychiatric Association [APA],
an autism spectrum disorder (ASD) such as anxiety, 1994). Both sets of scales are norm-referenced,
depression, withdrawal, social problems, attention and scale scores can be plotted on profiles that
problems, and aggression. The forms were allow clinicians to readily examine relative scale
designed to be used in multi-informant assessment elevations across several problem areas.
protocols for childhood EBD, but can also be used The CBCL 1.5–5 and CBCL 6–18 are scored
individually for screening children for EBDs. and interpreted similarly. The raw scores for
This review focuses primarily on the EBD scales items within each of the empirically based and
of the CBCL 1.5–5 and CBCL 6–18 for two DSM-oriented scales are summed and converted
reasons. First, although the TRF and the YSR to norm-referenced T-scores (M ¼ 50, SD ¼ 10).
strongly resemble the CBCL with respect to format A Total Problems T-score is also available and is
and the kinds of EBDs assessed, these two measures determined by the sum of all item scores. One set
have not received much study in children and youth of norms is provided for the CBCL 1.5–5, and
with ASD. Second, initial psychometric studies of separate norms are provided for each gender
the CBCL 1.5–5 and CBCL 6–18 have only within the 6–11 and 12–18 year age ranges on
recently been conducted and have implications for the CBCL 6–18. “Clinically significant” eleva-
their use in the screening and assessment of EBD in tions are indicated by T-scores 64 on the broad-
children and youth with ASD. band scales and 70 on the syndrome scales.
“Borderline” elevations range from 60 to 63 and
Description 65 to 69 on the broadband and narrowband syn-
The CBCL 1.5–5 contains 100 items and the CBCL drome scales, respectively. These qualitative cat-
6–18 contains 112 items that reflect statements egories reflect symptom severity, and scores
pertaining to specific emotional and behavioral falling within either category suggest the need
responses. Parents rate each item according to for a more comprehensive diagnostic assessment.
how true each statement is about their child:
0 “Not true,” 1 “Somewhat or Sometimes True,”
or 2 “Very True or Often True.” Open-ended items Historical Background
allow respondents to provide additional informa-
tion that may be important for an evaluator to know Historical Background: Studies of the CBCL in
about the child but was not covered by the items. ASD Samples
The CBCL 1.5–5 ratings describe a child’s func- During the last few years, the evidence base
tioning during the last two months, and ratings on pertaining to the clinical utility of the CBCL in
the CBCL 6–18 describe functioning during the evaluating children and youth with ASD has
past 6 months. Administration time is generally expanded steadily. Although research on the
10–20 minutes. CBCL forms that cover the 1.5–18 year age
The CBCL 1.5–5 and CBCL 6–18 each con- range remains in its early stages, it is one of the
tain two sets of scales referred to as empirically most frequently investigated third-party mea-
based and DSM-oriented scales. The empirically sures of emotional and behavioral disorders
based scales were derived through factor analysis (EBDs) in ASD samples. Most studies examined
of data from the general pediatric population. the extent to which the syndrome and broadband
These scales include “narrowband” scales which scales discriminated between children and youth
assess specific syndromes, as well as “broad- with and without an ASD. Far fewer studies
band” scales which assess for broader classes investigated a wider range of psychometric prop-
of emotional and behavioral problems. The erties such as factor structure, internal
consistency, and diagnostic accuracy with for both of these measures, consistent with
respect to identifying co-occurring EBDs in chil- Achenbach and Rescorla (2000, 2001). Scale reli-
dren and youth with ASD. Significant methodo- ability was generally good to excellent across the
logical differences were observed across these syndrome and broadband scales of each measure,
studies that included varied approaches to although the reliabilities of the Somatic
confirming an ASD diagnosis, whether the youth Complaints (CBCL 1.5–5) and Thought Problems
were evaluated for a co-occurring EBD, the clin- scales (CBCL 6–18) were low. C
ical status and characteristics of non-ASD com- To date, only one study provided evidence on
parison groups (e.g., typically developing, those the diagnostic accuracy of the CBCL 6–18 for
with developmental or psychiatric problems), and identifying co-occurring EBDs in youth with an
the specific CBCL measure used (e.g., preschool ASD. All youth were evaluated for ASD and a co-
vs. school-age forms, previous vs. current CBCL occurring EBD through a standardized multi-
measures, English vs. non-English versions). method assessment protocol. In addition to
Despite these important methodological differ- between-group differences across several empir-
ences and relatively uneven focus of the research, ically derived scales (i.e., ASD only vs. ASD +
data are starting to emerge to support use of the EBD), the CBCL 6–18 demonstrated good sensi-
CBCL as part of a multi-method assessment pro- tivity (>.80) for identifying co-occurring depres-
tocol for children and youth with an ASD. sion, anxiety, ADHD, and ODD in individuals
One consistent finding that emerged from these with an ASD. The specific scales with favorable
studies was that children and youth with an ASD sensitivity were those that were conceptually
often scored significantly higher than youth with- consistent with the target EBD under investiga-
out an ASD across several CBCL scales. Although tion. However, specificity was generally low.
the specific scales that best differentiated between Collectively, research on the CBCL in samples
ASD and non-ASD groups varied somewhat of children and youth with an ASD lends support
across studies, youth with an ASD often scored for its use in clinical and research settings. How-
significantly higher than comparison groups on ever, there is a need for additional and more broadly
the Withdrawn/Depressed, Social Problems, and focused research that addresses the clinical utility of
Thought Problems scales. Some data indicated the CBCL 1.5–5 and 6–18 for the various purposes
differences between parent report on the CBCL, of assessment which includes diagnosis, eligibility
teacher report on the TRF, and youth self-report determinations for school- and community-based
on the YSR with respect to the patterns and/or services, treatment planning, and assessing
severity of problems across the syndrome scales. response to intervention. The evidence base would
Differences between parents and teachers were be substantially enhanced with data from specific
also found on the DSM-oriented scales. Most of age groups, and those with various levels of autism
these findings were based on studies of the CBCL severity and intellectual disability. This would pro-
4–18 (Achenbach, 1991) and CBCL 6–18, and vide much more specific information to assist in the
much more study of the CBCL 1.5–5 is necessary. clinical decision-making of those professionals
Only two studies examined the factor structure who work with this heterogeneous population,
and scale reliability of the CBCL in samples of many of whom are often in need of both ASD-
youth with an ASD. The results supported the and EBD-specific treatment.
unidimensionality of nearly all CBCL 1.5–5 and
CBCL 6–18 empirically derived syndrome scales,
which indicated that one factor underlies each Psychometric Data
scale. Interestingly, factor analysis evidence indi-
cated that the CBCL 1.5–5 Sleep Problems scale Test Development and Psychometric
may actually consist of two factors: dyssomnias Properties
and parasomnias. The two factor internalizing- Rigorous psychometric evaluations were
externalizing factor structure was also supported conducted on the CBCL 1.5–5 and CBCL 6–18
as part of the test development process. Achenbach and Rescorla (2000, 2001) described
Achenbach and Rescorla (2000, 2001) reported scale construction in detail which included experts
several lines of evidence that supported CBCL in child psychology and psychiatry to help devise
scores as indicators of emotional and behavioral scale content. The CBCL 1.5–5 and CBCL 6–18
disorders in the general population. Although both include Affective Problems, Anxiety Problems,
there is close correspondence in the kinds of Attention Deficit/Hyperactivity Problems, and
syndromes that are measured by the CBCL 1.5– Oppositional Defiant Problems. Despite the fact
5 and CBCL 6–18, some differences exist and are that the names of these scales are the same for the
detailed next. CBCL 1.5–5 and CBCL 6–18, item content differs
Empirically Based Scales. Factor analyses of across the measures. The CBCL 1.5–5 also contains
test items were used to help construct the empir- Pervasive Developmental Problems, and the CBCL
ically based scales for both measures. For the 6–18 also contains Somatic Problems and Conduct
CBCL 1.5–5, seven first-order factors were iden- Problems.
tified, and these represented separate narrowband Psychometric Evidence. Both test manuals
EBD syndromes. Two higher order factors were provide several lines of psychometric evidence
also identified which reflected the broadband for the empirically based and DSM-oriented
scales. One was called the Internalizing Domain scales. The authors substantiated the CBCL’s
which consisted of four emotional syndromes content validity by citing years of research, clin-
(i.e., the first-order factors) that were labeled ical experience, and consultation with several
Emotionally Reactive, Anxious/Depressed, stakeholders in children’s mental health assisting
Somatic Complaints, and Withdrawn. The other in the item selection process. Tables 1 and 2
higher order factor, named the Externalizing summarize reliability and validity data most per-
Domain, consisted of two behavioral syndromes tinent to the major uses of the CBCL: screening,
which were called Attention Problems and treatment planning, progress monitoring, and eli-
Aggressive Behavior. One first-order factor, gibility determination. Interested readers should
Sleep Problems, did not belong to either higher consult the technical manuals for more psycho-
order factor. metric information about specific scales.
A slightly different set of syndrome scales was
found for the CBCL 6–18. While it too contained
two higher order Internalizing and Externalizing Clinical Uses
Domains, the syndromes that belonged to each
were different. The Internalizing Domain contained The CBCL 1.5–5 and CBCL 6–18 have wide
the Anxious/Depressed, Withdrawn/Depressed, and clinical utility in ASD assessment. High rates of
Somatic Complaints syndrome scales. The Exter- EBDs have been reported in children and youth
nalizing Domain contained the Rule-Breaking with ASD including depression, anxiety,
Behavior and Aggressive Behavior syndrome ADHD, and ODD, with studies reporting EBDs
scales. Three other syndrome scales did not belong throughout the pediatric age range and into
to either broadband scale: Social Problems, adulthood. These findings suggest that EBDs
Thought Problems, and Attention Problems. These may be characteristic of the ASD phenotype,
are considered mixed syndrome scales because although longitudinal studies are needed to
they had sizable factor loadings on both broad determine if EBDs are part of the ASD
domains in the Achenbach and Rescorla (2001) phenotype or truly comorbid conditions. Despite
factor analyses. this lack of consensus, children with ASD are
DSM-Oriented Scales. The DSM-oriented reported to be at high risk for EBD, and
scales were developed to be conceptually consistent therefore, the CBCL 1.5–5 and CBCL 6–18
with broad DSM-IV diagnostic categories. They should be considered for routine use in ASD
complement the empirically based scales to assist diagnostic assessment. Moreover, for those
practitioners in the differential diagnostic process. children who do not present with EBD upon
Child Behavior Checklist in Autism, Table 1 Overview of CBCL 1.5–5 psychometric properties
Range
Property/scale Low High Median
Internal consistency
Empirically derived .66 (Anxious/Depressed) .95 (Total Problems) .79
DSM oriented .63 (Anxiety Problems) .86 (Oppositional Defiant Problems) .78
Test-retest C
Empirically derived .68 (Anxious/Depressed) .92 (Sleep Problems) .87
DSM oriented .74 (ADHD Problems) .87 (Oppositional Defiant Problems) .85
Cross-informant agreement
Empirically derived .48 (Anxious/Depressed) .67 (Sleep Problems, Externalizing) .65
DSM oriented .51 (Affective Problems) .67 (Pervasive Developmental .65
Problems)
Stability (12 month)
Empirically derived .53 (Withdrawn/Depressed) .76 (Total Problems) .61
DSM oriented .52 (Pervasive Developmental .60 (Anxiety Problems) .55
Problems)
Odds ratios
Empirically derived 3 (Anxious/Depressed) 8 (Somatic Complaints, Withdrawn) 6
DSM oriented 3 (Anxiety Problems) 11 (Pervasive Developmental 6
Problems)
Percentage of referred youth
with deviant scores
Empirically derived 19 (Anxious/Depressed) 60 (Internalizing Domain) 36
DSM oriented 20 (Anxiety Problems) 50 (Pervasive Developmental 29
Problems)
The data presented in each table indicate that the CBCL 1.5–5 and CBCL 6–18 appear to be sufficiently reliable for
clinical use with the general population. The technical manuals each reported internal consistencies .89 for the
Internalizing and Externalizing Domains and for Total Problems. For the CBCL 1.5–5, some of the narrowband and
DSM-oriented scales had internal consistencies <.70, so it is especially important to interpret these scales in conjunction
with other clinical data (see Achenbach & Rescorla, 2000). Reported odds ratios indicated a strong relationship between
CBCL scores and referral status. That is, those with CBCL scores in the borderline/clinically significant ranges were far
more likely to be referred for mental health services than youth with scores below these ranges. A related finding
indicated that a sizable percentage of the youth who were referred for mental health services had scores in these elevated
ranges. Achenbach and Rescorla (2000, 2001) also presented significant correlations between CBCL scores and DSM
diagnoses. These data suggested that youth with elevated scores should be referred for a more comprehensive diagnostic
assessment.
initial diagnosis, regular screening throughout and personal distress for the affected child and
childhood should be completed as a means of family and may moderate response to
monitoring for EBD. This is particularly so for ASD-specific treatment. This may result in
critical developmental periods such as the later more restrictive interventions and/or placement
part of early childhood where difficulties with in more restrictive settings, neither of
attention and impulsivity may interfere with full which necessarily addresses the underlying
participation in an inclusive school setting and problem – the presence of an EBD. Therefore,
in adolescence where increasing self-awareness including the CBCL in ASD intervention
may increase risk for depression and anxiety. progress monitoring cannot only assist with
Thus, early detection is critical to informing identifying an EBD leading to the development
treatment planning specific to the EBD. Without and implementation of specific interventions,
appropriate treatment, the co-occurring EBD but it can also be used to monitor the child’s
may result in additional functional impairment response to any EBD interventions that may be
Child Behavior Checklist in Autism, Table 2 Overview of CBCL 6–18 psychometric properties
Range
Property/Scale Low High Median
Internal consistency
Empirically derived .78 (Somatic Complaints, Thought .97 (Total Problems) .85
Problems)
DSM oriented .72 (Anxiety Problems) .91 (Conduct Problems) .83
Test-Retest
Empirically derived .82 (Anxious/Depressed) .94 (Total Problems) .91
DSM oriented .80 (Anxiety Problems) .93 (ADHD, Conduct Problems) .88
Cross-informant agreement
Empirically derived .65 (Somatic Complaints) .85 (Rule Breaking, .75
Externalizing Domain)
DSM oriented .63 (Somatic Problems) .88 (Conduct Problems) .70
Stability (12 month)
Empirically derived .64 (Somatic Complaints) .82 (Externalizing Domain) .71
DSM oriented .31 (Somatic Problems) .80 (Conduct Problems) .66
Odds ratios
Empirically derived 6 (Somatic Complaints) 16 (Aggressive Behavior) 12
DSM oriented 4 (Somatic Problems) 17 (Conduct Problems) 12
Percentage of referred youth with
deviant scores
Empirically derived 27 (Somatic Complaints) 75 (Total Problems) 46
DSM oriented 24 (Somatic Problems) 57 (Conduct Problems) 49
The data presented in each table indicate that the CBCL 1.5–5 and CBCL 6–18 appear to be sufficiently reliable for
clinical use with the general population. The technical manuals each reported internal consistencies .89 for the
Internalizing and Externalizing Domains and for Total Problems. For the CBCL 1.5–5, some of the narrowband and
DSM-oriented scales had internal consistencies <.70, so it is especially important to interpret these scales in conjunction
with other clinical data (see Achenbach & Rescorla, 2000). Reported odds ratios indicated a strong relationship between
CBCL scores and referral status. That is, those with CBCL scores in the borderline/clinically significant ranges were far
more likely to be referred for mental health services than youth with scores below these ranges. A related finding
indicated that a sizable percentage of the youth who were referred for mental health services had scores in these elevated
ranges. Achenbach and Rescorla (2000, 2001) also presented significant correlations between CBCL scores and DSM
diagnoses. These data suggested that youth with elevated scores should be referred for a more comprehensive diagnostic
assessment.
implemented. Finally, the CBCL may play an Achenbach, T. M. (1991). Manual for the child behavior
important role in eligibility determination for checklist/4–18 and 1991 profile. Burlington, VT:
Department of Psychiatry, University of Vermont.
educational and social services. Achenbach, T. M., & Edelbrock, C. S. (1979). The child
behavior profile: II. Boys aged 12–16 and girls aged
6–11 and 12–16. Journal of Consulting and Clinical
See Also Psychology, 47(2), 223–233.
Achenbach, T. M., & Rescorla, L. A. (2000). Manual for
▶ Psychotic Disorder the ASEBA preschool forms & profiles. Burlington,
VT: University of Vermont Research Center for Chil-
▶ Standardized Behavior Checklists
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for
the ASEBA school-age forms & profiles. Burlington,
References and Readings VT: University of Vermont, Research Center for Chil-
Achenbach, T. M. (1978). The child behavior profile: I. American Psychiatric Association. (1994). Diagnostic
Boys aged 6–11. Journal of Consulting and Clinical and statistical manual of mental disorders (4th ed.).
Psychology, 46(3), 478–488. Washington, DC: Author.
Child Psychotherapy 587 C
Berube, R. L., & Achenbach, T. M. (2010). Bibliography 1.5–5 in a sample of children with autism spectrum
of published studies using the achenbach system of disorders. Journal of Autism and Developmental Dis-
empirically based assessment (2006th ed.). Burling- orders, 39(7), 986–995.
ton, VT: University of Vermont, Research Center for Pandolfi, V., Magyar, C. I., & Dill, C. A. (2011). An initial
Children, Youth, & Families. Available online at psychometric evaluation of the child behavior check-
www.ASEBA.org. list 6–18 in a sample of youth with autism spectrum
Biederman, J., Petty, C. R., Fried, R., Wozniak, J., Micco, disorders. Research in Autism Spectrum Disorders.
J. A., Henin, A., et al. (2010). Child behavior checklist
clinical scales discriminate referred youth with autism
doi: 10.1016/j.rasd.2011.03.009.
Rescorla, L. (1988). Cluster analytic identification of
C
spectrum disorder: A preliminary study. Journal of autistic preschoolers. Journal of Autism and Develop-
Developmental and Behavioral Pediatrics, 31(6), mental Disorders, 18(4), 475–492.
485–490. Sikora, D. M., Hall, T. A., Hartley, S. L., Gerrard-Morris,
Bolte, S., Dickhut, H., & Poustka, F. (1999). Patterns of A. E., & Cagle, S. (2008). Does parent report of behav-
parent-reported problems indicative in autism. Psy- ior differ across ADOS-G classifications: Analysis of
chopathology, 32, 93–97. scores from the CBCL and GARS. Journal of Autism
Duarte, C. S., Bordin, I. A. S., de Oliveira, A., & Bird, H. and Developmental Disorders, 38, 440–448.
(2003). The CBCL and the identification of children
with autism and related conditions in Brazil: Pilot
findings. Journal of Autism and Developmental Disor-
ders, 33(6), 703–707. Child Language
Gadow, K. D., DeVincent, C. J., & Drabick, D. A. G.
(2008). Oppositional defiant disorder as a clinical phe- ▶ Normal Language Development
notype in children with autism spectrum disorder.
1302–1310.
Georgiades, S., Szatmari, P., Duku, E., Zwaigenbaum, L., Child Psychotherapy
Bryson, S., Roberts, W., et al. (2010). Phenotypic over-
lap between core diagnostic features and emotional/
behavioral problems in preschool children with autism C. Enjey Lin
spectrum disorder. Journal of Autism and Developmen- Departments of Education and Psychiatry,
tal Disorders. doi: 10.1007/s10803-010-1158-9. University of California, Los Angeles, Los
Ghaziuddin, M., Ghaziuddin, N., & Greden, J. (2002). Angeles, CA, USA
Depression in persons with autism: Implications for
research and clinical care. Journal of Autism and
Gillberg, C., & Billstedt, E. (2000). Autism and Asperger Synonyms
syndrome: Coexistence with other clinical disorders.
Acta Psychiatrica Scandinavica, 102, 321–330.
Hurtig, T., Kuusikko, S., Mattila, M., Haapsamo, H., Clinical psychology; Mental health interventions
Ebeling, H., Jussila, K., et al. (2009). Multi-informant
reports of psychiatric symptoms among high-
functioning adolescents with Asperger syndrome or Definition
autism. Autism, 13(6), 583–598.
Kanne, S. M., Abbacchi, A. M., & Constantino, J. N. A therapeutic interaction between a child (the cli-
(2009). Multi-informant ratings of psychiatric symptom ent) and a trained therapist to alleviate the child’s
severity in children with autism spectrum disorders: The
importance of environmental context. Journal of Autism distress and improve functioning in everyday life.
and Developmental Disorders, 39(6), 856–864. Child psychotherapy is provided by licensed clini-
Kim, J. A., Szatmari, P., Bryson, S. E., Steiner, D. L., & cians (e.g., clinical psychologists, clinical social
Wilson, F. J. (2000). The prevalence of anxiety and workers, child and family counselors) using
mood problems among children with autism and
Asperger syndrome. Autism, 4, 117–131. a range of therapeutic approaches and strategies
Ooi, Y. P., Rescorla, L., Ang, R. P., Woo, B., & Fung, in order to alter feelings, thoughts, attitudes, or
D. S. S. (2010). Identification of autism spectrum behaviors. The broad goals of therapy are to
disorders using the child behavior checklist in Singa- improve adjustment and functioning in both intra-
pore. Journal of Autism and Developmental Disorders.
doi:10.1007/s10803-010-1015-x. personal and interpersonal spheres and to reduce
Pandolfi, V., Magyar, C. I., & Dill, C. A. (2009). Confir- maladaptive behaviors. Often more specific goals
matory factor analysis of the child behavior checklist are set for individual clients, depending on the
C 588 Child-Centered Approaches
therapeutic modality employed (e.g., ▶ Behavior characterizes child-centered approaches as those

Therapy). Child psychotherapy can include the in which, “Children’s preferences guide the
child’s parents as well as other significant mem- selection of materials; adults provide support
bers of the child’s family and community. and encourage, but do not require, that materials
are used and activities are carried out in the
See Also desired way. Rather than adult-supplied conse-
quences for certain behaviors, internal, naturally
▶ Applied Behavior Analysis occurring reinforcers are assumed to provide the
▶ Behavior Therapy motivation for learning” (National Research
▶ Cognitive Behavioral Therapy (CBT) Council [NRC], 2001, p.136). However, other
▶ Family Therapy authors note that some children may not learn
▶ Group Therapy skills following a “typical” developmental pro-
▶ Pivotal Response Training gression and may not provide sufficiently diverse
▶ Play Therapy interests to allow educators to follow a child’s
▶ Psychotherapy interests and therefore may be challenged to
teach across variety of priority areas (Volkmar &
References and Readings Wiesner, 2009). Volkmar & Wiesnar (2009) also
note that there is relatively less research on devel-
Block, S., & Harari, E. (2001). Psychotherapy, history of: opmental, child-centered approaches than behav-
Psychiatric aspects. In N. L. Smelser & P. B. Baltes ioral approaches, and effective implementation
(Eds.), International encyclopedia of the social and
behavioral sciences (pp. 12484–12491). Oxford: Elsevier. of child-centered approaches likely require
El-Ghoroury, N. H., & Krackow, E. (2011). A developmen- highly skilled interventionists. The National
tal-behavioral approach to outpatient psychotherapy Research Council (2001) suggested that for
with children with autism spectrum disorders. Journal children with fewer appropriate initiations, a
of Contemporary Psychotherapy, 41(1), 11–17.
Kazdin, A. E. (2000). Psychotherapy for children and behavioral approach may be more appropriate
adolescents: Directions for research and practice. than a child-centered approach and noted that
New York: Oxford University Press. more research is needed to demonstrate the effec-
Kazdin, A. E., & Johnson, B. (1994). Advances in psy- tiveness of child-centered approaches and relative
chotherapy for children and adolescents: Interrelations
of adjustment, development, and intervention. Journal effectiveness compared to other approaches.
of School Psychology, 32(3), 217–246. In contrast, a child-centered approach may be
Weisz, J. R., & Kazdin, A. E. (Eds.). (2010). Evidence- appropriate for children with a variety of interests,
based psychotherapies for children and adolescents thus facilitating teaching across a variety of skills.
(2nd ed.). New York: Guilford Press.

Child-Centered Approaches
National Research Council. (2001). Educating children
Mark Groskreutz
Press.
Special Education and Reading Department, Volkmar, F. R., & Wiesner, L. A. (2009). A practical
The Center of Excellence on Autism guide to autism: What every parent, family member,
Spectrum Disorders, Southern Connecticut and teacher needs to know. Hoboken, NJ: John
Wiley & Sons.
Definition
Child-Focused Approaches
In the National Research Council’s report,
Educating Children with Autism, the counsel ▶ Interventions: Child Centered Approaches
Childhood Apraxia of Speech (CAS) 589 C
inappropriate (Norbury, Bishop, & Tomblin,
Childhood Aphasia 2008).
The notion that language could be impaired in
Courtenay Norbury the context of “spared” capacities in other aspects of
Psychology Department, Royal Holloway, development led to labels such as specific language
University of London, Egham, Surrey, UK impairment (SLI) replacing dysphasia. However, in
practice, it is rare to see such discrete linguistic C
impairments in a developing child, and there is
Synonyms continuing controversy about how best to describe
children with more specific language difficulties
Congenital aphasia; Developmental dysphasia; (Bishop, 2010). In addition, there is considerable
Language disorder; Specific language debate about the nature of language impairment in
impairment autism spectrum disorders and whether some chil-
dren with ASD also have a comorbid SLI (Tomblin,
2011). In practice, it is preferable to describe the
Definition nature of the child’s language difficulties in detail
without recourse to diagnostic labels that make
Aphasia is derived from the Greek word aphatos, assumptions about etiology.
meaning “speechless,” and is characteristically
used to describe the profile of language impair-
ments seen in adults after a stroke or other focal See Also
neurological lesion. In the early nineteenth century,
physicians and neurologists such as Gall (1935, ▶ Language
cited in De Montfort Supple, 2010) described seem- ▶ Language Disorder
ingly similar language impairments in children.
These children could not speak but had apparently
normal understanding of language and did not References and Readings
appear to have general cognitive impairments.
The term congenital aphasia was first used by Bishop, D. V. M. (2009). Genes, cognition and communi-
cation: Insights from neurodevelopmental disorders.
Vaisse in 1866 (cited in de Montfort Supple,
The Year in Cognitive Neuroscience: Annals of the
2010), and related terms such as developmental New York Academy of Sciences, 1156, 1–18.
aphasia or dysphasia were widely used until the Bishop, D. V. M. (2010). Which neurodevelopmental
mid-twentieth century. The assumption behind disorders get researched and why? PLoS One, 5(11),
e15112. doi:doi:10.1371/journal.pone.0015112.
the use of these terms was that the neurobiological
De Montfort Supple, M. (2010). Child language disability:
source of language impairment in children was A historical perspective. Topics in Language Disorders,
similar to adult case; however, in recent years, it 30, 72–78.
has become clear that most developmental Norbury, C. F., Bishop, D. V. M., & Tomblin, J. B. (2008).
Understanding developmental language disorders
language disorders do not arise from focal
(pp. xiii–xv). Hove and New York: Psychology Press.
neurological insults. Instead, anomalies in brain Tomblin, J. B. (2011). Co-morbidity of autism and SLI:
development are subtle and not deterministic of Kinds, kin and complexity. International Journal of
language ability. There is also considerable evi- Language & Communication Disorders, 46(2), 127–137.
dence that the etiology of developmental language
disorders is more typically genetic, rather than the
result of acquired brain damage (Bishop, 2009).
Finally, most investigators would agree that the Childhood Apraxia of Speech (CAS)
boundary between language impairment and
normality is somewhat arbitrary, rendering the ▶ Developmental Apraxia
use of a “medical” term or “disease” category ▶ Verbal Apraxia
C 590 Childhood Autism
the CARS was refined, and separate forms were

Childhood Autism created based on a person’s developmental level.
The CARS2-HF was developed for use with indi-
▶ Autistic Disorder viduals over age 6 years, with IQs above 80, and
intact verbal communication skills. The CARS2-
ST (which is identical to the original CARS)
continues to be used for all children under age
Childhood Autism Rating Scale 6 years and for individuals over age 6 years either
with IQ scores of 79 or lower, or who have
Aaron Kaat and Luc Lecavalier impaired communication skills (Schopler, Van
Nisonger Center, Ohio State University, Bourgodien, Wellman, & Love, 2010).
Columbus, OH, USA The 14 behavior domains from the CARS and
maintained on the CARS2-ST include (1) relating
to people; (2) imitation; (3) emotional response;
Synonyms (4) body use; (5) object use; (6) adaptation to
change; (7) visual response; (8) listening
CARS, Second Edition, High-Functioning response; (9) taste, smell, and touch response
Version; CARS, Second Edition, Questionnaire and use; (10) fear or nervousness; (11) verbal
for Parents or Caregivers; CARS, Second communication; (12) nonverbal communication;
Edition, Standard Version; CARS; CARS2-HF; (13) activity level; (14) level and consistency of
CARS2-QPC; CARS2-ST intellectual response; in addition to (15) general
impressions. The CARS2-HF maintains the gen-
eral structure of the CARS, but it does not include
Abbreviations imitation and activity level. Instead, it adds
social-emotional understanding and thinking/
ASD Autism spectrum disorder cognitive integration skills. Behavioral descrip-
TEACCH Treatment and education of tions of several other items were also modified to
autistic and communication related be more applicable for individuals with a higher
handicapped children IQ (Schopler et al., 2010). When rating each
domain, a rater considers the peculiarity, fre-
quency, intensity, and duration of a behavioral
Description concern. Brief descriptions of the behaviors to be
observed are provided as anchors on the rating
The CARS has a long-standing history as one of forms, but a more detailed description, including
the most widely used diagnostic instruments for a definition and particular considerations for each
ASD. A trained observer rates an individual’s item, is provided in the CARS2 manual.
behavior on 14 items and provides a general The CARS2-QPC is a new form in the second
impressions score, each of which is rated on edition. It is an unscored questionnaire completed
a 7-point Likert scale (1–4 with ½ points). Scores by others who know the person being evaluated
represent severity of deviation compared to well. The CARS2-QPC can also provide infor-
expectations for one’s peers of the same chrono- mation about a person’s early development,
logical age: a score of 1 represents functioning which is not captured by the behavioral observa-
within normal limits, whereas a score of 4 repre- tions on the CARS2-ST and CARS2-HF, and
sents severely abnormal functioning. The CARS provide examples of behavior concerns that the
total score ranges from 15 to 60 with higher parent or caregiver notices. Schopler and col-
scores indicating a higher probability or severity leagues (2010) stated that parents or other care-
of autism. The CARS was intended to be used givers are not to complete either the CARS2-ST
regardless of age or level of functioning. In 2010, or CARS2-HF but should provide information on
Childhood Autism Rating Scale 591 C
the CARS2-QPC, which can then be used as Schopler, Reichler, & Renner, 1988). Although
a guide during a diagnostic or other direct most items were chosen because of their relation
interview. to the diagnostic criteria at the time, others were
The CARS surveys a wide range of behaviors. included because of their clinical or educational
These behaviors related to different conceptuali- relevance (e.g., object use, visual response, audi-
zations of ASD at the time the CARS was tory response, and taste, smell, and touch
developed, but not all of them relate to the response and use). From the time it was devel- C
DSM-IV-TR or to an earlier predecessor, the oped, the CARS was integrated with the
DSM-III-R. Although an interested user could TEACCH program to integrate assessment and
compare an individual’s score on specific items intervention.
to any of the diagnostic criteria on which the
CARS is based, including the DSM-IV,
a weighted score based on the current conceptu- Psychometric Data
alization of ASD is not available.
The CARS classifies a person as having minimal-
to-no symptoms of ASD, mild-to-moderate
Historical Background symptoms, or severe symptoms of an ASD. Clas-
sification cutoffs were originally determined by
The CARS was developed by Dr. Eric Schopler examining the distribution of CARS scores in
and colleagues in North Carolina to complement a sample of 537 children. Initially, a cutoff of 30
their outpatient treatment program, Division distinguished optimally between those with and
TEACCH. It was included as part of their diag- without ASD (Schopler et al., 1980). However,
nostic process and educational planning, often the recommended cutoff scores have changed
being completed as part of the Psycho- with time and now vary by age and CARS2 form.
educational Profile. Prior to its inception in In the development sample, the cutoff of 30 on
DSM-III (American Psychiatric Association, the CARS had a sensitivity of .88 and specificity
1980), there were multiple definitions and diag- of .86 (Schopler et al., 1988). Other studies have
nostic criteria for what is called ASD today. found similar results with children. Some
Schopler and colleagues developed the CARS researchers, however, have recommended higher
as their own rating system to distinguish between cutoffs for very young children and lower cutoffs
ASD and other developmental disorders for adolescents and adults. In one large study,
(Reichler & Schopler, 1971; Schopler, Reichler, a cutoff of 30 was supported among 4-year-olds,
DeVellis, & Daly, 1980) in an effort to overcome but a cutoff of 32 was optimal among 2-year-olds,
limitations of existing classification systems and since this resulted in better specificity
diagnostic measures. The CARS was originally (Chlebowski, Green, Barton, & Fein, 2010).
called the Childhood Psychosis Rating Scale On the CARS2-ST, the cutoff of 30 was
because it had a broader conceptualization than maintained for all children under age 13 years,
Kanner’s original definition of autism. The name but a cutoff of 28 best distinguished between
was changed to the CARS as the definition of minimal-to-no symptoms of ASD and mild-to-
autism expanded beyond Kanner’s strict moderate symptoms of an ASD for children
definition. over age 13 years. The CARS2-HF also uses
The behavior domains of the CARS are a cutoff of 28 to distinguish between minimal-
largely based on the British Working Party’s to-no symptoms of ASD and mild-to-moderate
diagnostic criteria for childhood psychosis symptoms of an ASD. In the CARS2-HF devel-
(Reichler & Schopler, 1971), but it also includes opment sample, this resulted in a sensitivity of
items based on Kanner’s primary features of .81 and a specificity of .87 (Schopler et al., 2010).
autism and the criteria proposed by Rutter and The CARS is strongly related to level of func-
by Ritvo and Freeman (Schopler et al., 1980; tioning. It may falsely identify individuals with
C 592 Childhood Autism Rating Scale
language impairments and cognitive impairments Schopler, Schaffer, & Michal, 1989). Test-retest
as having an ASD. This may be acceptable clin- reliability has not been evaluated for the CARS2-
ically for diagnostic screening but not for HF at this time.
research requiring precise diagnostic distinctions. The CARS has been translated into several
The magnitude of the correlations between intel- languages, including French, Japanese, Swedish,
lectual and adaptive functioning and CARS Icelandic, Indian, Spanish, and Korean. Diagnos-
scores is quite high (approximately r ¼ .7). tic cutoffs vary for the different versions, but
Although the CARS2-HF was developed to overall, they have shown similar psychometric
address this weakness, its relationship with IQ properties as the CARS. Evidence published in
has not been researched at the time of this English for internal consistency, inter-rater reli-
writing. ability, and diagnostic sensitivity and specificity
The CARS has demonstrated good concordant is available for the Japanese, Swedish, Icelandic,
validity with clinical judgment and with other and Indian versions (Nordin, Gillberg, & Nydén,
ASD diagnostic instruments, including the 1998; Russell et al., 2010; Saemundsen,
Autism Diagnostic Interview-Revised, and the Magnússon, Smári, & Sigurdardóttir, 2003;
Autism Diagnostic Observation Schedule. It has Tachimori, Osada, & Kurita, 2003).
also shown good convergence with ASD rating
scales, including the Autism Behavior Checklist,
Real-Life Rating Scale, and the Social Respon- Clinical Uses
siveness Scale.
Evidence for the reliability and validity of the The CARS and the CARS2 were designed to be
CARS was originally presented by Schopler and part of a comprehensive diagnostic evaluation for
colleagues (1980) for 537 children assessed over an ASD. Professionals other than clinicians have
a 10-year span as part of the TEACCH program. been shown to make reliable and valid ratings on
Internal consistency was .94. Other investigators the CARS after a modest level of training. The
have replicated this high level of internal consis- CARS also requires a rater to have some knowl-
tency for the CARS and the CARS2-ST. Among edge of age-appropriate functioning within each
the 994 participants in the CARS2-HF develop- of the behavioral domains. With such training,
ment sample, coefficient alpha was .96. However, the tool has been used successfully in clinical and
several investigations of the CARS have found educational settings, as part of a caregiver inter-
negative corrected item-total correlations, specif- view, in a chart review, and as a rating scale.
ically for the consistency of intellectual response Although it is possible to complete the CARS2-
item. ST based on information from a single source, the
Early investigations of inter-rater reliability CARS2-HF requires that multiple sources of
focused on ratings made by other professionals information be considered, one of which must
without specialized training in ASD (Schopler be a direct observation of the person being
et al., 1988). These and subsequent evaluations rated. Multiple sources of information and
of inter-rater reliability have found high agree- a behavioral observation are not required for the
ment on diagnostic classifications but lower CARS2-ST but would benefit the diagnostic pro-
agreement on specific items. Schopler and col- cess. It is recommended that direct behavioral
leagues (2010) found similar results with the observation by the trained observer be given
CARS2-HF development sample. greater weight in scoring than other information
Test-retest reliability for the CARS has been if they conflict (Schopler et al., 2010).
examined with a range from as little as 3 months Despite being designed to be completed by a
to more than 3 years between assessments. trained clinician, the CARS has been used, with
Across these studies, CARS scores are relatively or without adaptations, as a parent rating scale.
stable (rs > .70), though there is some evidence The CARS2 manual recommends that parents do
that scores decrease over time (e.g., Mesibov, not complete the CARS2-ST or CARS2-HF
Childhood Disintegrative Disorder (Heller’s Syndrome) 593 C
as a rating scale. Rather, the unscored CARS2- Saemundsen, E., Magnússon, P., Smári, J., &
QPC should be completed, which can guide an Sigurdardóttir, S. (2003). Autism diagnostic inter-
view-revised and the childhood autism rating scale:
interview and provide additional developmental Convergence and discrepancy in diagnosing autism.
information not captured on the CARS as part Journal of Autism and Developmental Disorders, 33,
of the overall diagnostic process. The psychomet- 319–328.
ric properties of the CARS, when used as Schopler, E., Reichler, R. J., DeVellis, R. F., & Daly, K.
a parent rating scale, have not been adequately
(1980). Toward objective classification of childhood
autism: Childhood autism rating scale (CARS). Jour-
C
studied. nal of Autism and Developmental Disorders, 10,
The CARS has also found uses within research 91–103.
studies (see Schopler et al., 2010 for examples). It Schopler, E., Reichler, R. J., & Renner, B. R. (1988). The
childhood autism rating scale. Los Angeles, CA:
has provided an ASD severity rating or supported Western Psychological Services.
an ASD diagnosis. The CARS has also been used Schopler, E., Van Bourgodien, M. E., Wellman, G. J., &
as an outcome measure for intervention studies, Love, S. R. (2010). Childhood autism rating scale
medication trials, and developmental studies. As (2nd ed.). Los Angeles, CA: Western Psychological
Services.
an outcome measure, the CARS has shown to be Tachimori, H., Osada, H., & Kurita, H. (2003). Childhood
sensitive to treatment effects and to maturational autism rating scale – Tokyo version for screening
changes. pervasive developmental disorders. Psychiatry and
Clinical Neurosciences, 57, 113–118.
See Also
▶ Autism Diagnostic Interview-Revised Childhood Disintegrative Disorder

▶ TEACCH Transition Assessment Profile ▶ Noradrenergic System
(TTAP)

Childhood Disintegrative Disorder
and statistical manual of mental disorders (3rd ed.).
(Heller’s Syndrome)
Chlebowski, C., Green, J. A., Barton, M. L., & Fein, D. Alexander Westphal, Avery Voos and Alexandra
(2010). Using the childhood autism rating scale to Ristow
diagnose autism spectrum disorders. Journal of Autism
Yale Child Study Center, New Haven,
Mesibov, G. B., Schopler, E., Schaffer, B., & Michal, N. CT, USA
(1989). Use of the childhood autism rating scale with
autistic adolescents and adults. Journal of the Ameri-
can Academy of Child and Adolescent Psychiatry, 28,
538–541.
Synonyms
Nordin, V., Gillberg, C., & Nydén, A. (1998). The Swed-
ish version of the childhood autism rating scale in Dementia infantilis; Disintegrative disorder;
a clinical setting. Journal of Autism and Developmen- Disintegrative psychosis; Heller’s syndrome
tal Disorders, 28, 69–75.
Reichler, R. J., & Schopler, E. (1971). Observations on the
nature of human relatedness. Journal of Autism and
Childhood Schizophrenia, 1, 283–296. Short Description or Definition
Russell, P. S. S., Daniel, A., Russell, S., Mammen, P.,
Abel, J. S., Raj, L. E., et al. (2010). Diagnostic accu-
racy, reliability, and validity of childhood autism rat-
Over a hundred years have passed since Theodore
ing scale in India. World Journal of Pediatrics, 6, Heller first described a disorder he called demen-
141–147. tia infantilis (Westphal, Schelinski, Volkmar, &
C 594 Childhood Disintegrative Disorder (Heller’s Syndrome)
Pelphrey, 2012), a predecessor of today’s “child- Categorization

hood disintegrative disorder” (CDD), in which
typically developing children over 2 years old Heller’s first description of CDD came at a time
undergo a severe and mostly irreversible regres- when classification systems for childhood mental
sion of developmental gains, including speech, illness barely existed, even before Eugene
sociability, and self-help skills. CDD is currently Bleuler had first used the term schizophrenia to
categorized as an autism spectrum disorder describe an illness of adults characterized by four
(ASD), and like the other ASDs, it is character- features, one of which was autism: a turning to
ized by social and language disabilities, as well as oneself. After Bleuler, childhood schizophrenia
rigid and repetitive patterns of behavior. Despite became the favored term for any childhood psy-
significant changes in classification systems and chiatric disorder, reflecting, in part, the wide-
theoretical orientations since 1908, the clinical spread belief that a disturbance manifest in
features described by Heller remain the backbone childhood must necessarily have a psychotic
of today’s CDD, making dementia infantilis per- basis. For years afterward, dementia infantilis
haps the longest-lived and most robust of the was part of a confusing swarm of disorders falling
classifications of the childhood psychiatric disor- into this category, many characterized by varying
ders. In the current DSM-IV and ICD-10 defini- degrees of autism. This confusion was partly
tions, CDD is defined on the basis of cleared up by the work of Leo Kanner, who, in
developmental history and clinical features. By 1943, co-opted the term autism to describe an
definition, development is normal until at least unusual but characteristic cluster of symptoms,
2 years of age (but typically 3–4 years). Subse- including social and language deficits and rigid-
quently, there is a regression of skills, in some ity, which he had observed in 11 children.
cases over days, in others, over months. Skills Although Kanner did, at one point, wonder
must be lost in at least two areas (although other whether his patients’ disorder had a psychotic
areas are usually affected); these include commu- basis, ultimately he was uneasy about classifying
nication, social interaction, toileting, or motor them in the childhood schizophrenia group.
abilities. Once established, the condition closely In 1971, Israel Kolvin described a bimodal
resembles autistic disorder (AD) behaviorally, pattern of onset of childhood schizophrenia, set-
defined by social and communication problems ting the stage for the creation of a formal distinc-
and stereotyped patterns of behavior. CDD is tion between what were subsequently recognized
rare. To date, less than 150 cases have been to be two very different groups: a late-onset group
described in the literature. This rarity has ham- suffered from hallucinations, delusions, and para-
pered research. Given the clinical overlap noia, and an early-onset group, Kanner’s chil-
between CDD and AD, combined with the lack dren, had impairments in social reciprocity and
of information on CDD, researchers have language development and exhibited rigid pat-
questioned whether CDD is a useful diagnostic terns of behavior. Kolvin’s study was followed
concept. On the other hand, it has been almost immediately by an influential paper by
established that children with CDD have signifi- Michael Rutter in 1972 in which he argued that
cantly worse adaptive and cognitive outcomes the label childhood schizophrenia had no clinical
than their counterparts with other ASDs, utility, as it was far too broad, and further mud-
suggesting that the category has prognostic util- dled by its own confused and confusing past. He
ity. Furthermore, the natural history of late and was not arguing that psychoses did not occur in
rapid regression to autism does not suggest children, but rather that the term childhood
a cumulative developmental process of the kind schizophrenia was being used to cover too many
thought to underlie the other ASDs, raising the different conditions. He distinguished three
possibility that the process underlying CDD, groups previously included in this category:
although convergent with the other ASDs, is early-onset adult-type schizophrenia, early infan-
entirely different from it. tile autism, and disintegrative psychosis.
Children in the first two of these groups were ones.” Later studies have corroborated these find-
described well by Kolvin’s data, but children in ings (Malhotra & Gupta, 2002; Volkmar et al.,
the third group, similar in many ways to Heller’s 1994; Volkmar & Rutter, 1995).
children, were anomalous, with a delayed onset Other lines of clinical evidence have
of the symptoms characteristic of early infantile reinforced the distinction between CDD and
autism. late-onset or regressive autism; this evidence is
Over the following years, CDD went by vari- summarized in Table 1. (1) Children with CDD C
ous names, including Heller’s syndrome and dis- experience deterioration across multiple domains
integrative psychosis, and at one point, it was (Wohlgemuth et al., 1994), particularly notice-
subsumed under the short-lived childhood-onset able in the deterioration of self-help skills such
pervasive developmental disorders. The diagnos- as toileting (Kurita, 1988; Volkmar, 1992). In
tic criteria for autistic disorder (AD) were broad- AD, regression is often isolated to language.
ened for the revised DSM-III-R criteria, (2) The onset of CDD tends to be rapid, whereas
engulfing CDD. In the ICD-10, CDD acquired with AD, it is generally slow and insidious
its present name and independence from AD. (Malhotra & Gupta, 2002). (3) Children with
The ICD-10 conception of CDD was consistent CDD more frequently have seizure disorders
with Heller’s original description. It described and EEG abnormalities (Kurita, Kita, & Miyake,
a normal development occurring before 1992; Kurita, Koyama, Setoya, Shimizu, &
a marked regression of a variety of skills, social Osada, 2004; Mouridsen, Rich, & Isager, 2000).
withdrawal, and rigid and repetitive patterns of (4) Children with CDD have higher levels of
behavior. In this formulation, the CDD diagnosis anxiety and stereotyped behaviors (Kurita et al.,
excluded concurrent diagnoses of any other per- 1992, 2004).
vasive developmental disorder (including AD), Because these variables are not directly
as well as schizophrenia, acquired aphasia, and related to the diagnostic criteria for CDD, they
mutism. The DSM-IV, like the ICD-10, recog- are evidence of the clinical validity of the disor-
nized CDD as a discrete entity. Although several der. However, a sub-category of children younger
differences exist between the ICD-10 and than two experiences a similarly rapid and dra-
DSM-IV formulations, they agree on the defining matic regression, although, according to strict
characteristic of the disorder: a regression in mul- criteria for regression, they are very rare (Rogers,
tiple domains after at least 2 years of typical 2004; Siperstein & Volkmar, 2004). Several
development. The DSM-IV criteria, which are authors (Hendry, 2000; Malhotra & Gupta,
identical to the revised DSM IV-R criteria. 2002) have also pointed out that the DSM and
With the categorization of CDD as a distinct WHO diagnostic criteria for AD allow for an age
entity, it became important to determine whether of onset up until 3 years old, creating a window
CDD cases were merely examples of late-onset or between 2 and 3 years of age when a child with
“regressive” AD (Rogers, 2004; Volkmar et al., a regression resulting in an ASD picture could
2005). To this end, Volkmar and Cohen (1989) equally well be described as having AD or CDD.
compared a group of children with CDD diagno- Furthermore, Kurita and colleagues (Kurita,
ses (by ICD-10 criteria) to a group of children 1988; Kurita et al., 1992) have described subtle
diagnosed with autism after 2 years of age and developmental delays prior to the age of 2 in
found that the children with CDD had accumu- cases they identified as having CDD, a finding
lated more skills prior to regression and ulti- at odds with the “apparently normal develop-
mately had significantly worse speech and ment” prior to regression required by both the
intellectual disabilities. They concluded that the ICD and DSM formulations. The presence of
“clinical features at the time of regression and both CDD-like regressions among children fall-
various outcome measures support the validity of ing into the AD category and of prodromal devel-
the diagnostic concept, particularly when such opmental delay among CDD cases could be taken
cases are compared to ‘late-onset’ autistic as evidence of continuity between the CDD and
Childhood Disintegrative Disorder (Heller’s Syndrome), Table 1 Distinctions between childhood disintegrative
disorder (CDD) and autistic disorder (AD)
CDD group characteristic Source Comparison group(s)
Before regression
Accumulated more skills Volkmar and Cohen (1989) Early-onset (<24 months) AD
Late-onset (>24 months) AD
Higher rates of finger pointing Kurita et al. (1992) AD with speech loss
Higher rates of bladder control Kurita et al. (1992) AD with speech loss
More likely to have developed phrase speech Kurita (1989) AD
During regression
More rapid deterioration Malhotra and Gupta (2002) AD
More likely to regress across multiple domains Wohlgemuth et al. (1994) AD
More likely to display anxiety Kurita et al. (2004) AD with speech loss
After regression
Language/Communication
More severe speech disabilities Volkmar and Cohen (1989) Early-onset (<24 months) AD
More likely to be mute Volkmar and Cohen (1989) Early-onset (<24 months) AD
Volkmar and Rutter (1995) Late-onset (>24 months) AD
Better nonverbal communication scores Kurita et al. (1992) AD without speech loss
Intellectual disabilities
More likely to have IQ <40 Volkmar and Rutter (1995) AD
More severe intellectual disabilitiesa Volkmar and Cohen (1989) Early-onset (<24 months) AD
Behavior
Higher levels of stereotyped behaviors Kurita et al. (2004) AD with speech loss
Less repetitive or restricted play Malhotra and Gupta (2002) AD
More aggression Malhotra and Gupta (2002) AD
Higher levels of anxietyb Kurita et al. (1992) AD with speech loss
Kurita et al. (2004) AD without speech loss
More even functioning on Childhood Autism Rating Kurita et al. (2004) AD with speech loss
Scale
More “autistic symptoms”c Volkmar and Cohen (1989) Early-onset (<24 months) AD
Other outcomes
Less abnormality in adaptation to environment Kurita et al. (2004) AD with speech loss
More likely to be in residential placement Volkmar and Cohen (1989) Early-onset (<24 months) AD
Volkmar and Rutter (1995) Late-onset (>24 months) AD
More frequent/lengthier admissions to psychiatric Mouridsen et al. (1999) AD
hospitals
Comorbidities
Higher rate of seizure disorders Kurita et al. (2004) AD with speech loss
AD without speech loss
Higher rate of EEG abnormalitiesd Kurita et al. (1992), AD with speech loss
Mouridsen et al. (1999) AD without speech loss
(continued)
Childhood Disintegrative Disorder (Heller’s Syndrome), Table 1 (continued)
CDD group characteristic Source Comparison group(s)
Higher rates of admittance to non-psychiatric hospital Mouridsen et al. (1999) AD
Other
Higher levels of anomalous auto-antibodies to neural Connolly et al. (2006) AD
substrates
More likely to have mother >30 years old at birth Kurita et al. (1992) AD with speech loss C
AD without speech loss
a
Kurita et al. (2004) found no difference between CDD group and comparison group
b
Malhotra and Gupta (2002) found no difference between CDD group and comparison group
c
Kurita et al. (2004) and Malhotra and Gupta (2002) found no difference between CDD group and comparison group
d
Kurita et al. (2004) found no difference between the CDD group and the comparison group
AD categories. On the other hand, this evidence than of kind. Within a dimensional framework,
could also support a distinct diagnostic concept of these differences of degree would be understood
CDD, marking the presence of a distinct and as revelatory of a continuum; they illustrate the
recognizable clinical entity which occasionally similarities between AD and CDD, rather than
breaks free from its diagnostic tethers. the differences. However, the distinct and dra-
Hendry (2000) has argued that the diagnostic matic natural history of the children currently
overlap between the AD and CDD together with described by the concept of CDD suggests that
the methodological limitations of the majority of from a research perspective there is more to be
previous studies of CDD vitiates the argument for gained from recognizing CDD as a freestanding
the distinction between CDD and AD by category and then looking at its overlap with
undermining the basis of the identification of other conditions than from eliminating the diag-
variables distinct to CDD. She concludes: nosis altogether. Without a distinct diagnostic
“CDD should not yet be considered distinct category as a justification and a focus, clinicians
from (AD), as not enough information exists to would be less likely to bring the unusual, late-
justify it as a separate diagnostic category” regressing children whom they see to the atten-
(Hendry, 2000). She proposes that the difficulties tion of researchers. From this point of view, not
she has listed mark an unwarranted dichotomiza- enough information exists to take the risk of
tion of a cohesive group and point to eliminating CDD as a separate category.
a fundamental problem specific to a categorical
diagnostic system and argues for a system based
on behavioral dimensions. A similar approach is Epidemiology
expected in the DSM-V. In a recent draft of the
revisions, the authors propose to eliminate the CDD is estimated to occur at a rate between 1 and
category of CDD, subsuming it into a general 2 per 100,000 children (Fombonne, 2005), mak-
autism spectrum disorder category, and capturing ing it the rarest of the ASDs. On the other hand,
the regression in a “dimension in ASD regarding regression in younger children appears to be less
trajectory” (American Psychiatric Association, rare, occurring in between 15% and 47% of chil-
2010). dren ultimately diagnosed with AD, with onset
To reconceptualize the ASDs along behav- occurring on average between 18 and 24 months
ioral dimensions would draw attention to the of age (Stefanatos, 2008). As with AD, CDD
fact that many of the factors that distinguish occurs in males with greater frequency than in
CDD from AD are differences of degree, rather females (Volkmar et al., 2005).
Natural History, Prognostic Factors, and normal sociability were more common in sub-
Outcomes jects with CDD than in those with ADSL. In
addition, subjects with CDD more frequently
From a diagnostic perspective, the natural history displayed anxiety, showed higher rates of EEG
of late regression to autistic behavior allows one abnormalities, and were more likely to have
to distinguish CDD from other ASDs. Studies mothers older than 30 years at the time of their
have looked at other factors as comparison delivery than either control group. Later, Kurita
points. Volkmar and Cohen (1989) compared et al. (2004) matched 10 children with CDD to 30
10 subjects diagnosed with CDD to 136 subjects age- and gender-matched peers with ADSL.
with “early-onset” autism (before 24 months) and This study found that anxiety during regression
19 subjects with “late-onset” autism (after was significantly more common in the CDD
24 months). The late-onset group showed the group; in addition, the CDD cohort had higher
highest mean IQ, followed by the early-onset rate of epilepsy and stereotypy, but less abnor-
group with autism and finally by the group with mality in adaptation to environment and overall
CDD. Subjects with CDD were significantly a more even functioning on the Childhood
more likely to be mute and to be in residential Autism Rating Scale-Tokyo Version (CARS-
placement than either group of subjects with TV). However, this study revealed no difference
autism (Volkmar & Cohen, 1989). In 1995, in EEG abnormalities, special education place-
another study by Volkmar and colleagues used ment, severe retardation, degree of autism
data from 26 cases of CDD accrued from the (CARS-TV total score), or functioning in other
DSM-IV field trial; 16 of the children had been CARS-TV.
given a CDD diagnosis by the rating clinician Malhotra and Gupta (2002) compared a cohort
(10 of the children were the same as those used of 12 cases of CDD to 21 cases of AD seen during
in the 1989 study), and another 10 children were a 10-year period. No difference was found in the
determined to meet the DSM-IV criteria for CDD presence of anxiety and affective symptoms,
although they had not been given a CDD diagno- smiling or muttering to self, loss of interest in
sis (Volkmar & Rutter, 1995). A cohort of 409 environment, or core autistic features. However,
peers who had been diagnosed with autistic the subjects with CDD showed significantly more
disorder was used for comparisons. Whether aggression and significantly less repetitive or
using diagnoses assigned by clinician raters or restricted play. Mouridsen and colleagues
DSM-IV criteria, subjects with CDD were more (1998) examined differences in medical symp-
likely to be mute, to have IQ less than 40, and to toms between a group of 13 subjects diagnosed
live in a residential placement. In addition, with “disintegrative psychosis” (CDD) and
subjects with CDD displayed significantly more a control group of 39 children with infantile
“autistic symptoms” than the control group with autism matched for gender, age, IQ, and social
autism. class. Throughout the average follow-up time of
Kurita and colleagues (1992) identified 18 sub- 22–23 years (with a range of 11–33 years),
jects with CDD by chart review and matched subjects with CDD were more likely to have
them to two control groups diagnosed during the been admitted to a nonpsychiatric hospital,
same time period: one consisting of 145 subjects accrued more nonpsychiatric admissions, and
with infantile autistic disorder without speech remained in the hospital for a longer period.
loss (ADWSL) and the other of 51 subjects with In addition, subjects with CDD also showed
autistic disorder and speech loss (ADSL). Sub- more frequent and lengthier admissions to psy-
jects with CDD had better nonverbal communi- chiatric hospitals (Mouridsen et al., 1998). The
cation scores after regression than subjects with authors suggested that these differences reflect
ADWSL and trended toward higher scores than a higher frequency and intensity of both medical
subject with ADSL (Kurita et al., 1992). Before and psychiatric symptoms among subjects
regression, finger pointing, bladder control, and with CDD.
Clinical Expression and a standard autism evaluation. For a detailed dis-
Pathophysiology cussion of this type of assessment, please refer to
the Evaluation Report section of this encyclope-
The average age of regression for children diag- dia. Although diagnostic clarity is an important
nosed with CDD falls between 3 and 4 years of aim of this type of evaluation, it is more important
age (Volkmar & Cohen, 1989). During the acute to generate a profile of the strengths and weak-
regression, behavioral changes may occur that nesses of the child as a guide for intervention. C
are unique to the period. Kurita et al. In the case of CDD, several aspects of this
(2004) found that 80% of a cohort of 10 children evaluation need particular emphasis. It is essen-
with CDD showed fearfulness during the period tial to document carefully the developmental
of regression. During the same period, Malhotra milestones obtained by the child prior to the
and Gupta (2002) reported elevated rates of period of regression, referring to pediatrician
hyperactivity (67%), aggression (42%), tantrums records, video footage, and any other record. It
(42%), sleep problems (33%), and loss of motor is also important to obtain a detailed description
skills (33%) in children with CDD. Many chil- of the behaviors that occurred during the period
dren later diagnosed with CDD come to clinical of acute regression and to place them along a time
attention during this period; however, the diag- line starting with the first point at which some-
nosis is rarely clear until the regression is com- thing was noted to be abnormal. Testing of com-
plete. After the regression is complete, children munication and cognitive ability should be
with CDD are clinically similar to those with AD tailored to the level of the child being examined.
and severe intellectual disability. Tests designed for younger children may be
Clearly, biological distinctions would go appropriate to accommodate the intellectual
a long way toward resolving the difficulties sur- disabilities associated with CDD. Once the level
rounding the differentiation of CDD and AD. But of cognitive function has been established, it
progress has been limited in the CDD field, partly provides a reference point for evaluations of
because of the rarity of the disorder. As with AD, adaptive function.
children with CDD seem to suffer more frequently An extensive medical evaluation is also indi-
from seizure disorders or exhibit some other EEG cated to rule out other diagnoses and
anomaly, suggesting the presence of brain pathol- comorbidities. Developmental pediatricians, child
ogy (Malhotra & Singh, 1993; Mouridsen et al., psychiatrists, or pediatric neurologists may do this
2000; Volkmar, 1992; Volkmar & Rutter, 1995). evaluation, but collaboration across disciplines is
More specific physiological markers, however, always important. For example, a developmental
have remained elusive. Higher levels of several pediatrician might consult a neurologist to help
anomalous autoantibodies to neural substrates in determine whether the regression should be
CDD subjects compared to AD subjects suggest expected to progress further and to rule out seizure
lines for future work (Connolly et al., 2006). activity, and consult a child psychiatrist for behav-
ioral management and long-term follow-up.
The differential diagnosis of CDD includes
Evaluation and Differential Diagnosis ruling out any disorder with a regression of devel-
opmental milestones (please see Regression sec-
A diagnostic evaluation of a suspected case of tion). A few examples include Landau-Kleffner,
CDD requires a comprehensive interdisciplinary mitochondrial disease, Rett’s, the gangliosidoses,
assessment, including a thorough developmental metachromatic leukodystrophy, the mucopoly-
and medical history, an assessment of socializa- saccharidoses, Hallervorden-Spatz, Hashimoto’s
tion using standardized diagnostic assessments, encephalitis, Niemann-Pick, and chorea-
an assessment of communication, and psycholog- acanthocytosis. Any of these disorders may first
ical testing of cognitive ability and adaptive func- manifest in behavioral changes of the type seen in
tion. Testing should follow the format of CDD. Given the variable outcomes and the
possibilities for treatment in these, and other A prospective 14-year outcome study. Developmental
regressive disorders, it is essential that they be Medicine and Child Neurology, 40(10), 702–707.
Connolly, A. M., Chez, M., Streif, E. M., Keeling, R. M.,
ruled out during the evaluation for CDD. This Golumbek, P. T., Kwon, J. M., et al. (2006). Brain-
process can include various genetic and meta- derived neurotrophic factor and autoantibodies to
bolic screens, electroencephalogram (EEG), and neural antigens in sera of children with autistic
structural magnetic resonance imaging (MRI). spectrum disorders, landau-kleffner syndrome, and
epilepsy. Biological Psychiatry, 59(4), 354–363.
Corbett, J. (1987). Development, disintegration and
dementia. Journal of Mental Deficiency Research, 31
Treatment (Pt 4), 349–356.
Dawson, G. (2000). What is childhood disintegrative
disorder, how is it different from autism, and what
Children later diagnosed with CDD have some- is believed to be its cause? Journal of Autism and
times undergone a variety of treatments during Developmental Disorders, 30(2), 177 (comment).
the acute period of regression, including steroids Evans-Jones, L. G., & Rosenbloom, L. (1978). Disinte-
and intravenous immunoglobulin (when an grative psychosis in childhood. Developmental Medi-
cine and Child Neurology, 20(4), 462–470.
encephalitic process is suspected), anticonvul- Fombonne, E. (2005). Epidemiology of autistic disorder
sants, and antipsychotics. However, no interven- and other pervasive developmental disorders. The
tion to date has been effective in changing the Journal of Clinical Psychiatry, 66(Suppl. 10), 3–8.
course of the regression associated with CDD. Heller, T. (1908). Uber dementia infantilis:
Verblödungsprozeß im kindesalter. Zeitschrift f€
ur die
Once a clear diagnosis of CDD has been Erforschung und Behandlung des Jugendlichen
established, treatment recommendations are the Schwachsinns, 2, 17–28.
same as those for autism (see Treatment). The Hendry, C. N. (2000). Childhood disintegrative disorder:
most effective role for pharmacology is to Should it be considered a distinct diagnosis? Clinical
Psychology Review, 20(1), 77–90.
address any problematic symptoms, such as Kolvin, I. (1971). Studies in the childhood psychoses.
aggression, associated with the disorder that I. Diagnostic criteria and classification. The British
might, if appropriately treated, facilitate Journal of Psychiatry: The Journal of Mental Science,
adjustment of the individual with AD. At best, 118(545), 381–384.
Kurita, H. (1988). The concept and nosology of Heller’s
pharmacology is an adjunct to the behavioral syndrome: Review of articles and report of two cases.
interventions targeted at the core social disability. The Japanese Journal of Psychiatry and Neurology,
Behavior modification and special education 42(4), 785–793.
have been successfully used to rebuild adaptive Kurita, H. (1989). Heller’s syndrome as a type of perva-
sive developmental disorder. Journal of Mental
skills. Any progress toward elucidating the path- Health, 35, 71-81.
ophysiology of CDD will also be progress toward Kurita, H., Kita, M., & Miyake, Y. (1992). A comparative
defining targets for prevention and intervention. study of development and symptoms among disinte-
grative psychosis and infantile autism with and with-
out speech loss. Journal of Autism and Developmental
Disorders, 22(2), 175–188.
See Also Kurita, H., Koyama, T., Setoya, Y., Shimizu, K., &
Osada, H. (2004). Validity of childhood disintegrative
▶ Interdisciplinary Team disorder apart from autistic disorder with speech
loss. European Child & Adolescent Psychiatry,
▶ Onset 13(4), 221–226.
▶ Regression Malhotra, S., & Gupta, N. (1999). Childhood disintegra-
tive disorder. Journal of Autism and Developmental
Disorders, 29(6), 491–498.
References and Readings Malhotra, S., & Gupta, N. (2002). Childhood disintegra-
tive disorder. Re-examination of the current concept.
American Psychiatric Association. 2010. Proposed Draft European Child & Adolescent Psychiatry, 11(3),
Revisions to DSM Disorders and Criteria. Retrieved 108–114.
from http://www.dsm5.org Malhotra, S., & Singh, S. P. (1993). Disintegrative psy-
Burd, L., Ivey, M., Barth, A., & Kerbeshian, J. (1998). chosis of childhood. An appraisal and case study. Acta
Two males with childhood disintegrative disorder: Paedopsychiatrica, 56(1), 37–40.
Childhood Psychosis 601 C
Mouridsen, S. E., Rich, B., & Isager, T. (1999). The
natural history of somatic morbidity in disintegrative Childhood Psychosis
psychosis and infantile autism: a validation study.
Brain and Development, 21(7), 447–452.
Mouridsen, S. E., Rich, B., & Isager, T. (2000). Fred R. Volkmar
A comparative study of genetic and neurobiological Director – Child Study Center, Irving B. Harris
findings in disintegrative psychosis and infantile Professor of Child Psychiatry, Pediatrics and
autism. Psychiatry and Clinical Neurosciences,
54(4), 441–446. Psychology, School of Medicine, C
Mouridsen, S. E., Rich, B., & Isager, T. (1998). Validity of Yale University, New Haven, CT, USA
childhood disintegrative psychosis. General findings
of a long-term follow-up study. The British Journal
of Psychiatry, 172, 263–267.
Rapin, I. (1995). Autistic regression and disintegrative
disorder: How important the role of epilepsy? Synonyms
Seminars in Pediatric Neurology, 2(4), 278–285.
Rogers, S. J. (2004). Developmental regression in Childhood schizophrenia
autism spectrum disorders. Mental Retardation and
Developmental Disabilities Research Reviews, 10(2),
139–143.
Journal of Autism and Childhood Schizophrenia, 2(4), Definition
315–337.
Siperstein, R., & Volkmar, F. (2004). Brief report: Paren-
tal reporting of regression in children with pervasive In common use, the term psychosis implies a loss
developmental disorders. Journal of Autism and of contact with reality. Typical psychotic phe-
Developmental Disorders, 34(6), 731–734. nomena include hallucinations (perceiving things
Stefanatos, G. A. (2008). Regression in Autistic Spectrum
that others do not), delusions, and other behaviors
Disorders. Neuropsychology Review, 18(4), 305–319.
Volkmar, F. R. (1992). Childhood disintegrative disorder: (e.g., catatonia). Often individuals with psychosis
Issues for DSM-IV. Journal of Autism and Develop- have trouble structuring their thinking (a thought
mental Disorders, 22(4), 625–642. disorder). In adolescents and adults, psychosis
Volkmar, F. R., & Cohen, D. J. (1989). Disintegrative
and psychotic phenomena can arise
disorder or “late onset” autism. Journal of Child
Psychology and Psychiatry, and Allied Disciplines, because of psychiatric or medical illness or expo-
30(5), 717–724. sure to certain substances (e.g., hallucinogenic
Volkmar, F. R., Klin, A., Siegel, B., Szatmari, P., Lord, C., drugs). In common use, the term is rather broad
Campbell, M., et al. (1994). Field trial for autistic
including a range of conditions. Psychiatric dis-
disorder in DSM-IV. The American Journal of Psychi-
atry, 151(9), 1361–1367. orders associated with psychosis include schizo-
Volkmar, F. R., Koenig, K., & State, M. (2005). Child- phrenia and bipolar type 1 disorder (what
hood disintegrative disorder. In F. R. Volkmar, A. previously was termed manic-depressive illness).
Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of
Psychotic phenomena can be seen in various
autism and pervasive developmental disorders (Vol.
1, pp. 70–78). Hoboken, NJ: Wiley. other conditions and may be more likely with
Volkmar, F. R., & Rutter, M. (1995). Childhood disinte- stress.
grative disorder: Results of the DSM-IV autism field In children, awareness of psychosis and psy-
trial. Journal of the American Academy of Child and
chotic phenomena is a relatively historically
Adolescent Psychiatry, 34(8), 1092–1095.
Westphal, A. R. N., Schelinski, S., Volkmar, F. R., & recent phenomenon (e.g., until the work of
Pelphrey, K. A. (2012). Revisiting regression in Maudsley in the 1800s it was assumed children
autism: Heller’s dementia infantilis. Includes A trans- were protected from such phenomena). However,
lation of U¨ber dementia infantilis. Journal of Autism
the description of what we now recognize as
and Developmental Disorders. (In Press)
Wohlgemuth, D., Klin, A., Cohen, D. J., & Volkmar, F. R. schizophrenia (or as it was once termed dementia
(1994). Childhood disintegrative disorder: praecox) led to rapid extension to children
Diagnosis and phenomenology. American Academy (dementia praecosissima (de Sanctis, 1906)).
of Child and Adolescent Psychiatry: Annual Meeting,
Kanner’s use of the term autism (Kanner, 1943)
New York.
C 602 Childhood Schizophrenia
quickly led to confusion over the issue of whether

we now think of as autism is a form of schizo- Childhood Schizophrenia
phrenia (see Volkmar & Tsatsanis, 2002) since
the term autism had earlier been used to describe Nitin Gogtay
self-centered thinking in schizophrenia (see Division of Child and Adolescent Psychiatry,
Volkmar, 1996 for a discussion). It took several National Institutes of Mental Health, Bethesda,
decades before it became clear that this was not in MD, USA
fact the case and that autistic disorder was a
distinctive condition (Kolvin, 1971; Rutter,
Synonyms
1972).
Given the major changes in children’s under-
Pediatric onset schizophrenia; Very early-onset
standing of reality, the term psychosis can be
schizophrenia
problematic in childhood. Before puberty, the
prototypic psychotic disorder, schizophrenia,
is profoundly uncommon although psychotic Short Description or Definition
phenomena can be observed, e.g., in relation
to stress, or as isolated phenomena. After age 5, Childhood-onset schizophrenia is defined by
the presence of psychotic symptoms is onset of psychosis before age 13 and is diagnosed
more concerning, and various factors (medical using unmodified DSM-IV criteria for diagnosis
conditions, drug abuse) can produce such of adult-onset schizophrenia.
symptoms.
Categorization
See Also Although the existence of childhood schizophre-

nia was recognized since early in the twentieth
▶ Childhood Schizophrenia century (Kraepelin, 1919; Nicolson & Rapoport,
1999), the nosological status of schizophrenia in
children was controversial for many years, and
References and Readings the Diagnostic and Statistical Manual of Mental
Disorders, Second Edition (DSM-II) category
de Sanctis, S. (1906). On some variations of dementia “childhood schizophrenia” included other psy-
praecox. Revista Sperimentali di Frenciatria, 32, chotic disorders in children, as well as autistic
141–165.
Kanner, L. (1943). Autistic disturbances of affective con- disorder, thus limiting the usefulness of early
tact. The Nervous Child, 2, 217–250. studies. The landmark studies by Kolvin (Kolvin,
Kolvin, I. (1971). Studies in the childhood psychoses. I. 1971; Kolvin, Garside, & Kidd, 1971; Kolvin,
Diagnostic criteria and classification. The British Jour- Humphrey, & McNay, 1971; Kolvin, Ounsted,
nal of Psychiatry, 118(545), 381–384.
Rutter, M. (1972). Childhood schizophrenia reconsidered. Humphrey, & McNay, 1971; Kolvin, Ounsted,
Journal of Autism and Childhood Schizophrenia, 2(4), Richardson, & Garside, 1971; Kolvin, Ounsted,
315–337. & Roth, 1971), however, clearly differentiated
Volkmar, F. R. (1996). Childhood and adolescent psycho- schizophrenia with oxnset in childhood from per-
sis: A review of the past 10 years. Journal of the Amer-
ican Academy of Child and Adolescent Psychiatry, vasive developmental disorders, and subsequent
35(7), 843–851. research over the years has established the clini-
Volkmar, F. R., & Tsatsanis, K. (2002). Psychosis cal and neurobiological continuity between the
and psychotic conditions in childhood and childhood- and adult-onset schizophrenia. Thus,
adolescence. In D. T. Marsh & M. A. Fristad (Eds.),
Handbook of serious emotional disturbance in COS is more appropriately categorized as the
children and adolescents. New York: John Wiley & childhood counterpart of the typical adult-onset
Sons. illness (Gogtay, 2008).
Childhood Schizophrenia 603 C
Epidemiology The general outcome remains poor with most
COS children continuing to show residual symp-
COS is rare and difficult to diagnose. As a result, toms: both cognitive deficits and/or psychotic
it is hard to estimate the exact incidence. Further- symptoms. In a recent analysis, at 2-year follow-
more, even today, high rates of misdiagnosis up, almost 75% of COS patients still reported either
remain as transient psychotic symptoms can positive or negative residual symptoms (Greenstein,
occur in healthy children (Caplan, 1994; Wolfe, Gochman, Rapoport, & Gogtay, 2008). The C
McGee, Williams, & Poulton, 2000; Schreier, clinical course, in general, tends to be non-episodic
1999), and fleeting hallucinations are not uncom- (unlike that for the adult illness), chronic, and
mon in nonpsychotic pediatric patients treatment refractory with most children ending up
(Lukianowicz, 1969; McKenna, Gordon, & on clozapine (discussed under treatment).
Rapoport, 1994) particularly in response to anx- Although there are no specific factors that can
iety and stress (Rothstein, 1981). Fully developed be detected in COS either during the premorbid
psychotic disorders in children, however, are rare or prodromal course of the illness, however,
and tend to be more severe than their adult coun- many features are more striking compared to the
terparts (Childs & Scriver, 1986), and recent data AOS during this period which are described
suggest that psychotic symptoms probably exist under pathophysiology.
as a continuous phenotype rather than an all-or-
none phenomenon (Poulton et al., 2000).
Based on the NIMH COS study experience Clinical Expression and
(described later), where over the past 20 years, Pathophysiology
we have evaluated over 3,000 referrals with
a potential diagnosis of schizophrenia. However, Premorbid Development
diagnosis could be confirmed only in 122 cases to A striking phenomenological feature of COS rela-
date after careful evaluation, which included tive to adult-onset schizophrenia appears to be the
inpatient observation and complete medication higher rates of early language, social, and motor
washout in most cases. These estimates put the developmental abnormalities, possibly reflecting
approximate incidence to be about 1/300th of the greater impairment in early brain development.
adult-onset illness. In the NIMH sample, premorbid development is
defined as development prior to 1 year before
Natural History, Prognostic Factors, and psychosis onset and assessed using the Cannon-
Outcomes Spoor Premorbid Adjustment Scale (PAS)
(Cannon-Spoor, Potkin, & Wyatt, 1982) and the
Most reports on the natural history and course of Hollis premorbid development scale (Hollis,
COS come from the NIMH longitudinal study of 1995); social and speech and language impair-
COS. ments were the most common abnormal features
Since 1990, children with early-onset psycho- in COS, which was also observed by four other
sis have been recruited nationally for diagnostic independent research centers (Alaghband-Rad
screening for COS at the NIMH. Diagnosis of et al., 1995; Asarnow & Ben-Meir, 1988; Gogtay,
COS is confirmed after an extensive evaluation, Sporn, et al., 2004; Green, Padron-Gayol,
which includes inpatient observation during Hardesty, & Bassiri, 1992; Hollis, 1995; Nicolson
a 3-week drug washout period. To date, 118 et al., 2000; Russell, Bott, & Sammons, 1989;
patients have participated in the study, including Watkins, Asarnow, & Tanguay, 1988).
43 boys and 31 girls with a mean age of 14.06 +
2.67 years and mean age of onset of psychosis Risk Factors
at 10.07 + 1.9 years. Once the diagnosis is con- Obstetric Complications
firmed, a structural brain MRI scan is obtained An analysis comparing the obstetric records of
with prospective re-scans at 2-year intervals. 60 COS children and 48 healthy siblings using
the Columbia Obstetrics Complication Scale Particularly striking have been the decreased per-
(Malaspina, 2003), a comprehensive measure- formance on the Trail Making Test part B (Keefe
ment scale consisting of 37 variables, did not et al., 1994) and digit span (Tuulio-Henriksson
find higher incidence of obstetric complications et al., 2002). When we compared neuropsycho-
in COS patients compared to the healthy sibling logical deficits in 67 parents and 24 full siblings of
control group (Ordonez et al., 2005). COS probands in comparison with matched com-
munity controls for Trail Making Tests A and
Eye Tracking B and Wechsler Intelligence Scale-Revised Digit
Smooth pursuit eye movement (SPEM) disorders Span and Vocabulary, COS siblings performed
have been reported in 25–40% of first-degree significantly poorer than community controls
relatives of schizophrenic probands (Holzman, although the rates of neuropsychological abnor-
2000), and other studies have suggested more malities for COS were not significantly higher
striking in COS than in AOS with a bilineal pat- than for AOS (Gochman et al., 2004).
tern of inheritance (Ross et al., 1999). In a recent
analysis, we compared 70 COS parents, 64 AOS Pervasive Developmental Disorder and COS
parents, and 20 COS siblings to separate matched Frequently, the diagnosis of autism or pervasive
control groups and found that the effect sizes for developmental disorder (PDD) has been raised
SPEM abnormalities were higher for COS than for early in the development in our cases, and some
AOS relatives, indicating that genetic factors studies have claimed that autism per se might be
underlying eye-tracking dysfunction may be more a risk factor for later psychosis (Cantor, Evans,
salient for COS (Sporn, Greenstein, et al., 2005). Pearce, & Pezzot-Pearce, 1982; Clarke,
LittleJohns, Corbett, & Joseph, 1989; Petty,
Familial Schizophrenia Spectrum Disorders Ornitz, Michelman, & Zimmerman, 1984). In
Schizophrenia spectrum disorders consist of the two large studies examining this systemati-
schizophrenia and schizoaffective disorders on cally, COS is preceded by and comorbid with
Axis I and schizotypal, paranoid, and pervasive developmental disorder in 30–50% of
schizoid personality disorders on Axis II cases. Epidemiologic and family studies also find
(Asarnow & Ben-Meir, 1988). A prior study association between the disorders, and both disor-
by Asarnow et al. showed higher rates of schizo- ders have evidence for accelerated trajectories of
phrenia spectrum diagnoses for COS anatomic brain development at ages near disorder
relatives than for relatives of probands with atten- onset, and a growing number of shared risk genes
tion deficit hyperactivity disorder or community and/or rare small chromosomal variants (micro-
controls (Asarnow et al., 2001). Similarly, deletions or duplications). Thus, core neurobio-
as expected in our recent analyses of parental logical processes are likely common for subsets
diagnosis in 97 parents of COS probands, of these two heterogeneous clinical groups.
97 parents of AOS probands, and matched
community controls, it was also found that rate of Neurocognitive Functioning in COS Probands
schizophrenia spectrum disorders was higher in Neuropsychological function in COS has been
COS than in AOS, and both were higher studied in depth by Robert Asarnow and col-
than community controls supporting the continuity leagues (Asarnow, 1999; Asarnow et al., 1994;
between COS and AOS, and more salient familial Asarnow, Brown, & Strandburg, 1995). While
genetic risk in COS (Nicolson et al., 2003). rote language skills and simple perceptual
processing are not impaired, these children per-
Familial Neurocognitive Functioning form poorly on tasks involving fine motor coor-
Cognitive abnormalities, executive functioning, dination, attention, and short-term and working
short-term memory, and language function are memory (Karatekin & Asarnow, 1998). Evoked-
well documented as endophenotypic measures potential studies show diminished amplitude of
for family members in AOS (Egan et al., 2001). brain electrical activity during these tasks
suggesting that allocation of necessary atten- outcome (Fenton & McGlashan, 1986; Huppert,
tional resources is deficient, which is also shared Weiss, Lim, Pratt, & Smith, 2001). As no prior
by schizophrenic adults (Asarnowet al., 1995). It studies have reported comorbidities for child-
is generally established for adult schizophrenia hood-onset schizophrenia (COS), we analyzed
that cognitive function deteriorates at onset the prevalence of comorbid Axis I diagnoses in
of psychosis but remains stable afterward 76 COS cases at the time of first NIMH admis-
(Goldberg, Hyde, Kleinman, & Weinberger, sion, and at 4-year follow-up (n ¼ 28), and cor- C
1993; Russell, Munro, Jones, Hemsley, & related the comorbid diagnoses with age of onset
Murray, 1997). Our earlier study had shown that of psychosis, clinical ratings of illness severity,
COS children (n ¼ 27) as well as MDI children familiality for schizophrenia spectrum disorders,
(n ¼ 24) share similar deficits in attention, learn- and early premorbid development.
ing, and abstraction that resembled the pattern in As has been seen with AOS, the most frequent
adult patients with schizophrenia (Kumra et al., comorbid diagnosis at NIMH screening was
2000). In a recent analysis on 71 COS probands depression (54%) followed by obsessive-
where preadmission IQ data were also available compulsive disorder (OCD; 21%), generalized
from medical and school record (n ¼ 27), post- anxiety disorder (GAD; 15%), and attention def-
psychotic cognitive function (defined as >3 years icit hyperactivity disorder (ADHD; 15%). The
of onset) for up to 8+ years was studied. As rate of “any” anxiety disorder (GAD, OCD, sep-
expected, all COS patients scored significantly aration anxiety, PTSD, and panic disorder com-
below age norms, but for 46 COS patients seen bined) at screening was 42%. Diagnosis of
systematically for follow-up, there was no post- comorbid depression correlated with poorer
psychotic IQ decline. Thus, in spite of greater global assessment of severity (GAS) scores, and
severity and generally poor clinical outcome, presence of an anxiety disorder only predicted
there was no evidence of a longer-term degenera- anxiety at 4-year follow-up. No other Axis
tive cognitive process in COS (Gochman, I diagnoses showed correlations with any clinical
Greenstein, Sporn, Gogtay, Keller, et al., 2003). measures, and there were no significant associa-
tions between comorbid diagnoses and IQ,
Comorbid Disorders familiality, medication status, premorbid func-
Comorbid psychiatric disorders, particularly tioning, or age of onset at psychosis. Interestingly,
DSM-defined mood and anxiety disorders, often there was no “current” comorbid depression at the
coexist with schizophrenia (Bermanzohn et al., 4-year follow-up visit, possibly due to our high
2000; Green, Canuso, Brenner, & Wojcik, 2003; use of antidepressant treatment (45%). However,
Huppert & Smith, 2005), although the hierarchi- the rates of anxiety disorders did not change much
cal system for DSM limits independent diagnoses at the 4-year follow-up, despite adjuvant anxiety
of comorbidities (Bermanzohn et al., 2000), and medication use, suggesting either refractory
these disorders may often be part of (or masked nature of these conditions or their close associa-
by) the symptoms of the primary illness. Alterna- tion with schizophrenia pathology.
tively, it is often assumed that symptoms such as
severe anxiety are the result of underlying schizo- Cortical Development in COS
phrenic process and that depressive symptoms Morphometric studies of COS populations have
are almost inevitable in schizophrenia; thus, the provided unique insights into schizophrenia brain
diagnoses of independent Axis I conditions are development. Initial COS studies using whole
often ignored (Bermanzohn et al.). However, lobe volumetric measures showed profound and
recent studies indicate that psychiatric global GM loss with ventricular expansion in
comorbidities can significantly alter the presen- COS (Gogtay, 2008; Rapoport et al., 1997,
tation, clinical course, or prognosis of the illness, 1999; Rapoport & Inoff-Germain, 2000). With
and thus, accurate diagnoses of comorbidities novel neuroimaging methodology, finer-scale
could have useful implications for disease brain mapping on the longitudinal data revealed
that the GM loss in COS had a characteristic “longitudinal” GM trajectories, but a recent anal-
back-to-front (parieto-frontal-temporal) pattern ysis comparing GM development between COS
of spread during adolescent years (Thompson subjects treated with clozapine and those with
et al., 2001) which appears to be an exaggeration olanzapine showed no differences in GM trajecto-
of the healthy GM developmental pattern ries (Mattai et al., 2010). Further studies are
(Gogtay, Giedd, et al., 2004), perhaps reflecting needed correlating medication exposure as
lack of inhibitory controls on the normal matura- a continuous measure with brain development, or
tional GM loss (Schoop, Gardziella, & Muller, on unmedicated subjects to address this question.
1997; Sowell, Thompson, Tessner, & Toga, GM abnormalities in schizophrenia may be, at
2001). As the children mature and become least in part, familial/trait markers (Cannon et al.,
young adults, the GM loss appears to slow down 2003; Gilbert, Montrose, Sahni, Diwadkar, &
and get circumscribed to prefrontal and temporal Keshavan, 2003; Weinberger & McClure, 2002;
cortices and merging into the adult schizophrenia Yucel et al., 2003). We have extended this ques-
pattern (Greenstein et al., 2006), establishing the tion in our studies to ask whether GM “trajecto-
neurobiological continuity between the two ries,” rather than deficits, are endophenotypes,
counterparts of the illness. indicting dysregulation of development as the
The GM deficits in schizophrenia may reflect crucial defect. Longitudinal GM findings in 52
a disease process that is pronounced earlier in the healthy full siblings of COS patients showed ini-
illness and/or at an earlier age, perhaps reflecting tial cortical GM deficits which not only did not
a stronger genetic vulnerability interacting with progress during adolescence (unlike their COS
the early brain developmental windows (Pantelis probands) but normalized by age 20. A recent
et al., 2003) and exaggerated (dysregulated) analysis using 47 non-overlapping healthy sib-
neurodevelopment (Lieberman, 1999; Lieberman lings matched with 48 non-overlapping healthy
et al., 2005; Woods, 1998). It is also possible that controls replicated these findings (Mattai et al.,
the structural GM differences are most dynamic in 2011). Several inferences can be drawn from
the first years around psychosis onset and then vary these findings. First, the pattern of “improving
with the illness over time perhaps influenced by GM deficits” and the localization to “prefrontal
other environmental or illness-related factors such and superior temporal areas” in both COS pro-
as medication exposure. Indeed a similar pattern of bands and siblings point toward overall similari-
brain changes has also been tracked as psychosis ties in the patterns of GM development in both
develops in those at risk (Pantelis et al., 2007). groups where healthy siblings show a more time
The diagnostic specificity of the GM trajecto- limited “shift to the left” compared to the COS
ries was explored by comparing individuals with probands (earlier deficits which are corrected
COS and children who were “ruled out” as having before adulthood). Second, this points to protec-
schizophrenia (Kumra et al., 1998). A surprising tive/restitutive factors in sibling brain develop-
40% of those followed longitudinally from this ment, which could relate to functional outcome
group converted to bipolar I disorder and had pre- (Gogtay, Greenstein, et al., 2007). Finally,
post onset scans. The developmental trajectories absence of parietal deficits in healthy siblings
for bipolar I children (with psychosis) showed may indicate that parietal deficits require
a subtle but distinct pattern of cortical GM gain a nongenetic trigger as supported by twin studies
in left temporal cortex and loss in right temporal of adult-onset cases (Cannon et al., 2002).
and bilateral subgenual cingulate cortices, pattern The profound GM loss in COS could, in the-
that has no overlap with that seen for COS ory, be only a perceived loss resulting from the
(Gogtay, Ordonez, et al., 2007). These observa- encroachment of continued white matter growth,
tions point toward diagnostic specificity of the a process that extends through at least the fourth
GM findings in COS (Gogtay, Ordonez, et al. decade (Benes, 1993; Benes, Turtle, Khan, &
2007; Gogtay, Sporn, et al., 2004). These studies Farol, 1994; Sowell, Thompson, Holmes,
still do not address the effects of medications on Jernigan, & Toga, 1999). New findings using
tensor-based morphometry (TBM) showed that more serious in school-age children (Polanczyk
COS patients actually had up to 2% slower WM et al., 2010; Poulton et al., 2000).
growth rates per year than healthy controls The disorders most commonly misdiagnosed
(p ¼ 0.02, all p-values corrected), with greater as childhood-onset schizophrenia are:
effect sizes in the right hemisphere (p ¼ 0.006) 1. Severe anxiety can lead to hallucination in
(Gogtay et al., 2008); thus, progressive GM def- children.
icits seen in COS do not appear secondary to WM 2. Affective disorders: Hallucinations are rela- C
growth (Gogtay 2008). tively common in pediatric bipolar disorder
and major depression (Chambers, Puig-
Genetic Studies Antich, Tabrizi, & Davies, 1982; Varanka,
While rare copy number variants (CNVs) have Weller, Weller, & Fristad, 1988). However,
been found to be increased for our COS popula- the psychotic symptoms in these conditions
tion (Walsh et al., 2008), only two variants tend to be mood congruent, and follow-up
(16p11.2 and 22q11) have shown a unique ana- studies on this population generally suggest
tomic brain profile (McCarthy et al., 2009; a stable clinical outcome (Garralda, 1984a;
Usiskin et al., 1999). Recently, genome-wide McClellan & McCurry, 1999; McClellan,
expression analyses of brain tissue from varied McCurry, Snell, & DuBose, 1999; Ulloa
postnatal ages indicated that schizophrenia sus- et al., 2000).
ceptibility genes are overrepresented during fron- 3. Organic psychosis and substance abuse disor-
tal cortical development (Choi, Zepp, Higgs, ders (may mimic withdrawal states or negative
Weickert, & Webster, 2009; Harris et al., 2009; symptoms) (Caplan, Shields, Mori, &
Webster, Elashoff, & Weickert, 2010; Wong, Yudovin, 1991; Garralda, 1984b).
Webster, Cassano, & Weickert, 2009). However, 4. Pervasive developmental disorders and child-
given the large number of weak genetic and envi- hood disintegrative disorder.
ronmental risk factors and increasing evidence 5. Children with conduct disorder and various
for the dimensional nature of psychosis other behavioral disturbances can show hallu-
(Polanczyk et al., 2010), it seems more and cinations (Garralda, 1984a, 1984b).
more likely that schizophrenia represents 6. The atypical psychosis group provisionally
a continuum of risk involving many factors. For labeled as “multidimensionally impaired
example, a recent population study found (MDI)” is an important differential diagnosis.
a ninefold risk of schizophrenia if the presence These patients are characterized by brief, tran-
of a parent with psychosis was combined with sient episodes of psychosis and perceptual
maternal depression during pregnancy (Maki disturbance, typically in response to stress,
et al., 2010). Other studies have documented emotional lability disproportionate to precipi-
other gene-environmental interactions such as tants, cognitive deficits as indicated by multi-
that between genetic risk and urban birth ple deficits in information processing, no clear
(van Os, Pedersen, & Mortensen, 2004). thought disorder, and high comorbidity with
ADHD. This group of patients is not ade-
quately characterized by existing DSM-IV
Evaluation and Differential Diagnosis categories (Kumra et al., 1998; McKenna
et al., 1994; Towbin, Dykens, Pearson, &
COS is difficult to diagnose as symptoms of psy- Cohen, 1993), and in DSM, these patients
chosis appear very early in a child’s life and are would be considered as psychosis NOS.
difficult to tease apart from other childhood phe- The psychosis of childhood-onset schizophre-
nomena such as normal imaginative play, behav- nia can usually be distinguished by its severe and
iors generated by situations or due to secondary pervasive nature and its non-episodic, unremit-
gain. Hallucinations are not uncommon in other- ting course (Nicolson & Rapoport, 1999). Addi-
wise healthy children although they tend to be tionally, these children show poorer premorbid
functioning in social, motor, and language improvement in mood or extrapyramidal side

domains, learning disabilities, and disruptive effects. Clozapine was, however, also associated
behavior disorders (Alaghband-Rad et al., 1995; with more overall side effects, including enuresis,
Green et al., 1992; Hollis, 1995), and although tachycardia, and hypertension. By 2-year follow-
not reported in studies of the premorbid history up, 15 patients were on clozapine, and there was
of adult-onset schizophrenia (Done, Crow, evidence of sustained clinical improvement,
Johnstone, & Sacker, 1994; Jones, Rodgers, but additional side effects emerged including
Murray, & Marmot, 1994), transient autistic lipid anomalies (N ¼ 3) and seizures (N ¼ 1).
symptoms such as hand flapping and echolalia Both treatments were associated with marked
occur in toddler years for a substantial minority weight gain. This study suggests that clozapine
of the children (Alaghband-Rad et al., 1995; should be the drug of choice in treatment-resistant
Russell et al., 1989), probably reflecting childhood-onset schizophrenia (Shaw et al., 2006).
compromised early brain development.
Adverse Effects of Clozapine
Treatment Clozapine, which is a lifeline for many of the
COS children, is associated with several side
Although rare, childhood-onset schizophrenia is effects. The NIMH study has started addressing
a devastating disorder, which is frequently resis- the question of how to manage these side effects
tant to treatment, and unfortunately, there is so that these children can continue to stay on
a narrow evidence base to guide treatment, par- clozapine.
ticularly as there are no trials comparing atypical
antipsychotics, which have become the mainstay Neutropenia and Akathisia
of current treatment. Two prior randomized con- Children and adolescents treated with clozapine
trolled trials established the superiority of typical have increased susceptibility to neutropenia. This
antipsychotics over placebo in COS (Pool, can be successfully managed by addition of lith-
Bloom, Mielke, Roniger, & Gallant, 1976; Spen- ium (Sporn et al., 2003). Similarly, akathisia seen
cer & Campbell, 1994), but only one trial had only rarely in adults on clozapine appears more
compared the efficacy and safety of two antipsy- common in children (6 out of 15 children recently
chotics, demonstrating the therapeutic superiority treated with clozapine had developed akathisia)
of clozapine over the typical antipsychotic halo- and can frequently manifest as worsening of psy-
peridol (Kumra et al., 1996). As a result of our chotic symptoms or agitation in children, which
prior study and studies in AOS patients (Davis, frequently results in dosage increment. This side
Chen, & Glick, 2003; Moncrieff, 2003), cloza- effect is responsive to adjunctive propranolol
pine has established itself as the de facto gold (Gogtay, Sporn, Alfaro, Mulqueen, & Rapoport,
standard in studies establishing antipsychotic 2002) treatment.
efficacy – particularly in a pediatric population.
Our recent double-blind randomized con- Weight Gain
trolled trial of comparing clozapine (n ¼ 12) Weight gain is a significant effect of atypical
with olanzapine (n ¼ 13) showed that clozapine antipsychotics and is more pronounced in chil-
was associated with a significant reduction in all dren and adolescents than in adults (Ratzoni
outcome measures, whereas olanzapine showed et al., 2002). Genetic risk for weight gain on
significant improvement only in measures of neg- atypical antipsychotics has been suggested
ative symptoms and in the BPRS. A direct com- (polymorphism in beta3 and alpha 1A adrenergic,
parison of treatment efficacy showed a significant 5-HT2C and histamine receptors, and TNF-
advantage for clozapine in the alleviation of neg- alpha) (Basile et al., 2001), and a number of
ative symptoms of schizophrenia (producing biochemical correlates or predictors of weight
a 4% greater reduction in SANS, p ¼ 0.04, effect gain have been reported in the literature (leptin,
size 0.89), which was not correlated with prolactin, triglyceride, and HDL levels).
In our recent analysis of 23 patients treated (2001). Schizophrenia and schizophrenia-spectrum
with clozapine who had at least one medication- personality disorders in the first-degree relatives of
children with schizophrenia: The UCLA family
free week, plasma levels of hormones putatively study. Archives of General Psychiatry, 58(6),
involved in weight and appetite regulation 581–588.
(leptin, insulin, ghrelin, adiponectin, amylin, Basile, V. S., Masellis, M., McIntyre, R. S., Meltzer,
TNF-alpha) were compared with age, sex, and H. Y., Lieberman, J. A., & Kennedy, J. L. (2001).
BMI-matched healthy controls. After 6 weeks
Genetic dissection of atypical antipsychotic-induced
weight gain: Novel preliminary data on the
C
on clozapine, COS children showed increases in pharmacogenetic puzzle. The Journal of Clinical Psy-
BMI (p ¼ 0.001) and leptin (p ¼ 0.01). For COS chiatry, 62(Suppl 23), 45–66.
patients, BMI at baseline and week 6 correlated Benes, F. M. (1993). The relationship between structural
brain imaging and histopathologic findings in schizo-
with insulin level (r ¼ 0.5, p ¼ 0.004). In addi- phrenia research. Harvard Review of Psychiatry, 1(2),
tion, increase in BMI was positively correlated 100–109.
with clinical improvement in CGI, SAPS, and Benes, F. M., Turtle, M., Khan, Y., & Farol, P. (1994).
SANS rating scales (p < 0.05). Our findings Myelination of a key relay zone in the hippocampal
formation occurs in the human brain during childhood,
suggest that clozapine-induced weight gain may adolescence, and adulthood. Archives of General Psy-
be associated with increased leptin, reduced chiatry, 51(6), 477–484.
adiponectin and ghrelin, and clinical improve- Bermanzohn, P. C., Porto, L., Arlow, P. B., Pollack, S.,
ment (Sporn, Bobb, et al., 2005). Stronger, R., & Siris, S. G. (2000). Hierarchical diag-
nosis in chronic schizophrenia: A clinical study of
co-occurring syndromes. Schizophrenia Bulletin,
26(3), 517–525.
See Also Cannon, T. D., Thompson, P. M., van Erp, T. G., Toga, A.
W., Poutanen, V. P., Huttunen, M., et al. (2002).
Cortex mapping reveals regionally specific patterns
▶ Childhood Psychosis of genetic and disease-specific gray-matter deficits in
twins discordant for schizophrenia. Proceedings of the
National Academy of Sciences of the United States of
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Walsh, T., McClellan, J. M., McCarthy, S. E., Addington,
tal disorder (COPDD) was originally used in the
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neurodevelopmental pathways in schizophrenia. Sci- profound disturbance in social relations and multi-
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Symptom development in childhood onset schizophre-
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29(6), 865–878. gory was intended to capture the children who
C 614 Children’s Communication Checklist (CCC-2)
presented with features of pervasive developmen- other professionals who know the child well. It
tal disorders but developed the disorder after takes between 5 and 15 min to complete.
30 months of age. In the DSM-III-Revised, the The ten scales are:
category was removed and the category pervasive A. Speech
developmental disorder not otherwise specified B. Syntax
(PDDNOS) was added. PDDNOS now refers to C. Semantics
those children who do not meet the criteria for D. Coherence
a specific pervasive developmental disorder but E. Inappropriate initiation (initiation in US
demonstrate features. version)
F. Stereotyped language (scripted language in
US version)
See Also G. Use of context
H. Nonverbal communication
▶ DSM-III I. Social relations
▶ Infantile Autism J. Interests
▶ Pervasive Developmental Disorder The first four scales, A to D, assess aspects of
language structure, vocabulary, and discourse.
These are all areas that are often impaired in
References and Readings non-autistic as well as autistic children with
language impairments.
American Psychiatric Association. (1980). Diagnostic The next four scales, E to H, cover aspects of
communication that are not easy to assess using
conventional language assessments but which are
often impaired in children with autistic spectrum
disorders.
Children’s Communication Checklist The last two scales, I and J, assess behaviors
(CCC-2) that are usually impaired in cases of autistic spec-
trum disorder.
Dorothy Bishop For each scale, there are seven items, five
Department of Experimental Psychology, describing difficulties and two describing strengths.
University of Oxford, Oxford, UK The first 50 items focus on children’s difficulties,
with items from different scales interleaved, and the
last 20 items describe children’s strengths. For each
Synonyms item, the respondent completes a rating reflecting
the frequency with which a behavior is observed.
CCC-2; Children’s communication checklist, 0. Less than once a week (or never)
version 2 1. At least once a week, but not every day
2. Once or twice a day
3. Several times (more than twice) a day (or
Description always)
The Children’s Communication Checklist (CCC-2) Uses of the CCC-2

is a checklist that is used to assess aspects of The CCC-2 can be used in three ways:
everyday communication that are difficult to 1. To give a quantitative estimate of pragmatic
evaluate using traditional language tests. It consists language impairments in children.
of 70 items divided into 10 subscales and is usually 2. To screen children for risk of language impair-
completed by a parent or other caregiver, though ment. Those identified as at risk can then be
useful information can be provided by teachers or referred for more detailed language assessment.
Children’s Communication Checklist (CCC-2) 615 C
3. To help identify children who may merit fur- A large-scale reliability study with CLIC-2 was
ther assessment for an autistic spectrum disor- conducted at special schools for language-impaired
der. It is important to stress that CCC-2 cannot children using ratings by teachers and therapists.
be used to diagnose autistic disorder; however, This too was not entirely satisfactory, with inter-
a finding of low scores on scales E to H, plus rater reliability being low for some items.
evidence of impairment on scales I and J,
indicates that a more detailed diagnostic eval- The Children’s Communication Checklist: C
uation for autism is merited. Original Version
The original Children’s Communication Checklist
Application and Availability was developed from CLIC-2 by selecting those
Norms are available for both UK and US items with highest inter-rater reliability and group-
standardization samples over the age range ing these into new scales on the basis of statistical
4–16 years. Both UK and US versions are criterion of internal consistency. This gave
published by Pearson Publishing. An electronic a checklist with nine scales: A, speech; B, syntax;
scorer comes with the checklist and is C, inappropriate initiation; D, cohesion; E, stereo-
recommended as manual scoring is complex. typed conversation; F, use of context; G, rapport; H,
Some of the items in the CCC-2 are not suit- interests; and I, social interaction.
able for describing adult communication. A mod- A validation study was conducted with the
ification of the CCC-2, the CC-A, was therefore CCC using a subset of children who had partici-
developed and normed for adults in 2009. pated in a national study of language-impaired
In addition, a self-report version, CC-SR, suit- 7-year-olds. Their teachers and therapists com-
able for literate teenagers and adults was devel- pleted CCCs independently for the same children,
oped in 2009, with UK norms. making it possible to assess inter-rater agreement.
Inter-rater reliability varied from scale to scale
but was good for a pragmatic composite and rea-
Historical Background sonable for other scales. The distribution of CCC
ratings also differentiated children who were cat-
Checklist for Language-Impaired Children egorized on clinical grounds into cases of definite,
(CLIC and CLIC-2) possible, or no semantic-pragmatic disorder.
CCC-2’s origins were in CLIC, a research instru- Up to this point, the CCC was used only to
ment that was devised as a means of identifying subclassify children already known to have
from within a language-impaired sample those a communication impairment. However, there
children with a clinical picture of “semantic- was growing interest in its potential in a broader
pragmatic disorder.” This subgroup had been context, both as a screening tool for language and
described clinically, and included children who communication problems and as a means of iden-
spoke in long and fluent sentences but whose use tifying pragmatic difficulties in children with psy-
of language was strange. Utterances may be tan- chiatric impairments. In addition, there seemed to
gential, off-topic, or long and rambling. The orig- be potential to extend data on the CCC to a broader
inal CLIC had 20 multiple-choice items, with the age range and to explore whether it would yield
respondent selecting which of five descriptions valid data with parents as respondents.
best described the child. CLIC was piloted with To consider these questions, a further study with
teachers and therapists but was found to be unsat- the CCC was carried out in collaboration with
isfactory because respondents often felt none of Dr. Gillian Baird, a developmental pediatrician at
the provided options described the child. Accord- a tertiary referral center in London, with results
ingly, the format was revised to create CLIC-2 in being published in 2001. CCC data were gathered
which each item described a single communica- from a sample of children aged 5–16 years who
tive behavior which was rated as “applies defi- were referred to the center for diagnostic assess-
nitely,” “applies somewhat,” or “does not apply.” ment. Two copies of the CCC were sent to parents
with their letter of appointment, and they were CCC-2, US version

asked to have the child’s teacher or therapist com- A US version of CCC-2 was subsequently stan-
plete one copy and to complete the other them- dardized and was published in 2006. Changes to
selves. In addition, CCC data were collected from the checklist itself were minor and just involved
31 typically developing children. Agreement alteration of wording to make it more suitable for
between parent and teacher ratings was only mod- the US context. The scoring, however, was
est (r ¼ .45), but both sets of ratings showed asso- altered so that the General Communication Com-
ciation with the child’s clinical diagnosis, with the posite was scaled with a mean of 100 and SD of
parent ratings giving particularly strong associa- 15. It is not therefore comparable to the UK
tion. Scores for the typically developing children version, which is based on the sum of eight sub-
showed little overlap with those from the clinical scales, with expected mean of 80. In addition,
sample, suggesting that the CCC might be useful as some changes were made to the names of scales.
a means of screening for communication problems The SIDC was renamed the Social Interaction
in general as well as of identifying pragmatic diffi- Difference Score (SIDI).
culties. In addition, this study indicated that chil-
dren with a diagnosis of autism obtained very low
scores on the CCC overall. Psychometric Data
Development of CCC-2 The UK version of CCC-2 was standardized on

When CCC had been in use for a few years, it was a sample of 542 children aged 4–16 years, which
decided to develop a new version of the checklist was broadly representative of the socioeconomic
for standardization in the UK. One major change distribution of the general population and covered
between CCC and CCC-2 was in the response a wide geographic range (though not all regions
format. It was decided that a more concrete rating were represented). Before deriving norms,
of frequency of observing a behavior would be responses were inspected to find cases where the
less subjective and easier to use than the original pattern of responses suggested poor comprehen-
response options. The CCC-2 also had the same sion of instructions; rules were specified to iden-
number of items for all of the scales and gave tify these, and they were excluded. Floor effects
more emphasis to items assessing non-pragmatic were obtained on all scales, especially at the older
aspects of communication such as speech and ages (i.e., many children had no evidence of
syntax. Tables are provided to transform raw impairment). Norms were derived for each scale
scores on each scale to age-scaled scores with from a regression equation that predicted total log
mean 10 and SD 3. CCC-2 also provided norms score from log age in months. These scores were
for two composite scores. The first, the General scaled to mean of 10 and SD of 3. Because of the
Communication Composite, is based on all the non-normality of the data, the scaled scores have
communication scales (A to H). This is effective a ceiling, which means that CCC-2 is not well
in discriminating children with any clinical diag- suited for assessing variations among children
nosis from typically developing children. The who have above-average communication skills.
second index, the Social Interaction Deviance The test manual reports internal consistency
Composite, is an index of mismatch between and inter-rater agreement for all scales. Coefficient
structural and pragmatic/social skills. This was alpha (internal consistency) was .65 or more for all
derived to give optimal discrimination between scales. Inter-rater reliability between a parent and
children with typical SLI and those with evidence a professional (teacher or speech-language thera-
of pragmatic difficulties. A low SIDC is seen pist) was not impressive for individual subscales.
when a child has intact structural language skills The inter-rater reliability for the General Commu-
but major pragmatic difficulties. This kind of nication Composite (GCC) was .396, and for
profile was characteristic of children with the Social Interaction Deviance Composite, it
a diagnosis of Asperger syndrome. was .790. Disagreement between parent and
Children’s Communication Checklist (CCC-2) 617 C
professional ratings generally took the form of somewhat higher than that found for the UK
professionals rating a lower level of impairment. sample. Inter-rater reliability was not assessed.
Validity was assessed using a sample of children Validity was assessed by considering scores
with diagnoses of specific language impairment from children from clinical samples including
(SLI), pragmatic language impairment (PLI), and those with SLI, pragmatic language impairment,
high-functioning autism (HFA) or Asperger syn- and autism spectrum disorder (ASD). The criteria
drome as well as twenty typically developing for diagnosing pragmatic language impairment C
(TD) children. There were striking differences are not provided. As with the UK sample, all
between the clinical groups and the TD group on three clinical groups showed impairments on all
all ten subscales. On the GCC, there was little ten subscales. SIDI scores of 11 or less were
overlap between the distribution of scores of the seen in 6% of children with SLI, none of those
clinical groups and the TD group. However, the with PLI, and 27% of those with ASD.
GCC did not differentiate well between the differ- Data on sensitivity and specificity are presented
ent types of disorder. Rather, it acted as a general for different cutoffs on the GCC. In general, as
indicator that the child had communication difficul- with the UK version, the GCC has good sensitivity
ties. The groups were better differentiated by the and specificity for distinguishing clinical cases
Social Interaction Deviance Composite (SIDC), from typically developing children, but it is not
which was formed by subtracting scores on prag- useful for distinguishing between clinical groups.
matic/social scales from those on the structural
language scales. This showed a progressive
increase in abnormality going from the SLI group Clinical Uses
through the PLI and HFA groups, with the Asperger
syndrome group obtaining the lowest scores. Nev- CCC-2 is a useful screening instrument for com-
ertheless, there were no sharp boundaries between munication disorders. The General Communica-
the groups, but rather a gradual progression. tion Composite (GCC) is useful for identifying
that a child has communication difficulties and
Australian Sample few affected children obtain a GCC above the
Normative data were also collected for 115 10th percentile. The GCC is not, however, useful
Australian schoolchildren aged 6, 9, or 12 years for distinguishing between different subtypes of
from the Perth Metropolitan Region. In general, disorder.
scale means for these children fell around one The SIDC is useful for identifying children
point below the expected mean of 10. It was who have an uneven communicative profile,
recommended therefore that different cutoffs with disproportionate impairment in pragmatic
should be used for Australian children. aspects of communication relative to structural
language skills. This composite has good reliabil-
CCC-2, US Edition ity and is sensitive to autistic spectrum disorders.
US norms were gathered for the CCC-2 US edi- It is recommended, however, that it should only
tion on a sample of 950 children aged 4–16 years. be interpreted for a child whose GCC is below the
This sample was well matched to US population 10th percentile.
demographics in terms of race/ethnicity, geo- The CCC-2 is not a diagnostic instrument for
graphic region, and parental educational level. autistic spectrum disorder (ASD). It can however
Norms were developed by a process of inferential be useful in screening for ASD. It is
norming. recommended that children who obtain low
Test-retest reliability was obtained by having scores on the GCC, including poor performance
a subset of respondents complete the CCC-2 on on the pragmatic scales, should be referred for
two occasions within a period of 1–28 days. full assessment for ASD.
Values were generally high, above .85, for differ- The profile of scores on different subscales is
ent age ranges. Internal consistency was too unreliable to be used diagnostically but can
nevertheless provide a useful starting point for Children’s Communication Checklist – 2. American
a discussion with a caregiver about a child’s Journal of Medical Genetics. Part B, Neuropsychiatric
Genetics, 141B, 117–122.
difficulties. Bishop, D. V. M., & McDonald, D. (2009). Identifying
In research contexts, CCC-2 can be useful for language impairment in children: Combining language
quantifying the extent of communication impair- test scores with parental report. International Journal of
ment in different domains. Deficits measured by Language & Communication Disorders, 44, 600–615.
Bishop, D., Whitehouse, A., & Sharp, M. (2009). Com-
the CCC-2 have been shown to be highly herita- munication checklist – self-report (CC-SR). London:
ble. The CCC-2 has been shown to be sensitive to Pearson Assessment.
the broader autism phenotype in siblings of chil- Broeders, M., Geurts, H., & Jennekens-Schinkel, A.
dren with ASD. (2010). Pragmatic communication deficits in children
with epilepsy. International Journal of Language &
CCC-2 has also been used with children with Communication Disorders, 45(5), 608–616.
genetic conditions such as Williams syndrome, Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R.
Down syndrome, and sex chromosome trisomies, (2011). Communication, listening, cognitive and
where it can be helpful in highlighting different speech perception skills in children with auditory
processing disorder (APD) or specific language
communicative deficits. impairment (SLI). Journal of Speech, Language, and
Hearing Research, 54(1), 211–227.
Geurts, H. M., Verté, S., Oosterlaan, J., Roeyers, H.,
See Also Hartman, C. A., Mulder, E. J., et al. (2004). Can the
Children’s Communication Checklist differentiate
between children with autism, children with ADHD,
▶ Communication Assessment and normal controls. Journal of Child Psychology and
▶ Pragmatic Language Impairment Psychiatry, 45, 1437–1453.
▶ Social Responsiveness Scale Laws, G., & Bishop, D. V. M. (2004). Pragmatic language
impairment and social deficits in Williams syndrome:
A comparison with Down’s syndrome and specific
language impairment. International Journal of Lan-
References and Readings guage & Communication Disorders, 39, 45–64.
Norbury, C. F., Nash, M., Bishop, D. V. M., & Baird, G.
Bishop, D. V. M. (1998). Development of the Children’s (2004). Using parental checklists to identify diagnostic
Communication Checklist (CCC): A method for groups in children with communication impairment:
assessing qualitative aspects of communicative A validation of the Children’s Communication Check-
impairment in children. Journal of Child Psychology list – 2. International Journal of Language & Commu-
and Psychiatry, 39, 879–891. nication Disorders, 39, 345–364.
Bishop, D. V. M. (2003). The Children’s Communication Philofsky, A., Fidler, D. J., & Hepburn, S. (2007). Prag-
Checklist, version 2 (CCC-2). London: Pearson. matic language profiles of school-age children with
Bishop, D. V. M. (2006). The Children’s Communication autism spectrum disorders and Williams syndrome.
Checklist, version 2 (CCC-2) US Edition. New Jersey: American Journal of Speech-Language Pathology,
Pearson. 16(4), 368–380.
Bishop, D. V. M., & Baird, G. (2001). Parent and teacher Verte, S., Geurts, H. M., Roeyers, H., Rosseel, Y.,
report of pragmatic aspects of communication: Use of Oosterlaan, J., & Sergeant, J. A. (2006). Can the Chil-
the Children’s Communication Checklist in a clinical dren’s Communication Checklist differentiate autism
setting. Developmental Medicine and Child Neurology, spectrum subtypes? Autism, 10(3), 266–287.
43, 809–818. Volden, J., & Phillips, L. (2010). Measuring pragmatic
Bishop, D. V. M., Jacobs, P. A., Lachlan, K., Wellesley, D., language in speakers with Autism spectrum disorder:
Barnicoat, A., Boyd, P. A., et al. (2010). autism, lan- Comparing the Children’s Communication Checklist-2
guage and communication in children with sex chromo- and the Test of Pragmatic Language. American Journal
some trisomies. Archives of Disease in Childhood, 96, of Speech-Language Pathology, 19, 204–212.
954–959. Whitehouse, A. J. O., & Bishop, D. V. M. (2009). Com-
Bishop, D. V. M., Laws, G., Adams, C., & Norbury, C. F. munication Checklist for Adults (CC-A). London:
(2006). High heritability of speech and language impair- Pearson.
ments in 6-year-old twins demonstrated using parent and Whitehouse, A. J. O., Coon, H., Miller, J., Salisbury, B., &
teacher report. Behavior Genetics, 36, 173–184. Bishop, D. V. M. (2010). Narrowing the broader
Bishop, D. V. M., Maybery, M., Wong, D., Maley, A., & Autism phenotype: A study using the Communication
Hallmayer, J. (2006). Characteristics of the broader Checklist – Adult version (CC-A). Autism, 14(6),
phenotype in autism: A study of siblings using the 559–574.
Children’s Global Assessment Scale 619 C
The CGAS has been further modified to meet
Children’s Communication Checklist, the need of scoring global functioning of children
Version 2 with autism age 4 and older. This scale is called
the Developmental Disabilities – CGAS (or DD-
▶ Children’s Communication Checklist (CCC-2) CGAS). The information used for scoring the
DD-CGAS relates to four main domain of func-
tioning: self-care, communication, social behav- C
ior, and school/academic performance. In each of
Children’s Global Assessment Scale these domains, the level of impairment can range
from none to extreme. The reference for deter-
Benedetto Vitiello mining the level of impairment is the level of
Child & Adolescent Treatment & Preventive functioning that would be expected by
Intervention Research Branch, NIMH, NIH, a typically developing child of the same chrono-
Bethesda, MD, USA logical age. Impairment in the main domains of
functioning is then used by the rating clinician to
formulate a final overall score of functioning (the
Synonyms DD-CGAS score) on a scale ranging from 100
(corresponding to superior functioning) to 1
Developmental Disabilities – Children’s Global (indicating extreme impairment). Also the DD-
Assessment Scale (DD-CGAS) CGAS provides descriptors for each decile (i.e.,
100–91: superior functioning within family,
school, and peers; 90–81: adequate functioning
Description in all areas; 80–71: most daily living activities at
age level but with slight impairment in at least
The Children’s Global Assessment Scale (CGAS) one; 70–61: most daily living activities at age
is a clinician-rated instrument that provides level but with moderate impairment in at least
a single score for the overall level of behavioral one domain; 60–51: moderate impairment in
and emotional functioning of a child aged functioning in most domains; 50–41: moderate
4–16 years. The CGAS is completed by a clinician impairment in functioning in most domains and
based on information acquired from direct exam- severe impairment in at least one domain; 40–31:
ination and/or derived from informants such as severe impairment in functioning in some
parents, educators, or case managers. Raters domains; 30–21: severe impairment in all
score the child’s most impaired level of function- domains and settings; 20–11: extreme impair-
ing for the period of interest (usually the past ment in at least one domain; 10–1: extreme and
month) on a scale ranging on a continuum from pervasive impairment with danger to self or
100 (corresponding to excellent functioning in all others and need for intensive constant supervi-
areas of life) to 1 (representing very poor function- sion). The time frame for the rating can vary but
ing with need for constant supervision). Anchoring typically is in the order of several weeks or
descriptors are provided for each decile of the months.
CGAS. While a score of 100–91 indicates superior
functioning and 90–81 good functioning, 80–71
applies to children with no more than slight Historical Background
impairment in functioning at home, at school, or
with peers. A score of 70 or below is usually The CGAS was introduced by Shaffer et al.
considered the threshold for the presence of defi- (1983) and is a modification of the Global Assess-
nite, although slight, functional impairment. Most ment Scale developed by Endicott and colleagues
children referred for clinical evaluation and treat- in 1976, which, in turn, was a revision of the
ment have scores of 60 or below. Health-Sickness Rating Scale, originally
C 620 Children’s Psychiatric Rating Scale
published by Luborsky in 1962. A similar scale is expected functioning based on normal develop-
the Global Assessment of Functioning (GAF), ment. The DD-CGAS allows direct comparisons
which constitutes the axis V of the DSM-IV to be made between functioning of children
multiaxial evaluation. The DD-CGAS is with autism and functioning of children with
a modification by Wagner et al. (2007) of the other mental disorders such as schizophrenia,
CGAS specifically to score the global level of depression, or anxiety.
functioning of children autism and other perva-
sive developmental disorders. Both the CGAS
and DD-CGAS have been translated in languages See Also
other than English and are used internationally.
▶ Functional Analysis
Psychometric Data
When used by raters trained in the clinical eval-
uation of children with mental illness, the CGAS Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P.,
Fisher, P., Bird, H., et al. (1983). A children’s global
was shown to have excellent inter-rater reliability
assessment scale (CGAS). Archives of General
(e.g., intraclass correlation coefficient around Psychiatry, 40, 1228–1231.
0.84), good test-retest stability, and acceptable Wagner, A., Lecavalier, L., Arnold, L. E., Aman, M. G.,
discriminant and concurrent validity. The Scahill, L., Stigler, K. A., et al. (2007). Developmental
disabilities modification of the Children’s Global
CGAS can detect treatment effects. For example,
Assessment Scale. Biological Psychiatry, 61,
it was able to discriminate between active antide- 504–511.
pressant treatment and placebo in adolescent
depression. The DD-CGAS too was found to
have very good inter-rater and test-retest reliabil-
ity when used by clinicians who were experts in Children’s Psychiatric Rating Scale
autism and other pervasive developmental disor-
ders and who had been trained in its use. Janine Robinson
DD-CGAS scores showed moderate correlation CLASS, Cambridgeshire & Peterborough NHS
with indices of adaptive behavior, intellectual Foundation Trust, Cambridge, UK
functioning, and severity of psychopathology.
Preliminary data obtained before and after
6 months of treatment indicate a moderate Synonyms
correlation between changes in the DD-CGAS
scores and changes on the Aberrant Behavior CPRS
Checklist and the Clinical Global Impressions-
Improvement scores.
Abbreviations
Clinical Uses ECDEU Early Clinical Drug Evaluation

Unit
The CGAS is a clinically useful instrument that
provides an overall score of the level of function-
ing of a child. The DD-CGAS is specifically Description
useful for rating functioning in the context of
autism or other pervasive developmental disorder The Children’s Psychiatric Rating Scale (CPRS)
and is a relatively simple way of indicating the is a multidimensional rating scale of childhood
observed global functioning relative to the psychopathology.
Children’s Psychiatric Rating Scale 621 C
The CPRS is not diagnostic, but rather Children’s Psychiatric Rating Scale, Table 1 Items
a broad-ranging rating scale of symptoms and with respective numbers on CPRS the CPRS (Overall &
Campbell, 1998)
behaviors which may contribute to diagnosis. In
addition, the scoring system enables the rating of Withdrawal (8) Loud voice (25)
severity of symptoms and presentation. Since the Rhythmic motions (28) Negative and
uncooperative (10)
scale measures the presence or absence of symp-
toms over a particular period of time, it is a useful
Abnormal object relationships (7) Hypoactivity (5)
C
Unspontaneous relationship to Fidgetiness (3)
instrument of treatment efficacy and has regularly examiner (16)
been the instrument of choice employed in clini- Underproductive speech (2) Hyperactivity (4)
cal trials. Angry affect (11) Other speech
Owing to the established subscale structure, an deviance (27)
abbreviated form, comprised of 14 questions rel- Lability of affect (20) Low voice (24)
evant to the autistic spectrum, has been employed
in studies evaluating treatment efficacy in
children with autism. It has also demonstrated
value in evaluating psychopathology in autism, Psychopharmacology Revised (Guy, 1976)
clarifying major behavioral dimensions among other pediatric scales integral to clinical
and identifying distinct subtypes (Overall & drug evaluation programs. At this stage, the
Campbell, 1988; Overall & Pfefferbaum,1988; CPRS was regarded as experimental, and no stan-
Pfefferbaum & Overall, 1983; Overall & dardization data were available.
Pfefferbaum, 1982; Overall et al., 1988). The instrument was designed to be employed
The CPRS is a clinician-rated scale, based on within a semi-structured interview format to be
(1) behaviors observed during clinical interview completed by clinicians and generally used
and (2) the child’s reporting of symptoms. The alongside parental- and teacher-completed mea-
autism-specific scale is based on observation sures. The rating system facilitated assessment at
only. various stages of a clinical trial, generally prior to
In the Diagnostic and Statistical Manual, third the commencement of treatment, during the mid-
edition (DSM-III, American Psychiatric Associ- dle and at the end of treatment. It was designed
ation [APA], 1980), a diagnosis of infantile for use with children up to the age of 15 years.
autism is made when four behavioral character- The first 28 items were rated on direct obser-
istics are present: (1) pervasive lack of respon- vation of behaviors at interview, while the latter
siveness to other people, (2) gross deficits in 34 were rated on the basis of the child’s verbal
language development, and (3) bizarre responses reporting of symptom presence at the time of the
to the environment. These behaviors can be rated interview or during the preceding 7 days. Ratings
whereas characteristic (4) speech deviance, such on a Likert scale were possible from not
as echolalia and pronominal reversal, may be answered, not present, very mild, mild, moderate,
more difficult to evaluate in individuals with little moderately severe, severe to extremely severe.
speech. These behaviors are deemed well The seven-point scale was effectively derived
represented by the 14 items on the autism scale from the Adult Brief Psychiatric Rating Scale
of the CPRS (Table 1). (Overall & Gorham, 1962).
The scoring was further developed by Fish
(1985). The rating scale comprised of two sec-
Historical Background tions (the original 63 items): In Section A, the
clinician rated both the observed behavior at
The CPRS was originally developed by the Psy- interview as well as the child’s reporting of symp-
chopharmacology Research Branch of the NIMH toms or behaviors. Section B represented the
as a general purpose instrument (1976). It fea- clinician’s overall view based on the integration
tured in the ECDEU Assessment Manual for of a range of data available, including maternal
C 622 Children’s Psychiatric Rating Scale
reports and school records. Hence, additional organicity. Furthermore, cluster analysis
areas were rated by clinicians with respect to revealed six distinct clusters of symptoms and
clusters of behavior such as withdrawal, aggres- features, thus enabling the grouping together of
sive behavior, hyperactive behavior, inadequate those DSM-III diagnoses which tend to have core
or immature behavior, and organic impairment. features and symptom profiles in common. Treat-
Ratings were made on the degree of abnormal- ment evaluation could thus be focused on the
ity from 0 to 9: none, present but not significant, particular dimensions of symptom presentation.
significant but mild, moderate, moderately Studies have served to demonstrate both
severe, severe, very severe and may be paralyz- predictive and construct validity in testing diag-
ing, item not relevant to child, and not known or nostic classifications.
not ascertained.
The measure has been valuable owing to the
breadth of the range of symptoms and behavioral Clinical Uses
manifestations assessed, while not being limited
to the DSM diagnostic criteria, since the scale The CPRS is a general purpose instrument for
was originally designed prior to the publication assessment of a broad range of childhood
of the DSM-III. psychopathology.
Overall and Pfefferbaum (1988) proposed an While the measure is used in its complete
abbreviated version of the CPRS to evaluate form, i.e., a 63-item rating scale, autism-specific
psychopathology in children with autism. They research has focused on a subset of 14 items
evaluated a subtest of the CPRS, comprising of relevant to the condition. The first 28 items on
14 questions relevant to the diagnosis of autism. the CPRS are deemed evaluable since they are
Fourteen of the 28 questions of the CPRS are items which are rated on the basis of clinical
included. Since these are based on observed observation of behavior at interview. Hence,
behaviors and symptoms, the subtest is useful they do not rely on a particular level of language
for those children with autism who have little or development. Fourteen of these 28 items have
no communicative language, who are severely been deemed relevant for the assessment and
disturbed or severely developmentally delayed. classification of symptoms and features observed
in children with autism (Overall and Campbell,
1988). The behaviors included in this subset are
Psychometric Data well matched with the behavioral criteria for
infantile autism first described in the DSM-III
No normative data existed for the CPRS in its (APA, 1980), including deficits in language
original form (Guy, 1976). development, odd responses to the environment,
Factor-analytic studies have subsequently and lack of responsiveness to other people.
supported a 6-syndrome subscale structure, Overall et al. (1988) conducted factor analysis
hence establishing the internal validity of the of the subset of the CPRS and noted four core
CPRS (Overall & Pfefferbaum, 1982; aspects which differentiated children with
Pfefferbaum & Overall, 1983). autism, namely, autism, anger/uncoopera-
Evaluation of the diagnostic factor structure of tiveness, hyperactivity, and speech deviance. In
the CPRS (Overall & Pfefferbaum, 1982; other words, scores on the scale differentiated
Pfefferbaum & Overall, 1983) confirmed the subgroups. However, these did not necessarily
scale’s usefulness in evaluating psychopathology differentiate children with autism from children
and measuring treatment response in different with other psychiatric conditions.
clinical groups. Seven core factors were identi- The 14-item CPRS continues to be employed
fied, namely, behavioral problems, depression, as the measure of choice in clinical trials. It is
thought disturbance, psychomotor excitation, generally completed by the clinician(s) following
psychomotor retardation, nervous/tension, and videotaped observations of children with autism.
Children’s Unit for Treatment and Evaluation (State University of New York at Binghamton) 623 C
This is in conjunction with parental ratings of Guy, W. (2000). Clinical Global Impressions (CGI) scale.
behavior and symptoms as well as other clinician Modified From: Rush, J., et al., Psychiatric measures.
APA: Washington, DC.
ratings such as the Clinical Global Impression Niederhofer, H. W., & Mair, S. A. (2003). Tianeptine:
Scale (CGI). The rating scale has demonstrated A novel strategy of psychopharmacological treatment
value in open-label and controlled psychophar- of children with autistic disorder. Human Psychophar-
macological trials. Improvement of 25% or more macology: Clinical and Experimental, 18(5),
on identified symptoms compared with baseline
389–393.
Overall, J. E., & Campbell, M. (1998). Behavioral assess-
C
ratings suggests child is a responder to the ment of psychopathology in children: Infantile autism.
medication. Journal of Child Psychology, 44, 708–716.
Studies have evaluated tolerability, long-term Overall, J. E., & Gorham, D. R. (1962). The brief psychi-
atric scale. Psychological Reports, 10, 799–812.
effects, and efficacy of specific psychotropic Overall, J. E., & Pfefferbaum, B. (1984). A brief scale for
medication in autistic disorder as well as compar- rating psychopathology in children. Innovations in
isons of different medication within this group. Clinical Practice: A Source Book, 3, 257–266.
Studies of specific psychiatric features associated
with autistic conditions and effects
of psychopharmacology have employed the
CPRS-14 (Gagliano et al., 2004). Children’s Social Behavior
Questionnaire
See Also ▶ CSBQ (Children’s Social Behavior

Questionnaire)
▶ DSM-III
▶ Risperidone
▶ Screening Measures
▶ Treatment Effectiveness Children’s Unit for Treatment and
Evaluation (State University of
New York at Binghamton)
Raymond G. Romanczyk
Institute for Child Development, State University
and statistical manual of mental disorders (3rd ed.). of New York, Binghamton, NY, USA
Washington, DC.
Text rev.). Washington, DC.
Definition
Campbell, M., & Palij, M. (1985). Documentation of demo-
graphic data and family history of psychiatric illness. The Institute for Child Development (ICD) at the
Psychopharmacology Bulletin, 21(4), 719–721. State University of New York at Binghamton
Fish, B. (1985). Children’s psychiatric rating scale.
Psychopharmacology Bulletin, 2(4), 753–770.
promotes the welfare of children who are chal-
Gagliano, A., Germano, E., Pustorino, G., Impallomeni, lenged by developmental, learning, and emo-
D’Arrigo, Calamoneri, F. and Spina, E. (2004). tional disorders. The institute serves as the focus
Risperidone treatment of children with autistic for service, research, undergraduate, and gradu-
disorder: Effectiveness, tolerability, and pharmacoki-
netic implications. Journal of Child and Adolescent
ate training programs, and the dissemination of
Psychopharmacology, 14(1), 39–47. basic and applied research. The institute supports
Guy, W. (1976). ECDEU Assessment Manual for Psycho- several units that provide treatment and educa-
pharmacology, Revised, 1976. Rockville, Maryland: tional services for children within an evidence-
United States Department of Health, Education, and
Welfare, Public Health Service, Alcohol, Drug Abuse,
based model. The Children’s Unit for Treatment
and Mental Health Administration. (DHEW Publica- and Evaluation provides services for children
tion No. (ADM) 76–338) with autism spectrum disorders and their families
C 624 Children’s Unit for Treatment and Evaluation (State University of New York at Binghamton)
in the context of early intervention, preschool, building for the sole use of the ICD. It is located
and school-age programs as well as additional next to the campus preschool services building
complimentary programs. permitting ease of cooperative programs for peer-
based activities.
The ICD was founded by Dr. Raymond G.
Romanczyk, a faculty member and clinical psy- An autism spectrum disorder affects not only the
chologist, in 1974, located on the State University individual but also the family, the community,
of New York (SUNY) at Binghamton campus. and the broader society. As a group, the impact
An ICD program, the Children’s Unit for Treat- on families is greater and more complex than
ment and Evaluation, was established in 1975 in most other disorders. This requires an intensity,
cooperation with a small group of parents who quality, and precision of educational and clinical
wished to receive extensive and intensive ser- services that is directed not only at the individual
vices for their children. Given the efficacy of with an autism spectrum disorder but also at the
the program, parents worked with local and family. Comprehensive service delivery cannot
state legislators to provide the unit an appropriate be impeded by bias, inappropriate and antiquated
connection to the region’s continuum of services. organizational structures, low expectation, or by
Special status was granted in 1977 through an act compartmentalizing services.
of the New York State Legislature (Senate Bill The guiding principal of the Institute for Child
5911-A) which allows the unit to exist with a dual Development is that providing a caring, warm,
status as a fully certified New York State Educa- supportive, enriched environment that respects
tion Department private school and at the same the dignity of individuals and celebrates their
time organizationally part of SUNY at Bingham- unique qualities and potential is the minimum
ton. The bill permits school districts, counties, starting point for educational and clinical ser-
and other state agencies to contract directly with vices. This principal is paired with
the unit for services. This also allows the unit to a comprehensive commitment to evidence-
function as a separate entity at the university based services drawing upon well-conducted,
level, rather than as the more typical “lab school” methodologically sound, empirical research.
or time-limited, grant-funded project. The unit Thus, educational and clinical research is utilized
was the first in New York to provide full-day on a continuing basis, and the ICD provides
intensive evidence-based services for children in mechanisms and opportunities for all program
the early intervention and preschool age range. staff to acquire and use research information on
At its start, the unit served just six children a timely basis, which includes weekly in-service
from the immediate area. The catchment area has training, visiting speakers, and consultants, as
grown quite large and now includes the well as attendance at professional conferences.
New York State counties of Broome, Tioga, Another priority is that there must be extensive,
Cortland, Tompkins, Chenango, and Onondaga, precise, quantitative, and frequent child assess-
and the Pennsylvania counties of Bradford, Sus- ment that permits the daily implementation of an
quehanna, and Sullivan, representing locations objective feedback loop for decision making
across urban, suburban, and rural areas. Cur- regarding appropriate goals, procedures, and
rently, approximately 50 children commute progress.
daily to the program from within an approxi- Given the emphasis on evidence-based
mately 75-mile radius. approaches to intervention, current practice is
The ICD has had multiple locations on the based upon research in behavioral approaches
campus since 1973. In 2001, the institute was (applied behavior analysis and cognitive behav-
moved to a spacious specially constructed ioral therapy), nomothetic and ideographic
assessment (such as functional behavior assess- a relative analysis of the child and family’s
ment), family systems, curriculum selection, needs in the context of the resources of the con-
basic attention and learning processes, social tinuum of services in the community of resi-
development, and comorbid disorders. Thus, the dence. The majority of children are diagnosed
program is not based on a specific “model” or with autistic disorder and have a history of poor
particular “approach,” but rather is dynamically response to intervention prior to admission.
based on contemporary methodologically sound Parent willingness and ability to participate in C
peer-reviewed research that has been replicated. the child’s program and attend family services
groups is highly variable upon admission and is
not a selection criterion.
Goals and Objectives
The program provides full-day, 12-month ser- Treatment Procedures

vices with emphasis on individual evaluation of
each child’s assets and deficits, past history, cur- Comprehensive intervention requires that at min-
rent functioning, the specific parameters of the imum the following three core areas of current
child’s learning pattern, and an analysis of diagnostic standards be addressed: (1) qualitative
maintaining factors of current behavior patterns impairment in social interaction, (2) qualitative
using functional behavior analysis. The goal of impairments in communication, and (3) restricted
the program is to remediate skill deficits that repetitive and stereotyped patterns of behavior,
prevent children from participating at their poten- interests, and activities. Further, salient comorbid
tial in the continuum of education services in disorders must be assessed and addressed, e.g.,
their community and to provide families with anxiety disorders.
training and support for their own needs. Empha- Next, a continuum model for comprehensive
sis is placed on acquisition of communication intervention is used that includes several critical
skills, social interaction skills, self-regulation procedural components:
skills, and reduction of stereotyped behavior and • Assessment (nomothetic and ideographic)
restricted interests. The average length of enroll- • Curriculum planning (goal selection, prioriti-
ment is 2.5 years as the emphasis is upon rapid zation, and sequencing)
reintegration into services in the child’s local • Intervention methodology (evidence based)
community. Thus, the unit is not a long-term • Ongoing progress monitoring (measurement
alternate educational placement but rather an for decision-making feedback loop)
intensive, focused, short-term intervention pro- • Family/caregiver involvement (to address
gram. Prioritized goals within a comprehensive both child and self needs)
program produce rapid transition to services in It is these components that are used to achieve
the child’s community. acquisition of skills and address behavior prob-
lems with emphasis on generalization of skill
repertoires in normative settings. A comprehen-
Treatment Participants sive curriculum, the IGS Curriculum
(Romanczyk, Lockshin, & Matey, 2000), is used
Children between the age of 1 and 10 are eligible to guide and structure assessments and goal spec-
to attend the unit’s program. Referrals come from ification. Utilization of a curriculum that provides
physicians, county health departments, and a developmentally sequenced compendium of
school districts via the NY system of Early Inter- goals permits identification of skills associated
vention Officials, the Committee on Preschool with the child’s strengths and weaknesses, guides
Special Education, and the Committee on Special further assessment of the limits of the child’s
Education. Because the unit’s catchment area is skills and performance, and permits meaningful
so expansive, admission criteria are based on discussion of goal selection and priorities with
parents as it helps in supplementing their knowl- Family Focus

edge of child development. A comprehensive A separate but highly intertwined program
curriculum that is developmentally sequenced emphasizes individualization of services. Family
ensures that assessment is directly linked to func- involvement is strongly encouraged and
tional instructional goals. supported. Because a child with an ASD affects
Settings for instruction, instructional proce- the whole family, this greatly influences the fam-
dures, and specific goals present a complex mix ily services provided. In addition to instruction in
of variables. Their interaction must be addressed specific procedures and skills so that families can
to allow optimal configuration from the perspec- conduct teaching programs at home, measure
tive of each factor. As an example, if emphasis is progress on specific skills, and objectively eval-
currently upon transition between two instruc- uate their child’s performance, the staff individ-
tional settings, then goals and procedures need ually tailor parent services to the needs and
to be adjusted to be appropriate within that values of each family. Families can choose from
context. a variety of ongoing services that include the
Likewise, if focus is upon acquisition of following:
a specific goal set, then settings and procedures • Didactic instruction to implement intensive
are adjusted to maximize speed and strength of language and social/emotional programs at
learning. This is a dynamic process, allowing home.
adjustment to changing child and family character- • Homework programs with parent with training
istics, as well as resource factors, while developing so that they can conduct more traditional
more and more sophisticated child repertoires. No “homework” preacademic/academic, leisure,
one variable has primacy, with emphasis placed on and self-help activities at home.
a coherent comprehensive program. • Each month a theme is identified for
Social development is a priority, and the pro- a “family-friendly” personal goal. Activities
gram is designed to improve social skills and during the month focus on workshops for par-
social problem solving. Activities are constructed ents. Staff increase emphasis on addressing
for individual strengths and deficits. Activities these goals at school and paralleling with
and projects focus on skill strengthening via use home programs to maximize generalization
of reinforcement, modeling, rehearsal, role and thus family success.
playing, cognitive behavior therapy, and anxiety An important additional program component
reduction approaches. is parent wellness. Wellness sessions are devoted
An additional component is the “Buddy to assisting caregivers in appropriately
Group,” an after school therapeutic social skills addressing individual family member needs
program. The program focus is on increasing the with particular emphasis on stress management.
quality of social interactions through participat- Components of the program include recognizing
ing in a variety of on-site and community activ- and quantifying stress, changing stress
ities with typical peers. Peer volunteers are area responding through relaxation training, diaphrag-
middle school children who function as matic breathing, progressive muscle relaxation,
“buddies” by relating to children with ASD as guided imagery, yoga, time management, and
they would to any other friend. This provides cognitive restructuring approaches.
realistic feedback and experiences as would be
encountered in typical casual social settings, and Technological Innovation
allows for more success in meeting complex Recently, there has been significant interest in the
social expectations. Teaching objectives focus use of technology, particularly computer technol-
on age-appropriate activities, learning social ogy, with individuals with autism. However,
expectations, and responding appropriately to great caution must be exercised in applying
the inherently variable consequences of social a technological approach to a problem that is at
interaction. its core a social interaction disorder.
The unit has been applying technology to the commissioned by the US Department of Educa-
provision of services since the 1970s and has tion. The Committee on Educational Interven-
been acknowledged as a pioneer in this area. tions for Children with Autism utilized specific
Staff are provided with sophisticated organiza- selection criteria in their search for model pro-
tional systems and technology to address the programs, based upon published reports and fre-
gram priorities. Appropriate utilization however, quency of citation. They identified ten programs
requires precise matching of need with solution. based upon their criteria, to illustrate “state-of- C
A major focus has been to provide staff with the-art” model approaches, which included the
useful tools that match their needs and abilities Children’s Unit for Treatment and Evaluation.
for application in complex and changing Because the unit is an evidence-based pro-
circumstances. gram as described above, there is a large body
From an administrative perspective, the prob- of research studies that are constantly increasing.
lem of efficiently collecting, organizing, Some relevant summaries of this research body
interpreting, and monitoring the voluminous include:
information needed to achieve comprehensive National Autism Center. (2009). National
program goals represents a continuing challenge. Standards Project – Addressing the need for evi-
A series of computer systems and databases are dence-based practice guidelines for autism spec-
utilized to organize each student’s educational trum disorders. Retrieved from http://www.
goal plan, specific habilitative goals, daily and nationalautismcenter.org/about/national.php
monthly progress on each goal, graphs of pro- National Research Council. (2001). Educating
gress, history of educational goals, and evalua- children with autism. Committee on Educational
tion of goals. The curriculum database is Interventions for Children with Autism. Division
connected to the above databases, which allows of Behavioral and Social Sciences and Education.
the selected goals from the IGS to be imported Washington, DC: National Academy Press.
into a student’s goal plans’ database. From this New York State Department of Health.
database, printed reports are generated as well as (1999). New York State Department of Health
large-screen video projection for staff meetings Clinical Practice Guideline: The Guideline Tech-
for review of individual children’s goals and pro- nical report. Autism/pervasive developmental
gress. The use of extensive computer-based ana- disorders, assessment, and intervention for
lytic tools for staff and high-efficiency database young children (age 0–3 years). Publication No.
software for goal selection and monitoring, and 4217.
extensive use of handheld computing devices Odom, S., Boyd, B., Hall, L., & Hume, K.
with custom-developed software for numerous (2010). Evaluation of comprehensive treatment
specialized activities are essential for efficient models for individuals with autism spectrum dis-
day-to-day operation within a normative, orders. Journal of Autism and Developmental
constrained program budget. The twin goals of Disorders, 40, 425–436.
the technology program are to improve accuracy Romanczyk, R. G., Gillis, J. M., White, S., &
and speed of data-based decision making while DiGennaro, F. (2008). Comprehensive treatment
simultaneously reducing staff “paperwork” packages for ASD: Perceived vs proven effec-
tedium which in turn allows more time to focus tiveness. In J. Matson (Ed.), Autism spectrum
on child and family needs. disorder: Evidence based assessment and treat-
ment across the lifespan. Cambridge, MA:
Elsevier Science.
Efficacy Information The National Professional Development
Center on Autism Spectrum Disorders. (2010).
The unit is one of the ten model programs cited in Retrieved from http://autismpdc.fpg.unc.edu/
the Educating Children with Autism report of the U.S. Department of Health and Human Ser-
National Research Council (2001) that was vices. (1999). Mental health: A report of the
surgeon general-executive summary. Rockville, incremental validity. Research in Autism Spec-

MD: U.S. Department of Health and Human trum Disorders, 5, 768–774.
Services, Substance Abuse and Mental Health Eagle, R., Romanczyk, R. G., &
Services Administration, Center for Mental Lenzenweger, M. (2010). Classification of chil-
Health Services, National Institutes of Health, dren with autism spectrum disorders: A finite
National Institute of Mental Health. mixture modeling approach to heterogeneity.
Research in Autism Spectrum Disorders, 4(4),
772–781.
Outcome Measurement Gillis, J. M., Callahan, E. H., & Romanczyk,
R. G. (2010). Assessment of social behavior in
For an applied educational/clinical setting, it is children with autism: The development of the
not possible to determine which specific factor or behavioral assessment of social interactions in
combination of factors are the most influential in young children. Research in Autism Spectrum
outcome. That requires controlled research with Disorders.
standardized procedures, specifies duration, and Gillis, J. M., Lockshin, S. B., Hammond
appropriate control groups. The explicit goal of Natof, T., & Romanczyk, R. G. (2009). Fear of
the unit is to quickly transition children routine physical exams in children with autism
from diverse families and communities to their spectrum disorders: Prevalence and intervention
home school districts and to enable them to par- effectiveness. Focus on Autism and Other Devel-
ticipate in the services in their community. The opmental Disorders, 24, 156–168.
specifics of this transition are unique for each Hammond Natof, T., & Romanczyk, R. G.
child and do not represent the achievement of an (2009). Teaching students with ASD: Does
absolute level of functioning. The duration of teacher enthusiasm make a difference? Behav-
participation is variable within the average of ioral Interventions, 24, 1, 55–72.
2.5 years.
Within these non-research parameters,
approximately 50% transition to typical educa- Qualifications of Treatment Providers
tional settings, 25% to “inclusion opportunity”
classrooms, and 25% to “self-contained” class- All professional staff hold appropriate licenses
rooms. Importantly, recall that the exit criteria are and certification for their respective professions.
specific to child, family, and school district goals, Additionally, 20% of the staff are also board-
and do not reflect “absolute” criteria. Thus, certified behavior analysts. They represent the
a given family and school district may have typ- following professions:
ical placement as their goal while another family Clinical psychology
and district have the goal of as quickly as possible Special education
having the child participate in their continuum of Neuropsychology
services (this is often the case for children who Nursing
must travel substantial distances each day to the Speech language pathology
program). Occupational therapy
The formal research that is conducted at the School psychology
ICD focuses primarily upon measurement/assess- Adaptive physical education
ment, process, and focused intervention out- In addition to professional staff, there are full-
comes. Some recent examples are: time staff in teacher aide, administrative, and
Callahan, E. H., Gillis, J. M., Romanczyk, technical staff positions.
R. G., & Mattson, R. E. (2011). The behavioral The ICD also has extensive educational pro-
assessment of social interactions in young gram. At the undergraduate level, there is an
children: An examination of convergent and intensive four-course sequence, three of which
Chlorpromazine 629 C
have practicum components, in addition to the
requirements of the major in psychology. Chlorpromazine
Selected graduate students in the doctoral clinical
psychology program, in addition to the program Maureen Early1, Craig Erickson1,2, Logan
requirements, participate for 4 years as staff Wink1,2 and Christopher J. McDougle3
1
members at the ICD under the supervision of Christian Sarkine Autism Treatment Center,
senior staff. Training is also provided for select Indianapolis, IN, USA C
2
postdoctoral fellows. Department of Psychiatry, Indiana University
3
See Also School, Lexington, MA, USA
▶ Applied Behavior Analysis

▶ Early Intensive Behavioral Intervention Synonyms
(EIBI)
▶ Family-Centered Care 3-(2-chloro-10 H-phenothiazin-10-yl)-N,N-
▶ Structured Behavioral Interventions dimethylpropan-1-amine hydrochloride; Chlor-
▶ UCLA Young Autism Project promazine hydrochloride; Thorazine
Definition
Lockshin, S. B., Gillis, J. M., & Romanczyk, R. G. (2005).

Helping your child with autism spectrum disorder: N
A step-by-step workbook for families. Oakland, CA:
New Harbinger.
Romanczyk, R. G., & Gillis, J. M. (2006). Autism &
the physiology of stress and anxiety. In G. Baron, G.
Groden, J. Groden, & L. Lipsitt (Eds.), Stress
and coping in autism. New York: Oxford University N Cl
Press.
Romanczyk, R. G., & Gillis, J. M. (2008). Practice guide-
lines for autism education and intervention: Historical
perspective and recent developments. In J. K. Luiselli, S
D. C. Russo, & W. P. Christian (Eds.), Effective prac-
tices for children with autism: Educational and behav- Chlorpromazine is a prescription drug in the
ior support interventions that work. New York: Oxford group of first-generation antipsychotics initially
University Press.
Romanczyk, R. G., & Gillis, J. M. (2010). Continuum- FDA-approved for medical use in the year 1957
based model of behavioral treatment for children with whose active ingredients are chlorpromazine and
autism: A multi-factor and multi-dimensional perspec- chlorpromazine hydrochloride which have
tive. In J. A. Mulick & E. A. Mayville (Eds.), Behav- the chemical formulas C17H19N2SCl and
ioral foundations of effective autism treatment.
Cornwall-on-Hudson, NY: Sloan Publishing. C17H19N2SCl·HCl, respectively. This drug is cur-
Romanczyk, R. G., Lockshin, S., Gillis, J. M., & Matey, L. rently only available in generic form. This drug
(2007). Institute for child development – Preschool can be used for the treatment of schizophrenia,
program. In S. Harris & J. Handleman (Eds.), Pre- bipolar mania, some psychotic symptoms of
school programs for children with autism (3rd ed.).
Austin, TX: Pro-Ed. dementia, and serotonin syndrome. Observed
Romanczyk, R. G., Lockshin, S. B., & Matey, L. (2000). side effects include drowsiness/sedation, parkin-
The individualized goal selection curriculum. Johnson sonism, orthostatic hypertension, tachycardia,
City, NY: CBT Associates. ECG abnormalities, anticholinergic effects,
C 630 Chlorpromazine Hydrochloride
galactorrhea, weight gain, photosensitivity, arousal, concentration, attention, and conscious-

rashes, and pigmentation. ness (Sadock, Sadock, & Ruiz, 2009). ACh pro-
jects from the brainstem neurotransmitter center
See Also and basal forebrain to numerous locations,
including the prefrontal cortex, basal forebrain,
▶ Antipsychotics: Drugs thalamus, hypothalamus, amygdala, and hippo-
campus (Stahl, 2008). ACh is formed from
two precursors: choline, synthesized from the
References and Readings diet and intraneuronal sources, and acetyl coen-
zyme A (AcCoA), made from glucose in the
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. neuronal mitochondria. The enzyme choline
(2001). Principles and practice of psychopharma- acetyltransferase acts on choline and AcCoA to
cotherapy (3rd ed.). Philadelphia: Lippincott Williams & create ACh.
Wilkins.
Stahl, S. M. (2000). Antipsychotic agents. In Essential ACh acts on muscarinic and nicotinic cholin-
psychopharmacology: Neuroscientific basis and clini- ergic receptors. Muscarinic receptors are
cal applications (pp. 401–458). Cambridge: so-named due to their binding preference for
Cambridge University Press. muscarine, a toxin found in poisonous mush-
Thioridazine (n.d.). Retrieved from the ChemSpider Wiki:
http://www.chemspider.com/Chemical-Structure.5253. rooms (Sadock et al., 2009). The five muscarinic
html receptors are M1, M2, M3, M4, and M5, and each
U.S. Food and Drug Administration (2011). Drugs@FDA. has a different anatomical structure. They are
Retrieved from: http://www.accessdata.fda.gov/ G protein-linked and can be excitatory or inhibi-
scripts/cder/drugsatfda/index.cfms
Wilkaitis, J., Mulvihill, T., & Nasrallah, H. A. (2006). tory. The M1 subtype on the postsynaptic neuron
Classic antipsychotic medications. In A. F. Schatzberg & is believed to regulate some memory functions.
C. B. Nemeroff (Eds.), Essentials of clinical psychophar- M1 receptors blocked by antipsychotic
macology (2nd ed., pp. 211–228). Washington, DC: medications can induce sedation and some
cognitive dysfunction. The presynaptic M2 recep-
tor is an autoreceptor, detecting excess ACh in
the synapse and preventing further release
of ACh. M3 receptors in pancreatic beta cells
Chlorpromazine Hydrochloride cause insulin secretion, so antagonism here
by atypical antipsychotics, like olanzapine and
▶ Chlorpromazine clozapine, can result in decreased insulin
secretion.
Nicotinic acetylcholine receptors (nAChR)
belong to a class of excitatory, ligand-gated ion
Cholinergic System channel receptors (Sadock et al., 2009). They
bind nicotine, the main addictive substance in
Carolyn A. Doyle1 and Christopher J. McDougle2 tobacco smoke. These receptors have subtypes
1
Indiana University School of Medicine, with variable affinities; the highest-affinity
Indianapolis, IN, USA subunits are in the thalamus, followed by the
2
Lurie Center for Autism/Harvard Medical substantia nigra, striatum, hippocampus, and
School, Lexington, MA, USA entorhinal cortex. There are fewer high-density
receptors in the cerebellar, parietal, and frontal
cortices. One of the most notable subtypes is
Definition the postsynaptic alpha-4 beta-2 subunit, which
is believed to regulate dopamine release in the
The cholinergic system utilizes acetylcholine nucleus accumbens (Stahl, 2008). This is the
(ACh) neurotransmission to regulate memory, likely target of tobacco nicotine in the brain,
Cholinergic System 631 C
strongly contributing to tobacco’s addictive a longer lasting sedative effect. Adverse effects
qualities. The alpha-7 subunit located on the post- include confusion, disorientation, hallucinations,
synaptic neuron is thought to regulate cognitive and memory impairment. In the eye, anticholin-
function in the prefrontal cortex, whereas the ergic agents cause paralysis of the ciliary muscle,
presynaptic alpha-7 subunit on cholinergic neu- leading to loss of accommodation, as well as
rons provides positive feedback for continued muscarinic blockade of the iris’ sphincter muscle,
release of ACh. The alpha-7 subunit of the nico- causing pupillary dilation. Additional ocular C
tinic receptor located on dopamine and glutamate effects include blurry vision, anhidrosis, and
neurons also regulates the release of these neuro- worsened narrow-angle glaucoma. In the cardio-
transmitters when ACh is present. vascular system, anticholinergic agents cause
The neurotransmitter ACh is partly regulated tachycardia due to muscarinic blockade of the
by two degradative enzymes, acetylcholinester- parasympathetic fibers in the atria. In toxic
ase (AChE) and butyrylcholinesterase (BuChE). doses, they can cause intraventricular conduction
These enzymes convert ACh back to choline, block. In the respiratory system, muscarinic
which is taken back up into the neuron blockade causes reduced glandular secretion of
for resynthesis into ACh (Stahl, 2008). AChE is the smooth muscle, leading to dry mouth. In the
considered the main enzyme that inactivates GI tract, inhibited parasympathetic control from
ACh. It is located throughout the brain, along anticholinergic blockade leads to decreased
the major projections as outlined above, as well motility, causing constipation, delayed gastric
as within the gastrointestinal (GI) tract, skeletal emptying, and paralytic ileus. In the genitouri-
muscle, red blood cells, lymphocytes, and plate- nary tract, anticholinergic agents relax
lets. The highest density of AChE is located in the the smooth muscle of the bladder and ureter,
caudate and putamen, with lower amounts in leading to urinary hesitancy, but they are also
areas such as the thalamus, hippocampus, and known to cause urinary retention. Despite their
cortices (frontal, temporal, parietal, occipital, reputation for adverse effects, anticholinergic
and cerebellum). BuChE is also located through- agents can be therapeutically useful. They
out the brain, mostly in glial cells, but can also be are commonly prescribed to prevent or improve
found in the GI tract, plasma, skeletal muscle, extrapyramidal side effects (EPS) caused by
placenta, and liver (Stahl, 2008). ACh is dopamine antagonists. EPS reactions
partly regulated by cholinergic vesicular trans- include dystonia, akathisia, and parkinsonism.
porters (VAChT) on synaptic vesicles, When antipsychotics block dopamine in the
which transport ACh into the vesicle (Sadock nigrostriatal tract, cholinergic activity is
et al., 2009). The highest densities of VAChT increased, resulting in the above-mentioned side
are also located in the caudate and putamen, as effects. Anticholinergic agents reduce the
well as the nucleus accumbens. Lower levels of increased cholinergic activity, restore balance to
binding occur in the cerebral cortex and the dysfunctioning neurotransmitter system, and
cerebellum. relieve symptoms of EPS.
Anticholinergic medications are some of the From a pathophysiological standpoint, the
most well-known medications to act on the cho- cholinergic system is most frequently associated
linergic system. They block the actions of ACh at with Alzheimer’s disease (AD). In AD, there is
either the muscarinic or nicotinic receptors, degeneration of cholinergic neurons in the
resulting in side effects such as sedation, analge- nucleus basalis due to deposition of amyloid
sia, and management of allergies (Sadock et al., plaque, leading to memory loss (Sadock et al.,
2009). These drugs impact numerous physiolog- 2009). AChE inhibitors prevent the destruction of
ical systems, including the ocular, cardiovascu- ACh, which prevents further memory loss in AD.
lar, respiratory, GI, genitourinary, and the central Some AChE inhibitors only inhibit AChE,
nervous system (CNS). In the CNS, these medi- whereas some inhibit both AChE and BuChE.
cations may be initially stimulating, followed by Depending on the individual, responses to these
C 632 Cholinergic System
agents vary, but the overall effect is prevention or Current Knowledge

slowing of disease progression (Stahl, 2008).
Examples of AChE inhibitors are donepezil, Impairment of the cholinergic system has been
amantadine, rivastigmine, and galantamine. implicated in the pathophysiology of autism.
Another disease process implicated in the Postmortem studies by Perry et al. (2001) show
pathophysiology of the cholinergic system is a 30% reduction of cortical muscarinic receptor
schizophrenia, as evidenced by the observation binding in the parietal cortex in autistic individ-
that antimuscarinic drugs improve negative uals compared with age-matched controls. Cho-
symptoms (Sadock et al.). Anticholinergic agents linergic neurons in the basal forebrain, an area
are known to worsen positive symptoms in thought to play a role in attention, are abnormally
patients with unstabilized schizophrenia, but large and plentiful in children with autism
they appear to have no effect on positive symp- (Baumann & Kemper, 1994). A study by Sokol
toms in stabilized patients (Sadock et al.). et al. (2002) found low cytosolic choline concen-
The cholinergic system is also implicated in trations as measured by hydrogen proton mag-
Parkinson’s disease (PD), which results netic resonance spectroscopy in ten children with
from dopamine deficiency and cholinergic autism. Imaging studies have also attempted to
excess. Anticholinergic agents can help reduce link neuroanatomical regions of the brain to core
parkinsonian tremor via muscarinic receptor domains of dysfunction observed in autism. Indi-
blockade, especially in combination with levo- viduals with autism have been noted to have
dopa, a first-line dopaminergic agent used to significant deficits in face perception (Grelotti
treat PD. et al., 2002; Schultz, 2005), which is believed to
play a notable role in social interaction. The neu-
roanatomical region linked to facial recognition
Historical Background is the fusiform gyrus, which contains the visual
pathway. This pathway is regulated by the
ACh was the first neurotransmitter to be discov- cholinergic system, suggesting a possible causal
ered. The first individual to uncover its existence relationship between the cholinergic system
was Henry Hallett Dale, a British pharmacologist and autistic social impairment. A study by
who lived between 1875 and 1968 (Raju, 1999). Suzuki et al. (2011) used positron-emission
While studying ergot extracts, Dale found that the tomography (PET) and a radiotracer to examine
extracts reversed the effects of epinephrine and AChE activity in 20 autistic adults compared to
concluded that ergot contained tyramine, hista- 20 age- and IQ-matched controls. The results
mine, and ACh. In 1914, Dale determined that showed a deficit in cholinergic innervations of
ACh was the “most suitable chemical” for para- the fusiform gyrus in the autistic subjects,
sympathetic neurotransmission, and coined the suggesting a possible explanation for social
terms “cholinergic” and “adrenergic.” Not long impairment in autism.
after his discovery, a German physician named There is evidence to suggest that specific cho-
Otto Loewi (1873–1961) was researching the linergic receptor subtypes play a role in the
autonomic nervous system when he discovered pathology and symptomatology of autism. It is
the presence of ACh and adrenaline in isolated believed that deficits in alpha4-containing recep-
hearts. The year was 1921, and Loewi was the tors predominate in autism (as well as in
first individual to underscore ACh’s importance Alzheimer’s disease), whereas other receptor sub-
in the nervous system. Loewi initially named types are associated with other disorders, like the
ACh “vagusstoff,” referencing its release from alpha-7 subtype and schizophrenia (Graham
the vagus nerve. These two men shared the et al., 2002). These observations may lead to
Nobel Prize in Physiology and Medicine in drug development targeting specific nicotinic
1936 “for discoveries related to chemical trans- receptor subtypes for alleviation of symptoms in
mission of nerve impulse.” autism. Similarly, a theory by Lippiello (2006)
Cholinergic System 633 C
suggests that autism is a disorder of “overfocused looked at the effect of donepezil in 34 children
attention,” unlike attention-deficit/hyperactivity and adolescents aged 8–17 years (IQ > 75). The
disorder (ADHD), which can be described as results showed some improvement on a number
a disorder of “underfocused attention.” These of measures of executive functioning, but there
two disorders theoretically sit at opposite ends were no statistically significant differences
of a spectrum with reversed neurophysiological between the donepezil and placebo groups.
mechanisms underlying their pathophysiology. The researchers concluded that short-term C
Lippiello hypothesizes that because nicotinic treatment with donepezil may have limited
cholinergic agonists have been shown to improve impact on cognitive functioning in those with
the symptoms of ADHD (Levin et al., 2001); autism.
perhaps nicotinic cholinergic antagonists may Retrospective and open-label trials are of
ameliorate the symptoms of autism. The concept limited utility in demonstrating effectiveness
of nicotinic receptor antagonists treating autism and safety of a medication due to their lack of
has not yet been explored in the literature, but experimental design, but they offer a glimpse
these concepts may lead to future initiatives in of possible directions that can be taken in the
studying the relationship between the anticholin- treatment of symptoms associated with autism.
ergic system and autism. A retrospective study by Hardan and Handen
Medications affecting the cholinergic system, (2002) examined the effects of donepezil, an
particularly AChE inhibitors, have been studied AChE inhibitor, in the treatment of 8 children
to treat symptoms associated with autism. These with autism, aged 7–19 years. The study found
agents increase ACh in brain regions related to a significant decrease in irritability and hyperac-
attention and memory, such as the cerebral cortex tivity according to the ABC, although attention
and basal forebrain (Yoo et al., 2007). Amanta- and memory were not measured. An open-label
dine is a drug approved for the prophylaxis of study by Nicolson et al. (2006) examined the
influenza A, but is commonly used in the treat- effects of galantamine, an AChE inhibitor and
ment of PD and EPS due to its antiparkinsonian nicotine receptor modulator, in the treatment of
effects (Sadock et al., 2009). A double-blind, 13 children with autism. Galantamine demon-
placebo-controlled study examined the effects strated reductions in parent-rated irritability and
of amantadine in 39 autistic children aged social withdrawal on the ABC, improvements in
5–19 years (King et al., 2001). The clinician- emotional lability and inattention on the
rated Aberrant Behavior Checklist rating scale Conners’ Parent Rating Scales-Revised, and
(ABC) showed statistical significance in the reduced anger on the clinician-rated children’s
amantadine-treated group within the domains Psychiatric Rating Scale. Hertzman (2003)
of hyperactivity and inappropriate speech reported three cases where galantamine promoted
(Blankenship et al., 2010). The parent-rated verbalization in adults with autism. Another
ABC did not show statistically significant open-label study by Chez et al. (2004) examined
improvement between the amantadine and pla- the AChE inhibitor rivastigmine tartrate and
cebo groups. Galantamine, another AChE inhib- found significant improvements in scores of
itor, was examined in 20 males with autism various measurements, including the Childhood
in a double-blind, placebo-controlled study Autism Rating Scale, Gardner’s Expressive One-
(Niederhofer et al., 2002). Using the ABC as Word Picture Vocabulary Test, and Conners’
a dependent measure, there were decreases in Parent Rating Scale.
the domains of irritability, hyperactivity, inade-
quate eye contact, and inappropriate speech.
Despite these promising observations, studies Future Directions
examining the effect of other AChE inhibitors
have found dissimilar results. A double-blind, pla- Future directions for research into the relation-
cebo-controlled study by Handen et al. (2011) ship between the cholinergic system and autism
C 634 Cholinergic System
will likely involve investigating cholinergic Graham, A. J., Martin-Ruiz, C. M., et al. (2002). Human
receptor subtypes, neuroimaging, and pharmaco- brain nicotinic receptors, their distribution and partic-
ipation in neuropsychiatric disorders. Current drug
logic treatment development. Cholinergic recep- targets. CNS and neurological disorders, 1(4),
tor subtypes occur at variable concentrations in 387–397.
the brain and are implicated in the pathophysiol- Grelotti, D. J., Gauthier, I., et al. (2002). Social interest
ogy of autism. Exploring their influence on atten- and the development of cortical face specialization:
What autism teaches us about face processing. Devel-
tion, memory, and cognition, as well as the core opmental Psychobiology, 40(3), 213–225.
diagnostic domain of social impairment, will Handen, B. L., Johnson, C. R., et al. (2011). Safety and
likely be a continued area of research. Neuroim- efficacy of donepezil in children and adolescents
aging of these receptors will continue to map with autism: Neuropsychological measures. Journal
of Child and Adolescent Psychopharmacology, 21(1),
areas of neuroanatomical dysfunction in autism. 43–50.
Medications affecting the cholinergic system Hardan, A. Y., & Handen, B. L. (2002). A retrospective
could be further explored as treatments for autism open trial of adjunctive donepezil in children and ado-
given the mixed results seen in existing studies. lescents with autistic disorder. Journal of Child and
Adolescent Psychopharmacology, 12(3), 237–241.
Double-blind, placebo-controlled trials are Hertzman, M. (2003). Galantamine in the treatment of
required to draw conclusions about medication adult autism: A report of three clinical cases. Interna-
safety and efficacy, and currently there are tional Journal of Psychiatry in Medicine, 33(4),
minimal studies examining the effectiveness of 395–398.
King, B. H., Wright, D. M., et al. (2001). Double-blind,
AChE inhibitors. Short-term studies of AChE placebo-controlled study of amantadine hydrochloride
inhibitors have shown mixed results, so it may in the treatment of children with autistic disorder.
be of benefit to employ them for longer periods Journal of the American Academy of Child and
before drawing definitive conclusions about their Adolescent Psychiatry, 40(6), 658–665.
Levin, E. D., Conners, C. K., et al. (2001). Effects of
efficacy. Lastly, the study of nicotinic cholinergic chronic nicotine and methylphenidate in adults with
receptor antagonists as a treatment for autism is attention deficit/hyperactivity disorder. Experimental
another possible, untapped direction. and Clinical Psychopharmacology, 9(1), 83–90.
Lippiello, P. M. (2006). Nicotinic cholinergic antagonists:
A novel approach for the treatment of autism. Medical
Hypotheses, 66(5), 985–990.
See Also Nicolson, R., Craven-Thuss, B., et al. (2006). A
prospective, open-label trial of galantamine in autistic
▶ Amantadine disorder. Journal of Child and Adolescent Psycho-
pharmacology, 16(5), 621–629.
▶ Anticholinergic Niederhofer, H., Staffen, W., et al. (2002). Galantamine
▶ Antipsychotics: Drugs may be effective in treating autistic disorder. BMJ,
▶ Atypical Antipsychotics 325(7377), 1422.
▶ Dopamine Perry, E. K., Lee, M. L., et al. (2001). Cholinergic activity
in autism: Abnormalities in the cerebral cortex and
basal forebrain. The American Journal of Psychiatry,
158(7), 1058–1066.
References and Readings Raju, T. N. (1999). The Nobel chronicles. 1936:
Henry Hallett Dale (1875–1968) and Otto Loewi
Baumann, M. L., & Kemper, T. L. (1994). Neuroanatomic (1873–1961). Lancet, 353(9150), 416.
observations of the brain in autism (pp. 119–145). Sadock, B.J., Sadock, V.A., and Ruiz, P. (2009). Kaplan &
Baltimore: Johns Hopkins University Press. Sadock’s comprehensive textbook of psychiatry,
Blakenship, K., Erickson, C. A., et al. (2011). Psychophar- volumes 1 & 2 (9th ed.) (pp. 67, 279–282, 298,
macological treatment of autism. In D. G. Amaral, G. 3014–3021). Philadelphia: Lippincott Williams and
Dawson, & D. H. Geschwind (Eds.), Autism spectrum Wilkens.
disorders (pp. 1194–1212). New York: Oxford Uni- Schultz, R. T. (2005). Developmental deficits in social
versity Press. Chapter 69. perception in autism: The role of the amygdala and
Chez, M. G., Aimonovitch, M., et al. (2004). Treating fusiform face area. International Journal of Develop-
autistic spectrum disorders in children: Utility of the mental Neuroscience, 23(2–3), 125–141.
cholinesterase inhibitor rivastigmine tartrate. Journal Sokol, D. K., Dunn, D. W., et al. (2002). Hydrogen proton
of Child Neurology, 19(3), 165–169. magnetic resonance spectroscopy in autism:
Chromosomal Abnormalities 635 C
Preliminary evidence of elevated choline/creatine In addition to the gain or loss of an entire
ratio. Journal of Child Neurology, 17(4), 245–249. chromosome, rearrangement of the order of
Stahl, S. M. (2008). Stahl’s essential psychopharmacol-
ogy: Neuroscientific basis and practical applications genetic material on a chromosome, or the gain
(3rd ed.) (pp. 206–207, 392, 449, 914–926). or loss of part of a chromosome, may result in
New York: Cambridge University Press. a genetic disorder. Chromosomal abnormalities
Suzuki, K., Sugihara, G., et al. (2011). Reduced acetyl- may be either balanced or unbalanced,
cholinesterase activity in the fusiform gyrus in adults
with autism spectrum disorders. Archives of General depending on whether the particular alteration C
Psychiatry, 68(3), 306–313. results in no net change in the total amount
Yoo, J. H., Valdovinos, M. G., et al. (2007). Relevance of genetic material, or a net change, respectively.
of donepezil in enhancing learning and memory in For example, a translocation is a chromosomal
special populations: A review of the literature. Journal
of Autism and Developmental Disorders, 37(10), rearrangement that occurs when segments of
1883–1901. nonhomologous chromosomes break off and are
transferred from one chromosome to another. In
a reciprocal translocation, there is an even
exchange of genetic material between the
two chromosomes. Other abnormalities include
Chromosomal Abnormalities deletions and duplications, which result in the net
loss or gain of genetic material, respectively,
Ellen J. Hoffman and inversions, which occur when two
Albert J. Solnit Integrated Training Program, breaks occur on the same chromosome, and
Yale Child Study Center, New Haven, CT, USA the piece that is cut out reinserts in the same
location, but in the opposite direction (Jorde
et al., 2010).
Synonyms Such abnormalities of chromosome structure
may be inherited, or can be new mutations, i.e.,
Alterations in chromosome structure or number occur de novo, in the parent’s germline. Such
abnormalities tend to occur at regions with repet-
itive sequences of DNA and are due to errors in
Structure recombination between homologous chromo-
somes. Trisomies of the autosomes are most
Humans have 22 pairs of autosomes (nonsex often due to errors in nondisjunction that occur
chromosomes) and 1 pair of sex chromosomes during meiosis, the risk of which increases with
(XX or XY). Genes are organized in a character- maternal age. In general, because most genes in
istic pattern on each chromosome. Any disrup- the human genome play a role in the development
tion of the total number of chromosomes, or the of the central nervous system, the larger the
order or amount of genetic material on a given region of the chromosome that is disrupted, the
chromosome, is considered to be a chromosomal more genes that are affected, and the greater
abnormality. Chromosomal abnormalities occur likelihood that the chromosomal abnormality
in about 1 in 150 live births and are the most will result in a developmental disability (Jorde
common cause of intellectual disability and et al., 2010; Nussbaum et al., 2007).
loss of a pregnancy (Jorde, Carey, & Bamshad, Changes in chromosome number are clearly
2010). An example of a syndrome caused by observable by karyotype. Similarly, large
disruption of chromosome number is Down chromosomal abnormalities, such as duplications
syndrome, the most common genetic cause of or deletions that cause the gain or loss of over
moderate intellectual disability, which is due a few million base pairs, can be detected by
to having three copies of chromosome 21, the banding pattern on a high-resolution karyo-
or trisomy 21 (Nussbaum, McInnes, & Willard, type (Nussbaum et al., 2007). However, the
2007). detection of smaller duplications or deletions
C 636 Chromosomal Abnormalities
was not possible until the development of more Function

advanced techniques, including fluorescence in
situ hybridization (FISH) and comparative geno- The study of chromosomal abnormalities in ASD
mic hybridization (CGH). FISH utilizes probes is particularly germane because individuals with
that bind to specific regions of DNA to identify idiopathic autism are more likely than unaffected
the precise location of a chromosomal break point individuals in the general population to have
and can be used to identify the genes that are abnormalities of chromosome structure (O’Roak
disrupted in that region. CGH involves the bind- & State, 2008). In particular, abnormalities in
ing, or hybridizing, of a patient’s genome to specific chromosome regions occur at a higher
a control genome, or in array-based CGH, which frequency in individuals with ASD. For example,
improves resolution, to a microarray that contains 1–3% of affected individuals were found to have
probes corresponding to a control genome such maternally inherited duplications of chromosome
that it is possible to detect net gains or losses of 15q11-13 (Veenstra-VanderWeele & Cook,
chromosomal regions. However, it is not possible 2004). Additional chromosomal regions that are
to detect abnormalities such as balanced translo- more often disrupted by structural abnormalities
cations using CGH, because there is no net change in ASD include 16p11 and 22q11, both of which
in the amount of genetic material in the patient’s have been associated with a range of psychiatric
genome compared to the control genome (Jorde disorders, consistent with the concept of pleiot-
et al., 2010; Nussbaum et al., 2007). ropy, which is an emerging theme in the genetics
These advances in molecular cytogenetics of ASD (Hoffman & State, 2010; State & Levitt,
improved our ability to detect smaller abnormal- 2011).
ities in chromosome structure, revealing regions Chromosomal abnormalities that are identifi-
of chromosomes that are associated with specific able by cytogenetics occur in an estimated 6–7%
developmental syndromes, and in some cases, an of individuals with ASD and in a higher percent-
increased risk of autism spectrum disorders age of individuals with ASD who have dysmor-
(ASD) (see below). Therefore, investigations of phic features and intellectual disability
abnormalities of chromosome structure in devel- (Abrahams & Geschwind, 2008). The likelihood
opmental syndromes have shaped the course and of finding a chromosomal abnormality depends
current approach to research in the genetics of on the resolution of the cytogenetics technique
ASD (Hoffman & State, 2010). For example, used. For example, approximately 2–5% of indi-
Prader-Willi and Angelman syndromes are viduals with ASD have a chromosomal abnor-
caused by a microdeletion (loss of less than five mality identifiable by karyotype (Reddy, 2005;
million base pairs of DNA) of chromosome Schaefer & Mendelsohn, 2008; Shen et al., 2010).
15q11-13. Inheritance of the microdeletion from Studies have found that yield improves with
the father results in Prader-Willi syndrome, while increasing resolution of the clinical test such
inheritance of a microdeletion in the same that clinical microarray has a higher rate than
region of the maternal chromosome leads to karyotype of detecting chromosomal abnormali-
Angelman syndrome, due to imprinting in ties, though, as discussed, the limitation of this
this region. In addition, DiGeorge syndrome, CGH-based test is that it cannot detect balanced
also called velocardiofacial syndrome, which translocations (Shen et al., 2010). In addition, the
causes intellectual disability, and craniofacial use of FISH for regions where structural abnor-
and heart defects, is caused by a microdeletion malities are more likely to occur in ASD is also
of chromosome 22q11.2 (Nussbaum et al., 2007). likely to improve yield (Reddy, 2005).
Structural abnormalities of each of these chromo- Recent guidelines recommend obtaining
somal regions are associated with an a karyotype as well as testing for fragile
increased risk of ASD (see below) (Hoffman & X syndrome (FXS) in the evaluation of all indi-
State, 2010). viduals with autism spectrum disorders (ASD)
Chromosomal Abnormalities 637 C
(Lintas & Persico, 2009; Schaefer & Pathophysiology
Mendelsohn, 2008). Tests for FXS in children
undergoing a genetic evaluation for ASD are One approach of current research is to utilize the
positive in up to 5% of cases (Reddy, 2005; findings of rare chromosomal abnormalities as
Schaefer & Mendelsohn, 2008). Recent studies a route toward understanding the underlying
have suggested that higher resolution cytogenet- pathophysiology of ASD. Therefore, known
ics tests should also be included as a standard part genetic syndromes that are associated with an C
of the evaluation of a child with ASD, given the increased risk of symptoms that are similar to
increased yield of the higher resolution tests those found in ASD may be instrumental
(Reddy, 2005; Shen et al., 2010). One of the in highlighting regions of chromosomes, and
challenges of conducting these tests remains therefore, individual genes, that may
the limitation in our ability to interpret the find- predispose to ASD. Elucidating the functions of
ings, particularly given that structural abnormal- these candidate genes can lead us to a better
ities may be inherited or de novo, and given the understanding of biological mechanisms that
pleiotropy of some of the regions implicated in may be causative.
ASD. It is important to observe that while any of the
As the technology used to detect chromosomal chromosomal abnormalities discussed above,
variation has improved in recent years, our ability e.g., 15q11-13, are individually rare in idiopathic
to identify abnormalities in chromosomal struc- ASD, symptoms consistent with a diagnosis of
ture in the research lab has advanced consider- ASD may occur at relatively high frequencies in
ably such that it is now possible to detect individuals with known genetic syndromes. For
accurately changes that are in the kilobase example, more than 40% of children with
range. These submicroscopic gains or losses of Angelman syndrome and 25% of males with
genetic material are called copy number varia- FXS have an ASD (Abrahams & Geschwind,
tions (CNVs). Since 2005, studies of CNVs have 2008). FXS is an important example of how the
made a major contribution to our understanding identification of a cytogenetic abnormality asso-
of the genetic architecture of ASD. Sebat and ciated with an increased risk of ASD can advance
colleagues were the first to identify an increased our knowledge of pathophysiology. FXS is the
association of de novo CNVs in families with one most common inherited cause of intellectual dis-
affected child (simplex) compared to multiplex ability (Cornish, Turk, & Hagerman, 2008). The
families, in which more than one child has autism genetic etiology was first identified because
(Sebat et al., 2007). This finding is consistent the mutation produces a constriction in the
with the rare variant hypothesis, which predicts X chromosome that is visible by light micros-
that individually rare, de novo variation accounts copy. Subsequent studies found that FXS is
for the risk of autism in families where only one caused by disruption of a single gene, fragile
child is affected. At the same time, studies of X mental retardation 1 (FMR1), by
CNVs in autism have shown that they have sim- a trinucleotide repeat expansion, and that this
ilar properties as other types of genetic variation. gene produces a protein that regulates the
That is, CNVs can either be inherited or arise de transport and activation of other molecules
novo, common or rare, and may or may not be that play important roles at the synapse of
associated with an increased risk of ASD nerve cells. Further analysis of the function
(Hoffman & State, 2010). Although CNVs that of FMR1 revealed a potential mechanism for
are associated with ASD are individually rare, reversing the adverse effects of the mutation
e.g., occur in only 1–2% of individuals with pharmacologically (Cornish et al., 2008).
ASD, as a group, these may occur in at least Importantly, FMR1 was identified as
10–20% of affected individuals (Abrahams & a candidate gene in ASD due to the increased
Geschwind, 2008). risk of ASD in individuals with FXS, even though
C 638 Chromosomal Abnormalities
mutations in FMR1 are individually rare in idio- References and Readings

pathic autism. Therefore, one approach to the
identification of novel candidate genes in ASD Abrahams, B. S., & Geschwind, D. H. (2008). Advances in
that is based on the rare variant hypothesis is to
ogy. Nature Reviews Genetics, 9(5), 341–355.
find rare cases of de novo chromosomal abnor- Bakkaloglu, B., O’Roak, B. J., Louvi, A., Gupta, A. R.,
malities in affected individuals and to identify Abelson, J. F., Morgan, T. M., et al. (2008). Molecular
precisely which genes are disrupted at the break cytogenetic analysis and resequencing of contactin
associated protein-like 2 in autism spectrum disorders.
points. This approach has led to crucial discover-
American Journal of Human Genetics, 82(1), 165–173.
ies, including the identification of the following Cornish, K., Turk, J., & Hagerman, R. (2008). The fragile
susceptibility genes: contactin-associated pro- X continuum: New advances and perspectives. Jour-
tein-like 2 (CNTNAP2), contactin 4 (CNTN4), nal of Intellectual Disability Research, 52(Pt 6),
469–482.
neuroligin 4X (NLGN4X), and SH3 and
Durand, C. M., Betancur, C., Boeckers, T. M., Bockmann,
multiple ankyrin repeat domains 3 (SHANK3) J., Chaste, P., Fauchereau, F., et al. (2007). Mutations
(Bakkaloglu et al., 2008; Durand et al., 2007; in the gene encoding the synaptic scaffolding protein
Fernandez et al., 2004; Jamain et al., 2003). SHANK3 are associated with autism spectrum disor-
ders. Nature Genetics, 39(1), 25–27.
While disruptions of these genes are rare in idio-
Fernandez, T., Morgan, T., Davis, N., Klin, A., Morris, A.,
pathic autism, their identification as candidates Farhi, A., et al. (2004). Disruption of contactin 4
has been important in elucidating the pathophys- (CNTN4) results in developmental delay and other
iology of ASD by illuminating potential biologi- features of 3p deletion syndrome. American Journal
of Human Genetics, 74(6), 1286–1293.
cal mechanisms, such as synapse formation and
Hoffman, E. J., & State, M. W. (2010). Progress in cyto-
function. genetics: Implications for child psychopathology.
In recent studies, CNVs serve a similar func- Journal of the American Academy of Child and Ado-
tion as large chromosomal disruptions, lescent Psychiatry, 49(8), 736–751; quiz 856–737.
Jamain, S., Quach, H., Betancur, C., Rastam, M.,
highlighting genes that are likely to play a role
Colineaux, C., Gillberg, I. C., et al. (2003). Mutations
in ASD. However, one of the challenges that of the X-linked genes encoding neuroligins NLGN3
current researchers face is the high degree of and NLGN4 are associated with autism. Nature Genet-
structural variation that exists throughout the ics, 34(1), 27–29.
Jorde, L. B., Carey, J. C., & Bamshad, M. J. (2010). Jorde:
genomes of affected and unaffected individuals,
Medical genetics (4th ed.). Philadelphia: Mosby.
which often confounds the interpretation of Lintas, C., & Persico, A. M. (2009). Autistic phenotypes
CNV studies. Nonetheless, it is clear that abnor- and genetic testing: State-of-the-art for the clinical
malities in chromosome structure have the geneticist. Journal of Medical Genetics, 46(1), 1–8.
Nussbaum, R. L., McInnes, R. R., & Willard, H. F. (2007).
potential to offer insight into the genetic
Nussbaum: Thompson & Thompson genetics in medi-
etiology of ASD. By following the leads from cine (7th ed.). Philadelphia: Saunders Elsevier.
studies of chromosomal abnormalities, O’Roak, B. J., & State, M. W. (2008). Autism genetics:
current research aims to illuminate common Strategies, challenges, and opportunities. Autism
Research, 1(1), 4–17.
mechanisms involving candidate genes and,
Reddy, K. S. (2005). Cytogenetic abnormalities and frag-
thereby, to identify new approaches for ile-X syndrome in autism spectrum disorder. BMC
treatment. Medical Genetics, 6, 3.
Schaefer, G. B., & Mendelsohn, N. J. (2008). Clinical
genetics evaluation in identifying the etiology of
autism spectrum disorders. Genetics in Medicine,
10(4), 301–305.
See Also Sebat, J., Lakshmi, B., Malhotra, D., Troge, J., Lese-Mar-
tin, C., Walsh, T., et al. (2007). Strong association of
▶ Angelman/Prader-Willi Syndromes de novo copy number mutations with autism. Science,
316(5823), 445–449.
▶ Common Disease-Rare Variant Hypothesis Shen, Y., Dies, K. A., Holm, I. A., Bridgemohan, C.,
▶ Fragile X Syndrome Sobeih, M. M., Caronna, E. B., et al. (2010). Clinical
▶ Karyotype genetic testing for patients with autism spectrum dis-
▶ Pleiotropy orders. Pediatrics, 125(4), e727–e735.
Chromosome 15q11–q13 639 C
State, M. W., & Levitt, P. (2011). The conundrums of gene is an imprinting center, which helps to
understanding genetic risks for autism spectrum disor- determine the parental imprint of the chromo-
ders. Nature Neuroscience, 14(12), 1499–1506.
Veenstra-VanderWeele, J., & Cook, E. H., Jr. (2004). some (Saitoh et al., 1996).
Molecular genetics of autism spectrum disorder. The entire region is prone to complex
Molecular Psychiatry, 9(9), 819–832. rearrangements in chromosomal structure and
has been implicated in Autism Spectrum
Disorders (ASDs) as well as in schizophrenia, C
epilepsy, and intellectual disability. Within the
Chromosome 15q11–q13 interval, there are a number of specific points
that are particularly likely to serve as the bound-
Abha R. Gupta aries for changes in chromosomal structure.
Developmental-Behavioral Pediatrics, Child These are called breakpoints and have been
Study Center, Yale University, New Haven, CT, numbered BP (breakpoint) 1–BP5. Duplications
USA of the maternal chromosome extending from
either the centromere or BP1 to BP5 are among
the most common changes in chromosomal
Synonyms structure identified in ASD (Sanders et al.,
2011). A high proportion of patients with
Angelman/Prader-Willi locus duplications at this locus meet diagnostic criteria
for ASD (Abrahams & Geschwind, 2008).
Conversely, in some clinical ASD cohorts, up
Definition to 1% of patients show maternal duplications of
this interval (Sanders et al., 2011). In addition,
This region on the long arm of chromosome 15 deletions of the BP1–BP2 region and BP4–BP5
is adjacent to the centromere and is 14.6 million regions have been associated with schizophrenia,
bases in size. It spans genomic coordinates deletions of BP4–BP5 have been implicated
19,000,001–33,600,000 (GRCh37/hg19 assem- in epilepsy and intellectual disability, and
bly, UCSC Genome Browser). It contains numer- duplications within the BP4–BP5 interval have
ous genes, some of which are subject to genomic been identified in patients with ASD and intellec-
imprinting, a phenomenon by which a gene(s) tual disability and are also not infrequently seen
is silent on either the maternally or paternally trans- in unaffected individuals (Sanders et al., 2011).
mitted chromosome. Mutations in this locus are
responsible for Angelman and Prader-Willi Syn-
dromes. Deficiency of the maternally expressed See Also
UBE3A gene causes Angelman Syndrome. While
it has not been definitively determined which gene ▶ Angelman/Prader-Willi Syndromes
(s) in the interval cause PWS, deficiency of pater- ▶ Copy Number Variation
nally expressed small nucleolar RNAs (snoRNAs)
has been considered the leading suspect.
Other genes at this locus include those which References and Readings
encode subunits of the GABA receptors,
Abrahams, B. S., & Geschwind, D. H. (2008). Advances in
GABRB3, GABRA5, and GABRG3. CYFIP1 autism genetics: On the threshold of a new neurobiol-
encodes a protein, which interacts with the ogy. Nature Reviews Genetics, 9, 341–355.
Fragile X mental retardation protein, FMRP UCSC Genome Browser, GRCh37/hg19 (February 2009)
(Schenck, Bardoni, Moro, Bagni, & Mandel, Assembly. Retrieved 27 Apr, 2012 from http://genome.
ucsc.edu/
2001). SNRPN encodes a small nuclear ribonu- Saitoh, S., Buiting, K., Rogan, P. K., Buxton, J. L.,
cleoprotein that is involved in mRNA processing. Driscoll, D. J., Arnemann, J., et al. (1996). Minimal
The upstream untranslated region (50 UTR) of this definition of the imprinting center and fixation of
C 640 Chronic Dyskinesia
chromosome 15q11-q13 epigenotype by imprinting callosum, continuing through the cingulate sulcus.
mutations. Proceedings of the National Academy Traditionally, the cingulate cortex is divided into
of Sciences of the United States of America, 93,
7811–7815. an anterior portion or anterior cingulate and
Sanders, S., Ercan-Sencicek, A. G., Hus, V., Luo, R., a posterior portion or posterior cingulate. Broadly,
Murtha, M. T., Moreno-De-Luca, D., et al. (2011). the anterior cingulate is involved in self-regulatory
Multiple recurrent de novo CNVs, including duplica- and executive control functions, social and emo-
tions of 7q11.23 Williams syndrome region, are
strongly associated with autism. Neuron, 70, 863–885. tional processing, and respiratory control. The
Schenck, A., Bardoni, B., Moro, A., Bagni, C., & posterior cingulate is thought to be involved in
Mandel, J. L. (2001). A highly conserved protein supporting internally directed thought. As a key
family interacting with the fragile X mental retardation node of the default mode network, the posterior
protein (FMRP) and displaying selective interactions
with FMRP-related proteins FXR1P and FXR2P. cingulate cortex is thought to play a role in mod-
Proceedings of the National Academy of Sciences of ulating the dynamic interplay between the default
the United States of America, 98, 8844–8849. mode network and attention networks providing
for efficient allocation of attention.
Chronic Dyskinesia
See Also
▶ Tardive Dyskinesia
▶ ERN
▶ Error-Related Negativity
Chronic Hairpulling ▶ Feedback-Related Negativity
▶ Trichotillomania
Vogt, B. A. (Ed.). (2009). Cingulate neurobiology and

Chronological Age Appropriateness disease. Oxford: Oxford University Press.
▶ Developmentally Appropriate Practice (DAP)

Cingulum
CII Susan Y. Bookheimer

Department of Psychiatry and Biobehavioral
▶ Communication Intention Inventory Sciences, UCLA School of Medicine,
Cingulate Cortex
Synonyms
Michael J. Crowley
Developmental Electrophysiology Laboratory, Cingulum bundle
Yale Child Study Center, New Haven,
CT, USA
Definition
Definition The cingulum, also known as the cingulum

bundle, is a fiber tract in the brain that connects
The cingulate cortex is a brain region located in the the cingulate gyrus, found in the midline of the
medial portion of the cortex, just above the corpus brain above the corpus callosum, to the entorhinal
Circle of Friends 641 C
cortex, found in the base of the anterior temporal
lobe. The tract lies between the cingulate gyrus Circle of Friends
and the corpus callosum, curving around the back
of the callosum and extending into the anterior Howard Goldstein
temporal lobe. The brain structures that the cin- Human Development and Family Science, The
gulum connects both belong to the limbic system, Ohio State University, Columbus, OH, USA
which is involved in the experience and regula- C
tion of emotional states as well as memory. The
cingulate gyrus has many functions including Definition
helping to selectively attend to relevant stimuli
in the environment. Thus, the cingulum may send Circle of friends is a conceptual framework that
attended signals from the cingulate gyrus into has been used to develop interventions to pro-
a pathway that allows salient information to mote inclusion of individuals with disabilities in
become encoded into long-term memories. mainstream settings through relationship devel-
opment with peers, especially individuals at par-
See Also ticular risk of rejection or social isolation. A more
specific definition refers to “circle of friends” as
▶ Cingulate Cortex a group of people who gather around a person
▶ Limbic System who has become excluded or isolated (Falvey,
Forest, Pearpoint & Rosenberg, 1997).

Nezamzadeh, M., Wedeen, V. J., Wang, R., Zhang, Y.,
Zhan, W., Young, K., Meyerhoff, D. J., Weiner, M. W., The circle of friends intervention was initially
& Schuff, N. (2010). In-vivo investigation of the
human cingulum bundle using the optimization of developed in Canada to facilitate the deinstitu-
MR diffusion spectrum imaging. European Journal of tionalization of people with disabilities
Radiology, 75(1), e29–e36. transitioning to their local communities. Circle
Pugliese, L., Catani, M., Ameis, S., Dell’Acqua, F., of friends was subsequently applied to supporting
Thiebaut de Schotten, M., Murphy, C., Robertson, D.,
Deeley, Q., Daly, E., & Murphy, D. G. (2009). the inclusion of pupils with special needs in their
The anatomy of extended limbic pathways in Asperger local mainstream schools (Forest & Lusthaus,
syndrome: a preliminary diffusion tensor imaging 1989). Circle of friends also was adapted to sup-
tractography study. Neuroimage, 47(2), 427–434. port children experiencing emotional, behavioral,
van den Heuvel, M., Mandl, R., Luigjes, J., & Hulshoff Pol,
H. (2008). Microstructural organization of the cingulum and social difficulties in schools (Newton, Tay-
tract and the level of default mode functional connec- lor, & Wilson, 1996; Pearpoint, Forest, &
tivity. Journal of Neurosciences, 28(43), 10844–10851. O’Brien, 1996). The basic implementation of
circle of friends involved enlisting the help
of classmates through conducting a whole-class
meeting and then setting up a voluntary, special
Cingulum Bundle group or a “circle of friends.” This circle of
friends group helps to set, monitor, and review
▶ Cingulum weekly targets in a meeting facilitated by an
adult. Parents also have been encouraged to
establish circle of friends (Turnbull, Pereira, &
Blue-Banning, 1999). Other social skills
Cipralex (Canada) interventions that have involved peer-mediated
interventions, such as peer buddies (e.g., English,
▶ Escitalopram Goldstein, Shafer, & Kaczmarek, 1997) or peer
C 642 Circle of Friends
support networks (e.g., Haring & Breen, 1992), or within natural community settings. Building
have sometimes been referred to as consistent the circle of friendship changes the people who
with the circle of friends approach. may be moving from other circles, e.g., “associ-
ates,” as well as the person with the disability
who is at the center of the circle.
Rationale or Underlying Theory As described below, the people in the circle of
friendship are provided information to deepen
The original conceptualization of circle of friends their appreciation of the person at the center of
was graphically represented by a set of concentric the circle, the characteristics of their disorder, as
circles. The center of the circle represents the well as their individual strengths, interests, and
individual with a disability who is the focus of desires. They are called upon to identify targets
intervention. The second circle is called the circle that will enhance the social inclusion of the
of intimacy and includes people who are called person, to assist with the learning process, and
“anchors.” This circle represents the close rela- to track progress. Ultimately, the persons in the
tionships that one cannot live without. The third peer group are expected to develop authentic
circle is called the circle of friendship and friendships characterized by supportive, recipro-
includes people who are called “allies.” The cir- cal relationships that will expand social inclusion
cle represents friends and close relatives. They as the person with disabilities learns to adapt
are people one can count on in difficult times and successfully to a growing set of social
who one can confide in. If friendship relation- circumstances.
ships are sparse, one is prone to isolation, and
this may result in anger and depression. The
fourth circle is the circle of participation and Goals and Objectives
includes people who are called “associates.”
Associates are people with whom one may The goal of circle of friends programs is to pro-
interact in the community, in school, in houses mote social inclusion of individuals at risk of
of worship, etc. The fifth circle is the circle of rejection or isolation from the community. Circle
exchange and includes people who are “paid.” of friends programs could promote increased
This would encompass interactions with teachers, support within the different circles or levels,
aides, medical providers, therapists, hairdressers, such as extended family, friends, neighbors, and
etc. People with disabilities may interact with faith communities, but the main objective is to
more than the usual number of paid members. increase the circle of friendship.
These individuals appear to set the agenda for
the person with disabilities through scheduled
appointments, policy requirements, and their Treatment Participants
limited availability.
These concentric circles are sometimes Circle of friends has been applied to a variety of
referred to as circles of support. They can change populations of individuals of all ages with dis-
over time, especially at life transitions that may abilities. Applicability to individuals with autism
change the cast of people in one’s life. This is readily apparent, as social and communication
model recognizes the stability of the inner circle skills tend to be an area of weakness that typically
of intimacy, but points out that other relationships must be addressed to promote social inclusion of
are important to develop human potential and individuals with autism. Peer approaches to
experience. In particular, the circle of friends promoting social inclusion are prevalent in pre-
intervention emphasizes the need to grow the school settings, but have been applied to school
circle of friendship to maximize inclusion of age and older individuals as well. Transitions to
the person with disabilities in mainstream society different school, vocational, and residential set-
and to minimize the likelihood of isolation from tings are each likely to require a reevaluation of
Circle of Friends 643 C
one’s circle of friends and the need for additional of circle of friends programs, although they
efforts to provide supportive social partners at have not been developed from the circle of
various levels. friends conceptual framework.
Treatment Procedures Efficacy Information

C
Interventions deemed most consistent with the Few evaluations of circle of friends programs
circle of friends framework are likely to begin have been conducted. Many of those evaluations
with filling in names in the concentric circles of have reported encouraging results using qualita-
anchors, allies, associates, and paid members. tive case study methodologies or have been
The interventionist uses this information to illus- largely descriptive in nature (Barrett & Randall,
trate the importance of peer friendships, rather 2004; Calabrese et al., 2008; Gus, 2000; Newton
than relationships with mainly paid adults. The et al., 1996; Whitaker, Barratt, Joy, Potter, &
intervention program usually provides new and Thomas, 1998). A lack of a standard treatment
accurate information about the nature of the dis- protocol hinders replication and makes evalua-
ability, such as the characteristics of autism, and tions of circle of friends difficult.
the nature of increased support among allies and Small-scale group design studies have shown
associates in particular. Peers are called upon to improvements in social skills compared to com-
identify positive features or assets of the individ- parison groups (Kalyva & Avramidis, 2005). On
ual who is the focus of intervention. As peers the other hand, Frederickson and colleagues
discuss strengths, interests, preferences, and (Frederickson, Warren &, Turner, 2005) found
desires of their peer with autism, they are guided that improved social acceptance on the part of
to recognize that everybody has their own special classmates tended to diminish over time and there
abilities and areas of needs. The overlap between were no discernable long-term effects seen in the
features of autism and the areas that they may find social skills of primary grade children with
difficult when interacting with their peer with autism. Owen-DeSchryver, Carr, Cale, and
autism are highlighted. The peers are encouraged Blakely-Smith (2008) employed peer training
to discuss their own strengths and weaknesses as based at least in part on circle of friends and
well. This process is meant to increase social showed, in a multiple baseline design across
acceptance as well as identifying unique needs peer groups, that peers’ initiations increased
or skills that the peers might help the individual after training and a corresponding increase in
with disabilities master to increase acceptance. initiations and responses was seen in children
Weaknesses are discussed as “things one is still with ASD. An examination of the single-subject
learning to do.” Thus, the peers are given primary graphs reveals a strong correspondence between
responsibility for helping identify social targets peer behavior and the corresponding social
and identifying ways to encourage learning on the behavior of the children with autism. Long-term
part of the person with a disability. They also may maintenance and generalization of effects were
be asked to track progress and to be sensitive to not evaluated, however. Miller, Cooke, Test, and
new skills that might be needed to adapt to White (2003) also used a multiple baseline design
a growing array of social situations. An adult across peers and found improved social skills
facilitator typically meets with a group of peers during lunchtime following friendship circle
and the person with the disability on a regular training. They also found impressive mainte-
basis to help sustain the effort and ensure that nance and generalization to recess and other
interactions are supportive, encouraging, and activities for two of the three participants.
acceptable to all involved. Peer-mediated interventions have repeatedly
A number of peer buddy and peer network been shown to have robust effects on improving
interventions have been considered exemplars the social behavior of young children with autism
C 644 Circle of Friends
(McConnell, 2002; Rogers, 2000). However, See Also

there are few studies that evaluate maintenance
of effects and the extent to which peer relation- ▶ Inclusion
ship development results. Perhaps more consis- ▶ Peer-Mediated Intervention
tent with the circle of friends framework is the ▶ Social Interaction Supports
promising research on peer support networks that ▶ Social Interventions
have been shown to be efficacious in promoting ▶ Social Skill Interventions
prosocial behavior in youth with ASD (e.g., Har-
ing & Breen, 1992; Harrell, Kamps, & Kravits,
1997; Hughes et al., 1999). References and Readings
Barrett, W., & Randall, L. (2004). Investigating the circle

Outcome Measurement of friends approach: Adaptations and implications for
practice. Educational Psychology in Practice, 20,
353–368.
One measure of the effects of circle of friends Calabrese, R., Patterson, J., Lieu, F., Goodvin, S.,
programs is an assessment of the number of Hummel, C., & Nance, E. (2008). An appreciative
people who are identified and who identify them- inquiry into the circle of friends program: The benefits
of social inclusion of students with disabilities. Inter-
selves within the circles of friendship. In addi- national Journal of Whole Schooling, 4(2), 20–49.
tion, sociometric ratings can be used to determine English, K., Goldstein, H., Shafer, K., & Kaczmarek, L.
whether the individual has an elevated (1997). Promoting interactions among preschoolers
social status within a classroom or another social with and without disabilities: Effects of a buddy
skills-training program. Exceptional Children, 63,
network. Social network analyses also could be 229–243.
used to determine whether individuals with Falvey, M., Forest, M., Pearpoint, J., & Rosenberg, R.
disabilities move from the periphery to more (1997). All my life’s a circle. Toronto, Canada: Inclu-
central roles with more reciprocal friendship sion Press.
Forest, M., & Lusthaus, E. (1989). Promoting educational
nominations. equality for all students. Circles and maps. In
Observational data collection systems typi- S. Stainback, W. Stainback, & M. Forest (Eds.), Edu-
cally monitor the rate of social initiations and cating all students in the mainstream of regular edu-
responses. Alternatively, they could monitor cation (pp. 43–57). Baltimore: Paul H. Brookes.
Frederickson, N., Warren, L., & Turner, J. (2005). “Circle
more specific, targeted behaviors. For example, of friends”-An exploration of impact over time. Edu-
subsequent to circle of friends training, annoying cational Psychology in Practice, 21, 197–217.
or disruptive behaviors might be expected to Gus, L. (2000). Autism: Promoting peer understanding.
occur less often and appropriate topic shifts, shar- Educational Psychology in Practice, 16(3), 461–468.
Haring, T. G., & Breen, C. G. (1992). A peer-mediated
ing, complimenting, or other positive social social network intervention to enhance social integra-
behaviors being learned might be expected to tion of persons with moderate and severe disabilities.
occur more frequently. Journal of Applied Behavior Analysis, 25, 319–333.
Social skills rating scales also are available Harrell, L. G., Kamps, D., & Kravits, T. (1997). The
effects of peer networks on social-communicative
that can be administered to teachers, parents, or behaviors for students with autism. Focus on Autism
peer groups. and other Developmental Disabilities, 12, 241–256.
Hughes, C., Guth, C., Hall, S., Presley, J., Dye, M., &
Byers, C. (1999). They are my best friends. Peer
buddies promote inclusion in high school. Teaching
Qualifications of Treatment Providers Exceptional Children, 31, 32–37.
Kalyva, E., & Avramidis, E. (2005). Improving commu-
Circle of friends programs have been nication between children with autism and their peers
implemented by a variety of professionals, through the “circle of friends”: A small-scale interven-
tion study. Journal of Applied Research in Intellectual
including teachers, special educators, Disabilities, 18, 253–261.
counselors, speech-language pathologists, as McConnell, S. R. (2002). Interventions to facilitate social
well as parents. interaction for young children with autism: Review of
Circumstantiality 645 C
available research and recommendations for educa- Definition
tional intervention and future research. Journal of
Miller, M., Cooke, N., Test, D., & White, R. (2003). A pattern of speech characterized by provision of
Effects of friendship circles on the social interactions a mix of relevant and irrelevant information seen
of elementary age students with mild disabilities. Jour- in some psychiatric disorders. Typically,
nal of Behavioral Education, 12(3), 167–184. although some aspects of narrative are present,
Newton, C., Taylor, G., & Wilson, D. (1996). Circles of
friends: An inclusive approach to meeting emotional the inclusion of extraneous detail and only C
and behavioral needs. Educational Psychology in minimally relevant (or irrelevant) information
Practice, 11(4), 41–48. makes it difficult to follow the speaker’s thought.
Owen-DeSchryver, J. S., Carr, E. G., Cale, S. I., & Blakely- Often individuals need to be reminded of the
Smith, A. (2008). Promoting social interactions
between students with autism spectrum disorders and topic or question because they lose track of the
their peers in inclusive school settings. Focus on Autism topic. Typically the patient has difficulty in
and Other Developmental Disabilities, 23(1), 15–28. separating relevant from irrelevant information
Pearpoint, J., Forest, M., & O’Brien, J. (1996). MAPS, while describing an event. The patient often
circles of friends and PATH. Powerful tools to help
build caring communities. In S. Stainback & W. includes all details and presents them in
Stainback (Eds.), Inclusion: A guide for educators a sequential order, with the result that the main
(pp. 67–86). Baltimore: Paul H. Brookes. thread of thought becomes lost as one association
Rogers, S. J. (2000). Interventions that facilitate sociali- leads to another. Frequently the person may need
zation in children with autism. Journal of Autism and
Developmental Disorders, 30, 399–409. to have questions repeated because the main
Turnbull, A., Pereira, L., & Blue-Banning, M. (1999). point of answers has become lost in the confusion
Parents’ facilitation of friendships between their chil- of unnecessary detail. Circumstantial thinking/
dren with a disability and friends without a disability. speech is most commonly seen in schizophrenia
Research and Practice for Persons with Severe Dis-
abilities, 24(2), 85–99. and obsessive compulsive disorder. It can also be
Whitaker, P., Barratt, P., Joy, H., Potter, M., & Thomas, G. observed in some neurological syndromes
(1998). Children with autism and peer group support: (including epilepsy syndromes) at the interface
Using “circles of friends”. British Journal of Special of neurology and psychiatry. Individuals with
Education, 25(2), 60–64.
Asperger’s disorder may have difficulties with
monitoring conversational cues and often provide
tremendous detail about topics of special interest
but usually remain highly focused on their topic.
Circumstantial Thinking
▶ Circumstantiality See Also
▶ Asperger’s Disorder
▶ Obsessive-Compulsive Disorder (OCD)
Circumstantiality ▶ Schizophrenia
Fred R. Volkmar
Director – Child Study Center, Irving B. Harris References and Readings
Benson, D. F. (1991). The Geschwind syndrome.
Advances in Neurology, 55, 411–421.
University, New Haven, CT, USA Hoeppner, J. B., Garron, D. C., et al. (1987). Epilepsy and
verbosity. Epilepsia, 28(1), 35–40.
Koyama, T., & Kurita, H. (2008). Cognitive profile
difference between normally intelligent children with
Synonyms Asperger’s disorder and those with pervasive develop-
mental disorder not otherwise specified. Psychiatry &
Circumstantial thinking Clinical Neurosciences, 62(6), 691–696.
C 646 cis-N,N-dimethyl-9-[3-(4-methyl-1-piperazinyl)-propylidene] Thioxanthene-2-sulfonamide
North, C. S., Kienstra, D. M., et al. (2006). Interrater References and Readings
reliability and coding guide for nonpsychotic formal
thought disorder. Perceptual & Motor Skills, 103(2), King, B. H., Hollander, E., Sikich, L., McCracken, J. T.,
395–411. Scahill, L., Bregman, J. D., et al. (2009). Lack
of efficacy of citalopram in children with autism spec-
trum disorders and high levels of repetitive behavior.
Citalopram ineffective in children with autism.
cis-N,N-dimethyl-9-[3-(4-methyl-1- Archives of General Psychiatry, 66(6), 583–590.
piperazinyl)-propylidene]
Thioxanthene-2-sulfonamide
▶ Thiothixene CLAMS
▶ Clinical Linguistic and Auditory Milestone

Scale
Citalopram

Nursing & Child Psychiatry, Yale University Clancy Autism Behavior Scale
New Haven, CT, USA ▶ Clancy Behavior Scale
Synonyms
Clancy Behavior Scale
Escitalopram
Zachary Warren and Elizabeth
Howell Dohrmann
Definition Vanderbilt Kennedy Center, Treatment and
Research Institute for Autism Spectrum
Citalopram is used to treat depression and anxiety Disorders (TRIAD), Nashville, TN, USA
disorders. Citalopram is a selective serotonin
reuptake inhibitors (SSRI) used to treat depres-
sion and anxiety disorders. A large-scale, Synonyms
multisite trial of citalopram in 149 children with
autism spectrum disorders showed that it was no CABS; Clancy autism behavior scale
better than placebo for reducing repetitive behav-
ior. Citalopram is chemically related to the newer
SSRI, escitalopram, which is a single chemical Description
isomer of the molecule. By contrast, citalopram is
a so-called racemic mixture, which means that The Clancy Behavior Scale is an early autism
there are two isomers in citalopram. descriptive and classification tool first published
in 1969 by Clancy, Dugdale, and Rendle-Short in
order to better describe and classify autism in
See Also young children. Mothers provided reports of
child difficulty across 14 major domains, and
▶ Anxiety Disorders the instrument was suggestive of “infantile
▶ Depressive Disorder autism” if seven or more of these domains were
▶ Escitalopram endorsed as areas of concern.
Class Versus Variable 647 C
Historical Background infantile autism. The scale has not been
extensively studied, nor is it commonly
In the mid-to-late 1960s, the clinical researchers utilized across clinical populations at present.
Helen Clancy, Alan Dugdale, and John Rendle- However, recently, research teams in
Short in the Department of Child Health from the China (Chen et al., 2007; Ke, Luo, &
University of Queensland, Bribane, Australia, Tao, 2002) have discussed exploring the scale’s
attempted to develop a tool for more reliably usefulness in screening for autism and differenti- C
describing and accurately identifying young ating between other language and cognitive
children with autism. They suggested that accu- disorders.
rate classification could be enhanced by identify-
ing significant vulnerabilities across a 14- point
major manifestation scale including great diffi- See Also
culty in mixing and playing with other children,
acts as deaf, strong resistance to any learning, ▶ Childhood Autism Rating Scale
lack of fear about realistic dangers, resists change
in routine, prefers to indicate needs by gestures,
laughing and giggling for no apparent reason, not References and Readings
cuddly as a baby, marked physical overactivity,
no eye contact, unusual attachment to a particular Capute, A. J., Derivan, A. T., Chauvel, P. J., & Rodriguez,
A. (1975). Infantile autism: I. A prospective study of
object or objects, spins objects especially round
the diagnosis. Developmental Medicine and Child
ones, repetitive and sustained odd play, and Neurology, 17, 58–62.
standoffish manner. While the scale promoted Chen, Y., Chen, Z-M., Hu R-L, et al. (2007). Language
the use of specific tools and rating systems for Disorder Center of the First Affiliated
Hospital of Jinan University, Guangzhou 510630,
improved descriptive and classification purposes,
China; Clinical application of Clancy autism
it was not extensively studied or utilized across behavior scale[J];Guangdong Medical Journal;
clinical populations over time. 2007-03.
Clancy, H., Dugdale, A., & Rendle-Short, J. (1969).
The diagnosis of infantile autism. Developmental
Medicine and Child Neurology, 11, 432–442.
Psychometric Data Kanner, L. (1943). Autistic disturbances of affective
contact. Nerv Child, 2, 217–250. Kanner, L. (1968).
Fairly limited data regarding the scale’s psycho- Reprint. Acta Paedopsychiatr, 35(4), 100–136.
PMID 4880460.
metric properties is available. Capute, Derivan,
Ke, X. Y., Luo, S. J., Tao G. T. (2002). (Child Mental
Chauvel, and Rodriguez (1975) conducted Health Research Center of Nanjing Brain Hospital
a prospective study of 200 children to evaluate the Affiliated of NJMU, Nanjing, 210029, China);
reliability and validity of the Clancy Behavioral A study of Clancy behavior scale on childhood
autism [J]. Acta Academiae Medicinae Jiangxi;
Scale. Using only the scale, 48 of 200 children
2002-06.
met cutoffs for autism risk; however, only one of Rimland, B. (1971). The differentiation of childhood
these children actually fulfilled Kanner’s (1943) psychoses: An analysis of checklists for 2,218 psy-
criteria for infantile autism. These false positives chotic children. Journal of Autism and Childhood
Schizophrenia, 1, 161–174.
were suggested to correlate with increasing
severity of cognitive deficits, learning disorders,
and hearing loss.
Clinical Uses Class Versus Variable
This scale utilizes parent report of behavior to ▶ Dimensional Versus Categorical

indicate symptoms across 14 symptoms of Classification
C 648 Classical Conditioning
a dinner bell, instead of for the actual food itself;

Classical Conditioning the sexual response evoked by a familiar scent or
perfume, without the presence of the actual per-
Jennifer Wick son associated with the memory. Classical con-
Community Consultation Program, Division of ditioning can result in fear, hunger, and sexual
Neurodevelopmental and Behavioral Pediatrics, and sleep responses, conditioned to a once-
University of Rochester School of Medicine and neutral event or stimulus. Thus, it is a human
Dentistry, Rochester, NY, USA ability to predict or anticipate an upcoming plea-
surable or aversive event (Rescorla & Wagner,
1972). The prediction and anticipation may gen-
Synonyms eralize to other similar stimuli.
Though mathematical models and contempo-
Associative learning; Pavlovian conditioning rary descriptions of “configural encoding”
have been developed to account for and/or predict
the complexities of classical conditioning (Rescorla
Definition & Wagner, 1972; Rescorla, 2003), the occurrence is
visible in everyday events. Any environmental
The learning phenomena behind Pavlov’s often- event that pairs the human senses (i.e., stimuli)
cited salivating dogs (Pavlov, 1927) or Little and human need or emotion is a prime opportunity
Albert’s terror and crying in response to a white for classical conditioning to take place.
rat (Watson & Rayner, 1920) are perhaps more In the applied field of autism intervention and
scientifically extraordinary than are common treatment research, classical conditioning
sense. It is a unique phenomenon that demon- approaches take a backseat to operant condition-
strates the intricacies of how the brain forms ing approaches. However, a classical conditioning
memories and makes meaning. Classical condi- procedure, systematic desensitization, has been
tioning, or “Pavlovian conditioning,” is a type of used to reduce unwanted fear in children with
associative learning. The association between autism (Love, Matson, & West, 1990); this proce-
stimuli, or events that are linked in close timing, dure involves gradually increasing the intensity of
may be solidified after one or two pairings of the a fear-evoking stimulus. Classical conditioning
events in close succession. For example, most of has also been used in laboratory studies of char-
us know that a flash of lightning (visual stimuli) acteristics associated with autism. For example,
will likely result in a thunderous boom (auditory Stanton, Peloso, Brown, and Rodier (2007) found
stimuli), which can be loud and frightening. that classical conditioning of an eyeblink response
When an individual cringes/winces at the light- occurred more rapidly in a rodent model of autism
ning, instead of and before the thunder is emitted, than in other rodents. Similarly, Sear, Finn, and
classical conditioning has occurred – that is, the Steinmetz (1994) found more rapid eyeblink con-
lightning became a “conditioned” trigger for fear. ditioning in children with autism than in typically
In anticipation of the thunder, the individual developing children.
reacts to the lightning and not the thunder itself.
Classical conditioning explains a broad num-
ber of phenomena in our everyday learning. Not See Also
to be confused with operant conditioning, which
is a closely related form of associative learning ▶ Operant Conditioning
(and the learning phenomenon upon which
applied behavioral analysis is based; see Skinner References and Readings
1953, 1957), classical conditioning is the learning
that results from associating two closely timed Journal of Autism Developmental Disorders 1994
events: the salivating that takes place upon Dec;24(6):737–751.
Classroom Management 649 C
Love, S. R., Matson, J. L., & West, D. (1990). Mothers as routines of a classroom so that teaching and
effective therapists for autistic children’s phobias. learning can proceed in a safe and effective
Pavlov, I. P. (1927). Conditioned reflexes: An investigation manner.
of the physiological activity of the cerebral cortex (G.V.
Anrep, Trans.). London: Oxford University Press.
Poulos, A. M., & Thompson, R. F. (2004). Timing of Historical Background
conditioned responses utilizing electrical stimulation
in the region of the interpositus nucleus as a CS. Inte-
C
grative Psychological and Behavioral Science: The Historically, specialists in the field of education
Official Journal of the Pavlovian Society, 39, 83–94. state that classroom management encourages the
Rescorla, R. A. (2003). Contemporary study of Pavlovian establishment of student self-control through
conditioning. Spanish Journal of Psychology, 6,
185–195. positive achievement and behavior. Classroom
Rescorla, R. A., & Wagner, A. R. (1972). A theory of management is closely linked to issues of moti-
Pavlovian conditioning: Variations in the effective- vation, establishing a climate of respect between
ness of reinforcement and nonreinforcement. In A. H. classroom staff and students and also consistent
Black & W. F. Prokasy (Eds.), Classical conditioning
II (pp. 64–99). Appleton: Century-Crofts. discipline. The teacher is at a huge advantage
Sear, L. L., Finn, R. R., & Steinmetz, J. E. (1994). Abnor- when she or he spends the time to set up class-
mal classical eye-blink conditioning in autism. Journal room management that looks at content manage-
of Autism and Developmental Disorders, 24, 737–751. ment (skills that cut across subjects and activities;
Skinner, B. F. (1953). Science and human behavior.
New York: Macmillan. cf. instructional management skills, sequencing
Skinner, B. F. (1957). Verbal behavior. Englewood Cliffs, and integrating additional instructional activities,
NJ: Prentice-Hall. as well as instruction-related discipline problems
Stanton, M. E., Peloso, E., Brown, K. L., & Rodier, P. [Kounin as cited in Froyen & Iverson, 1999,
(2007). Discrimination learning and reversal of the
conditioned eyeblink reflex in a rodent model of p. 128]), conduct management (inclusion of
autism. Behavioral Brain Research, 176, 133–140. human diversity into one’s instructional philoso-
Watson, J. B., & Rayner, R. (1920). Conditioned emotional phy), and covenant management (classroom
reactions. Journal of Experimental Psychology, 3, 1–14. group and social systems). Research demon-
strates that a high incidence of disciplinary prob-
lems in the classroom results in a significant
impact on effectiveness of teaching and learning.
Classroom Aide Additional research indicates that strong consis-
tent management and organizational skills lead
▶ Para-educator to fewer classroom discipline problems (www.
▶ Paraprofessional intime.uni.edu/model/teacher/teac3summary.html).
Throughout the years, classroom management
has created areas of debate among teachers; how-
ever, it is widely recognized that a key component
Classroom Management of classroom management is the application and
implementation of behavioral approaches.
Susan A. Mason Sulzer-Azaroff (1981 in Bijou & Ruiz, p. 64)
Services for Students with Autism Spectrum stated the use of behavior modification in the
Disorders, Montgomery County Public Schools, classroom parallels the development of behavior
Silver Spring, MD, USA modification in the field of mental health. The
majority of early studies conducted in the 1960s
focused on the reduction of disruptive behaviors
Definition by changing teacher behavior; however, this
early application of behavior principles did not
Classroom management refers to ways of orga- teach the students an alternative behavior. Care-
nizing resources, students, procedures, and ful consideration of research shared by
C 650 Classroom Management
Birnbrauer, Wolf, Kidder, and Tague (1965), related to academic subjects, lighting, noise
Brigham and Sherman (1968), and Buell, Stod- levels, and the like).
dard, Harris, and Baer (1968) yielded the need to 2. Tasks should be presented with clear begin-
focus on using behavioral procedures to teach nings and ends – students should be able to
students in a way that classroom productivity, recognize when they should start and finish
language development, and social skills were work as well as when they should put away
promoted (Sulzer-Azaroff, 1981 in Bijou & materials (they also need to know where the
Ruiz, 1981. pp. 65–67). Subsequent research has materials go).
contributed to a growing body of research 3. Routines should be incorporated into the
that supports positive classroom management classroom and flexibility taught and incorpo-
through the use of modeling behavior expecta- rated into plans, that is, program for routine
tions and using differential reinforcement proce- and change.
dures (Sulzer-Azaroff & Mayer, 1986). 4. Tasks should be clearly organized, and infor-
Throughout the years, this research has become mation should be presented visually.
more refined and focused on a variety of needs 5. Materials and tasks should be structured and
that are represented in the learning characteristics modified so that the student is able to indepen-
of students with autism spectrum disorders dently respond to the task/lesson.
(ASD). 6. Transitions join tasks together in a natural way
– specific transitional elements link tasks
together into multi task systems.
Current Knowledge 7. Communication is used to foster indepen-
dence – systems are designed so that commu-
The current trends in education emphasize the nication takes place as much as possible
establishment and use of positive behavioral without adult presence and dependence.
intervention and supports and school-wide posi- 8. Specific work systems are set up (Montgom-
tive behavioral intervention and supports. The ery County Public Schools, Services for
use of such systems is best practice; however, Students with Autism Spectrum Disorders,
students with ASD present unique characteristics 2009).
within a learning environment. The teacher is Students with ASD rely heavily on structure
challenged to incorporate these unique learning and predictable routines, and as such structure
needs into meaningful classroom management and predictable routines should be incorporated
and instruction. To do this, the teacher must into classroom management. It is key to use these
take into account the needs of the learner in structures and routines consistently and with
a variety of educational settings. These settings fidelity. Students with ASD also may need cus-
necessitate careful thought about physical struc- tomized visual daily schedules, reduced auditory
ture, instructional management, the student’s input, succinct verbal instructions that emphasize
ability in the areas of communication and social key points, consideration of reduced visual dis-
skills, and the need to teach the student how to tractions (e.g., movement, reflections, back-
learn under a variety of conditions. ground patterns), and consideration of reducing
Classroom management for the student with other environmental stimuli that may be incom-
ASD should include consideration of the follow- patible with the sensory sensitivities that are asso-
ing aspects of instruction: ciated with autism spectrum disorders (e.g.,
1. Physical space in the classroom needs to be set temperatures, textures, smells, tastes, the need
up with clearly defined areas that have visual to move or have movement breaks). The student
boundaries (e.g., independent work areas, with ASD will also need to have advance warning
group work areas, an area for use of technol- about changes in his/her environment, they may
ogy such as a SMART Board or computer, need a special place to go to that offers opportu-
areas that have critical visual information nity for relaxation and/or relief from stressful
Classroom Structure 651 C
situations that may result from innate anxiety. Spectrum Disorders. Unpublished Manuscript, Silver
The student also needs to have contact with Spring, MD.
Moore, S. T. (2002). Asperger syndrome and the elemen-
peers who model and offer appropriate social tary school experience: Practical solutions for aca-
interactions. The teacher should consider the demic & social difficulties. Shawnee Mission, KS:
needs of the student with ASD with regard to Autism Asperger Publishing Company.
teaching specific communication and social skills Pierangelo, R., & Giuliani, G. (2008). Teaching students
and should structure the environment in a way
with autism spectrum disorders. Thousand Oaks, CA:
Corwin Press.
C
that promotes these skills within the context of Quill, K. A. (1995). Teaching children with autism: Strat-
daily routines. egies to enhance communication and socialization.
New York: Delmar.
Scott, T. M., Anderson, C. M., & Alter, P. (2012). Man-
aging classroom behavior using positive behavior sup-
Future Directions ports. Boston: Pearson.
Sulzer-Azaroff, B. (1981). Issues and trends in behavior
Students with ASD are increasingly present in modification in the classroom. In S. W. Bijou &
R. Ruiz (Eds.), Behavior modification contributions
general education settings and classrooms. As to education (pp. 63–93). New Jersey: Lawrence
such, teachers need to be aware of their unique Erlbaum Associates.
learning profiles and ways to incorporate their Sulzer-Azaroff, B., & Mayer, G. R. (1986). Achieving
needs into classroom management. The current educational excellence using behavioral strategies.
New York: Holt, Rinehart, and Winston.
movement of the use of positive behavioral inter- www.intime.uni.edu/model/teacher/teac3summary.html
vention systems and school-wide positive behav- www.pbis.org/school/what_is_swpbs.aspx
ioral intervention supports is a start in this
direction; however, individualization will remain
paramount if students with ASD are to have
a successful educational experience.
Classroom Structure
See Also Catherine Davies

Indiana Resource Center for Autism Indiana
▶ Positive Behavioral Support University, Bloomington, IN, USA
Synonyms
Birnbrauer, J. S., Wolf, M. M., Kidder, J. D., & Tague, C.

Organization of the physical learning
(1965). Classroom behaviour of retarded pupils with environment
token reinforcement. Journal of Experimental Child
Bijou, S., & Ruiz, R. (Eds.) (1981) Behavior Modification
Contributions to Education, New Jersey: Lawrence
Definition
Erlbaum Associates Publishers.
Buell, Stoddard, Harris, & Baer, (1968); (Hart & Risley, How the physical environment is organized to
1995). For many years, teachers and 118 / May 2009 facilitate student success in learning (Interactive
Behavioral Disorders, 34(3), 118–135.
Froyen, L. A., & Iverson, A. M. (1999). Schoolwide and
Collaborative Autism Network (ICAN), n.d.).
classroom management: The reflective educator- For students with autism spectrum disorders
leader (3rd ed.). New Jersey: Prentice Hall. (ASD), classrooms should include a high degree
Fullerton, A., Stratton, J., Coyne, P., & Gray, C. (1996). of structure in order to ensure success (Bodfish,
Higher functioning adolescents and young adults with
autism: A teacher’s Guide. Austin, TX: Pro-Ed.
2004; Iovannone, Dunlap, Huber, & Kincaid,
Montgomery County Public Schools, Montgomery 2003; Mesibov & Shea, 2010). The Structured
County Maryland, Services for Students with Autism Teaching approach (an evidence-based approach
C 652 Client Assistance Program
devised by the TEACCH [Treatment and References and Readings

Education of Autistic and related Communica-
tion-handicapped CHildren] Program in North Ball, J. (n.d.). Structured classrooms, virtual speaker by
talk autism [video]. Retrieved January 25, 2011, from
Carolina, Mesibov & Shea) includes structuring
http://www.talkautism.com/Components/Video/Video.
the physical environment (it also incorporates the aspx?v¼59
strategic environment of learning approaches Bodfish, J. W. (2004). Treating the core features of autism:
which will not be considered here). Are we there yet? Mental Retardation and Develop-
mental Disabilities Research Reviews, 10, 318–326.
Effective classroom structure for students with
Interactive Collaborative Autism Network (ICAN). (n.d.).
ASD should include (Ball, n.d.; Mesibov, Shea, Classroom structure. Retrieved January 25, 2011,
& Schopler, 2004; Mesibov & Shea, 2010): from http://www.autismnetwork.org/modules/envi-
• Physical structure – using furniture to demon- ron/cstructure/index.html
Iovannone, R., Dunlap, G., Huber, H., & Kincaid, D.
strate expectations and reduce distractions.
(2003). Effective educational practices for students
• Visual schedules – using objects, pictures, or with autism spectrum disorders. Focus on Autism and
the written word to show the student the Other Developmental Disabilities, 18, 150–165.
sequence of events. Mesibov, G. B., & Shea, V. (2010). The TEACCH pro-
gram in the era of evidence-based practice. Journal of
• Visually structured individual tasks that
incorporate object, picture, and/or written Mesibov, G., Shea, V., & Schopler, E. (2004). The
instructions. TEACCH approach to autism spectrum disorders.
• Organizing a sequence of individual tasks New York: Springer.
using visual work/activity systems – using
objects, pictures, letters, numbers, or the writ-
ten word, tasks are organized to show the
student what they have to do, how many Client Assistance Program
tasks they need to do, how they are
progressing, when they will be finished, and ▶ Protection and Advocacy System (P&A)
what they are going to do next. For example,
lining up the tasks on the students’ left and
having them move them to their right when
completed. Clinical Assessment
Within these features, the key to student suc-
cess is that the details of the structure of the Steven E. Kroupa1 and Colleen Quinn2
1
classroom are individualized according to the Department of Psychiatry, The University of
strengths and weaknesses of each student North Carolina at Chapel Hill, Chapel Hill,
(Mesibov et al., 2004). NC, USA
2
TEACCH-Fayetteville Center, Fayetteville,
NC, USA
See Also
▶ Culture and Autism Definition

▶ Educational Interventions
▶ Pictorial Cues/Visual Supports (CR) Clinical assessment is the art and science of
▶ Structured Classrooms understanding a person’s behavior from
▶ Structured Teaching a variety of perspectives (e.g., biological, psycho-
▶ TEACCH Transition Assessment Profile logical, and social/cultural) and within the
(TTAP) different contexts in which he or she lives. As
▶ Visual Schedule a science, clinical assessment strives to develop
▶ Visual Supports procedures and judgments based upon empirical
Clinical Assessment 653 C
evidence and the critical evaluation of that evi- with ASD (e.g., Wing & Potter, 2009), greater
dence. As an art, clinical assessment relies on the public and media attention, and advances in bio-
creativity and innovation of the clinician to syn- logical knowledge and medical technology, there
thesize relevant findings and to develop new the- is new promise for significant advances in bio-
oretical models, new assessment tools, and new medical applications in the assessment of ASD
applications of existing knowledge and skills (Goldstein, Naglieri, & Ozonoff, 2009; Volkmar,
beyond the limits of current research, yet still State, & Klin, 2009). C
guided by the values, principles, and consensus
expert opinion of what constitutes best practices.
Clinical assessment, in general, is always Historical Background
defined within the current historical and cultural
context, the training and credentials of the clini- The description of autism as a diagnostic term
cian, and the purpose of the evaluation. Similarly, began formally with Kanner’s description in
clinical assessment of autism spectrum disorders 1943 (Kanner, 1943). Professionals working in
(ASD) is shaped by the current state of knowl- this area fell into a few categories: those who
edge regarding the characteristics of ASD, licens- used the descriptions very broadly, those who
ing requirements for clinical practice, and the used the symptoms to diagnosis very narrowly,
referral question(s) that will be addressed by the those who said autism was part of other childhood
evaluation. (Throughout this entry, the terms disorders, those who said autism was separate
autism and autism spectrum disorder are used from other childhood disorders, and those who
interchangeably and considered to be essentially used the terms autism and childhood schizophre-
synonymous with pervasive developmental dis- nia interchangeably (Feinstein, 2010). Other
order. These terms, as used here, are inclusive of researchers started trying to specify observable
all subtypes, unless otherwise noted.) The current behaviors and came up with sets of criteria. Over
best practice use of the biopsychosocial model of the years, researchers developed their own
clinical assessment integrates the most relevant criteria for what defined autism behaviors, and
information about the biological, psychological, as a result, criteria used for diagnosis changed.
and social/cultural processes that contribute to Confusion with diagnostic labeling, criteria,
a broad and deep understanding of the presenting and exclusionary criteria persisted for many
problem(s). This multifaceted, investigative years even as researchers started assembling
model also has the greatest potential to identify lists of criteria to be used to diagnose autism.
the most effective targets or “choice points” of One of the first assessment tools used
timely interventions. was a checklist developed by C. G. Polan and
Currently, ASD is primarily defined by spe- B. L. Spencer in 1959 (Feinstein, 2010). A list
cific developmental and behavioral markers (e.g., of other early assessment tools can be found in
American Psychiatric Association [APA], 2000; Table 1.
World Health Organization [WHO], 1993). Con- These instruments were the forerunners of
sequently, the most valid and reliable measures modern clinical assessments used for diagnosing
for ASD are, broadly speaking, psychological ASD. Analyses regarding the psychometric prop-
(i.e., behavioral, developmental, psychoedu- erties of the tools are not discussed in this entry as
cational, and neuropsychological) in nature. their inclusion relates to the available tools for
Medical assessment is usually undertaken to that period of time, as well as to show the histor-
assess the general health of the individual, con- ical progression. The best diagnostic assessments
tributing medical conditions, comorbid medical focus on social and communication challenges
disorders, and the response to medications known (Ozonoff, Goodlin-Jones, & Solomon, 2005).
to impact behavior. With the “epidemic” growth Current assessment tools have expanded their
in the numbers of individuals being identified items to include subtleties associated with people
C 654 Clinical Assessment
Clinical Assessment, Table 1 Historical look at the assessment for autism spectrum disorders
Year
Name of instrument Authors published/used Purpose
Rimland’s Diagnostic Bernard Rimland 1964, 1965 Originally a checklist for parents to
Checklist for Behavior- complete and submit regarding the child’s
Disturbed Children early development, language development,
(Form E-1) – An and behavior. E-2 added more questions
appendix in the book and slightly expanded the age range.
Infantile Autism. Gathered more information for the analysis
Replaced by form E-2 of behaviors related to the autism spectrum
the following year and for a possible autism diagnosis
Behaviour Rating Bertram Ruttenberg, Mitchell 1966, 1977 An observation and rating system for
Instrument for Autistic Dratman, Julia Fraknoi, and assessing the behavior of autistic or
and Atypical Children Charles Wenar/Bertram autistic-like children
(BRIAAC), Second Ruttenberg at the Center for
Edition in 1977 Autistic Children, Beth Kalish,
Charles Wenar, Enid Wolf
A parental questionnaire Helen Clancy, Alan Dugdale, 1969 Questionnaire to assist with the
for the Diagnosis of and John Rendle-Short identification of autism in childhood. Data
Infantile Autism gained by using the Creak Committee’s
criteria from 1961
Handicap Behaviour and Lorna Wing and Judith Gould 1978 Designed to gain information on children
Skills (HBS) with mental retardation or psychosis
Autism Behavior David Krug, Joel Arick, and 1978–1980 Assess, identify, and program for children
Checklist/Autism Patricia Almond with autism within an educational setting
Screening Instrument
for Educational
Planning (ASIEP)
Behavior Observation B.J. Freeman, Edward Ritvo, 1978 Devise a method for analyzing behavior
Scale for Autism (BOS) D. Guthrie, P. Schroth, and J. associated with an autism diagnosis, assist
Ball with the diagnosis of autism, and assess
behavioral changes over time
Psychoeducational Eric Schopler and Robert 1979 A developmental assessment designed for
Profile (PEP) Reichler autistic and psychotic children to provide
a profile of the child’s strengths and needs
Childhood Autism Eric Schopler, Robert Reichler, 1980 Assist with diagnosis, help distinguish
Rating Scale (CARS) Robert DeVellis, and Kenneth children with autism from children with
Daly/Eric Scholper, Robert other disorders, and help determine
Reichler, and Barbara Renner severity level
Autism Observation Bryna Siegel, Thomas Anders, 1986 Developing a classification system for
Scale Ronald Ciaranello, Bruce subtypes of children with autism and
Bienenstock, and Helena autistic-like symptoms
Kraemer
Autism Diagnostic Ann LeCouteur, Michael 1989 Interview questions for caregivers to assist
Interview (ADI) Rutter, Catherine Lord, Patricia professionals with diagnosing and
Rios, Sarah Robertson, Mary distinguishing among the pervasive
Holdgrafer, and John developmental disorders
McLennan
Autism Diagnostic Catherine Lord, Michael 1989 Observe social and communication
Observation Schedule Rutter, Susan Goode, behaviors and the quality of those
(ADOS) Jacquelyn Heemsbergen, behaviors in children with autism and
Heather Jordan, Lynn related disorders. Also helps in
Mawhood, and Eric Schopler distinguishing autism and related disorders
from non-autistic disorders and typical
development
who are on the milder end of the autism spectrum. instruments (e.g., Sattler & Hoge, 2006) – the
Today, the field has behavior checklists, direct use of formal tests with individuals being
screening measures, and diagnostic instruments. evaluated for ASD requires that the individual
Table 2 includes currently used tools related to has the ability and motivation to tolerate and
the screening or diagnosis of ASD. Instruments cooperate in the socially reciprocal activities
showing psychometric promise or those tools that define the evaluation experience. The ability
where reviewers have mentioned the need for to regulate oneself in the presence of an unfamil- C
stronger psychometric properties were not iar adult, to attend to the spoken and unspoken
included. As a result, the reader may find reviews expectations for appropriate behavior, and to be
of these and other instruments in other sections of motivated to perform “to the best of one’s ability”
the encyclopedia. As the criteria for ASD are examples of prosocial behaviors that are typ-
broaden and even more subtle characteristics are ically learned at a very young age, but may be
noticed, assessment developers continue looking underdeveloped in a person with ASD. Conse-
for ways to assess high-functioning individuals quently, unless compensatory strategies are
with ASD. effectively utilized by the examiner, the result
may be a child who is (inappropriately) described
as “untestable” (Schopler & Mesibov, 1988).
Current Knowledge Adding to these test-taking social challenges,
the fact that many individuals with ASD may
General Considerations in the Clinical not be able to meet the receptive and expressive
Assessment of ASD language demands inherent in many tests and the
Although the more classic forms of autism may likelihood that the individual with ASD may not
be accurately and reliably diagnosed by most find his or her narrow interests stimulated by the
professionals who have met minimal require- standard test items, a generic clinical evaluation
ments (in terms of training and experience) in may assist in confirming an individual’s diagno-
clinical assessment, the variation in characteris- sis, but the potential for the individual to learn
tics across the spectrum, the myriad comorbid and adapt with individualized supports may be
conditions, and the complex interplay with envi- largely unexplored. The key is to have a thorough
ronmental factors (e.g., parenting style and fam- understanding of how ASD affects an individ-
ily stress) require a higher standard of expertise in ual’s ability to learn and adapt, and to have
order to be proficient in assessing individuals a repertoire of assessment or teaching strategies
with ASD. The essential impact of autism on an that can be evaluated along with the individual
individual, itself, can make traditional methods (e.g., Klinger, O’Kelly, & Mussey, 2009; Shea &
of clinical assessment inadequate, even when Mesibov, 2009).
used by otherwise experienced and competent The second consideration is that establishing
examiners. Anecdotal evidence gathered from rapport with the individual with ASD is just as
years of experience working with individuals on important as it is with someone who does not
the spectrum suggests that additional consider- have ASD, but that the process of developing
ations may be as important in conducting a robust rapport may need to be more deliberate and
and meaningful assessment as are the specific require more creativity, and will likely be facili-
techniques or procedures identified and discussed tated with detailed information about the individ-
in the professional literature. ual’s unique strengths and interests (things to
The first of these additional considerations has utilize, such as favorite toys or topics), and
to do with the levels of social expectation that are challenges (things to avoid, such as excessive
built into most assessment procedures. Of the talking). It is the clinical experience of the
four methods used in clinical assessment – authors that examiners with a genuine fondness
interview, observation, informal assessment, for working with individuals with ASD and the
and the use of norm-referenced and standardized knowledge, compassion, persistence, and
Clinical Assessment, Table 2 Current instruments and interactive tools for assessing autism spectrum disorders
Year
Title Author(s) published Purpose
Autism Diagnostic Interview- Catherine Lord, Michael Rutter, 1994, Assist with the diagnosis of autism
Revised (ADI-R) and Ann Le Couteur/Michael 2003 and helps differentiate between
Rutter, Ann Le Couteur, and autism and other developmental
Catherine Lord disorders
Social Communication Michael Rutter, Anthony Bailey, 2003 Based on the ADI-R. Can be used
Questionnaire (SCQ): (two and Catherine Lord as a screener or to gain diagnostic
versions) Current Behavior or information
Lifetime Behavior
Autism Diagnostic Observation Catherine Lord, Susan Rissi, Linda 2000, Interactive and semi-structured
Schedule (ADOS) Lambrecht, Edwin Cook, Bennett 2003 assessment of characteristics
Leventhal, Pamela DiLavore, related to autism spectrum
Andrew Pickles, and Michael disorders, particularly social and
Rutter/Catherine Lord, Michael communication skills
Rutter, Pamela DiLavore, and
Susan Rissi
Parent Interview for Autism Wendy Stone and Kerry Hogan/ 1993, Tracks changes in child’s
(PIA) Wendy Stone, Elaine Coonrod, 2003 characteristics of autism. Can also
Stacie Pozdol, and Lauren Turner differentiate autism from other
developmental disorders
Psychoeducational Profile, Third Eric Scholper, Margaret Lansing, 2005 Gathers information relevant for
Edition (PEP-III) Robert Reichler, and Lee Marcus a diagnosis, identifies child’s
strengths and needs, and provides
developmental levels
Autism Spectrum Rating Scale Sam Goldstein and Jack Naglieri 2009 Rating scale assessing behaviors
(ASRS) related to ASDs. Completed by
parents or teachers. Provides T-
scores. Long and short versions are
available. Assists with diagnosis,
differential diagnosis, and
comparing the individual
suspected of having an ASD to
a normed group
Childhood Autism Rating Scale, Eric Schopler, Mary Van 2010 Expanded the original CARS and
Second Edition – Standard Bourgondien, Janette Wellman, provides an updated literature
Version (CARS2-ST) and High- and Steve Love review. Added a HF version for
Functioning Version (CARS2- individuals suspected of having
HF) HFA/AS/PDD-NOS. The Standard
Version is redesigned. Both
versions offer T-scores
resilience to go along with that passion tend to all be compromised in a family with a child with
obtain the most consistently helpful information special needs. As a result of reallocating precious
from clinical evaluations. family resources, the family of a child with ASD
And finally, ASD not only impacts the can sometimes become more “autistic” itself with
affected individual, but it can have a profound reduced social opportunities to attend church or
effect on the individual’s family and on those invite neighbors over for dinner, for example,
who work with the individual at school or in the with little time or energy for couples to go on
community (e.g., Schopler & Mesibov, 1984). “dates” or to communicate one-on-one, or by
Indeed, social opportunities, effective communi- eliminating or modifying leisure options (e.g.,
cations, and the pursuit of individual interests can a family vacation to Disney World) because of
challenges the child with ASD might face. Con- information; (c) the various contexts in which
sequently, the various contexts in which the indi- the individual functions; (d) perspectives from
vidual with ASD lives and functions need to be parents and multidisciplinary professionals; and
assessed and targeted with constructive sugges- (e) the immediate, intermediate, and long-term
tions. A supportive and collaborative relationship goals for the individual (see also Cohen, 1976).
with families (and other care providers, schools, These multidimensional assessments target the
and community agencies) and a clear, honest, and whole person, including multiple areas of C
sensitive presentation of the evaluation findings functioning (e.g., academic, communication,
contribute to a better assessment. These and social) to determine relative strengths and
factors together can also have the potentially weaknesses (e.g., Goldstein et al., 2009;
therapeutic benefit of helping parents come to Schopler & Mesibov, 1988), thereby allowing
terms with their child’s diagnosis in ways that for strength-based programming. In addition,
help them obtain services, advocate for their emerging skills are assessed in order to generate
child, and assist all family members to cope treatment or educational goals that are specific,
more effectively (e.g., Mesibov, Shea, & concrete, and immediate (e.g., Hogan & Marcus,
Schopler, 2005). 2009). Practically, predetermined assessment
protocols and eligibility requirements of service
Specific Guidelines and Procedures in the agencies (e.g., Shea & Mesibov, 2009); reim-
Clinical Assessment of ASD bursement schedules of funding sources; and the
Several excellent resources have emerged in the time, energy, and expertise of the clinician also
past 10 years that outline specific guidelines and factor in assessment planning decisions. The
evidence-informed procedures for conducting most common types of ASD assessments involve
clinical assessments of ASD. For students in determining (a) whether or not an individual
training or those professionals interested in should be referred for a more thorough evalua-
a refresher course, textbooks on clinical assess- tion; (b) relevant diagnosis(es); (c) strengths and
ment that include a chapter on autistic disorder weaknesses in information processing, learning,
are available (e.g., Sattler & Hoge, 2006). For and performance; and (d) the potential for the
those individuals or agencies wishing to establish individual to live and work independently. Each
their expertise in this area, specific practice type of assessment establishes an empirically-
parameters for what constitutes current best prac- informed best practices basis for addressing the
tices have been published (Filipek et al., 1999; presenting concerns, whether they are, for exam-
Volkmar et al., 1999). For those wanting ple, behavioral, academic, or legal. Each of these
a comprehensive and concise overview of evi- types of evaluations will be discussed briefly in
dence-informed practices and empirically- the following sections. Clinical assessment to
validated measures, well-written articles are weigh the costs/benefits of specific medication
easily accessible (Ozonoff et al., 2005). And for trials, or other experimental and sometimes con-
those looking for a comprehensive discussion of troversial treatments, is beyond the scope of the
the relevant issues in the assessment of ASD, present discussion.
there are both earlier and recently published
options (Goldstein et al., 2009; Schopler & Screening Evaluation of ASD
Mesibov, 1988). There is a good deal of consen- There are a number of very good publications that
sus regarding current best practices, which will discuss relevant issues and available measures for
be summarized in this section. Interested readers screening young children for developmental
will find additional detail by consulting these delays, in general, and ASD, in particular
resources mentioned previously. (e.g., Filipek et al., 1999; Rogers, 2001). Screen-
An individualized assessment plan is typically ing procedures can be categorized as somewhat
organized around (a) identified and latent con- less structured (e.g., interviews, observations,
cerns; (b) the methods used to gather relevant and interactions) and rely on the clinical expertise
of the professional, or they may involve a formal uncertainty surrounding the individual’s behav-
procedure requiring a standardized administra- ior and prognosis, enhance communications
tion and adapted to both trained and untrained about the individual, and facilitate access to
informants. Screening procedures are oftentimes available resources and effective treatments.
designed to be used by primary and secondary Although ASD is generally considered to be
healthcare providers, and they are evaluated a neurodevelopmental disorder, there are cur-
based upon how efficiently they identify children rently no biomedical tests or procedures upon
who should be referred to a secondary care which a diagnosis can be made. Information
agency for a broad assessment of developmental about an individual’s early development and cur-
delays (first level screening) or to a highly spe- rent behaviors gathered through interviews with
cialized tertiary care agency that has expertise in parents and teachers, and observations made dur-
ASD (second level screening). The Modified ing structured and unstructured interactions with
Checklist for Autism in Toddlers (M-CHAT), the individual form the basis for determining if
the Social Communication Questionnaire the individual meets criteria for an ASD diagno-
(SCQ), the Pervasive Developmental Disorder sis. Familiarity with normal child development
Screening Test (PDDST), and the Screening and the broad spectrum of developmental and
Tool for Autism in Toddlers (STAT) are some psychiatric disorders is essential in determining
of the most frequently cited checklists used to the appropriate diagnosis(es). Inconsistencies in
screen for ASD (e.g., Rogers, 2001; Shea & abilities and performance are, by definition,
Mesibov, 2009). These measures target a range markers for ASD. Especially for the higher func-
of observable behaviors (e.g., joint attention, tioning individual, overt symptoms are fre-
responding to one’s name, imaginative play, and quently context specific, and a thorough
repetitive behaviors) present or absent in young evaluation will gather information from
developing children that indicate a heighten risk a variety of settings (see also, e.g., Ozonoff
for being diagnosed with ASD. et al., 2005). Autism-informed clinical interviews
The need for reliable and effective screening with parents and autism-informed systematic
procedures for ASD has received heightened observations of clients during structured and
attention recently due to the increasing incidence unstructured interactions, when combined with
of ASD worldwide and the importance of effec- a review of previous medical and educational
tive early intervention programs for decreasing records, constitute the core components of
the short- and long-term adverse impact of the a diagnostic evaluation for ASD. Currently, the
disorder (e.g., National Research Council [NRC], Autism Diagnostic Interview-Revised (ADI-R)
2001). Early screening and early diagnostic and the Autism Diagnostic Observation Schedule
assessment is an especially active area of (ADOS) are considered by many to reflect the
research currently, and there are a number of highest standard of evidence-based practice for
recently published references in this area (e.g., both clinical and research purposes (e.g., Ozonoff
Chawarska, Klin, & Volkmar, 2008). et al.). A medical evaluation and intellectual,
communication, and adaptive behavior testing
Diagnostic Evaluation of ASD are essential in ruling out other possible explana-
The purpose of the diagnostic assessment is to use tions or in ruling in comorbid conditions. Infor-
valid and reliable methods to get meaningful mation from other cognitive and behavior
information about how an individual functions assessments can also provide useful information
and, as appropriate, to assign a diagnostic label that can help clarify a diagnosis (Goldstein et al.,
to the individual. The diagnostic label signifies 2009; Ozonoff et al., 2005).
a kind and degree of abnormal behavior and
development that characterize a subset of Psychoeducational Evaluation of ASD
a given population. Diagnostic labels are helpful There is increasing evidence that the structure
when they can be used to better manage the and function of the brain are different in
individuals with ASD, but the precise and essen- treatment and an individualized educational
tial nature of the differences remains unclear. plan are only possible when the unique qualities
Even so, these suspected anomalies are presumed of how the individual relates to him- or herself
to account for the differences in how individuals and to the surrounding environments are
with autism process sensory information, learn, understood.
reason, and perform daily activities. Understand-
ing these unique patterns of information Vocational Evaluation of ASD C
processing and behavior is the primary goal Recent changes to state and federal guidelines
of the psychoeducational/neuropsychological regarding the education of special needs students
assessment of ASD. As mentioned earlier, have resulted in a renewed interest in developing
obtaining valid and reliable test results is no assessment procedures that can facilitate plan-
easy matter when working with some individuals ning for the transition to adulthood. For some
on the autism spectrum, but it is essential if individuals on the autism spectrum, this may
meaningful goals can be targeted and effective involve paid or voluntary work in the community,
strategies developed. A comprehensive as well as semi-independent or independent liv-
psychoeducational evaluation, broadly speaking, ing arrangements. A comprehensive vocational
may begin with an assessment of intellectual assessment may outline potential areas of
functioning, communication skills, academic employment or community involvement, and
abilities, and social and adaptive behaviors. the supports and strategies that can maximize
More sophisticated assessments may target spe- independent functioning. Structured and mean-
cific areas of cognitive and emotional functioning ingful activities, community inclusion, and
known to be relative strengths (e.g., rote memory, greater levels of independence often result in
visual attention and visual/spatial reasoning, rou- the best possible outcome for adults with ASD.
tinized learning and performance) or weaknesses A comprehensive vocational assessment focuses
(e.g., verbal abilities, novel problem solving, not only on vocational skills and interests but on
integrated and applied skills) in individuals with work habits, communication skills, the ability to
ASD. Although some of these skills can be adapt to different physical environments; and the
assessed in individuals with lower abilities, necessary stress coping, social, and leisure skills
most of the recent developments in this area that can help determine the level and the supports
stem from work with higher functioning individ- that will allow the individual to be successfully
uals. Both formal and informal measures are integrated into the community.
being used to assess cognitive abilities such as The recently revised TEACCH Transition
executive functioning, perspective-taking, cen- Assessment Profile (TTAP) (formerly known as
tral coherence, cognitive flexibility, and social the Adolescent and Adult Psychoeducational
cognition and problem solving (e.g., Corbett, Profile) is an example of a comprehensive voca-
Carmean, & Fein, 2009). Subtle language and tional assessment for adolescents and adults with
communication skills assessed may include ASD. Although the strengths of its psychometric
understanding figurative language and language properties continue to be researched, this assess-
concepts, and pragmatic communication skills ment tool is a combination of structured inter-
(Paul & Wilson, 2009). Imaginative and interac- view, observation, and informal assessment
tive play skills, and individual leisure activities techniques designed to be utilized in the natural
are also typically assessed. The goal of home, work, and community settings in which the
a diagnostic evaluation is to determine how the individual lives. Vocational assessments of indi-
individual is like others who have had a particular viduals with ASD seem to demand a greater
diagnostic label assigned to them. The goal degree of ecological validity than some of the
of a psychoeducational evaluation is to determine other measures discussed in this article, and the
how the individual is different than TTAP appears to have been designed with this in
a generic group of individuals. Individualized mind.
Future Directions of whether everyone who is quirky, rigid, differ-

ent, or eccentric needs a diagnosis. Because of
Criteria for the DSM-V (Diagnostic and Statisti- increased media coverage, an increasing number
cal Manual of Mental Disorder, Fifth Edition) of referrals are being made to specialized clinics
may have an affect on what an ASD assessment by family members and colleagues of individuals
will look like in the future. As diagnostic indica- who are clearly unusual, but who seem to func-
tors change so will diagnostic instruments need to tion reasonably well in society without
be modified. Currently, children are being evalu- a diagnosis. Adults who learn about ASD through
ated for ASD at increasingly younger ages, some media or personal experience may wonder if they
as young as 12 months. Concerned parents and have a diagnosis on the spectrum. Clinicians will
professionals are looking for reliable assessment need to understand the diagnostic criteria being
tools and procedures that can be used with these used, the strengths and limitations of the instru-
very young children. Another area for future ments available, and the presenting problem to
research involves highly individualized matching best use their professional judgment in making
of treatment strategies to specific biological, neu- decisions about further assessment.
ropsychological, or behavioral indicators. For
example, clinical assessment may at some point
in the future work in conjunction with genetic See Also
testing to determine diagnoses and recommended
treatment protocols. Currently, the technology ▶ Academic Skills
does not exist to match strategies or interventions ▶ Autism Diagnostic Interview-Revised
with genetic markers, but future research may ▶ Autism Diagnostic Observation Schedule
discover which subtypes of ASD respond best to ▶ Childhood Autism Rating Scale
particular strategies. As a result, the expectations ▶ Diagnosis and Classification
and look of clinical assessment may change to ▶ Informal Assessment
match future definitions, concerns, and emerging ▶ Medical Evaluation in Autism
technologies. ▶ Observational Assessments
Assessment in the future may increasingly ▶ Screening Measures
include more widespread use of teleconferencing ▶ Social Communication Questionnaire
and digital surveillance. Computer-based assess- ▶ TEACCH Transition Assessment Profile
ment tools for caregivers and clients will likely (TTAP)
become mainstream. Practitioners will need to
stay alert to the trends, best practices, and ethics
related to using technology for assessment and References and Readings
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changing public policies regarding reimburse- American Psychiatric Association. (2000). Diagnostic
ment and health insurance reform. Redesigned and statistical manual of mental disorders (4th ed.,
Text Rev.). Washington, DC: Author.
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ments but not others. They will likely continue to spectrum disorders in infants and toddlers: Diagnosis,
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in the assessment of autism spectrum disorders. measure is administered in conjunction with the
In S. Goldstein, J. A. Naglieri, & S. Ozonoff (Eds.), Cognitive Adaptive Test (CAT), a 57-item
Assessment of autism spectrum disorders assessment of visual-motor functioning. The test
(pp. 117–137). New York: Guilford Press.
Volkmar, F. R., Cook, J., Edwin, H., Pomeroy, J., uses standardized methods for obtaining informa-
Realmuto, G., & Tanguay, P. (1999). Practice param- tion from parent report and from direct interac-
eters for the assessment and treatment of children, tion between the examiner and the child. The
adolescents, and adults with autism and other perva- CLAMS utilizes parent report and focuses on
sive developmental disorders. Journal of the American
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32S–54S. dren up to 3 years of age.
C 662 Clinical Linguistic and Auditory Milestone Scale
Historical Background therapists in order to allow them to distinguish

between global developmental delay and recep-
The Clinical Linguistic and Auditory Milestone tive/expressive language problems. It consists of
Scale (CLAMS) was initially developed by Dr. 100 items that are completed in-office using par-
Arnold J. Capute to screen for language delays in ent report and direct elicitation. Administration
young children between birth and 3 years of age. time is estimated to be from 6 to 20 min to
The initial version of the scale was developed in complete both “streams,” the Cognitive Adaptive
1973 (Capute & Biehl, 1973), with revisions in Test (CAT) and the Clinical Linguistic and Audi-
1978 (Capute & Accardo, 1978). It was originally tory Milestone Scale (CLAMS). Forms are avail-
developed as a brief screening measure for able in multiple languages including English,
pediatricians within an office setting. The mea- Spanish, and Russian.
sure was first normed in 1986 (Capute, Palmer,
Shapiro, Wachtel, Schmidt, & Ross 1986).
A visual-motor scale, the Cognitive Adaptive References and Readings
Test (CAT), was subsequently added to the
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Cognitive adaptive test/clinical linguistic and auditory
in the differential diagnosis of isolated language
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to as the CAT/CLAMS. The CAT/CLAMS was The Capute scales. biomedical and social perspec-
tives. MD, USA: Timonium, York Press.
revised and renamed “The Capute Scales,” with
Bayley, N. (2006). Bayley scales of infant and toddler devel-
the most recent standardization procedures com- opment (3rd ed.). San Antonio: Harcourt Assessment.
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(1997). Using the clinical linguistic and auditory mile-
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auditory milestones during the first two years of life:
Various versions of the CLAMS and Capute A language inventory for the practitioner. Clinical
Scales have been revised and standardized over
Capute, A. J., & Biehl, R. F. (1973). Functional develop-
a period of 30 years. Most recently, in 2004, mental evaluation. Prerequisite to habilitation. Pediat-
the Capute Scales were standardized on ric Clinics of North America, 20, 3–26.
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S., & Ross, A. (1986). Clinical linguistic and auditory
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noteworthy that historically the CLAMS has cor- guistic auditory milestone scale in early cognitive
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ment tool for the early detection of mental retardation and
communicative disorders. Mental Retardation and
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C
Clinical Significance
Clinical Psychology Domenic V. Cicchetti

Departments of Psychiatry and Biometry,
Karen Tang Yale Child Study Center, Yale University,
Department of Psychology, University of Notre New Haven, CT, USA
Dame, Notre Dame, IN, USA
Definition
Definition
Statistical vs. Clinical Significance: Statistical
Clinical psychology focuses on the diagnosis and significance means simply that a result in
treatment of mental illness, abnormal behavior, a given comparison occurs beyond what one
and psychological disorders in individuals. In would expect by chance alone. Here, and by
1907, American psychologist Lightner Witmer accepted convention, a comparative result is
first coined the term and defined clinical psychol- declared statistically significant if it occurs at or
ogy as the study of individuals through observa- beyond the 5% level. By simple subtraction, this
tional or experimental methods to promote means that there is a 95% possibility that the
change in individuals. result did not occur by chance.
A clinical psychologist has a doctorate (Ph.D. The caveat here, and one that many journal
or Psy.D.) in clinical psychology, whereas editors and even some unenlightened biostatisti-
a psychiatrist has a medical degree (M.D.). cians fail to grasp, is that given a large enough
A clinical psychologist must be licensed by number of cases or N, a given comparative result
a state licensing board in order to conduct clinical will inevitably occur beyond chance, at the 5%
work as a “clinical psychologist.” A clinical psy- level of statistical significance.
chologist can be involved in the assessment or In order to guard against this so-called big N
treatment of Autism Spectrum Disorders (ASD). phenomenon, enlightened biostatisticians have
In addition, a number of clinical psychologists devised guidelines for defining a result as having
conduct research on ASD. reached a level of clinical, as well as statistical
significance.
A concrete example, albeit an apocryphal one,
can be derived easily from the field of autism
See Also spectrum research.
Suppose an inexperienced clinician on a scale
▶ Child Psychotherapy of 0–100% agrees with the diagnosis of child-
▶ Clinical Social Worker hood autism, in 500 cases at 10%. With such
▶ Psychiatrist a large N of cases, the result turns out to be
▶ Psychologist statistically significant with a chance probability
▶ School Psychologist at the scientifically acceptable level of 5%.
C 664 Clinical Social Worker
Well, any self-respecting autism expert References and Readings

would tell you that 10% chance-corrected agree-
ment, from a clinical perspective, is poor or Cicchetti, D. V., & Sparrow, S. S. (1981). Developing
criteria for establishing interrater reliability of specific
trivial.
items: Applications to assessment of adaptive behav-
Clinical significance to the rescue comes in the ior. American Journal of Mental Deficiency, 86,
form of a set of clinical criteria developed by 127–137.
Cicchetti and Sparrow (1981) by which: Cicchetti, D. V. (1994). Guidelines, criteria, and rules of
thumb for evaluating normed and standardized a
Size of Reliability Coefficient Clinical Significance assessment instruments. Psychological Assessment, 6,
284–290.
<0.40 Poor Fleiss, J. L. (1981). Statistical methods for rates and pro-
0.40–0.59 Fair portions. New York: Wiley.
0.60–0.74 Good Fleiss, J. L., Levin, B., & Paik, M. C. (2003). Statistical
0.75–1.00 Excellent methods for rates and proportions (3rd ed.).
New York: Wiley.
Landis, J. R., & Koch, G. G. (1977). The measurement of
Earlier, in 1977, Landis & Koch provided the
observer agreement for categorical data. Biometrics,
following guidelines for also interpreting the 33, 159–174.
level of clinical or practical significance of
chance-corrected inter-examiner agreement
levels:
Size of Reliability Clinical Social Worker

Coefficient Level of Clinical Significance
Below 0 Poor Lisa Castagnola
0.0–0.20 Slight Child Study Center, The Edward Zigler Center in
0.21–0.40 Fair Child Development & Social Policy, Yale
0.41–0.60 Moderate University School of Medicine, New Haven,
0.61–0.80 Substantial CT, USA
0.81–1.00 Almost Perfect
Similarly, Fleiss (1981) and Fleiss, Levin, &

Synonyms
Paik (2003) also suggested conceptually similar
guidelines by which:
Clinician; Mental health practitioner; Therapist
Size of Reliability
Coefficient Level of Clinical Significance
<0.40 Poor Definition
0.40–0.75 Fair to Good agreement
Above 0.75 Excellent agreement Social work is a broad field with a wide range of
variation in areas of professional practice. Clinical
Finally, conceptually similar guidelines rang- social workers are social work professionals who
ing from, say, Poor to Excellent or Trivial to Very provide direct services to client populations. This is
Large, have been developed for correlations of in contrast to non-clinically based social workers
various types, and for judging the internal con- who may practice in the realm of social adminis-
sistency level of assessment instruments (e.g., tration or who may be more focused on broad-
Cicchetti, 1994). based advocacy and policy reform at the national,
state, and community levels. Clinical social
workers strive to improve the quality of life and
See Also advocate for clients on a more individual level. The
term clinical social worker is most closely associ-
▶ Statistical Significance ated with social workers who provide direct mental
Clock Drawing 665 C
health and behavioral health services. These thera- intern under close supervision. All social workers
peutic services are provided in a variety of settings must complete a significant number of supervised
including hospitals, community mental health direct practice hours beyond their degree program
clinics, schools, residential facilities, and correc- to qualify for advanced licensure. Distinction of
tional facilities. Clinical social workers provide advanced practice is commonly noted as Licensed
services for a variety of populations that cover the Clinical Social Worker (LCSW) or Licensed Inde-
entire life span including children, adolescents, pendent Social Worker (LISW). All professional C
adults, and the elderly and intervene by working social workers are trained and expected to practice
directly with individuals, couples, families, and within the Social Work Code of Ethics as
groups (Hepworth, Larsen, Rooney, Rooney, & established by the National Association of Social
Strom-Gottfriend, 2006, p. 25). Workers (NASW).
Clinical social workers are knowledgeable on
a wide variety of mental health disorders and are See Also
well versed and qualified to conduct mental health
assessments, render diagnoses, develop treatment ▶ Psychiatrist
plans, and provide short- and long-term treatment.
In comparison to other trained mental health
professionals, the social work approach gives References and Readings
special attention to the client’s stated goals and
incorporates these goals into treatment while also Hepworth, D. H., Larsen, J., Rooney, R. H., Rooney, G. D.,
taking into account client’s functioning within his & Strom-Gottfriend, K. (2006). Direct social work
practice: Theory and skills (7th ed.). Canada: Thomson.
or her environment. Additional social work values
National Association of Social Workers. http://www.
include high regard for dignity and worth of client, naswdc.org/
upholding human rights, and respect for diversity West, J., Kohout, J., Pion, G. M., Wicherski, M. M.,
(Hepworth et al., 2006, pp. 8–11). Vandivort-Warren, R. E., & Palmiter, M. L. (2001).
Mental health practitioners and trainees. In R. W.
Clinical social workers are the largest group of
Manderscheid & M. J. Henderson (Eds.), Mental
mental health providers in the United States health, United States 2000 (pp. 279–315). Washington,
(Manderscheid & Henderson, 2001). As such, DC: Department of Health and Human Services,
clinical social workers are often direct service US Govt. Print.
providers to children and adults with autism
spectrum disorders (ASD). Due to being employed
in a variety of settings, social workers are often Clinician
among the first healthcare providers to identify
signs and symptoms of developmental delays in ▶ Clinical Social Worker
children. Additionally, multidisciplinary ASD ▶ Psychologist
assessment team models may include a clinical
social worker. Following an ASD diagnosis,
clinically trained social workers provide support
and education to families, assist in implementing Clock Drawing
behavioral interventions, and link clients to addi-
tional services and resources. Social workers also Lauren Schmitt
play a key role as advocates for clients with ASD Psychiatry, UT Southwestern Medical Center,
within a variety of community systems. Dallas, TX, USA
Professional social workers typically have
a Master of Social Work (MSW) degree. Most
MSW programs are accredited by the Council on Synonyms
Social Work Education (CSWE) and require
a substantial number of direct practice hours as an CDT; Clock-drawing test
C 666 Clock-Drawing Test
Definition
Clock-Drawing Test
The clock drawing test (CDT) is
a neuropsychological assessment tool completed ▶ Clock Drawing
with pencil-and-paper that examines executive
functioning, motor planning, and visuospatial
skills. The test typically consists of two phases:
command and copy. In the command phase, sub- Clomipramine
jects are asked to draw the face of a clock and add
hands to indicate a specific time (usually 10 past Maureen Early1, Carolyn A. Doyle2,
11). In the copy phase, subjects are asked to copy Logan Wink1,3, Craig Erickson1,3 and
a pre-drawn clock. Performance on the test is Christopher J. McDougle4
1
assessed by determining whether the hand-drawn Christian Sarkine Autism Treatment Center,
clock meets certain criteria. Administrators may Indianapolis, IN, USA
2
score the clock according to the following: number Indiana University School of Medicine,
inclusions and location, spacing, organization, and Indianapolis, IN, USA
3
correctness of hand position. Although the above Department of Psychiatry, Indiana University
instructions and scaled scoring system are com- School of Medicine, Indianapolis, IN, USA
4
monly used, there is no standardized method of Lurie Center for Autism/Harvard Medical
administration or scoring. Performance errors in School, Lexington, MA, USA
the CDT are indicative of impairment in executive
functioning.
This test is used in neurological and psychiatric Synonyms
patient populations, most commonly completed
with at-risk dementia and Alzheimer’s patients. It 3-Chloro-5-[3-(dimethylamino)propyl]-10,11-
is sometimes used as a part of a neuropsychological dihydro-5H-dibenz[b,f]azepine monohydro-
assessment for children with Autism Spectrum chloride; Anafranil; Clomipramine (CMI)
Disorder. hydrochloride
See Also Indications
▶ Executive Function (EF) Clomipramine is a tricyclic antidepressant

▶ Motor Planning (TCA). TCAs block the reuptake of serotonin
and norepinephrine in the neuronal synapse,
resulting in increased concentrations of both
References and Readings neurotransmitters. This is the mechanism
by which it is thought that TCAs exert their
Freedman, M., Leach, L., Kaplan, E., Winocur, G., therapeutic effects. In the United States, clomip-
Shulman, K. I., & Delis, D. C. (1994). Clock drawing: ramine is FDA-approved for the treatment of
A neuropsychological analysis. Oxford: Oxford Uni- obsessive-compulsive disorder (OCD) in
versity Press.
Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A
children, adolescents, and adults. Behind selec-
compendium of neuropscyhological tests: Administra- tive serotonin reuptake inhibitors (SSRIs),
tion, norms, and commentary (3rd ed.). Oxford: clomipramine is among the drugs of choice for
Oxford University Press. the treatment of OCD (Stahl, 2008, 2009). It is
Sunderland, T., et al. (1989). Clock drawing in
Alzheimer’s disease. A novel measure of dementia
also often prescribed for depression (including
severity. Journal of American Geriatric Society, severe and treatment-resistant depression),
37(8), 725–729. PMID: 2754157. cataplexy syndrome, anxiety, insomnia, and
Clomipramine 667 C
neuropathic or chronic pain, although it is not a2-adrenergic autoreceptor which inhibits the
FDA-approved for any of these disorders (Stahl, further release of norepinephrine into the syn-
2009). Unfortunately, its adverse effect profile apse. After this autoreceptor is desensitized, the
has limited its use in many patients. amount of synaptic norepinephrine increases.
Although the postsynaptic norepinephrine recep-
tor is downregulated by the increase in the
Mechanisms of Action amount of synaptic norepinephrine, this effect C
seems less significant than the increase in synap-
The exact mechanisms of action are unknown for tic norepinephrine. However, no known connec-
the tricyclic antidepressants (TCAs) including tion exists between the inhibition of the reuptake
clomipramine. However, likely mechanisms of of norepinephrine by desmethylclomipramine
action are suggested from the binding activity and the treatment of OCD.
and receptor affinities of the active compounds
of these drugs and from what is known about the
pathophysiology of the disorder being treated. Specific Compounds and Properties
Dysregulation of serotonin and dopamine or
both is thought to be implicated in OCD. Clomip- Clomipramine has the International Union of Pure
ramine is thought to alleviate obsessions and and Applied Chemistry (IUPAC) name 3-chloro-
compulsions in OCD through its inhibition of 5-[3-(dimethylamino)propyl]-10,11-dihydro-5H-
the reuptake of serotonin in the brain. Its stron- dibenz[b, f]azepine monohydrochloride and the
gest neurological action is its activity as chemical formula C19H23ClN2·HCl. The chemi-
a serotonin reuptake inhibitor (SRI), and it has cal structure of clomipramine only differs from
been described as being “a relatively selective that of the TCA imipramine in that clomipramine
[SRI]” (Andreasen & Black, 2001a, “Somatic has an additional chloride atom. Pure clomipra-
Treatments,” p. 721). mine hydrochloride is a solid, white crystalline
The SRI action of TCAs causes an increase in powder at room temperature and is soluble in the
the amount of synaptic serotonin. Before the polar solvents water, methanol, and methylene
neurons are desensitized to the drug, this increase chloride but not in the non-polar solvents ethyl
in synaptic serotonin is counteracted by its stim- ether and hexanes (Fig. 1).
ulation of the presynaptic serotonin autoreceptor Clomipramine is metabolized by the liver via
which inhibits the further release of serotonin into undergoing N-demethylation of clomipramine to
the synapse. After about 10–14 days of drug the active metabolite desmethylclomipramine
treatment, this autoreceptor is desensitized, and and subsequently by N-oxidation and aromatic
the amount of synaptic serotonin increases. TCAs hydroxylation. These processes are catalyzed by
also increase the activity of postsynaptic the enzymes CYP 1A2, 2C19, and 3A3/4, and
serotonin1A receptors and downregulate seroto- CYP 2D6 (clomipramine and desmethylclo-
nin2 receptors further augmenting the effects of mipramine), respectively. Aromatic hydroxyl-
the serotonin. ation is important for the elimination of the drug
The active metabolite of clomipramine, in the body.
desmethylclomipramine, is not an SRI but In plasma, clomipramine has a half-life of
inhibits the reuptake of norepinephrine. This nor- 15–60 h, a clearance of 20–120 Liters per hour
epinephrine reuptake inhibition is thought to (L/h), and a therapeutic dose range of 150–300
increase the effects of norepinephrine by increas- mg per day (mg/day). This drug has a therapeutic
ing the amount of norepinephrine in the synapse plasma level of greater than 150 nanograms (ng)
by blocking the reuptake of norepinephrine. of clomipramine and desmethylclomipramine per
Before the neurons are desensitized to the drug, milliliter (mL). The main pharmacological action
this increase in synaptic norepinephrine is of the TCAs with tertiary amines on their side
counteracted by its stimulation of the presynaptic chains, including clomipramine, is to inhibit the
C 668 Clomipramine
N NH
Cl HCl Cl
N
N
Clomipramine, Fig.1 Chemical structure of

clomipramine Clomipramine, Fig. 2 Chemical structure of desmethyl-
clomipramine, active metabolite of clomipramine
reuptake of serotonin, although it also

downregulates serotonin receptors. Clomipra- regarding reducing hair-pulling behavior, but
mine is the strongest SRI of the TCAs. TCAs controlled studies have yet to be undertaken.
with a tertiary amine structure on the side chain Reports have indicated that clomipramine may
of the molecule, such as is the case with clomip- also be used to treat depersonalization disorder.
ramine, have shown less tolerability than those Clomipramine may be used to treat self-injurious
with secondary amines on the side chains (Fig. 2). and stereotypic movements in stereotypic move-
Desmethylclomipramine is metabolized by ment disorder.
the liver, leading to the elimination of the drug Clomipramine is not currently approved for
in the body. The main pharmacological action of the treatment of autism or other autism spectrum
the TCAs with secondary amines on their side disorders (ASDs), but researchers have studied its
chains, including desmethylclomipramine, is to effectiveness in treating symptoms associated
inhibit the reuptake of norepinephrine. with ASDs, particularly autistic disorder. Gordon
et al. (1992) found that clomipramine was more
efficacious than desipramine and placebo on rat-
Clinical Use (Including Side Effects) ings of autism and anger, as well as repetitive or
compulsive behaviors, in children with autism
The brand-name drug Anafranil has been aged 6–18 years. Gordon et al. (1993) found
FDA-approved for the treatment of obsessions that clomipramine was more efficacious than
and compulsions in individuals with OCD since desipramine and placebo in children with autism
1989. Its active ingredient clomipramine is cur- with regard to stereotypies, anger, and compul-
rently used for the treatment of depression in sive, ritualized behavior. It was also superior to
Europe. Clomipramine has also been shown to placebo in managing hyperactivity. In an open-
be effective in studies to treat hyperactivity in label trial looking in adults with ASDs, Brodkin
children with autistic disorder and attention def- et al. (1997) found that clomipramine may be
icit hyperactivity disorder (ADHD) and to treat effective at reducing repetitive thoughts and
the symptoms of panic disorder, Tourette’s syn- actions and aggressive behavior and for improv-
drome, cataplexy, and body dysmorphic disorder. ing eye contact and verbal responsiveness.
This drug has also been found to be effective in In another open-label trial looking at hospitalized
preventing relapse of anorexia nervosa. Addition- children aged 3.5–8.7 years with autistic disor-
ally, preliminary studies of the use of TCAs such der, Sanchez et al. (1996) found clomipramine to
as clomipramine for the treatment of trichotillo- not be therapeutic and posited that young autistic
mania have suggested at least some efficacy children may be more prone to experiencing
Clomipramine 669 C
unwanted side effects compared to older patients. increased depression in individuals with major
Remington et al. (2001) compared clomipramine depressive disorder (MDD), decreased blood
to haloperidol and placebo in patients with autis- pressure, and tachycardia. Adverse effects may
tic disorder aged 10–36 years and found that include seizure, tremor, sedation, fatigue, dry
clomipramine was comparable to haloperidol in mouth, dizziness, somnolence, constipation,
terms of improvement in maladaptive symptoms. nausea, increased sweating, impairment of mem-
Haloperidol was better tolerated than clomipra- ory, delirium, cardiac arrhythmias, cardiac arrest, C
mine. Hazell (2007) reviewed the literature headache, abnormal vision, anorexia, dyspepsia,
looking at available treatments for attention insomnia, orthostasis, sexual dysfunction, weight
deficit hyperactivity disorder (ADHD) symptoms gain, and anticholinergic effects.
in autistic disorder and found clomipramine to be
of unlikely benefit.
A typical starting dose in adults is 25–75 mg See Also
per day (mg/day) of clomipramine. The dose is
titrated up by 75 mg/day each week to the ▶ Anticholinergic
therapeutic dose range of 150–300 mg/day. ▶ Antidepressant Medications
In children, demethylation of clomipramine to ▶ Desipramine
desmethylclomipramine is faster than in adults; ▶ Norepinephrine
as a result, children require higher doses of med- ▶ Obsessive-Compulsive Disorder (OCD)
ication per kilogram (kg) of body weight than do ▶ Repetitive Behavior
adults since desmethylclomipramine lacks the ▶ Serotonin
serotonin reuptake activity of clomipramine. ▶ Serotonin Reuptake Inhibitors (SRIs)
An effective dose for children is generally ▶ Stereotypic Behavior
2.5–3.5 mg clomipramine/kg body weight.
When puberty begins in a child taking clomipra-
mine, the dose can be decreased by up to half of References and Readings
the previous dose. To discontinue a TCA, the
drug must be tapered. Clomipramine can be 3-Chloro-10,11-dihydro-N-methyl-5H-dibenz(b,f)azepine-
tapered by 25 mg every 2–3 days. Relapse may 5-propanamine (n.d.). Retrieved from the ChemSpider
Wiki: http://www.chemspider.com/RecordView.aspx?
occur upon discontinuation. The abrupt discon-
rid¼de5fed0d-ac0b-46c1-a74c-6c89dd040665
tinuation of a dose within the therapeutic range of Aman, M. G., & Langworthy, K. S. (2000). Pharmaco-
a TCA may induce cholinergic rebound syn- therapy for hyperactivity in children with autism and
drome, and cases have been reported of rebound other pervasive developmental disorders. Journal of
manic or hypomanic episodes upon abrupt
Anafranil (n.d.). Retrieved from the ChemSpider
discontinuation of a TCA. Wiki: http://www.chemspider.com/RecordView.aspx?
TCAs become toxic at concentrations greater rid¼8ccb3154-90d1-41a6-8dec-d574ae7d6bc1
than 450 ng/mL. Overdose may result in any of Andreasen, N. C., & Black, D. W. (2001a). Somatic treat-
ments. In Introductory textbook of psychiatry (3rd ed.,
the following: agitation, confusion, convulsions,
pp. 709–759). Washington, DC: American Psychiatric
hypotension, tachycardia, cardiac conduction Publishing.
delays, anticholinergic blockade, bowel and blad- Andreasen, N. C., & Black, D. W. (2001b). Dissociative
der paralysis, disturbed temperature regulation, disorders. In Introductory textbook of psychiatry
(3rd ed., pp. 389–401). Washington, DC: American
mydriasis (abnormal pupil dilation), and delir- Psychiatric Publishing.
ium. A TCA overdose may induce a coma, some- Brodkin, E. S., McDougle, C. J., et al. (1997). Clomipra-
times with shock and respiratory depression, mine in adults with pervasive developmental disor-
which typically lasts less than 1 day. Patients at ders: A prospective open-label investigation. Journal
of Child and Adolescent Psychopharmacology, 7(2),
risk for making a suicide attempt should be given
109–121.
weekly, nonrefillable prescriptions of their Gordon, C. T., Rapoport, J. L., et al. (1992). Differential
TCAs. Risks include suicidal ideation or response of seven subjects with autistic disorder to
C 670 Clomipramine (CMI) Hydrochloride
clomipramine and desipramine. The American Journal Stahl, S. M. (2000). Essential psychopharmacology:
of Psychiatry, 149(3), 363–366. Neuroscientific basis and clinical applications.
Gordon, C. T., State, R. C., et al. (1993). A double-blind Cambridge, NY: Cambridge University Press.
comparison of clomipramine, desipramine, and Stahl, S. M. (2008). Stahl’s essential psychopharmacology:
placebo in the treatment of autistic disorder. Archives Neuroscientific basis and practical applications
of General Psychiatry, 50(6), 441–447. (3rd ed., p. 770). New York: Cambridge University
Hazell, P. (2007). Drug therapy for attention-deficit/ Press.
hyperactivity disorder-like symptoms in autistic disor- Stahl, S. M. (2009). Stahl’s essential psychopharmacology:
der. Journal of Paediatrics and Child Health, 43(1–2), The prescriber’s guide (3rd ed., pp. 89–95). New Delhi,
19–24. India: Cambridge University Press.
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. U.S. Food and Drug Administration. (2011).
(2001a). Treatment with antidepressants. In Principles Drugs@FDA. Retrieved from http://www.accessdata.
and practice of psychopharmacotherapy (3rd ed., fda.gov/scripts/cder/drugsatfda/index.cfm
pp. 215–325). Philadelphia: Lippincott Williams & Wagner, K. D. (2006). Treatment of childhood
Wilkins. and adolescent disorders. In A. F. Schatzberg &
Janicak, P. G., Davis, J. M., Preskorn, S. H., & Ayd, F. J. C. B. Nemeroff (Eds.), Essentials of clinical psycho-
(2001b). Assessment and treatment of special pharmacology (2nd ed., pp. 181–197). Washington,
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(2001c). Assessment and treatment of other disorders.
In Principles and practice of psychopharmacotherapy
(3rd ed., pp. 523–558). Philadelphia: Lippincott Clomipramine (CMI) Hydrochloride
Williams & Wilkins.
Kelly, M. W., & Myers, C. W. (1990). Clomipramine:
A tricyclic antidepressant effective in obsessive com- ▶ Clomipramine
pulsive disorder. The Annals of Pharmacotherapy, 24,
739–744.
Martin, A., & Volkmar, F. R. (2007). Lewis’s child and
adolescent psychiatry: A comprehensive textbook
(4th ed.). Philadelphia: Lippincott Williams & Clonidine
Wilkins.
Nelson, J. C. (2006). Tricyclic and tetracyclic drugs. Lawrence David Scahill
In A. F. Schatzberg & C. B. Nemeroff (Eds.), Essen- Nursing & Child Psychiatry, Yale University
tials of clinical psychopharmacology (2nd ed.,
pp. 5–29). Washington, DC: American Psychiatric School of Nursing, Yale Child Study Center,
Publishing. New Haven, CT, USA
Pigott, T. A., & Seay, S. M. (1999). A review of the
efficacy of selective serotonin reuptake inhibitors in
obsessive-compulsive disorder. The Journal of
Clinical Psychiatry, 60, 101–106. Synonyms
Remington, G., Sloman, L., et al. (2001). Clomipramine
versus haloperidol in the treatment of autistic disorder: Catapres; Kapvay; Nexiclon
A double-blind, placebo-controlled, crossover study.
Journal of Clinical Psychopharmacology, 21(4),
440–444.
Rosenbaum, J. F., & Tollefson, G. D. (2006). Fluoxetine. Definition
In A. F. Schatzberg & C. B. Nemeroff (Eds.), Essen-
tials of clinical psychopharmacology (2nd ed., Clonidine has not been well studied in children
pp. 31–46). Washington, DC: American Psychiatric
Publishing. with autism. To date, there have been only a few
Sadock, B. J., & Sadock, V. A. (2005). Kaplan and small studies. The most common adverse effect
Sadock’s pocket handbook of clinical psychiatry (4th of clonidine is sedation. Blood pressure is rarely
ed.). Philadelphia: Lippincott Williams & Wilkins. a problem – but should be monitored. The seda-
Sanchez, L. E., Campbell, M., et al. (1996). A pilot study
of clomipramine in young autistic children. Journal tive effects appear to be especially common in
of the American Academy of Child and Adolescent children with autism spectrum disorders and the
Psychiatry, 35(4), 537–544. medication is not commonly used in this
Clozapine 671 C
population. Another common clinical application Definition
of clonidine is to aid sleep in children with autism
spectrum disorders, Tourette syndrome, and Clozapine is an atypical antipsychotic that is
ADHD. Although the sedative effects are evident FDA-approved for the management of treat-
when clonidine is given before bedtime, it has not ment-resistant schizophrenia. It is believed to
been well studied for this purpose. antagonize dopamine-2 (D2) receptors, which
In recent years, two long-acting preparations causes reduced symptoms of psychosis and sta- C
of clonidine have entered the marketplace. One of bilizes affective symptoms, as well as serotonin
these formulations of extended-release clonidine 2A (5-HT2A) receptors, causing enhanced dopa-
is approved for the treatment of attention mine release in certain brain regions and possibly
deficit/hyperactivity disorder, but has not been improving cognitive and affective symptoms
studied in children with autism spectrum (Stahl, 2009). However, its pharmacological pro-
disorders. file is highly complex and likely involves multi-
ple pathways yet to be uncovered.
Clozapine is typically reserved for patients
References and Readings who have not responded to other antipsychotic
medications or who have suffered unwanted side
Ghaziuddin, M., Tsai, L., et al. (1992). Clonidine for effects from such therapies, such as tardive dys-
autism. Journal of Child & Adolescent Psychophar-
macology, 2(4), 239–240.
kinesia or extrapyramidal symptoms (EPS)
Jaselskis, C. A., Cook, E. H., et al. (1992). Clonidine (Novartis, 2010). Clozapine rarely causes
treatment of hyperactive and impulsive children with tardive dyskinesia and is even known to reduce
autistic disorder. Journal of Clinical Psychopharma- dyskinesias and EPS, like dystonia (Saddock &
cology, 12(5), 322–327.
Saddock, 2007). It is the only antipsychotic that
Ming, X., Gordon, E., et al. (2008). Use of clonidine in
children with autism spectrum disorders. Brain & has demonstrated a reduced risk of suicidal
Development, 30(7), 454–460. behavior in patients with schizophrenia and
schizoaffective disorder (Novartis, 2010). For
many of these reasons, clozapine is considered
the “gold standard” in the treatment of schizo-
phrenia and schizoaffective disorder, but its use is
Clopine limited by its side effect profile. A potentially
fatal adverse effect is agranulocytosis, character-
▶ Clozapine ized by a decreased white blood cell count (WBC
< 2,000/mm3) and experienced in 1–2% of
patients who take clozapine after 1 year of treat-
ment. Every patient undergoing clozapine
Clozapine treatment receives weekly blood draws for
6 months, followed by biweekly blood draws for
Christopher J. McDougle1 and Carolyn A. Doyle2 an additional 6 months, to monitor for agranulo-
1
Lurie Center for Autism/Harvard Medical cytosis. This can be a cumbersome and painful
School, Lexington, MA, USA process, which is why clozapine is often reserved
2
Indiana University School of Medicine, for those who have had minimal success with
Indianapolis, IN, USA other medications. Other adverse effects include
an increased risk of seizures, excessive saliva-
tion, weight gain, cardiometabolic risk, and
Synonyms myocarditis (Stahl, 2008).
Clozapine is not currently approved for treat-
Azaleptin; Clopine; Denzapine; FazaClo; ment of autism spectrum disorders (ASDs). There
Froidir; Klozapol; Leponex; Zaponex have been, however, four case reports of
C 672 Cluster Analysis
clozapine use in the treatment of individuals (3rd ed., pp. 409–410). New York: Cambridge Univer-
with autistic disorder (autism). These reports sity Press.
Stahl, S. M. (2009). Stahl’s essential psychopharmacol-
described clozapine use in a 32-year-old autistic ogy: The prescriber’s guide (3rd ed., pp. 113–118).
male (Gobbi & Pulvirenti, 2001), three autistic New Dehli: Cambridge University Press.
children ranging in age from 8 to 12 years Zuddas, A., Ledda, M. G., Fratta, A., Muglia, P., &
(Zuddas et al., 1996), a 17-year-old autistic ado- Cianchetti, C. (1996). Clinical effects of clozapine on
autistic disorder. The American Journal of Psychiatry,
lescent male with mental retardation (Chen et al., 153(5), 738.
2001), and a 15-year-old autistic female
(Lambrey et al., 2010). Overall, these reports
suggested favorable improvement in some symp-
toms, particularly aggressiveness. Double-blind,
placebo-controlled data is needed before recom- Cluster Analysis
mendations can be made regarding the efficacy of
clozapine use in treating ASDs. Clinical benefit Vicki Bitsika
must be heavily weighed against clozapine’s Faculty of Humanities and Social Sciences, Bond
extensive side effect profile before starting it in University, Robina, QLD, Australia
any patient.
Definition
See Also
Cluster analysis is a statistical technique which
▶ Antipsychotics: Drugs seeks to group individuals according to their sim-
▶ Atypical Antipsychotics ilar characteristics. That is, “clusters” of charac-
▶ Dopamine teristics which might, for example, group
▶ Serotonin individuals who make pottery would include
▶ Tardive Dyskinesia fine motor skill, eye-hand coordination, sensitive
tactile receptors in fingers and hands, high level
of ability to perceive moisture content in earth
materials, and good color discrimination. While
not all individuals with one or two of these char-
Chen, N. C., Bedair, H. S., Mckay, B., Bowers, M. B., & acteristics will be able to become a good potter
Mazure, C. (2001). Clozaril in the treatment of with appropriate training, people who possess all
aggression in an adolescent with autistic disorder. or most of these features will have a distinct
The Journal of Clinical Psychiatry, 62(6), 479–480.
advantage in becoming talented potters. Simi-
Gobbi, G., & Pulvirenti, L. (2001). Long-term treatment
with clozapine in an adult with autistic disorder larly, individuals who exhibit the cluster of symp-
accompanied by aggressive behaviour. Journal of Psy- toms associated with an Autism Spectrum
chiatry & Neuroscience, 26(4), 340–341. Disorder will be more likely to actually have
Lambrey, S., Falissard, B., Martin-Barrero, M., Bonnefoy,
this condition. However, because there is sub-
C., Quilici, G., Rosier, A., & Guillin, O. (2010). Effec-
tiveness of clozapine for the treatment of aggression in stantial variation in symptom expression between
an adolescent with autistic disorder. Journal of Child individuals with particular autism disorders,
and Adolescent Psychopharmacology, 20(1), 79–80. there has been some conjecture as to what
Novartis Pharmaceuticals Corporation. (2010). Prescribing
comprises Autistic Disorder versus Aspergers
information. Retrieved October, 2011, from http://www.
pharma.us.novartis.com/product/pi/pdf/Clozaril.pdf Syndrome or Pervasive Developmental Disorder-
Saddock, B. J., & Saddock, V. A. (2007). Kaplan & Not Otherwise Specified. Cluster analysis allows
Saddock’s Synopsis of psychiatry:Behavioral sciences/ for identification of clinical subgroups (based on
chinical psychiatry (p. 1095). Philadelphia: Lippincott
the type, number of, and severity of symptoms) to
Williams & Wilkens, a Wolters Kluwer Business.
Stahl, S. M. (2008). Stahl’s essential psychopharmacol- facilitate recommendations for appropriate treat-
ogy: Neuroscientific basis and practical applications ment – especially early in life when specialized
Cluster Analysis 673 C
intervention has the potential to result in the the DSM-III-R. This new diagnostic label
greatest positive outcomes for the individual. acknowledged the possible presence of two
autism subtypes (i.e., Infantile Autism and
Regressive Autism) distinguished on the basis
Historical Background of the age at which children displayed the pattern
of impairments indicative of neurological
The evolution of conceptualizations of autism abnormality. C
and reflection of these in the major diagnostic The DSM-IV (APA, 1994) and its revision, the
manuals is important in understanding the bar- DSM-IV-TR (APA, 2000), offered a broader
riers to accurate diagnosis of those individuals diagnostic framework which allowed for identi-
who either do not fit a predetermined diagnostic fication of high functioning individuals with
profile due to subtle expression of symptoms or average to above average cognitive ability and
who present with a complex combination of reasonably well-developed language skills. In
impairments impacted by comorbid disorders. addition to specifying five subtypes of Pervasive
The transition of autism from an all-or-none con- Developmental Disorder (i.e., ▶ Autistic
dition with one fixed constellation of symptoms Disorder, Aspergers Disorder, Rett’s Disorder,
to a spectrum representing substantial variation in ▶ Childhood Disintegrative Disorder, and
symptom expression has been significant in shap- ▶ Pervasive Developmental Disorder-Not Other-
ing clinicians’ utilization of diagnostic criteria wise Specified), there was revision of the diag-
for the purpose of accurate identification. This nostic criteria to encompass a wider range of
transition is best exemplified in the changes to atypical behaviors and reduce the number of
diagnostic categories shown in the Diagnostic symptoms required for a formal diagnosis. In
and Statistical Manual (DSM manual) from its the case of Autistic Disorder, the DSM-IV-TR
initial publication in 1952 to the 5th edition due (APA, 2000) maintained the “triad of impair-
for release in 2013. Since the DSM has remained ment” model (Wing & Gould, 1979) with stipu-
prominent in formal decisions regarding the stan- lation that qualitative discrepancies, between the
dards for diagnosis of autism conditions, the evo- child and chronologically similar peers, should
lution in autism conceptualizations will be occur in social interaction (at least two of four
examined in relation to DSM adaptations to symptom clusters) and communication (at least
those standards over time. one of four symptom clusters), along with pres-
Despite its robust history in the clinical ence of restricted, repetitive, and stereotyped
research since 1943, autism was not recognized patterns of behavior, interests, and activities
as a distinct disorder of childhood in the DSM (at least one of four symptoms clusters). Despite
until its third edition (▶ DSM-III: APA, 1980). this expansion of diagnostic categories, clinical
The DSM-III conceptualized autism as an all-or- researchers (e.g., Lord & Risi, 2000; Schuler &
none condition by presenting one diagnostic cat- Fletcher, 2002; Tidmarsh & Volkmar, 2003) con-
egory (i.e., Infantile Autism) and six diagnostic tinued to argue that the variability in manifesta-
criteria with the stipulation that evidence of tion of symptoms from one individual to another
impaired functioning was required for all six of was not adequately addressed by the DSM-IV-
these for a diagnosis of autism to be made. This TR (APA, 2000), thus risking poor identification
basis for classification was criticized as being of high functioning individuals. Also, strict
limited because it focused only on those cases in adherence to the “triad of impairment” model
which neurological impairment was evident at did not acknowledge the full constellation of
birth. Children who exhibited regression in func- difficulties (e.g., hypersensitivity to sensory stim-
tioning between the ages of 18 and 36 months uli in the environment, restricted diet, and poor
were not clearly represented, thus leading to sub- sleeping patterns) of clinical significance in
sequent revision of the Infantile Autism category understanding the issues which disrupted daily
to Autistic Disorder in 1987 with publication of functioning and would require specialized
intervention (Keane, 2004; Lord & Risi, 2000). incapable of responding to due to underlying
The latest version of the DSM, currently in draft skill deficits. This inclusion in the DSM-V draft
form, contains some evidence of attempts to provides a basis for continued monitoring of
encompass a broader range of functional levels cases with suspected ASD to ensure they are
in autism and these attempts will be further accurately identified and provided with access
discussed. to specialized educational support at the earliest
possible time.
Notwithstanding these potentially advanta-
Current Knowledge geous revisions to diagnostic criteria, alternations
such as amalgamation of diagnostic categories
The term Autism Spectrum Disorder (ASD), first and removal of Aspergers Disorder as a distinct
introduced by Lorna Wing in 1992, has replaced diagnostic label have created controversy in the
Pervasive Developmental Disorder as the collec- clinical field. Further, the anticipated elucidation
tive label for ▶ Autistic Disorder, ▶ Aspergers in methods for identification of complex cases
Disorder, ▶ Pervasive Developmental Disorder- and those with more subtle symptom manifesta-
Not Otherwise Specified, and ▶ Childhood tion has not been realized. Marttila et al. (2011)
Disintegrative Disorder with this last condition applied the draft DSM-V diagnostic criteria for
being an addition to the group of diagnoses ASD to evaluate 26 children with an autism con-
represented by the ASD label. It is also proposed dition confirmed by their Autism Diagnostic
that the three impairment domains listed in earlier Interview-Revised (ADI-R) and Autistic Diag-
editions of the DSM be reduced by merging the nostic Observation Schedule (ADOS) scores.
communication and social behavior categories Those researchers reported that DSM-IV criteria
(Criterion 1) on the basis that symptoms in these were not of sufficient sensitivity to identify high
domains are interrelated and possibly due to sim- functioning children with well-developed com-
ilar contextual antecedents. In addition, it is munication skills and paucity of stereotyped and
argued that atypical communication is not exclu- repetitive behavior. Findings such as these
sive to autistic disorder nor is it significant to emphasize that the heterogeneity which exists in
functional impairment in all cases, thus leading the autism spectrum cannot be adequately
to its re-conception as a contributing rather than accounted for by diagnostic categories requiring
defining aspect of ASD. Further, Criterion 1 a fixed profile of symptoms for formal diagnosis.
requires evidence of developmental delay in all Witwer and Lecavalier (2008) report that there is
three areas of social/communication functioning significant variation in symptom manifestation
which include deficits in: social-emotional reci- within DSM diagnostic categories and argue for
procity, nonverbal communication, and capacity greater investigation of alternative approaches to
to maintain relationships. The second diagnostic categorization.
criterion pertains to presence of fixated interests Cluster analysis shows promise as a system for
and repetitive behaviors with stipulation that clarifying differences in functioning across the
atypical performance be recorded for two of autism spectrum by leading to identification of
four symptom clusters: (1) stereotyped or repeti- subgroups which are potentially independent of
tive speech, motor movements, or use of objects; diagnostic labels. Cluster analytic investigations
(2) excessive adherence to routines; (3) restricted of the past decade have focused on detection of
interests of abnormal intensity; and (4) hyper-or those dimensions (arising from skill deficits)
hypo-reactivity to sensory input or unusual inter- most capable of providing a valid basis for dif-
est in sensory aspects of the environment. Inter- ferentiating between groups of individuals with
estingly, the DSM-V draft includes a diagnostic an autism condition. While the spectrum concept
criterion which states that symptoms might not of autism argues that there is an underlying
become evident until the child is exposed to dimension or set of dimensions along which all
social stimuli which create demand (s)he is individuals will vary, there is still debate over
Cluster Analysis 675 C
precisely what constitutes this underlying dimen- Robins, Bakeman, & Adamson, (2009) presented
sion (Szatmari, 1992). A large proportion of stud- a three-cluster solution for 186 toddlers who fell
ies have examined whether impairment in into homogeneous groups due to variation in
particular aspects of functioning (e.g., cognitive social/communication and cognitive skills plus
vs. adaptive behavior) or combinations of deficits the rate and intensity of repetitive behavior and
(e.g., cognitive plus social skill) represent presence of abnormal sensory responding. Lane,
a reliable basis for forming homogeneous autism Young, Baker, and Angley (2010) and Lane, C
subgroups. Other studies have sought to examine Dennis, and Geraghty (2011) used model-based
whether number of symptoms or severity of def- cluster analysis of parent reports of their chil-
icits might result in accurate differentiation to dren’s sensory responses to explore the presence
allow for a more inclusive basis for understand- of subgroups differentiated on the basis of type of
ing and treating individuals on the autism sensory processing dysfunction. Those
spectrum. researchers identified three sensory subtypes
Eaves, Ho, and Eaves (1994) reported on (i.e., sensory-based inattentive seeking, sensory
a cluster analysis which grouped children into modulation with movement sensitivity, and sen-
four subtypes based on number of symptoms sory modulation with taste/smell sensitivity) and
and extent of cognitive impairment. Groups argued that these subtypes would have
were described as representing typical autism a differential impact on core autism symptoms
(autistic disorder), low functioning autism (intel- as well as requiring different remediation strate-
lectually impaired), high functioning autism gies. Verte et al. (2006) examined the question of
(Aspergers disorder), and “hard to diagnose” whether children with autism disorder could be
with mild to moderate cognitive disability and differentiated into subgroups based primarily on
a family history of learning difficulties. their scores from the Children’s Communication
Researchers such as Prior et al. (1998) have indi- Checklist and reported a three-cluster solution in
cated that the distinguishing feature between which differentiation was achieved in relation to
autism subgroups is related to the severity of severity of communication deficits such as inap-
social and cognitive impairments rather than dis- propriate initiation, stereotyped conversation,
tinctive symptom patterns. That study supported and interactional rapport. Studies such as this
the concept of a spectrum of autistic dysfunction indicate that it is variation in the social-pragmatic
which places children on a continuum from low aspects of language which allows for separation
functioning to high functioning. The concept of of individuals into clinical subgroups rather than
a spectrum was previously supported by Sevin verbal ability per se. The significance of using
et al. (1995) who suggested that the degree of language performance to assist in establishing
impairment in the core features of autism (i.e., specific subgroups of individuals has been previ-
social interaction, language and communication, ously discussed by Tager-Flusberg and Joseph
and restricted and ritualistic behaviors) is the (2003). In both studies, level of cognitive disabil-
most important basis for making sense of the ity was found to mediate the effects of language
variety of behaviors which fall under the impairment.
umbrella of autism. Fernell, Hedvall, Norrelgen,
Eriksoson, Hoglund-Carlsson, & Barnevik-
Olsson, (2010) also argued for the significance Future Directions
of symptom severity in clarifying the variations
in functioning which characterize individuals Manualized diagnostic systems, although neces-
with an autism disorder. Those researchers sary for standardization of decisions regarding
presented a seven-cluster model of subgroups of the presence of autism, have not represented all
preschool children who were differentiated on the aspects of the spectrum well. The DSM-V draft,
basis of cognition, behavior, speech and lan- despite its proposed revisions in the diagnostic
guage, and motor control. Similarly, Wiggins, categories for autism disorder, does not appear to
offer substantial improvement in accounting for autism disorder based on the presenting behav-
the full range of phenotypes which present in the iors which interfere with their functioning. How-
clinical environment (Marttila et al., 2011). This ever, further investigations are necessary to aid
limitation is exacerbated by the clinical finding differentiation not only in relation to behavioral
that individuals with the same diagnosis can and topography and intensity but also variations in
do exhibit varying profiles of impairment and this behavior resulting from exposure to particu-
behavioral disturbance, thus leading to heteroge- lar environmental stimuli. Reclassification of
neity within diagnostic groups (Witwer & individuals with an ASD into clearly defined sub-
Lecavalier, 2008). Clinical issues such as these groups, according to suggestions such as those
bring into question the common practice of using raised here, can only promote a better under-
a diagnostic label as the basis for intervention standing of their particular needs and clinical
planning. This label-driven intervention treatment to aid effective functioning across the
approach, which guides clinicians in the field to lifespan.
apply genetic strategies designed to remediate
aspects of autism, has not resulted in strong pos-
itive outcomes and prompted the call for addi- See Also
tional analyses to elucidate specific autism
subgroups that can be treated more directly ▶ Statistical Approaches to Subtyping
(Bitsika, 2008; Perry, Flanagan, Grier, and
Freeman, 2009).
Identification and description of clinical sub- References and Readings
groups via statistical methods such as cluster
analysis can contribute to development of American Psychiatric Association (1980). Diagnostic and
targeted interventions capable of building statistical manual of mental disorders – DSM-III (3rd
competencies to enhance positive outcomes for ed.). Washington, DC: Author.
American Psychiatric Association (1994). Diagnostic
individuals with an autism disorder in the long and statistical manual of mental disorders – DSM-IV
term. There are a number of considerations which (4th ed.). Washington, DC: Author.
might be of merit in maximizing the contribution American Psychiatric Association (2000). Diagnostic and
of cluster analysis to effective treatment. statistical manual of mental disorders, text revision –
DSM-IV-TR (4th ed.). Washington, DC: Author.
Traditionally, studies in this field have relied on Bitsika, V. (2008). Including an analysis of difficult
total scores from standardized tests (e.g., WISC behaviour in the assessment of children with an
Full Scale IQ) to establish clinical subgroups Autism spectrum disorder: Implications for school
which share the same characteristics on specified psychologists. Australian Journal of Guidance and
Counselling, 18, 1–14.
dimensions (e.g., social skill and communication). Bitsika, V., Sharpley, C. F., & Orapeleng, S. (2008).
It is suggested that future research elaborates on Using cognitive, adaptive and behavioral indices for
standardized data via inclusion of subtest scores cluster analysis of ASD subgroups. Journal of Intel-
to facilitate an in-depth investigation of specific lectual Disability Research, 52, 973–985.
Chawarska, K., Klin, A., Paul, R., Macari, S., &
abilities. Although differentiation of individuals Volkmar, F. (2009). A prospective study of toddlers
with autism disorder on the basis of global abili- with ASD: Short-term diagnostic and cognitive
ties such as intelligence and adaptive behavior outcomes. Child Psychology and Psychiatry, 50,
has been useful in more precise classification, it 1235–1245.
Eaves, L. C., Ho, H. H., & Eaves, D. M. (1994). Subtypes
is their behavioral challenges which are particu- of Autism by cluster analysis. Journal of Autism and
larly disruptive to social functioning and often Developmental Disorders, 24, 3–22.
the reason for referrals for intervention. Fernell, E., Hedvall, A., Norrelgen, F., Eriksoson, M.,
Researchers (e.g., Bitsika, Sharpley, & Hoglund-Carlsson, L., Barnevik-Olsson, M., et al.
(2010). Developmental profiles in preschool children
Orapeleng, 2008; Prior et al., 1998; Waterhouse with Autism spectrum disorders referred for interven-
et al., 1996) have made some progress in tion. Research in Developmental Disabilities, 31,
establishing subgroups of individuals with an 790–799.
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Keane, E. (2004). Autism: The heart of the disorder? Waterhouse, L., Morris, R., Allen, D., Dunn, M., Fein, D.,
Sensory processing social engagement – illustrations Feinstein, C., et al. (1996). Diagnosis and classification
from autobiographical accounts and selected research in Autism. Journal of Autism and Developmental
findings. Australian Journal of Early Childhood, 29, Disorders, 26, 59–86.
8–14. Wiggins, L. D., Robins, D. L., Bakeman, R. &
Lane, A. E., Dennis, S. J., & Geraghty, M. E. (2011). Adamson, L. B. (2009). Brief report: sensory
Brief report: Further evidence of sensory subtypes abnormalities as distinguishing symptoms of n autism
in Autism. Journal of Autism and Developmental
Disorders, 41, 826–831.
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children,
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Lane, A. E., Young, R. L., Baker, A. E., & Angley, M. T. 1087–1091.
(2010). Sensory processing subtypes in Autism: Asso- Wiggins, L. D., Robins, D. L., Adamson, L. B., Bakeman,
ciation with adaptive behaviour. Journal of Autism and R., & Henrich, C. C. (2011). Support for a dimensional
Developmental Disorders, 40, 112–122. view of Autism spectrum disorders in toddlers. Jour-
Lord, C., & Risi, S. (2000). Diagnosis of Autism spectrum nal of Autism and Developmental Disorder.
disorders in young children. In A. Wetherby & B. doi:10.1007/s10803-011-1230-0.
Prizant (Eds.), Autism spectrum disorders: A transac- Wing, L., & Gould, J. (1979). Severe impairments
tional developmental perspective (pp. 167–190). of social interaction and associated abnormalities in
Baltimore: Paul H. Brookes. children: Epidemiology and classification. Journal
Marttila, M., Keilinen, M., Linna, S., Jussila, K., of Autism and Developmental Disorders, 9, 11–29.
Ebeling, H., Bloigu, R., et al. (2011). Autism spectrum Witwer, A. N., & Lecavalier, L. (2008). Examining
disorders according to DSM-IV-TR and comparison the validity of Autism spectrum disorder subtypes.
with DSM-5 draft criteria: An epidemiological Journal of Autism and Developmental Disorders, 38,
study. Journal of the American Academy of Child 1611–1624.
Perry, A., Flanagan, H. E., Grier, J. D., & Freeman, N. L.
(2009). Brief report: The Vineland adaptive behavior
scales in young children with Autism spectrum disor-
ders at different cognitive levels. Journal of Autism
and Developmental Disorders, 39, 1066–1078. Cluster Reports and Autism
Prior, M., Eisnemajer, R., Leekam, S., Wing, L., Gould, J.,
Ong, B., et al. (1998). Are there subtypes within
Gayle C. Windham
the Autistic spectrum? A cluster analysis of a group
of children with Autistic spectrum disorders. Division of Environmental and
Journal of Child Psychology and Psychiatry, 39, Occupational Disease Control, CA
893–902. Department of Public Health, Richmond,
Schuler, A. L., & Fletcher, C. E. (2002). Making commu-
CA, USA
nication meaningful: Cracking the language interac-
tion code. In R. L. Gabriels & D. E. Hill (Eds.), Autism:
From research to individualized practice (pp. 127–154).
London: Jessica Kingsley. Definition
Sevin, J. A., Matson, J. L., Coe, D., Love, S. R.,
Matese, M. J., & Benavidez, D. A. (1995). Empirically
derived subtypes of pervasive developmental disor- Using an epidemiological definition, a “cluster”
ders: A cluster analytic study. Journal of Autism and is an aggregation of health-related events or dis-
Developmental Disorders, 25, 561–578. eases that are grouped together in time and/or
Szatmari, P. (1992). The validity of Autistic spectrum
space in greater than expected (real or perceived)
disorders: A literature review. Journal of Autism and
Developmental Disorders, 22, 583–600. frequencies (Centers for Disease Control [CDC],
Tager-Flusberg, H., & Joseph, R. M. (2003). Identifying 1990). “Clustering” is usually used to describe
neurocognitive phenotypes in Autism. Philosophical aggregations of relatively uncommon diseases,
Transactions of the Royal Society of London, 358,
such as cancer or birth defects, in a population
303–314.
Tidmarsh, L., & Volkmar, F. (2003). Diagnosis and epi- or geographic area for which no known cause
demiology of Autism spectrum disorders. Canadian exists, but may be suspected. This definition
Journal of Psychiatry, 48, 517–525. will be used, in contrast to, for example, cluster-
Verte, S., Geurts, H. M., Roeyers, H., Rosseel, Y.,
ing of disease traits or symptoms, such as in ASD,
Ossterlaan, J., & Sergeant, J. A. (2006). Can the
children’s communication checklist differentiate that might be used to classify subtypes of
Autism spectrum subtypes? Autism, 10, 266–287. a condition.
C 678 Cluster Reports and Autism
Historical Background had occurred among young homosexual men in

Los Angeles, which began the identification of
Unusual events such as clusters occur regularly, the AIDS epidemic.
often by chance alone, so there are many consid- Although less common, investigations of
erations that come into defining or further inves- noninfectious disease clusters have also resulted
tigating a cluster of disease. From a statistical in notable examples of breakthroughs linking
perspective, it is almost inevitable that some a health effect to an exposure, such as
schools, workplaces, or neighborhoods will be angiosarcoma among vinyl chloride workers,
associated with clusters of chronic diseases, adenocarcinoma of the vagina associated with
which may lead to concern on the part of the maternal use of diethylstilbestrol (DES), and
seemingly affected group. When first noticed, phocomelia with the use of thalidomide; these
cases in a cluster are often suspected as resulting tend to have more of a time component with an
from the same specific cause rather than as inde- alert clinician seeing more cases in a short period
pendent events (e.g., coin tosses) that happened than expected, but ended up affecting
to have occurred by chance in one place or time a widespread population geographically. More
period. A cluster may be investigated to help often, health investigations may not identify the
determine whether there is a common cause, in cause of the cluster due to methodologic limita-
which case the definition of the underlying pop- tions, usually of small sample size (Wartenberg
ulation in space and time is critical (see below), & Greenberg, 1990) or because of the role of
but even so there are often no reasons identified chance. There are several steps to be taken in
for the cluster. For example, for a relatively a careful cluster evaluation, including
uncommon disease like autism with establishing a specific case definition, so for
a prevalence of up to 1 in a 100 children, in example, different types of birth defects or can-
a small enough population, such as a few blocks cers are not grouped together; defining the popu-
in a neighborhood, one family with two affected lation denominator in person-time; confirming
children could constitute a greater than expected suspected cases and comparing rates to those in
occurrence statistically but yield little informa- the literature; and accounting for known causes
tion on causes. (Agency for Toxic Substances and Disease Reg-
Infectious diseases typically have time and istry [ATSDR], 2000; CDC, 1990). The step of
place components. Investigating clusters, such defining the appropriate population, for example,
as the classic church picnic, can lead to identifi- an entire school versus one block of
cation of the source of the infection and thus the a neighborhood, or identifying the appropriate
means to stop it or prevent it in the future. If exposure period may result in realizing that the
clusters are of sufficient size and importance, prevalence of the disease is actually within
they may be evaluated as outbreaks or eventually expected. If a cluster is confirmed, the next step
turn into epidemics. Often, when clusters are is to assess common factors or possible exposure
recognized, they are reported to departments or pathways to generate hypotheses about etiologic
officials in the local area. Several breakthroughs mechanisms.
and triumphs in infectious disease control have There are numerous methods developed for
resulted from the epidemiologic evaluation of identifying clusters, sometimes called cluster
clusters of cases. Well-known examples include or geospatial analysis, to determine whether
cholera linked to the Broad Street pump in Lon- cases are linked in time or place (Rothenberg
don by John Snow in the 1850s, the investigation & Thacker, 1992). These can also be used with
of cases of pneumonia at the Bellevue-Stratford routine disease-monitoring data to identify spa-
Hotel in Philadelphia in 1976 leading to the iden- tially related subgroups that may have a common
tification of Legionnaires’ disease and the venti- cause or to learn more about etiologic mecha-
lation system as a source, and the 1981 report that nisms. Detailed description of these methods is
seven cases of Pneumocystis carinii pneumonia beyond the scope of this discussion.
Cluster Reports and Autism 679 C
Current Knowledge There have been popular media reports of
“clusters” or higher rates of autism occurring in
Clusters of Autism areas where information technology (IT) compa-
Few clusters of autism have been reported, but nies cluster, such as the Silicon Valley in
this is not necessarily unexpected as reports of California. Although not limited to one work-
clusters may be handled only at the local level. place as would be typical for a cluster, Baron-
The best known is the Brick Township cluster in Cohen et al. (1997) reported that fathers and C
New Jersey, initially reported by a parent group grandfathers of children with autism were
concerned about the number of children with overrepresented in the field of engineering. Two
autism and environmental issues due to the prox- subsequent studies raised the possibility that dif-
imity of several Superfund sites (Bertrand et al., ferences in ascertainment due to SES might
2001; CDC, 2000). Their community survey explain the results (Jarrold & Routh, 1998;
identified an apparently high rate of autism, so Windham, Fessel, & Grether, 2009). The latter
the Centers for Disease Control and Prevention study, conducted in California, did not find that
(CDC) and the Agency for Toxic Substances and fathers were overrepresented in “high-tech”
Disease Registry (ATSDR) conducted an exten- fields such as engineering and computer pro-
sive investigation in 1998 to identify and clini- gramming, but mothers were. A very recent
cally confirm all cases. The prevalence they study reported higher prevalence of autism in
determined was about four times higher than the a high-density IT region of the Netherlands com-
frequently cited prevalence in the literature at the pared to other areas, based on school reports, so
time of 1 per 1,000. The exposure assessment by further investigation will be done (Roelfsema
ATSDR did not reveal any links between envi- et al., 2011). The CA study conducted in a six-
ronmental contamination and the cases. When county region of the San Francisco Bay Area did
studies with similar methods of intensive case not find overrepresentation of cases with autism
finding were compared, the prevalence was deter- born in the county that includes Silicon Valley
mined to be more similar. Routine surveillance compared to controls (Windham et al., 2009).
figures for autism were not available in the USA Autism could be said to “cluster” in families
at that time, so this cluster in part led to the given the strong genetic component, but this is
implementation of such a system coordinated by a different topic (see ▶ Genetics, ▶ Broader
the CDC, i.e., the Autism and Developmental Autism Phenotype)
Disabilities Monitoring (ADDM) program (Rice Two recent studies (Mazumdar et al., 2010;
et al., 2007). Van Meter et al., 2010) used complex methods to
Another parent-initiated report of an autism identify clusters of autism based on residence at
cluster occurred in the UK, which was also birth in California in order to generate hypotheses
resolved as being consistent with a higher preva- about environmental exposures or other drivers
lence of autism than commonly known at the time of autism prevalence at the local level. Both were
(Baron-Cohen, et al. 1999). Futher confirming the based on essentially the same data from the state-
difficulties of studying small clusters (n ¼ 7) and wide Department of Developmental Services
appropriate comparison groups, the rate would only (DDS) database, which has been used for surveil-
be considered higher than expected when compared lance purposes (Windham et al., 2011), but with
to rates in children under age 5 rather than in those slightly different birth years and methods. Clus-
under age 18. A cluster of autism has recently been ters were identified in both studies but the extent
reported to the Minnesota Department of Health by to which known factors, or differences in service
parents of Somali children, supported by findings in criteria by area, were evaluated was not clear in
Sweden (Barnevik-Olsson, Gillberg, & Fernell, one of the studies (Mazumdar et al., 2010). After
2010), which has led to current investigation to accounting for several factors, including DDS
identify possible risk factors and to learn more regional center, the other study found the cluster-
about the causes of autism. ing was related to high parental education
C 680 Cluttering
(Van Meter et al., 2010), which may be related to September, 2011, www.cdc.gov/ncbddd/dd/report.
successfully seeking services for affected chil- htm
Jarrold, C., & Routh, D. A. (1998) Is there really a link
dren. Potential environmental causes of autism between engineering and autism? A reply. Autism, 2,
merit further investigation. 281–289.
Mazumdar, S., King, M., Liu, K. Y., Zerubavel, N., &
Bearman, P. (2010). The spatial structure of autism
in California, 1993–2001. Health & Place, 16(3),
Future Directions 539–546. Epub 2010 Jan 22.
Rice, C., Baio, J., Van Naarden Braun, K., Doernberg, N.,
The occurrence of clusters is not predictable, so Meaney, F. J., Kirby, R. S., et al. (2007). A public
the merit of further investigation must be consid- health collaboration for the surveillance of autism
spectrum disorders. Paediatric and Perinatal Epide-
ered on an ad hoc basis. As there are now several miology, 211, 79–90.
surveillance systems for autism, cluster analyses Roelfsema, M. T., Hoekstra, R. A., Allison, C.,
could be conducted to identify so-called hot spots Wheelwright, S., Brayne, C., Matthews, F. E., et al.
and thus possible risk factors. However, it seems (2011). Are autism spectrum conditions more
prevalent in the information technology region?
potentially less useful for studying the etiology of A school-based study of three regions the Netherlands.
autism given its broad multifactorial nature. Journal of Autism and Devopmental Disord.
doi:10.1007/s10803-011-1302-1.
Rothenberg, R. B., & Thacker, S. B. (1992). Guidelines
for the investigation of clusters of adverse health
See Also events. In P. Elliott, J. Cuziak, D. English, & R. Stern
(Eds.), Geographical and environmental epidemiol-
▶ Genetics ogy: methods for small-area studies (pp. 264–277).
▶ Broader Autism Phenotype Oxford: Oxford University Press.
Van Meter, K. C., Christiansen, L. E., Delwiche, L. D.,
Azari, R., Carpenter, T. E., & Hertz-Picciotto, I.
(2010). Geographic distribution of autism in Califor-
nia: A retrospective birth cohort analysis. Autism
References and Readings Research, 3(1), 19–29.
Wartenberg, D., & Greenberg, M. (1990). Detecting dis-
Agency for Toxic Substances and Disease Registry ease clusters: The importance of statistical power.
(ATSDR). (2000). “Definition of Clusters”, Case Stud- American Journal of Epidemiology, 132, S156–S166.
ies in Environmental Medicine (CSEM). U.S. Depart- Windham, G. C., Anderson, M. C., Croen, L. A.,
ment of Health and Human Services. Smith, K. S., Collins, J., & Grether, J. K. (2011).
Barnevik-Olsson, M., Gillberg, C., & Fernell, E. (2010). Birth prevalence of autism spectrum disorders in the
Prevalence of autism in children of Somali origin living San Francisco bay area by demographic and ascertain-
in Stockholm: Brief report of an at-risk population. ment source characteristics. Journal of Autism and
Developmental Medicine and Child Neurology, 52(12), Developmental Disorders, 41, 1362–1372.
1167–1168. doi:10.1111/j.1469-8749.2010.03812.x. Windham, G. C., Fessel, K., & Grether, J. K. (2009).
Epub 2010 Oct 21. Autism spectrum disorders in relation to parental occu-
Baron-Cohen, S., Saunders, K., & Chakrabarti, S. (1999). pation in technical fields. Autism Research, 2,
Does autism cluster geographically? A research note. 183–191.
Autism, 3, 39–43.
Baron-Cohen, S., Wheelwright, S., Stott, C., Bolton, P., &
Goodyer, I. (1997). Is there a link between engineering
and autism? Autism, 1, 153–163.
Bertrand, J., Mars, A., Boyle, C., Bove, F., Yeargin-Allsopp, Cluttering
M., & Decoufle, P. (2001). Prevalence of autism in the
United States population: the Brick Township, New Jer-
▶ Fluency and Fluency Disorders
sey, investigation. Pediatrics, 108, 1155–1161.
Centers for Disease Control (CDC). (1990). Guidelines for
investigating clusters of health events. MMWR, 39
(RR-11), pp. 1–23.
Centers for Disease Control and Prevention (CDC).
(2000). Prevalence of autism in Brick Township, New
CNTN4
Jersey, 1998: Community report. April 2000. U.S.
Department of Health and Human Services. Accessed ▶ CNTN4: Contactin 4
CNTN4: Contactin 4 681 C
maintenance of brain neuronal networks. Subse-
CNTN4: Contactin 4 quently, Saito, Mimmack, Kishimoto, Keverne,
and Emson (1998) concluded that this protein is
Thomas Fernandez involved in synaptogenesis by studying its expres-
Yale Child Study Center, Yale University School sion pattern in the development of rat olfactory
of Medicine, New Haven, CT, USA sensory neurons.
The expression profile of CNTN4 in the adult C
human brain has been examined by Northern blot
Synonyms analysis, but these studies are limited in scope.
CNTN4 expression is most prominent in the cer-
AXCAM; BIG-2; CNTN4 ebellum, occipital lobe, and frontal lobe,
followed by thalamus, cerebral cortex, and
substantia nigra (Kamei et al., 2000).
Structure
Contactin 4 is a neuronal membrane protein. Pathophysiology

In humans, it is encoded by the gene CNTN4,
located on chromosome 3p26.3-p26.2, Several studies of developmental disorders have
containing 24 exons, and spanning 957 kb. Alter- implicated CNTN4 and suggest an important role
native splicing results in multiple transcript var- in normal and abnormal central nervous system
iants. The largest splice variant of contactin 4 (CNS) development. Specifically, disruption of
(1,026 amino acids) shares 44–66% identity this gene may play a role in 3p-deletion syndrome
with other contactin proteins. It has six immuno- and autism spectrum disorders (ASD), as
globulin-like domains, four fibronectin type III- evidenced by the studies described below.
like repeats, one C-terminal glycosylphosphati- Fernandez et al. (2004, 2008) studied the
dylinositol (GPI) anchor to the extracellular part breakpoints of a de novo balanced translocation
of the cell membrane, and one N-terminal signal (t(3;10)(p26;q26)) in a boy with characteristic
peptide. These domains are conserved between physical features of 3p-deletion syndrome who
the human and rat ortholog (BIG-2). A smaller met the criteria for ASD with impaired social
splice variant (CNTN4A, 282 amino acids) has functioning, verbal and nonverbal developmental
two fibronectin type III-like repeats and one GPI- delay, and repetitive behaviors. Fine mapping of
anchoring domain (Zeng et al., 2002). the breakpoint on chromosome 3 revealed disrup-
tion of CNTN4, and this gene maps within the
previously defined minimal candidate region for
Function 3p-deletion syndrome. These results suggested
a causal relationship between CNTN4 disruption
Contactin 4 is a member of the immunoglobulin and 3p-deletion syndrome and a possible rela-
superfamily of neuronal cell adhesion molecules tionship with ASD.
involved in axon growth, guidance, and fascicula- Roohi et al. (2009) identified paternally
tion in the central nervous system. It is a member of inherited copy number variants (CNV) disrupting
the contactin subgroup of these molecules and is CNTN4 in 3 of 92 subjects with ASD (deletions in
believed to function in the formation of axon con- two affected siblings and a duplication in an
nections and plasticity in the developing nervous unrelated affected child). This report further
system. Yoshihara et al. (1995) studied the rat implicated CNTN4 as a candidate gene in ASD.
ortholog protein, BIG-2, in vitro and found that it Glessner et al. (2009) reported a study of
promoted neurite outgrowth when used as genome-wide copy number variation in two
a neuronal substrate. Overall, their results suggest ASD and control cohorts. Among other ASD
that this protein has a role in the formation and candidate genes, they found a significant increase
C 682 CNVs
in inherited CNV deletions (p ¼ 0.004) and dupli- Fernandez, T., Morgan, T., Davis, N., Klin, A., Morris, A.,
cations (p ¼ 0.013) overlapping CNTN4 in cases Farhi, A., et al. (2008). Disruption of contactin 4
(CNTN4) results in developmental delay and other fea-
versus controls. tures of 3p deletion syndrome (vol 74, pg 1286, 2004).
Most recently, Cottrell et al. (2011) identified American Journal of Human Genetics, 82(6), 1385.
unique nonsynonymous variants of CNTN4 in 4 Glessner, J., Wang, K., Cai, G., Korvatska, O., Kim, C.,
of 75 ASD-affected individuals versus 1 of 107 Wood, S., et al. (2009). Autism genome-wide copy
number variation reveals ubiquitin and neuronal
unaffected controls. All variants occurred at genes. Nature, 459(7246), 569–573.
highly conserved positions in the gene and were Kamei, Y., Takeda, Y., Teramoto, K., Tsutsumi, O.,
predicted to be deleterious. However, this burden Taketani, Y., & Watanabe, K. (2000). Human NB-2
differential did not reach statistical significance of the contactin subgroup molecules: Chromosomal
localization of the gene (CNTN5) and distinct expres-
or segregate with ASD in all affected families, sion pattern from other subgroup members. Genomics,
leaving some question about the role of CNTN4 69(1), 113–119.
variants in ASD pathogenesis. Online Mendelian Inheritance in Man, OMIM®. McKusick-
Overall, there is evidence that CNTN4 plays Nathans Institute of Genetic Medicine, Johns Hopkins
University (Baltimore, MD), Dec 20, 2011. World Wide
an important role in the normal development and Web URL: http://omim.org/entry/607280
maintenance of CNS function. It has been pro- Osterfield, M., Egelund, R., Young, L. M., & Flanagan,
posed that the molecular basis of CNTN4 J. G. (2008). Interaction of amyloid precursor protein
neurodevelopmental functions is conferred by with contactins and NgCAM in the retinotectal system.
Development, 135(6), 1189–1199.
interactions with other proteins (Zuko, Bouyain, Roohi, J., Montagna, C., Tegay, D. H., Palmer, L. E.,
van der Zwaag, & Burbach, 2011), including DeVincent, C., Pomeroy, J. C., et al. (2009). Disrup-
protein tyrosine phosphatase receptor gamma tion of contactin 4 in three subjects with autism spec-
(PTPRG) (Bouyain & Watkins, 2010) and trum disorder. Journal of Medical Genetics, 46(3),
176–182.
amyloid precursor protein (APP) (Osterfield, Saito, H., Mimmack, M., Kishimoto, J., Keverne, E. B., &
Egelund, Young, & Flanagan, 2008). Emson, P. C. (1998). Expression of olfactory recep-
tors, G-proteins and AxCAMs during the development
and maturation of olfactory sensory neurons in the
mouse. Brain Research. Developmental Brain
See Also Research, 110(1), 69–81.
Shimoda, Y., & Watanabe, K. (2009). Contactins: Emerging
▶ Contactin-Associated Protein 2 key roles in the development and function of the nervous
system. Cell Adhesion & Migration, 3(1), 64–70.
Yoshihara, Y., Kawasaki, M., Tamada, A., Nagata, S.,
Kagamiyama, H., & Mori, K. (1995). Overlapping
References and Readings and differential expression of BIG-2, BIG-1, TAG-1,
and F3: Four members of an axon-associated cell
Bouyain, S., & Watkins, D. J. (2010). The protein tyrosine adhesion molecule subgroup of the immunoglobulin
phosphatases PTPRZ and PTPRG bind to distinct mem- superfamily. Journal of Neurobiology, 28(1), 51–69.
bers of the contactin family of neural recognition mole- Zeng, L., Zhang, C., Xu, J., Ye, X., Wu, Q., Dai, J., et al.
cules. Proceedings of the National Academy of Sciences (2002). A novel splice variant of the cell adhesion
of the United States of America, 107(6), 2443–2448. molecule contactin 4 (CNTN4) is mainly expressed
Cottrell, C. E., Bir, N., Varga, E., Alvarez, C. E., Bouyain, in human brain. Journal of Human Genetics, 47(9),
S., Zernzach, R., et al. (2011). Contactin 4 as an autism 497–499.
susceptibility locus. Autism Research, 4(3), 189–199. Zuko, A., Bouyain, S., van der Zwaag, B., & Burbach, J. P.
Fernandez, T., Garcia-Gonzalez, I., Mason, C., (2011). Contactins: Structural aspects in relation to
Hernandez-Zaragoza, G., Ledezma-Rodriguez, V., developmental functions in brain disease. Advances in
Anguiano-Alvarez, V., et al. (2008). Molecular char- Protein Chemistry and Structural Biology, 84, 143–180.
acterization of a patient With 3p deletion syndrome
and a review of the literature. American Journal of
Medical Genetics, 146A(21), 2746–2752.
Fernandez, T., Morgan, T., Davis, N., Klin, A., Morris, A.,
Farhi, A., et al. (2004). Disruption of contactin 4
(CNTN4) results in developmental delay and other
CNVs
features of 3p deletion syndrome. American Journal
of Human Genetics, 74(6), 1286–1293. ▶ Copy Number Variation
Cognitive Behavioral Therapy (CBT) 683 C
Cochlea Cognitive Behavioral Therapy (CBT)
Jennifer McCullagh Jeffrey J. Wood1, Eric Storch2, Cori Fujii3,

Department of Communication Disorders, Patricia Renno4, Lindsey Sterling5, Wei-Chin
Southern Connecticut State University, Hwang6 and Marilyn Van Dyke7
New Haven, CT, USA 1
Departments of Psychiatry and C
Education, University of California,
Synonyms 2
Departments of Pediatrics and Psychiatry,
University of South Florida, St. Petersburg,
Inner ear FL, USA
3
Division of Psychological Studies in Education,
University of California, Los Angeles,
Definition Los Angeles, CA, USA
4
Department of Education,
The cochlea is the auditory portion of the inner University of California, Los Angeles,
ear which is embedded in the temporal bone. Los Angeles, CA, USA
5
It consists of membranes, fluids, hair cells, Department of Psychiatry, Jane & Terry
and VIII nerve endings. The organ of Corti, Semel Institute for Neuroscience &
housed in the snail-shaped cochlea, contains Human Behavior UCLA, Los Angeles,
many cells, including the inner and outer hair CA, USA
6
cells, and is responsible for converting mechani- Department of Psychology, Claremont
cal energy from the middle ear into electrical McKenna College, Claremont, CA, USA
7
energy. That energy is passed to auditory nerve Psychological Studies, UCLA’s Graduate
fibers. School of Education and Information Systems,
University of California, Los Angeles,
See Also
▶ Auditory Acuity Definition

▶ Auditory System
▶ Hearing Cognitive behavioral therapy (CBT) treatments
are based upon cognitive science models of the
mind and mental life. Contemporary CBT treat-
References and Readings ments have been particularly influenced by the
memory retrieval competition model
Clarke, W., & Ohlemiller, K. (2008). Anatomy and (e.g., Brewin, 2006). Conceptualized in informa-
physiology of hearing for audiologists. Clifton Park,
NY: Thomson, Delmar Learning. tion processing terms, CBT aims to promote
Musiek, F. E., & Baran, J. A. (2007). The auditory system: retrievable memories of adaptive responses
Anatomy, physiology, and clinical correlates. Boston: that can successfully compete with and
Pearson. suppress memories of previously learned mal-
adaptive responses evoked under “real-world”
conditions outside the therapy office. This pro-
cess leads to an increase of realistic appraisals of
Coefficient Alpha the environment and the self, more appropriate
behavior, and greater capacity to regulate strong
▶ Cronbach’s Alpha emotion.
C 684 Cognitive Behavioral Therapy (CBT)
Historical Background a cognitive appraisal theory of emotion

(cf. Lazarus, 1991); the idea being that thought
Cognitive behavioral therapy is rooted in tradi- in its various forms drives emotion and behavior.
tions of behavioral and cognitive (or rational) A key therapeutic technique in the early cognitive
therapy. During the early behavioral learning therapies was the use of logic to identify and
theory experiments of the early twentieth cen- challenge faulty thought processes. The assump-
tury, many of which were conducted with animal tion was that irrational thoughts would be
subjects (e.g., by Pavlov, Thorndike, and Hull), “replaced” with more rational ones, leading to
several case studies were conducted with fear improved emotional states and behavioral
conditioning in children. John Watson responses. Indeed, early research on cognitive
(1920) and Mary Cover Jones (1924) used appli- therapies offered evidence of good treatment
cations of classical conditioning to induce or response in terms of symptom reduction, partic-
eradicate fears (phobias) in young children. ularly with regard to emotion disorders such as
These are generally considered the earliest anxiety and depression (Beck, 1970; Watkins,
behavior therapy cases (Rachman, 1997). 1975). Relatively little cognitive therapy research
Skinner, with the advent of radical behaviorism, was conducted with individuals on the autism
popularized applications of operant conditioning spectrum in this early period.
for modifying human behavior; this was As the cognitive and behavioral traditions
quickly applied to a variety of developmental merged into integrative CBT packages, core
and psychiatric conditions including autism methods used to achieve symptom remission
(e.g., Ferster & DeMyer, 1962; Lovaas, emerged: psychoeducation (learning about the
Schreibman, Koegel, & Rehm, 1971), with nature of one’s mental health condition), Socratic
some early successes in basic abilities such as questioning and collaborative discussions to
imitation and language use. Concurrent with build up awareness of thought and emotion and
these developments in behavior therapy, promi- to teach thought- and behavior-based
nent researchers were publishing data suggesting coping skills, and behavioral experimentation,
that traditional psychodynamic psychotherapies in which alternative responses to challenging sit-
were proving ineffective with individuals with uations are attempted in real-world settings and
autism (e.g., Kanner & Eisenberg, 1955; Rutter, then reflected upon in structured discussions in
1968). Behavior therapy remains a staple compo- order to build up potent memories of adaptive
nent of modern CBT, including CBT treatments patterns of thought and behavior for future
for people with autism. use in similar (not necessarily identical) situa-
Cognitive and rational therapies (referred to as tions (e.g., Brewin, 2006). At present, there
cognitive therapy for the remainder of this entry, is increasing interest in the application of
for simplicity) emerged in the context of the CBT to individuals with ASD, as described
“cognitive revolution” in psychology, which below.
rejected the thesis of radical behaviorism that
mental states, such as thoughts, were
unmeasurable and inconsequential. Cognitive Rationale or Underlying Theory
psychology, with models of attention, memory,
perception, and language, and their integration, With the increasing fund of knowledge emanat-
underlies the original cognitive therapies devel- ing from cognitive science research in recent
oped by Ellis (1957) and Beck (1963). A core decades, a number of critical findings were
principle of cognitive therapy is that certain published that helped refine the model of mental
“errors” of thought (misperceptions, misattribu- states in cognitive psychology (see, e.g.,
tions, all-or-nothing thinking, etc.) lead to inap- Anderson’s (2004) model of the architecture of
propriate emotional reactions, behaviors, or both. the mind). A generally accepted view from the
The underlying model is often referred to as modern literature is that long-term memories can
be nearly indelible and that it is common to have human learning and memory in the service of
multiple, competing memory representations behavioral change, the two approaches are not
(schemata) of the same event or concept (Brewin, necessarily at odds. The extreme view of radical
2006). Hence, rather than “replacing” maladap- behaviorism, rejecting the importance of mental
tive thoughts with adaptive ones, it is more likely states, is not commonly practiced in modern psy-
that new adaptive thoughts can be learned and chology, even among those who subscribe to
strengthened using certain memory enhancement behaviorism as a primary explanatory and clini- C
techniques, and, under certain conditions, these cal tool. Fundamentally, learning via association
new memories can partially or fully suppress and learning via higher cognitive processes (e.g.,
older maladaptive memories. Promoting such conceptual reasoning) are complementary and
learning is, in fact, a fundamental goal of con- may occur either in serial or in parallel in any
temporary cognitive therapy (e.g., Brewin, 2006). given learning situation. Cognitive behavioral
Nonetheless, the older maladaptive memories are therapy, accepting this affinity between the
likely still accessible and can return to conscious- behavioral and cognitive perspectives, sought to
ness under certain conditions (e.g., Rodriguez, capitalize on all effective means of human learn-
Craske, Mineka, & Hladek, 1999) underscoring ing – tailored to the cognitive and developmental
the “indelibility” of many memories and the level of a given population – to promote clinical
challenge facing therapists endeavoring to help change. As a result, often multiple treatment
individuals cope more effectively and employ techniques spanning both associationist and
more useful skills under varied conditions. cognitivist approaches to clinical change are
These properties of human memory have led combined into CBT treatment “packages” that
cognitive therapists to a memory retrieval com- layer multiple forms of learning together. Exam-
petition model of therapy that endeavors to ples are CBT programs for anxiety disorders that
enhance recall of beliefs and skills under chal- involve a number of thought-based approaches to
lenging conditions that promote adaptive change (e.g., cognitive restructuring; mindful
responses (Brewin, 2006). awareness) married together with associationist
Although cognitive and behavioral therapies approaches such as gradual exposure to feared
were developed in parallel in the middle of the stimuli and self-reward (e.g., Kendall, 1994)
twentieth century, cognitive therapy had behav- and CBT programs for depression, which
ioral elements right from the beginning. For combine identifying and challenging “erroneous”
example, clients were encouraged to challenge ways of thinking (e.g., all-or-nothing thinking)
their negative views about specific situations by with behavioral techniques like self-modeling
engaging in “behavioral experimentation” and and pleasant activity scheduling (e.g., Weisz,
testing these situations out in person (e.g., initi- Valeri, McCarty, & Moore, 1999). These
ating a brief conversation with others in a social two basic modalities of learning are thought
group in which one feels like an outsider to test to complement one another and promote
whether one will be rejected). Although such more comprehensive formation of adaptive
strategies involve behavioral change, the goal is memories.
not specifically to develop a new response linked
with a given condition (e.g., a behavioral view of
clinical change) but rather to acquire new infor- Goals and Objectives
mation that can promote adaptive beliefs about
the situation that, with sufficient rehearsal, can CBT is intended to treat a wide variety of mental
occlude the current unrealistic, negative percep- health and developmental disorders, although the
tions of the situation and therefore change target population is expected to have some capac-
behavior. ity to communicate and, thus, benefit from main-
Although behaviorism and the cognitive sci- line cognitive techniques (in contrast, many
ence perspective emphasize different aspects of purely behavioral therapies do not assume
substantial functional communication, particu- • The belief that rules are inviolable and abso-
larly those used in the treatment of ASD). Histor- lute (leading to behaviors such as tattletaling
ically, the most common targets of treatment for as well as the sadness that often ensues after
CBT have been mood and anxiety disorders experiencing rejection from others regarding
(including obsessive-compulsive disorder; this behavior or telling on oneself as often seen
OCD), with high levels of evidence for treatment in pediatric OCD and the anxiety that accom-
efficacy in both conditions (Butler, Chapman, panies that behavior)
Forman, & Beck, 2006; James, Soler, & • An individual’s belief that others are
Weatherall, 2005). There are CBT-based pro- uninterested in talking or playing with
grams for many other conditions as well, with him/her because they have not always
somewhat more tentative levels of support due responded positively to the individual’s ideas
to either a lack of large, rigorous studies or mixed in the past (leading to anxiety and social
results. Disruptive behavior disorders, habit dis- avoidance)
orders, substance use disorders, psychotic disor- • A corresponding belief that playing with
ders, and personality disorders are among the others is mostly about getting to choose the
other conditions commonly treated with CBT. game and set the rules, winning, and having
Autism spectrum disorders have also been the the longest possible turn, rather than enjoying
target of some recent CBT programs. Most of an activity together and the sociability that
these latter programs have focused on associated goes with it (leading to egocentric, self-
symptoms (e.g., anxiety) in individuals with ASD oriented behavior, poor sportsmanship, and,
(e.g., Sofronoff, Attwood, & Hinton, 2005); sev- often, ultimately sadness at the negative social
eral have targeted core autism symptoms (e.g., feedback that can ensue)
social engagement) as well (e.g., Wood et al., With regard to these types of maladaptive
2009a). responses, CBT aims to help individuals chal-
As noted in the section on rationale, contem- lenge faulty assumptions by using logic, evi-
porary CBT aims to build up the strength of dence, and direct observation to arrive at more
memory for adaptive responses – thoughts, emo- realistic conclusions and alter behavior accord-
tions, and behaviors – when individuals are in ingly. With the adoption of realistic beliefs and
challenging situations that typically elicit mal- corresponding behaviors often comes emotional
adaptive responses. Here are some examples of relief. For example, in response to anxious beliefs
maladaptive responses of various types, particu- about being scrutinized by others, many CBT
larly those that are commonly seen in ASD programs would encourage an individual to chal-
(see, e.g., case studies presented in Sze & lenge these beliefs by using logic and simple
Wood, 2007, 2008; Lehmkuhl, Storch, behavioral experiments (e.g., tripping on purpose
Bodfish, & Geffken, 2008): in public or other “mistakes” to test what types of
• The belief that others are scrutinizing one’s reactions one receives) to foster new attitudes
every move (leading to anxiety, dysfluency, (e.g., “people really do not care about a lot of
tentativeness, and reticence) minor mistakes you might make, and as for big
• A belief that life is not worthwhile because it ones, it is their problem if they laugh at you, not
is full of challenges (leading to sadness or yours”) and corresponding behaviors (e.g., taking
irritability, retreat into comforting but solitary more risks in public) (e.g., Kendall, 1994).
activities like electronics, or self-harm) Improvement in emotional states is expected to
• The belief that nothing short of perfect is good follow successful acquisition of these kinds of
enough, so why try if that is not attainable adaptive beliefs and behaviors. Some forms of
(leading to avoidance of specific tasks viewed CBT also involve adopting a disengaged attitude
in this light and, often, conflict and anger with regard to one’s negative emotions – an
stemming from social pressure to make an approach that aims to change cognitive appraisal
effort anyway) of emotion to reduce the intensity and
aversiveness of states such as sadness, anxiety, response with few limitations (Norton & Price,
and perseverative thought (Ost, 2008). 2007; Weisz, McCarty, & Valeri, 2006; In-Albon
A fundamental difference between CBT and & Schneider, 2007). Although numerous studies
strictly behavioral treatments (e.g., operant or of predictors of treatment response have been
classical conditioning-based models) is the con- conducted, few consistent trends have emerged.
ceptualization of mechanisms of change and The method of delivery is undoubtedly influen-
complementary intervention techniques. While tial, however. The younger the children are, the C
purely behavioral interventions assume that more likely they are going to need parent involve-
largely automatic (and unobservable) learning ment. Children with ASD also appear to do better
processes (e.g., extinction, associative learning, with parent involvement than with child-only
modeling) promote behavioral change and symp- CBT (Sofronoff et al., 2005; Puleo & Kendall,
tom remission, CBT-based models seek to pro- 2011). No reliable differences have been found
mote changes in thinking and volitional behavior with regard to gender or comorbidity. It is assumed
(e.g., identifying and challenging maladaptive that greater intellectual ability should promote
interpretations of social situations) that are adapt- greater understanding of the cognitive therapy
able to multiple situational contexts. A simple aspects of treatment, all other things being equal,
example of phobia treatment illustrates differ- but this has not been studied carefully. Furthermore,
ences between CBT and purely behavioral appropriate modifications of treatment for individ-
approaches: in the former, catastrophic beliefs uals with intellectual disabilities may make CBT
about a feared stimulus would be identified and accessible and comparable in effectiveness across
challenged to build up to facing the phobic stim- a wide range of intellectual functioning (Suveg,
ulus, and after habituation occurs, the therapy Comer, Furr, & Kendall, 2006).
would promote the development of principles
for thinking about the feared stimulus differently
to build a benign memory schema of the stimulus Treatment Procedures
that could compete with and suppress the fearful
schema that the patient had prior to treatment CBT is generally presented in an interactive tuto-
(e.g., Wood & McLeod, 2008). In contrast, rial format, with a lesson plan, some form of
a purely behavioral approach would involve grad- instruction, practice, and review. Although it is
ual exposure to a feared stimulus to achieve extinc- relatively structured, CBT is responsive to client
tion of the conditioned (fearful) response with no characteristics, interests, and level of engagement.
emphasis on related thoughts, and when fear and Forming a positive alliance with the client is an
avoidance were eliminated in one setting, the pro- ongoing goal in CBT to enhance the client’s moti-
cedure might be repeated in several other settings vation to learn and use skills (e.g., Chiu, McLeod,
in an effort to achieve generalization. Clearly, the Har, & Wood, 2009). CBT for mood- and anxiety-
putative learning processes and corresponding related problems typically involves teaching cog-
techniques used to promote change differ signifi- nitive and behavioral skills followed by a skills
cantly in these two types of treatments (further practice phase in simulated and “real-world” situ-
description of CBT technique is given below). ations (e.g., Kendall, 1994). In one of the more
influential clinical trials of CBT for pediatric anx-
iety disorders in typically developing youth, Ken-
Treatment Participants dall et al. (1997) found that the cognitive
intervention aspects of the treatment (e.g., challeng-
CBT has been found efficacious across a wide ing irrational beliefs) alone were not effective in
range of populations, particularly in neurotypical reducing children’s anxiety levels. Only when cog-
groups. Typical pediatric and adult populations nitive training was paired with in vivo exposure
affected by depression, anxiety, and other psychi- elements (facing fears rather than avoiding them)
atric conditions have shown good treatment did CBT become an efficacious intervention.
For individuals with ASD and concurrent anx- in various real-world settings such as parks
iety, the general CBT approach of challenging and school playgrounds repeatedly until
irrational fearful beliefs and developing rational a sufficiently advanced level of the skill (e.g.,
beliefs is employed, although other elements of joining recess games without fear) is evidenced
treatment have varied widely from program to consistently. No clinical trials thus far have
program. In these programs for individuals with compared the relative efficacy of structured
ASD, there has been wide variation with regard to group-format CBT interventions with individu-
the emphasis placed on in vivo exposure relative ally administered, modularized interventions of
to other treatment elements (e.g., cartooning, this kind.
role-playing). At the extremes of the continuum, Anger and aggression have been the target of
the Wood et al. (2009b) program involves in vivo some CBT programs, particularly in neurotypical
exposure at home on a daily basis for the majority youth (e.g., Kazdin, 2005). In a randomized con-
of the 16-session treatment, which spans trolled trial conducted by Sofronoff and col-
4–5 months for most youth; whereas the leagues (2007), a CBT program was devised to
Sofronoff et al. (2005) 6-session treatment address anger problems in youth with ASD.
focuses on a series of creative anxiety manage- Treatment consisted of six weekly 2-h sessions
ment skills tailored for youth with ASD, but with for both child and parent. The manualized ther-
no explicit in vivo exposure elements. Some (but apy sessions focused on exploring positive and
not all) CBT trials conducted with typically negative emotions, cognitions related to coping
developing children and youth with anxiety dis- with anger, social stories to promote emotion
orders (e.g., Barrett, Dadds, & Rapee, 1996; management, and designing individualized
Barrett, 1998; Wood, Piacentini, Southam- coping plans for anger management.
Gerow, Chu, & Sigman, 2006) have found that With regard to treatments for ASD symptoms –
including parent training in the intervention leads such as social deficits – only a few programs have
to superior intervention effects as compared to been developed within a CBT framework.
exclusively child-focused treatments. Many of Bauminger (2002) developed a school-based
the group design studies for youth with ASD CBT program, noting that maladaptive cognition
and high anxiety have included concurrent accounts for some of the interpersonal behavior in
child- and parent-intervention components. youth with ASD and that, therefore, adaptive
The majority of the treatment programs that alterations to cognitive structures could make a
have been studied for individuals with ASD have positive impact on interpersonal behavior. In the
used a group-therapy treatment format with Bauminger (2002) intervention, several elements
a structured sequence of sessions for all partici- are notable: children’s classroom teachers are
pants. Others have used an individual therapy responsible for a 3-h-per-week, 7-month interven-
format with modular design (see Chorpita, Tay- tion conducted at school that relies heavily on
lor, Francis, Moffitt, & Austin, 2004) in which guiding a dyad consisting of the target child and
individual treatment components were selected a typically developing peer through a series of 13
by the therapist and supervisor on a session-by- social skill lessons (e.g., cooperating) that are to
session basis using a clinical algorithm matching be practiced at recess, on the phone, on playdates,
the client’s presenting characteristics with and so forth. Parents are also asked to support
corresponding treatment elements (e.g., Wood children in learning and implementing
et al., 2009a, b). As an example, a child who these social skills. The intervention was presented
was socially anxious at school would receive by the teacher to the dyad, allowing for individu-
a social coaching module in which social alization (e.g., by having pairs of children
approach behaviors are broken down into steps, choose activities that they both liked). The Wood
anxious beliefs about each step are discussed et al. (2009a, b) program, described above,
and challenged, and then steps are practiced also addresses social and repetitive symptoms
of ASD, integrating these target symptoms into and showed significant reductions in anxiety
the treatment hierarchy with emotion-related based on parent report. In a study of
symptoms. a manualized, individualized CBT program, 40
children aged 7–11 years were randomized to
either 16 sessions of CBT or a wait list (Wood
Efficacy Information et al., 2009b). Participating children had an aver-
age of 4.18 psychiatric disorders at intake. C
CBT treatments for anxiety in ASD have been Despite the high level of comorbidity, children
generally successful. Sofronoff et al. (2005) eval- randomized to CBT had primary outcomes com-
uated two variants of a 6-week CBT program for parable to those of other studies treating child-
anxiety in youth with ASD in group-therapy for- hood anxiety in typically developing patients
mat. Parent-report measures showed declines in (see, e.g., Barrett, Dadds, & Rapee, 1996; Wood
child anxiety symptoms in the CBT groups et al., 2006), with large effect sizes for most
as compared to a wait list group. Similarly, in outcome measures; remission of all anxiety dis-
12- and 16-week group-therapy CBT interven- orders for over half of the children by
tions for comorbid anxiety and ASD in children, posttreatment or follow-up; and a high rate of
Chalfant, Rapee, and Carroll (2007) found that positive treatment response on the Clinical
anxiety outcomes were superior for the immedi- Global Impressions–Improvement scale (CGI-I)
ate treatment group relative to the wait list arm. (78.5% from intent-to-treat analyses). As with the
However, limitations of these studies were that Reaven et al. (2009) study, child-reported anxiety
the study therapists, rather than independent eval- did not differ significantly from pretreatment to
uators blind to treatment assignment, adminis- follow-up; however, a floor effect was expected,
tered the posttreatment diagnostic interviews as baseline levels were low and decreased with
and that treatment fidelity was not assessed. treatment.
Reaven and colleagues (2009) studied 33 chil- In the Wood et al. (2009a) CBT intervention
dren (aged 8–14 years) with ASD and comorbid (N ¼ 19), there was also a statistically significant
anxiety disorders and, using a nonrandomized difference between the CBT group and the wait
assignment paradigm, assigned them to immedi- list group at posttreatment/post-wait-list on total
ate treatment in group-therapy format CBT or parent-reported autism symptoms on the Social
a wait list. Outcome measures were child- and Responsiveness Scale, with a medium to large
parent-reported anxiety symptoms using psycho- effect size. Treatment gains were maintained at
metrically sound questionnaires. Youth in the 3-month follow-up. Of course, this study was
immediate treatment group improved more than limited by a small sample and reliance on parent
the waiting list group on parent-reported symp- reports of symptomatology, which are vulnerable
toms, but not child-reported symptoms. This may to bias. Evidence-based assessments of
have been attributable to low pretreatment child- core autism symptoms based on independent
report symptom scores. evaluators’ ratings and direct observations of
White and colleagues (2009) examined a children’s behavior (e.g., the ADOS) should be
manualized 11-week CBT program for the treat- employed in future studies of CBT programs like
ment of anxiety in four youth aged 12–17 years this one to determine their potential for reducing
with high-functioning ASD. The program the expression and severity of core autism
consisted of individualized therapy sessions symptoms.
with high levels of parent involvement and In the Sofronoff et al. (2007) anger manage-
group-therapy sessions mainly for the teaching ment CBT program, there was a significant
and practicing of social skills. At posttreatment, reduction in the number of parent-reported
three of the four adolescents no longer met diag- anger episodes after treatment in the immediate
nostic criteria for their targeted anxiety disorder intervention group, with gains maintained
6 weeks after treatment completion. Qualitative whether there is more merit in individually ori-
interviews conducted with participants’ teachers ented social interventions in autism (if, as
posttreatment revealed participants’ use of strat- Bauminger notes, the child’s ecological influ-
egies they had learned through the program to ences are addressed through the individual inter-
manage their anger within their classroom. One vention), as compared to group-based
methodological weakness in this study was that interventions, than has traditionally been
no diagnostic criteria or operational definition of assumed.
an externalizing disorder was used for case selec-
tion at pretreatment. In addition, all outcome
measures were parent-report, with the exception Outcome Measurement
of the qualitative interviews with teachers.
In the Bauminger (2002; 2007a) individual In defining desirable study features for research
interventions for social deficits in ASD, a pre- intended to establish efficacious treatments,
post design without control group was used, and Chambless and Hollon (1998) noted that it was
children approximately doubled their number of important that valid and reliable measures of
observed positive social interchanges with peers symptom counts or diagnostic status, preferably
in naturalistic observations at school – particu- including those rated by an evaluator blind to
larly eye contact, expressions of interest in others, treatment status and study hypotheses, be used
and talking about their own experiences. as primary outcome measures. Of the small num-
They were more likely to initiate positive inter- ber of controlled trials of CBT for individuals
actions than they were to respond positively to with ASD, most have included this kind of mea-
peers’ initiations to them. Teachers also rated sure. Many of these have focused on comorbid
children as improved in certain positive social mental health features such as anxiety
skills on the Social Skills Rating Scale. A 4- (e.g., Chalfant et al., 2007), and one of these trials
month follow-up assessment provided evidence utilized a parent-rated measure of core autism
of maintenance of treatment effects (Bauminger, symptoms that is norm-referenced and used in
2007a). This treatment model is promising and the diagnosis of ASD (Wood et al., 2009a). The
merits a more thorough evaluation in Bauminger studies also used observational mea-
a randomized trial. sures in the school setting, an objective measure
A group-therapy CBT treatment (with 3–6 with high ecological validity. Many of the studies
children per group, at least half of whom were of CBT in ASD have also used parent-, teacher-,
typically developing) with many commonalities or self-report, which are useful as secondary indi-
with the Bauminger (2002) intervention, but ces of treatment outcome but may be biased by
focusing more on within-group interaction as expectancy effects and other sequelae of being
a vehicle for learning, was also evaluated by unblinded.
Bauminger (2007b). Again, an AB design was
used (N ¼ 26). While there was substantial
improvement in social behaviors among the ther- Qualifications of Treatment Providers
apy group members while interacting during the
sessions from pre- to posttreatment, this effect Practitioners are generally licensed clinical psy-
did not generalize to the playground setting, in chologists with a doctoral degree in psychology.
which no significant improvement was found in However, other professionals with licensure to
social behaviors over the course of the 7-month provide psychotherapy to children (e.g., school
interval from baseline to posttreatment. Since psychologists, licensed clinical social workers,
Bauminger essentially adapted the therapeutic child and family therapists) with appropriate
concepts and methods from her more individually training can conduct CBT treatments. Regardless
oriented CBT interventions (2002, 2007a) for this of specific license and degree, a specialization in
group-therapy trial, it is worth considering individuals with ASD and specific training
(including one-on-one supervision) in CBT for Ellis, A. (1957). Outcome of employing three techniques
individuals with ASD are essential qualifications of psychotherapy. Journal of Clinical Psychology, 13,
344–350.
for the professional delivery of this type of Ferster, C. B., & Demyer, M. K. (1962). A method for the
treatment. experimental analysis of the behavior of autistic chil-
dren. The American Journal of Orthopsychiatry, 32(1),
89–98.
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NJ: Harwood. sive cognitive rehabilitation intervention
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Cognitive Enhancement Therapy 693 C
in attention, memory, and problem-solving with available interventions for adults. The many sim-
a small group-based social-cognitive training ilarities between autism and schizophrenia had
curriculum designed to improve perspective- led classic psychiatric nosologists to characterize
taking, social context appraisal, emotion percep- the disorders within the same diagnostic cate-
tion and management, and other key aspects of gory. Although the categorizing of autism with
social cognition. Through these integrated activ- schizophrenia was ultimately found to be inaccu-
ities, Cognitive Enhancement Therapy addresses rate, due to sharp distinctions relating to the pres- C
the core neurocognitive and social-cognitive ence of psychosis and age of onset, evidence
deficits experienced by verbal adults with autism continues to highlight that both disorders are
spectrum disorders. similarly affected by marked impairments in
neurocognitive and social-cognitive function
(Goldstein, Minshew, Allen, & Seaton, 2002),
Historical Background which may reflect similar pathophysiologic pro-
cesses (Pinkham, Hopfinger, Pelphrey, Piven, &
Cognitive Enhancement Therapy (CET) was Penn, 2007). Such findings provide early support
developed in the 1990s by Professor G. E. Hogarty for the applicability of CET to adults with autism
for the treatment of social and nonsocial cognitive spectrum disorders.
impairments in schizophrenia. The development of In 2009, CET investigators S. M. Eack, D. P.
CET was influenced by the holistic cognitive reha- Greenwald, and S. S. Hogarty began collaborat-
bilitation approach of Ben-Yishay and colleagues ing with autism expert N. J. Minshew at the
(1985) for individuals suffering from a traumatic University of Pittsburgh to adapt and conduct
brain injury, as well as Brenner’s (2000) Integrated the initial feasibility studies of CET in autism.
Psychological Therapy for schizophrenia. During With early support from the National Institute of
the late 1990s and early 2000s, Hogarty and col- Mental Health and the Pennsylvania Department
leagues conducted a series of research studies of Health, CET treatment materials were success-
supported by the National Institute of Mental fully adapted from schizophrenia to verbal adults
Health that developed CET, established its evi- with autism spectrum disorders. In addition, an
dence base for patients with schizophrenia and uncontrolled feasibility study is underway to
schizoaffective disorder (Eack et al., 2009; assess the acceptability of the intervention in
Hogarty et al., 2004), and created autism and measure initial levels of efficacy. As
a comprehensive treatment manual outlining the expected, CET is proving to be highly applicable
methods of the approach (Hogarty & Greenwald, to adults with autism and satisfying and accept-
2006). A key finding from these studies was that able to recipients. Preliminary outcome data are
CET could not only improve core social and non- also indicating its effectiveness for this popula-
social cognitive impairments in schizophrenia, but tion. An ongoing randomized controlled trial is
that its early application could protect against brain currently being conducted at the University of
loss and support gray matter growth in areas of the Pittsburgh to confirm these findings and establish
brain involved in social-cognitive information the evidence base for CET in verbal adults with
processing (Eack et al., 2010). autism spectrum disorders.
The positive findings of CET in schizophrenia
led the investigators and other researchers to con-
sider the potential applicability of the interven- Rationale or Underlying Theory
tion to other disorders that are characterized by
core deficits in information processing and social The underlying theoretical framework for CET
cognition. Autism spectrum disorders were relies upon a neurodevelopmental model of
viewed as primary candidates due to their chronic schizophrenia (Hogarty & Flesher, 1999), which
and debilitating nature, the presence of pervasive may be applicable to other conditions, such as
impairments in social cognition, and lack of autism. Neurodevelopmental models situate the
C 694 Cognitive Enhancement Therapy
core disease process in mental and neurological such as observing the social context and under-
conditions within the brain, and impairments in standing the perspective of others. The develop-
brain development and function result in core ment of these abilities is a key aspect of the
deficits in cognitive functioning that lead to social-cognitive curriculum in CET, which is
social and vocational disability. Consistent with practiced within a small-group context.
neurobehavioral models of autism (Minshew &
Goldstein, 1998), genetic alterations result in
early brain abnormalities that affect the develop- Goals and Objectives
ment of neural systems responsible for
supporting the acquisition of higher-order The overall goal of CET is to enhance
social-cognitive abilities. CET is a developmen- neurocognitive and social-cognitive functioning
tal approach in that it aims to facilitate cognitive as a method of improving social adjustment,
development by shifting reliance from early and adaptive function, and quality of life. This is
effortful serial cognitive processing to a gistful achieved through targeting of two broad goals in
and spontaneous abstraction of social themes the treatment. The first goal is to foster higher-
needed for effective interpersonal interaction. order thinking among CET participants. The
The treatment methods employed in CET find emphasis in CET is on helping individuals learn
their theoretical basis in models of brain plastic- to shift from an earlier, preadolescent cognitive
ity and sociological theories of secondary social- style of processing that is characterized by pas-
ization. The ability of the brain to be shaped, at sivity, concreteness, rigidity, and rehearsal to
even a basic molecular level, by environmental a more adult style of information processing
experiences has been well established and is that is active, abstract, flexible, and spontaneous.
known as neuroplasticity. Strategic practice of The second goal is to help individuals develop
cognitive exercises that activate different brain “social wisdom” or the ability to act wisely in
systems has been shown to enhance brain func- social situations, not by learning and rehearsing
tion, synaptic connections, and cortical organiza- scripted rules for behavior, but by developing the
tion. CET builds on this evidence to provide social-cognitive abilities that allow for an accu-
adults with autism the opportunity to engage in rate assessment of and response to spontaneous
targeted cognitive exercises and experiences interpersonal interactions. To accomplish this,
designed to enhance brain functions associated individuals learn how to appraise different social
with improved social and nonsocial cognition. contexts and identify the related rules and norms
The enhancement of social cognition is an essen- for behavior; take the perspective of others to
tial goal of CET and relies on the sociological understand their feelings and intentions; be fore-
principles of secondary socialization, where indi- sightful in responding to social situations;
viduals must develop the ability to abstract infor- acknowledge and participate in the reciprocal
mal rules for behavior from appraising the nature of social interactions; and ultimately
context of unrehearsed social situations. Children develop a greater level of social comfort. These
are initially socialized using primary socializa- two goals serve as a guiding foundation for all
tion methods that focus on direct instruction, activities in CET and are actively addressed
usually from parents and teachers (e.g., “use during both neurocognitive training and social-
your napkin,” “don’t hit your sister,” and “wait cognitive group sessions.
until it’s your turn”). However, as the complexity
of their social world expands, rigid rules for
behavior become less useful, and there is a need Treatment Participants
for cognitive flexibility in socialization that rec-
ognizes the fluidity of adult interactions. Further Treatment experiences in providing CET to
social-cognitive development must utilize sec- adults with autism spectrum disorders indicate
ondary sources of information to guide behavior, that a large number of individuals with these
conditions are likely to benefit from the interven- reasoning, and executive functioning, and it
tion. Adults with autism have many strengths that both relies upon and reinforces the attention and
they bring to CET, and the goal is to build on memory abilities gained in previous modules.
these strengths to help improve adaptive function Unlike other cognitive remediation programs,
and quality of life. The treatment is applicable to participants in CET receive neurocognitive train-
verbal adults with autism, Asperger’s syndrome, ing in pairs, which affords opportunities for
or pervasive developmental disorder not other- socialization and to begin learning important C
wise specified who have an IQ 80 and experi- early aspects of social cognition, such as giving
ence significant social and cognitive disability. support. Neurocognitive training is facilitated by
Currently, CET treatment materials are only a therapist “coach” who promotes strategic think-
available in the English language, and thus profi- ing about how to complete a given exercise and
ciency with English is also important. Individuals integrates key CET concepts into the sessions,
unlikely to benefit from CET include those with such as managing emotions, gistful processing,
significant intellectual disabilities (IQ < 80), working memory, cognitive flexibility, and
individuals who have not developed language foresightfulness.
skills, and individuals with an organic brain syn- After approximately 2–3 months of attention
drome, substance use problems, persistent training, three to four participant pairs (six to
suicidality, or disruptive behaviors not conducive eight participants) form a small social-cognitive
to a group context. Individuals with autism group. The emphasis of these weekly social-
commonly experience comorbid psychiatric con- cognitive group sessions is on enhancing social
ditions, such as anxiety or depression, and as long comfort and the abilities needed for effective
as these conditions are stabilized and managed socialization, interpersonal interactions, and suc-
appropriately, individuals with these conditions cessful adjustment to adult life. All group ses-
are still likely to benefit from CET. sions follow a highly structured format that
allows for spontaneity but also keeps the group
process predictable and efficient. Each group ses-
Treatment Procedures sion begins by distributing an agenda along with
handouts for the psychoeducational lecture for
Cognitive Enhancement Therapy integrates 60 h the day. Participants are then asked to present
of computer-based neurocognitive training in their homework assignment based on the previ-
attention, memory, and problem-solving with 45 ous week’s lecture, and homework presentations
1.5-h weekly social-cognitive group sessions pro- are chaired by one of the group members, who
vided over the course of 18 months. Treatment asks the members to volunteer to present their
begins with a thorough assessment of the partic- homework. The chairperson role is designed to
ipant’s cognitive and social difficulties. Subse- facilitate working memory, organization, and
quently, participants begin neurocognitive cognitive flexibility. After the homework presen-
training in attention. Neurocognitive training tation is finished, select participants complete an
contains three sequential modules: an attention in-group cognitive exercise designed to enhance
module, a memory module, and a problem- social cognition. Exercises are usually performed
solving module. Attention training focuses on in pairs and require participants to practice the
increasing processing speed, sustaining attention, social-cognitive abilities they are learning in the
inhibiting irrelevant stimuli, and shifting atten- group, such as perspective-taking, social context
tion. Memory training focuses on developing appraisal, gistfulness, and reading nonverbal
a categorizing capacity, cognitive flexibility, cues. The group members who are not actively
and the ability to abstract and recall the “gist” or completing the exercise are asked to give feed-
main point from information to be remembered. back to their peers on their performance. This
Finally, problem-solving training focuses on important task promotes observational skills and
improving foresightfulness and planning, engagement for group members and provides the
C 696 Cognitive Enhancement Therapy
opportunity to give support and practice giving 2011; Hogarty, Greenwald, & Eack, 2006).
appropriate feedback in an organized, construc- Evidence of the durability of these effects has
tive way. Finally, a psychoeducational lecture is also been positive, with studies indicating that
given on a new topic on social cognition, and the effects of CET on cognition and functioning
homework is assigned to facilitate application can be maintained for at least 1 year post treat-
outside of the group setting. ment (Eack, Greenwald, Hogarty, & Keshavan,
A broad number of social-cognitive topics are 2010; Hogarty et al., 2006). Finally, evidence has
covered throughout the 45 group sessions and indicated that CET has a direct effect on the
include perspective-taking, emotion perception, brain, in that it can protect against gray matter
stress management, understanding the social loss, and even result in increased levels of gray
“gist,” giving support, reciprocity, and social matter in social-cognitive brain networks when
context appraisal, among others. The goal is to applied in the early course of schizophrenia
provide participants with the core social- (Eack et al., 2010).
cognitive abilities they need to succeed in Efficacy information on CET effects specific
reaching their goals, build better relationships, to the autism population is only recently emerg-
and communicate and interact effectively with ing. Currently, an ongoing uncontrolled feasibil-
others. Neurocognitive training proceeds concur- ity study is being conducted with support from
rently throughout the time individuals are also the National Institute of Mental Health. Prelimi-
participating in the social-cognitive groups nary treatment data are encouraging and indicate
until the completion of all attention, memory, similar benefits in this population as were
and problem-solving computer exercises. A com- observed in patients with schizophrenia. How-
plete description of the original treatment ever, it must be noted that efficacy data in adults
methods and procedures used in CET is outlined with autism spectrum disorders are limited at this
in detail in Cognitive Enhancement Therapy: the time, and a randomized controlled trial of the
Training Manual by Hogarty and Greenwald effects of CET in this population is currently
(2006), and adaptations specific to adults with being conducted to provide more definitive
autism spectrum disorders are forthcoming in evidence of the effects of this intervention in
a supplement to this treatment manual. verbal adults with autism.
Efficacy Information Outcome Measurement
The development of CET was supported by the Outcome assessment is important in CET to
National Institute of Mental Health, and primary guide clinician behavior and provide feedback
data regarding its efficacy come from two ran- on success to participants. Several outcome mea-
domized controlled trials among individuals with sures are included in the CET program that are
schizophrenia and schizoaffective disorder. easy to complete by participants and clinicians
Effects of CET on neurocognition and social and provide a sensitive metric upon which to
cognition in both of these studies were large gauge progress. The attention training software
(range of d ¼.58–3.09), and effects on functional utilized in CET developed by Ben-Yishay and
outcome and social adjustment were also highly colleagues (1985) contains a simple reaction
significant and large (range of d ¼ 1.40–2.59) time assessment of processing speed, and it is
(Eack et al., 2009; Hogarty et al., 2004). Further, recommended that clinicians utilize this assess-
mediator analyses from these studies indicated ment before beginning attention training and
that the benefits CET had on cognition were sig- every nine months thereafter until the completion
nificant contributors to the improved adjustment of treatment. Two interview-based assessments,
and adaptive function of participants (Eack, the Social Cognition Profile and the Cognitive
Pogue-Geile, Greenwald, Hogarty, & Keshavan, Styles Inventory (Hogarty et al., 2004), provide
assessments of both neurocognitive and social- different from any treatment approach clinicians
cognitive improvement during treatment. It is have provided before to adults with autism.
recommended that these assessments be admin- Consequently, beyond having the requisite edu-
istered to participants prior to beginning treat- cational and work experience in order to be
ment and every nine months thereafter. These knowledgeable about the treatment of autism, it
standardized assessment instruments will provide is of utmost importance that potential providers
both clinicians and participants with a greater are open and willing to learn a new approach. C
understanding of the cognitive strengths and lim- Some providers become comfortable with certain
itations of the participant and his/her degree of techniques and have considerable difficulty when
improvement during CET. a new treatment requires them to deviate from
For clinics and programs that have access to their usual practices. In this way, effective CET
neuropsychological testing materials, several clinicians must be cognitively flexible them-
standardized assessments are useful, but not selves so that they can open up to new ways to
required for judging progress in CET. These help persons with autism. Clinicians that are
include the revised Wechsler Memory Scale, uncomfortable with deviating from a traditional
Wisconsin Card Sorting Test, Trails B, and the psychotherapeutic stance where they provide the
California Verbal Learning Test. In addition, the instruction and advice to solve the problems for
Mayer-Salovey-Caruso Emotional Intelligence their patients (instead of helping the individual
Test (Mayer, Salovey, Caruso, & Sitarenios, learn to solve their own problems) will have
2003) has proven to be an effective assessment difficulty becoming an effective CET coach.
of components of social cognition during CET Finally, it should be noted that a qualified
and is self-administered through a computer. clinician is not enough to provide CET. Group
Information from these assessments can be useful sessions are conducted with a minimum of two
for treatment planning as well as examining qualified clinicians, which significantly enhances
progress. the process by introducing a greater diversity of
ideas and insights into how to help participants.
In addition, the feasibility of implementing CET
Qualifications of Treatment Providers without strong administrative and supervisory
support is limited. As with all successful inter-
Qualified providers of CET are not limited to vention programs, a commitment is required by
a single profession. In research studies on CET, clinicians and the agency to invest the necessary
individuals from many different backgrounds and resources, training, and time to provide this com-
disciplines have been successfully trained to pro- prehensive approach. The training required to
vide the treatment. This has included social learn CET is extensive and ongoing, making
workers, psychologists, and psychiatric clinical a strong commitment from the agency essential
nurse specialists, all of which make up the pri- to successful implementation. In summary, CET
mary workforce who serves adults with autism is an innovative intervention that holds promise
spectrum disorders. The critical qualifications for improving adaptive function and lives of
for providing CET include education in verbal adults with autism spectrum disorders.
a human service profession (preferably at
a master’s level), experience (2 or more years)
in the treatment of verbal adults with autism or See Also
similar conditions, a willingness to resist
a traditional psychotherapeutic approach, and an ▶ Autistic Disorder
eagerness and commitment to learn new ▶ Empirically Supported Treatments
approaches to intervention. ▶ Functional Connectivity
The methods and intervention approaches ▶ Social Cognition
employed in CET are novel and likely to be ▶ Theory of Mind
C 698 Cognitive Flexibility
References and Readings Retardation and Developmental Disabilities Research

Reviews, 4, 129–136.
Ben-Yishay, Y., Rattok, J., Lakin, P., Piasetsky, E., Pinkham, A. E., Hopfinger, J. B., Pelphrey, K. A.,
Ross, B., Silver, S., et al. (1985). Neuropsychological Piven, J., & Penn, D. L. (2007). Neural bases for
rehabilitation, quest for a holistic approach. Seminars impaired social cognition in schizophrenia and autism
in Neurology, 5, 252–259. spectrum disorders. Schizophrenia Research, 99,
Brenner, H. D. (2000). Psychological therapy in schizo- 164–175.
phrenia: What is the evidence? Acta Psychiatrica
Scandinavica, 102, 74–77.
Eack, S. M., Greenwald, D. P., Hogarty, S. S., Cooley,
S. J., DiBarry, A. L., Montrose, D. M., et al. (2009).
Cognitive enhancement therapy for early-course
schizophrenia: Effects of a two-year randomized Cognitive Flexibility
controlled trial. Psychiatric Services, 60, 1468–1476.
Eack, S. M., Greenwald, D. P., Hogarty, S. S., &
C. Enjey Lin
Keshavan, M. S. (2010). One-year durability of the
effects of cognitive enhancement therapy on func- Departments of Education and Psychiatry,
tional outcome in early schizophrenia. Schizophrenia University of California, Los Angeles,
Research, 120, 210–216. Los Angeles, CA, USA
Eack, S. M., Hogarty, G. E., Cho, R. Y., Prasad, K. M. R.,
Greenwald, D. P., Hogarty, S. S., et al. (2010).
Neuroprotective effects of cognitive enhancement
therapy against gray matter loss in early schizophrenia: Synonyms
Results from a two-year randomized controlled trial.
Archives of General Psychiatry, 67, 674–682.
Cognitive shifting; Mental flexibility; Set shifting
Eack, S. M., Pogue-Geile, M. F., Greenwald, D. P.,
Hogarty, S. S., & Keshavan, M. S. (2011).
Mechanisms of functional improvement in a two-year
trial of cognitive enhancement therapy for early Definition
schizophrenia. Psychological Medicine, 41,
1253–1261.
Goldstein, G., Minshew, N. J., Allen, D. N., & Cognitive flexibility refers to the cognitive func-
Seaton, B. E. (2002). High-functioning autism and tion of adaptively shifting mental actions and
schizophrenia a comparison of an early and late onset behaviors based on feedback from the environ-
neurodevelopmental disorder. Archives of Clinical
ment. It is a dimension of executive functioning,
Hogarty, G. E., & Flesher, S. (1999). Developmental which is considered to be impaired in many peo-
theory for a cognitive enhancement therapy of schizo- ple with autism spectrum disorders (ASD). Exec-
phrenia. Schizophrenia Bulletin, 25, 677–692. utive functioning refers to a broad category of
Hogarty, G. E., Flesher, S., Ulrich, R., Carter, M.,
complex or higher-order cognitive skills that is
Greenwald, D., Pogue-Geile, M., et al. (2004).
Cognitive enhancement therapy for schizophrenia. crucial for organizing and selecting relevant
Effects of a 2-year randomized trial on cognition information, planning responses, and executing
and behavior. Archives of General Psychiatry, 61, actions. Compromised cognitive flexibility in
866–876.
ASD may contribute to challenges with appropri-
Hogarty, G. E., & Greenwald, D. P. (2006). Cognitive
enhancement therapy: The training manual. ately adapting to changes in interpersonal and
Pittsburgh, PA: University of Pittsburgh Medical environmental demands (e.g., social situations).
Center Authors. Available through www.CognitiveEn- Difficulty switching problem-solving strategies
hancementTherapy.com.
or adapting responses in the face of situational
Hogarty, G. E., Greenwald, D. P., & Eack, S. M. (2006).
Durability and mechanism of effects of cognitive changes characterize the experiences of people
enhancement therapy. Psychiatric Services, 57, with ASD and can be explained by impairments
1751–1757. in cognitive flexibility. Some evidence suggests
Mayer, J. D., Salovey, P., Caruso, D. R., & Sitarenios, G.
that cognitive flexibility predicts social outcomes
(2003). Measuring emotional intelligence with the
MSCEIT V2.0. Emotion, 3, 97–105. in ASD. Better performance on cognitive flexi-
Minshew, N. J., & Goldstein, G. (1998). Autism as bility measures alone predicted greater improve-
a disorder of complex information processing. Mental ment in scores of social competence over time in
Cognitive Skills 699 C
high-functioning adolescents and adults with References and Readings
ASD (e.g., Berger, Aerts, van Spaendonck,
Cools, & Teunisse, 2003). Berger, H. J. C., Aerts, F. H. T. M., van Spaendonck, K. P. M.,
Cools, A. R., & Teunisse, J. (2003). Central coherence
Studies assessing cognitive flexibility and
and cognitive shifting in relation to social improvement
related functions in ASD have found moderately in high-functioning young adults with autism. Journal
robust findings of impaired flexibility, but not of Clinical and Experimental Neuropsychology, 25(4),
without mixed results. Card sorting tests, such 502–511. C
Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., &
as the Wisconsin Card Sorting Test (WCST;
Curtiss, G. (1993). Wisconsin card sorting test man-
Heaton et al., 1993), are one type of neuropsy- ual: Revised and expanded. Odessa, FL: Psychological
chological assessment that have been sensitive to Assessment Resources.
measuring aspects of executive functioning, Kaland, N., Smith, L., & Mortensen, E. L. (2008). Brief
report: Cognitive flexibility and focused attention in
particularly cognitive flexibility. Several aspects
children and adolescents with Asperger syndrome or
of impaired cognitive flexibility in ASD have high-functioning autism as measured on the comput-
been identified, yet these factors have yet to be erized version of the Wisconsin card sorting test. Jour-
uniformly observed across studies. In one study, nal of Autism and Developmental Disorders, 38(6),
1161–1165.
high-functioning adolescents with ASD
Shu, B., Lung, F., Tien, A. Y., & Chen, B. (2001). Exec-
performed significantly poorer on the WCST in utive function deficits in non-retarded autistic chil-
maintaining their cognitive set (a set of mental dren. Autism, 5(2), 165–174.
plans or rules deduced from direct feedback) Pennington, B. F., & Ozonoff, S. (1996). Executive func-
tions and developmental psychopathology. Journal of
relative to a typically developing control group
Child Psychology and Psychiatry., 37(1), 51–87. Spe-
(Kaland, Smith, & Mortensen, 2008). No other cial Issue: Annual Research Review.
significant differences in performance such as
perseverative errors (repeatedly using
a previously successful strategy despite feedback
that it is no longer effective) were observed. Cognitive Measures
Other studies using the WCST have demon-
strated that perseverative errors are more com- ▶ Differential Ability Scales (DAS and DAS-II)
mon in individuals with ASD (e.g., Shu, Lung,
Tien, & Chen, 2001) as well as poorer perfor-
mance on the total number of errors, completion
of categories, and number of trials required to Cognitive Shifting
complete a category relative to control groups
(e.g., Pennington & Ozonoff, 1996). A lack of ▶ Cognitive Flexibility
uniform findings indicates that cognitive flexibil-
ity is complex and multidimensional. It is likely
affected by various factors related to cognitive
and executive functioning, explaining the varia- Cognitive Skills
tions in cognitive flexibility observed across the
ASD population. Marjorie Solomon
Sciences, UC Davis M.I.N.D. Institute,
See Also Sacramento, CA, USA
▶ Attention
▶ Executive Function (EF) Definition
▶ Perseveration
▶ Sameness, Insistence on The term “cognition” refers to mental processes or
▶ Wisconsin Card Sorting Test (WCST) forms of information processing. These processes
C 700 Cognitive Skills
include attention, memory, learning, decision mak- involves spared simple information processing in
ing, reasoning, and problem solving. In the study of domains of motor functioning, memory, language,
autism, a distinction often is drawn between social and reasoning, with selective impairment in com-
and/or nonsocial forms of cognition given the pre- plex information processing, not involving visual-
sumed centrality of social deficits to the disorder. spatial processing, across these domains. They
Some also consider language to be a cognitive went on to argue that “this profile is not consistent
domain. The focus of this entry, however, is on with a single primary deficit, but with a multiple
cognition that is not explicitly social or language primary deficit model in which the deficit pattern
related. For more extensive discussions of social within and across domains is reflective of the com-
cognition and language, the reader is referred to plexity of the information processing demands.
other definitions in this encyclopedia. This neuropsychological profile is furthermore
consistent with the neurophysiologic characteriza-
tion of autism as a late information processing
Historical Background disorder with sparing of early information
processing.” This way of conceptualizing autism
Cognition is a term that became very popular in also has been extended to the neuroscience of
psychology with the onset of the “cognitive revo- autism. Here, autism has been portrayed as
lution” in the 1950s. This “revolution” resulted a disorder involving reduced functional connectiv-
from the advent and use of computers. Academic ity (synchronous activity) between brain regions
psychology borrowed computer and artificial intel- and neural circuits (Just, Cherkassy, Keller, &
ligence information processing concepts and used Minshew, 2004), resulting in reduced synchrony
them to derive testable hypotheses related to human among cortical regions supporting higher cogni-
thought processes. This new field, “cognitive tion. Three important topics in higher cognition in
psychology,” had a large impact on the larger ASD are discussed below.
discipline of psychology and replaced behaviorism
as the dominant paradigm. Rapidly advancing Cognitive Level and IQ in ASD
fields of neuroscience, social psychology, and First, it is important to provide background about
developmental psychology also began to influence cognitive ability level in ASD because it pro-
the larger field of psychology. This resulted in the foundly influences performance in areas of higher
genesis of cognitive neuroscience, which seeks to cognition, as well as multiple areas of function-
understand the neural and other biological mecha- ing. The study of cognitive abilities in ASD also
nisms underlying thought; social cognitive neuro- has attracted considerable research because the
science, which employs findings from social patterning of intellectual strengths and challenges
psychology and attempts to understand their neuro- in persons with ASD may be very different than
biology; and developmental cognitive neurosci- that present in typically developing individuals,
ence, which examines the neurobiology of and this has clear implications for education and
development in an effort to explain typical and intervention strategies.
atypical growth and development. One of the challenges inherent in working with
individuals with ASD is that they display a very
wide range of cognitive ability levels ranging from
Current Knowledge intellectual disability to intellectual giftedness.
Diagnostic conventions have changed considerably
Many researchers, writing from different perspec- over the last 20 years, and while it once was believe
tives, have arrived at the conclusion that individ- that 75% of affected individuals displayed intellec-
uals with ASD exhibit a curious set of cognitive tual disability, this figure now has dropped to about
strengths and challenges. For example, Minshew 40% according to a Centers for Disease Control
and colleagues (Minshew, Goldstein, & Siegel, publication in 2009 (Rice, 2009). Twenty years
1997) articulated the point of view that ASD ago, the most common finding was that individuals
with ASD had an IQ profile with stronger visuospa- area found that persons with ASD only showed
tial abilities (as assessed by the block design deficits in focusing and executing and shifting
subtest) than verbal (and especially comprehension (Goldstein, Johnson, & Minshew, 2001).
subtest) abilities (Goldstein et al., 2008). More According to another prominent view (Posner,
recently, it has been argued that those with Walker, Friedrich, & Rafal, 1984), attention is
Asperger syndrome display the opposite profile thought to have three components, which each is
(VIQ > PIQ) or that the intellectual profiles of subserved by different neural networks and their C
those with ASD are no different than those found interactions. The first of these, alerting, involves
in the general population. These discrepancies may becoming more sensitive to incoming information
in part be explained by variations in the ages of on either a tonic (steady state) or episodic (in
samples and how they were ascertained. Recently, response to an event) basis. This network selects
it has been demonstrated that persons with autism information from sensory input. The second com-
and Asperger syndrome perform better on intelli- ponent in this model is orienting. It is similar to
gence tests that assess their perceptual and espe- attention shifting (see Allen & Courchesne, 2001).
cially visual reasoning abilities (Raven’s The third component of attention is executive con-
Progressive Matrices) versus more language-based trol, which is a multidimensional system responsi-
tests like the Wechsler scales (Dawson et al., 2007). ble for inhibition, planning, conflict monitoring,
and cognitive flexibility. Similar to Goldstein,
Attention in Autism Johnson, and Minshew (2001), a recent study
There is an extensive research literature using the Posner model found that orienting was
suggesting that individuals with autism exhibit impaired in individuals with ASD (Keehn, Lin-
atypical patterns of attending to their environ- coln, Muller, & Townsend, 2010).
ment. They may be poor at allocating attention
to relevant visual stimuli, and they are at times Learning and Memory in Autism
overly selective and focused in what they attend Memory in autism is characterized by several
to. They can find it hard to disengage from what unique features (see Boucher & Bowler 2008 for
they are viewing. They may have problems a recent volume on memory in autism). Individuals
switching or redirecting attention between with cognitive ability levels in at least the average
divided streams of information (i.e., visual and range tend to be as good as typically developing
auditory stimuli). They may not pay attention to individuals on short-term memory tasks, including
novel stimuli the same way as typically develop- those involving auditory, visual, and motor stimuli.
ing persons. This unusual attention processing Across all functioning levels, they also demon-
may affect their development and learning and strate largely preserved nondeclarative (implicit)
produce pattern of early emerging but persistent memory (memory that occurs largely outside of
sociocommunicative deficits (Dawson, Meltzoff, conscious awareness). They also are unimpaired
Osterling, Rinaldi, & Brown, 1998). at memory tasks involving simple cued recall,
There are several different conceptual models where cues are provided to them. However, they
of attention that have been used to study autism. are inefficient at spontaneously using contextual
The first was developed by Mirsky et al. (1991). cues to help them remember and do not naturally
According to this model, which was derived using use memory strategies that would leverage these
a factor analysis (mathematical grouping by com- cues. For example, they do not reliably employ
mon features) of commonly used tests, compo- grouping cues when presented with list learning
nents of attention include encoding (to receive tasks that contain semantically similar clusters of
and interpret incoming information), focusing and words that facilitate recall. Sometimes this failure
executing (to focus and perform a task in the face to use presented cues can be an advantage. For
of distraction), sustaining (to maintain attention example, they may produce fewer “false” memo-
over time), and shifting (to adaptively shift the ries on tasks that try to trick the participant into
focus of attention). One well-known study in this remembering nonpresented materials that are
C 702 Cognitive Skills
semantically similar to presented ones because both the ability to identify concepts (i.e., to rec-
they are not distracted by such lures. They also ognize underlying category attributes so as to
appear to lack the facilitated memory for materials better understand them) and the ability to form
related to themselves (self-referenced memory), concepts based on these discriminations. This
which is present in typically developing individ- latter function has been referred to as
uals. They also show deficits in memory for infor- generativity.
mation about emotions. Concept identification abilities come online
Individuals with ASDs also display a curious during the first year of life in typical develop-
pattern of learning strengths and challenges. ment, and children with autism appear to acquire
Their lower level learning involving contin- simple classification abilities involving the phys-
gency-shaped procedures, implicit information, ical world (e.g., the ability to sort objects) simi-
single items of information/facts, and habits is larly to children with other developmental delays.
intact. The effectiveness of interventions pre- However, it is unclear whether individuals with
mised on operant conditioning such as applied autism can categorize based on more representa-
behavior analysis (ABA), the ability to memorize tional and abstract criteria. Some have found that
large bodies of facts about special interests, and lower functioning children have difficulty with
the preference for routines and sameness all con- sorting tasks that involve abstract categories,
stitute evidence of their bias toward lower level though older higher functioning individuals do
learning. not appear to have these difficulties.
However, individuals with ASDs show defi- In contrast to concept identification, concept
cits in higher level learning that relies on abstract formation involves an “open-field” situation in
goals and reasoning and on the efficient transfer which the individual must initiate behaviors to
of learning to new situations and problems solve a problem. This type of initiation, or
(known as generalization). In order to generalize, “generativity,” is recognized as a deficit area for
organisms must make and keep in mind relational children (Bishop & Norbury, 2005) and adults
links between memory traces that share common (Turner, 1999) with HFASD. Concept formation,
elements. This permits the transfer of what has but not concept identification, as assessed by the
been learned to novel contexts with similar but Goldstein-Scheerer object sorting task, has been
largely different features. Individuals with ASDs found to differentiate children with HFASD from
are inefficient learners. They exhibit excessively others.
narrow stimulus discrimination at the expense of Deficits in concept formation may limit the
generalization (ORiordan & Plaisted, 2001). ability of individuals with HFASD to generate
They often focus on idiosyncratic and overly cognitive schemas that promote the efficient orga-
selective aspects of stimuli. They fail to recog- nization of social and nonsocial information.
nize and/or maintain online important cues sig- Impairments in the ability to create organizing
naling similarities across every day events and schemas for initiating new social behaviors and
settings. Consequently, they are unable to lever- routines (i.e., meeting new people, entering differ-
age what they already know to navigate new ent and unstructured social situations, and/or
situations. These deficits likely underlie the char- conducting reciprocal conversations) would
acteristic academic, social, and adaptive func- greatly disrupt daily social functioning. Similarly,
tioning problems they face. the inability to conceptualize, represent, and inte-
grate multiple perspectives would produce deficits
Reasoning and Problem Solving in Autism in interpersonal relationships. The replicated find-
Abstract reasoning is a form of higher cognition ing that generativity is predictive of play quality in
that requires the mental process of considering young children supports these assertions.
and manipulating information about events, Several studies have used tasks similar to the
objects, and concepts not in the immediate envi- guessing game “20 questions,” where players
ronment. Abstract reasoning is thought to involve must guess the identity of items (persons, places,
or things) in less than 20 questions. To perform strengths and how they can be harnessed in
well, they must ask efficient questions that nar- the service of educational strategy develop-
row the possible guesses on each try. Individuals ment and vocational training.
with ASD perform poorly on this task, and their 3. The study of development of cognition
task performance reliably distinguishes them through the lifespan in persons with ASD is
from typically developing individuals. On this in its infancy. The field is only now publishing
type of task, they tend to use strategies that elim- findings about cognitive control in older adult- C
inate single items versus groups of items. It has hood. More studies are needed that cover the
been suggested that this reflects a fundamental full range of cognitive abilities in toddlers,
problem in concept formation – the spontaneous children, adolescents and adults with ASD.
generation of categories to support goal-directed 4. There have been virtually no studies of deci-
cognitive processing. These problems appear to sion making in persons with ASD. This is an
be related somewhat to the executive function important gap in knowledge, given that such
deficits of affected individuals. these would be useful to help with the transi-
Finally, following the study described above tion to adulthood.
that high-functioning persons with autism per- 5. More learning studies are needed to examine the
form better on the intelligence tests that involve neural substrates of learning in persons with
more visuospatial versus verbal reasoning – the ASD. These will help provide an evidence
Raven’s Progressive Matrices test (Dawson et al., base for ABA and may teach us about effective
2007) – there now have been several that show strategies for helping persons with ASD to over-
that aspects of conditional and analogical reason- come their deficits in generalization.
ing are relatively preserved in persons with ASDs.

Future Directions
Allen, G., & Courchesne, E. (2001). Attention function
Cognition is a very important topic in ASD and dysfunction in autism. Frontiers in Bioscience, 6,
research because it appears that the disorders 105–119.
involve unique strengths and challenges in this Bishop, D.V.M., & Norbury, C. (2005). Executive func-
tion in children with communication impairments, in
area, which are integrally related to educational, relation to autistic symptomatology. 1: Generativity.
social, and behavioral functioning. A better Autism, 9, 7–27
understanding of cognitive style in ASD would Boucher, J., & Bowler, D. (2008). Memory in autism.
produce important information that helps us Cambridge: Cambridge University Press.
Carpenter, M., Pennington, B. E., & Rogers, S. J. (2002).
understand the biological basis of the disorders Interrelations among social-cognitive skills in young
and what to do to help those with them to achieve children with autism. Journal of Autism and Develop-
their human potential. mental Disorders, 32(2), 91–106.
Some interesting areas for future research Dawson, G., Meltzoff, A., Osterling, J., Rinaldi, J., &
Brown, E. (1998). Children with autism fail to orient
include: to naturally occurring social stimuli. Journal of Autism
1. More extensive use of evoked response poten- and Developmental Disorders, 28, 479–485.
tial studies which are particularly well suited Dawson, M. Soulieres, I., Gernsbacher, M., & Mottron, L.
to studying attention. These can be coupled (2007). The level and nature of autistic intelligence.
Psychological Science, 18, 657–662.
with imaging studies to learn more about the Frith, U. (2000). Cognitive explanations of autism. In K. Lee
neural substrates of higher cognition problems (Ed.), Childhood cognitive development: The essential
and what to do to help those with them. readings (Essential readings in development psychology,
2. The Raven’s Progressive Matrices finding out- pp. 324–337). Malden, MA: Blackwell Publishers.
Just, M., Cherkassy, V. L., Keller, T., & Minshew, N.
lines above are intriguing and point to the (2004). Cortical activation and synchronization during
clear strengths of persons with ASD. We sentence comprehension in high-functioning autism:
need more research to better elaborate such Evidence of underconnectivity. Brain, 127, 1811–1821.
C 704 Cohen Syndrome
Keehn, B., Lincoln, A., Muller, R. -A., & Townsend, J. which was first described in 1973 by Cohen and
(2010). Attentional networks in children and adoles- coworkers (Cohen, Hall, Smith, Graham, &
cents with autism spectrum disorder. Journal of Child
Psychology and Psychiatry, 51, 1251–1259. Lampert, 1973). The first patients studied with
Minshew, N., Goldstein, G., & Siegel, D. J. (1997). Cohen syndrome were reported to have mental
Neuropsychologic functioning in autism Profile of a com- retardation, microcephaly, antimongoloid slant,
plex information processing disorder. Journal of the mild maxillary hypoplasia, short philtrum, open
International Neuropsychological Society, 3, 303–316.
Mirsky, A. F., Anthony, B. J., Duncan, C. C., Ahearn, M., mouth with prominent maxillary central incisors,
& Kellam, S. (1991). Analysis of the elements of micrognathia, highly arched narrow palate,
attention: A neuropsychological approach. Neuropsy- crowded teeth, hypotonia, obesity, narrow hands
chological Review, 2, 109–145. and feet, tapering extremities, cubitus valgus,
ORiordan, M., & Plaisted, K. (2001). Enhanced discrim-
ination in autism. Quarterly Journal of Experimental genua valga, lumbar lordosis, mild thoracic scolio-
Psychology, 54, 961–979. sis, and hyperextensibility of the joints. Subsequent
Posner, M., Walker, J. A., Friedrich, F. J., & Rafal, R. to this first report, there have been descriptions in
(1984). Effects of parietal injury on covert orienting of the literature of more than 100 patients suggested to
attention. Journal of Neuroscience, 4, 1863–1874.
Russo, N., Flanagan, T., Iarocci, G., Berringer, D., Zelazo, have Cohen syndrome (Fig. 1).
P. D., & Burack, J. A. (2007). Deconstructing execu-
tive deficits among persons with autism: Implications
for cognitive neuroscience. Brain & Cognition, 65(1), Historical Background
77–86.
Sahyoun, C., Soulières, I., Belliveau, J. W., Mottron, L.,
& Mody, M. (2009). Cognitive differences in picto- History
rial reasoning between high-functioning autism and In 1968 and 1972, Dr. Michael Cohen and his
Asperger’s syndrome. Journal of Autism and Devel- collaborators from the United States observed two
Sandberg, A. D., Nyden, A., Gilberg, C., & Hjelmquist, E. sibs and a third patient, respectively, with a previ-
(1993). The cognitive profile in infantile autism: ously unrecognized pattern of abnormalities. In
A study of 70 children and adolescents using the 1973, they diagnosed these patients with a newly
Griffiths Mental Developmental Scale. British Journal recognized syndrome (Cohen et al., 1973). In
of Psychology, 84(3), 365–373.
Solomon, M., Ozonoff, S. J., Cummings, N., & Carter, another report, Carey and Hall established Cohen
C. S. (2008). Cognitive control in autism spectrum syndrome as a clinical entity by presenting four new
disorders. International Journal of Developmental patients with similar findings (Carey & Hall, 1978).
Neuroscience, 26(2), 239–247. Since then, a large number of patients with
Turner, M. (1999). Generating novel ideas: Fluency per-
formance in high-functioning and learning disabled Cohen syndrome have been found in Finland. Six
individuals with autism. Journal of Child Psychology of these were reported in 1984 by Norio et al. on
and Psychiatr, 40, 189–201. a small group of Finnish patients with Cohen
syndrome, presenting microcephaly, neutropenia,
and specific ophthalmic abnormalities, namely,
high myopia and retinal dystrophy (Norio, Raitta, &
Cohen Syndrome Lindahl, 1984). Recently, a novel disease-causing
gene (COH1; chromosome 8q22) was identified in
Ozgur Pirgon this interval which encodes a transmembrane
Department of Pediatrics, Division of Pediatric protein presumably involved in vesicle-mediated
Endocrinology, S. Demirel University, Isparta, sorting and intracellular protein transport
Turkey (Kolehmainen et al., 2003).
Genetics and Etiology

Definition Many of the reported patients have been sibs, with
healthy parents. In five Finnish families, the parents
Cohen syndrome (Mendelian Inheritance in Man were consanguineous. Thus, Cohen syndrome is
[MIM 216550]) is an autosomal recessive disorder considered to be an autosomal recessive disorder.
Cohen Syndrome 705 C
Cohen Syndrome, Fig. 1 Case 1 showing the charac- limbs (b). Case 3 showing the prominent upper incisors,
teristic facial appearance (a). Case 2 showing the charac- high nasal bridge, and antimongoloid slant of the eyes
teristic body shape of Cohen syndrome: a truncal (c) (From archive of Ozgur Pirgon)
distribution of body fat, with comparatively slender
In Finland, linkage studies were performed with the adult brain suggesting a role in neuronal differ-
assumption of autosomal recessive inheritance, and entiation (Mochida et al., 2004). This suggests
the gene was mapped to the long arm of chromo- that COH1 primarily functions in postmitotic
some 8 (Tahvanainen et al., 1994). cells, which may be the reason for the postnatal
The gene responsible for Cohen syndrome, microcephaly seen in Cohen syndrome (Seifert
VPS13B (MIM# 607817), also known as COH1, et al., 2006).
is located on chromosome 8q22 (Kolehmainen
et al., 2003). VPS13B is a large gene: it spans Incidence and Prevalence
a region of 864 kb and has 62 exons, with putative Cohen syndrome is a rare autosomal recessive
transmembrane domains and functional motifs disorder with incidence rates (based on Finnish
specific for intracellular vesicle-mediated data) estimated as 1 per 105,000 (Kivitie-Kallio,
protein sorting (VPS) (Kolehmainen et al., Eronen, Lipsanen-Nyman, Marttinen, & Norio,
2003; Seifert et al., 2009; Velayos-Baeza, 1999). To date over 100 reports of individuals
Vettori, Copley, Dobson-Stone, & Monaco, with Cohen Syndrome have been published,
2004). The function of the protein encoded by but most are single case or small group studies,
COH1 is mostly unknown. Although in the and relatively few involve large samples.
majority of patients clinically diagnosed as hav- Patients have been identified worldwide but are
ing Cohen syndrome, homozygous or compound overrepresented in the Finnish population.
heterozygous mutations in VPS13B are identi-
fied, in about 20–30%, only one heterozygous Diagnosis
mutation is detected, and in 12%, no mutations Establishing the clinical diagnosis of Cohen syn-
are found (Kolehmainen et al., 2004; Seifert et al., drome has historically been challenging. The first
2009). Overall, more than 50 COH1 mutations patients studied with Cohen syndrome were
have been reported in association with Cohen reported to have mental retardation, microcephaly,
syndrome. Most are termination mutations and antimongoloid slant, mild maxillary hypoplasia,
predicted to result in a null allele, while missense short philtrum, open mouth with prominent maxil-
mutations and larger deletions are less common lary central incisors, micrognathia, highly arched
(Seifert et al., 2006). For these patients, the under- narrow palate, crowded teeth, hypotonia, obesity,
lying cause remains uncertain. narrow hands and feet, tapering extremities, cubitus
The mouse homologue of COH1 is widely valgus, genua valga, lumbar lordosis, mild thoracic
expressed in neurons of the postnatal and scoliosis, and hyperextensibility of the joints.
The clinical diagnosis of Cohen syndrome Cohen Syndrome, Table 1 Diagnostic criteria for diag-
is difficult to make in infancy. At infancy, the nosis of Cohen syndrome seen in individuals from various
ethnic backgrounds with proven COH1 mutations (Falk
characteristic facial features are difficult to rec- et al., 2004)
ognize, but they become more and more evident
Major Retinal dystrophy appearing by midchildhood
by 5–10 years of age and remain recognizable for signs Progressive high myopia
decades but tend to lose their most characteristic
Acquired microcephaly
appearance after middle age (Kivitie-Kallio et al.,
Nonprogressive mental retardation, global
2001). Neonatal feeding problems are common. developmental delay
Babies are often hypotonic during the first Hypotonia
months of life. Joint hyperextensibility
The initial description of Cohen syndrome Minor Truncal obesity appearing in or after
features included obesity, mental retardation, signs midchildhood
hypotonia, narrow hands and feet, and Small or narrow hands and feet
a distinctive craniofacial appearance (Cohen Short stature
et al., 1973). Broad phenotypic variability in sub- Friendly disposition
Noncyclic granulocytopenia or low total white
sequent patients diagnosed with Cohen syndrome
blood cell count with or without aphthous ulcers
has created significant confusion as to diagnostic
accuracy (Chandler & Clayton-Smith, 2002;
Friedman & Sack, 1982). The characteristic
facial appearance, developmental delay, myopia, 3. Childhood hypotonia and joint
narrow hands with slender and tapering fingers, hyperextensibility
narrow feet, and generalized joint hyperexten- 4. Retinochoroidal dystrophy and myopia by
sibility were present in all patients with Cohen 5 years of age
syndrome investigated for their study. However, 5. Periods of isolated neutropenia
microcephaly, short stature, truncal obesity, neu- In 2003, Chandler et al. linked the diagnosis of
tropenia, and retinopathy were not present in Cohen syndrome to the presence of at least two of
some of the patients. the following major criteria in a child with sig-
Greater clinical variability is observed in case nificant learning difficulties:
reports of Cohen syndrome from outside Finland. 1. Facial gestalt, characterized by thick hair, eye-
A comparison of features among different Cohen brows, and eyelashes; wave-shaped, down-
syndrome populations with shared linkage to the ward slanting palpebral fissures; prominent,
COH1 locus or known COH1 gene mutations beak-shaped nose; short, upturned philtrum
may help better define criteria for which to sus- with grimacing expression on smiling
pect Cohen syndrome. 2. Pigmentary retinopathy
Although the various physical abnormalities 3. Neutropenia (defined as <2 109/L)
associated with Cohen syndrome have been widely In association with a number of less specific
documented, there is still a lack of consistency in but supportive criteria, namely:
diagnosis. The facial features are often a first indi- 1. Early-onset, progressive myopia
cation of a diagnostic pathway in the examination 2. Microcephaly
of patients presenting with developmental delay. 3. Truncal obesity with slender extremities
In 2001, Kivitie-Kallio and Norio proposed 4. Joint hyperextensibility (Table 1)
the following features as essential for the diagno-
sis of Cohen syndrome:
1. Nonprogressive mental retardation, motor clum- Current Knowledge
siness, and microcephaly
2. Typical facial features, including wave- Differential Diagnosis
shaped eyelids, short philtrum, thick hair, Conditions to be considered in the differential
and low hairline diagnosis of the Cohen syndrome include the
Prader-Willi syndrome, Rubinstein-Taybi syn- Hypotonia can be either of central origin or
drome, Borjeson-Forssman-Lehmann syndrome, related to a possible connective tissue disorder
Bardet-Biedl syndrome, and Mirhosseini- (Norio et al., 1984). All patients learn to walk by
Holmes-Walton syndrome. Mirhosseini-Holmes- the age of 2 5 years. The incidence of seizures
Walton syndrome may be the same syndrome as in Cohen syndrome is approximately 6% (North
Cohen syndrome (Steinlein, Tariverdian, Boll, & et al., 1985). EEG abnormalities in Cohen syn-
Vogel, 1991). However, the clinical phenotype of drome have also been reported in two cases by C
these conditions is quite distinct and very Goecke, Majewski, Kauther, and Sterzel (1982).
different from that of Cohen syndrome. Deafness, Except for oppiness, no signs of muscle disease
diabetes mellitus, and cardiomyopathy are char- are found.
acteristic of Alström syndrome while the Brain MRI is considered normal, although
patients are usually of normal intellect (Michaud corpus callosum is relatively enlarged. Previous
et al., 1996). Postaxial polydactyly and renal dys- studies on MRI findings in Cohen patients disclosed
plasia are diagnostic features of Bardet-Biedl syn- no focal signal intensity alterations in the brain and
drome (Beales, Warner, Hitman, Thakker, & no alterations between the gray and white matter
Flinter, 1997). Prader-Willi syndrome is (Kivitie-Kallio et al., 2001). Furthermore, some
characterized by severe hypotonia and feeding authors reported in some patients with Cohen syn-
difficulties in early infancy, followed in later drome a relatively enlarged corpus callosum, thus
infancy or early childhood by excessive eating suggesting to consider this a possible hallmark of
and obesity. the syndrome. An increased diameter of the body of
the corpus callosum was described in a group of 15
Specific Characteristics Finnish Cohen syndrome patients (Kivitie-Kallio &
Cohen syndrome has been proposed to be Norio, 2001), a clinical feature not reported by
subdivided into two types (i.e., Finnish type other large studies of non-Finnish Cohen syndrome
and Jewish type) (Kondo, Nagataki, & Miyagi, patients (Hennies, Rauch, & Seifert, 2004;
1990). Phenotypes common to both types are Kolehmainen et al., 2004; Seifert et al., 2006).
nonprogressive psychomotor retardation, micro- All authors also proposed that though MRI
cephaly, characteristic facial features, retinal alone cannot confirm the diagnosis and no definite
dystrophy, and intermittent neutropenia (Fried- measurements can be recommended for clinical
man & Sack, 1982; Sack & Friedman, 1986). use, any clinical suspicion of Cohen syndrome
The characteristic facial features include high- would have been reinforced by the MRI finding
arched or wave-shaped eyelids, a short philtrum, of an enlarged corpus callosum in a microcephalic
thick hair, and low hairline. Both types are head and normal signal intensities of gray and
further classified by the presence (Finnish type) white matter (Kivitie-Kallio et al., 2001).
or absence (Jewish type) of retinal anomalies
(Kondo et al., 1990). Craniofacial
Craniofacial features are often essential in syn-
Neurological drome diagnosis. Suspicion of Cohen syndrome
Intracranial abnormalities have been reported in usually arises when a mentally retarded child has
Cohen syndrome patients; however, the findings facial features considered typical of this syndrome.
are inconsistent. Microcephaly, considered by Reduced head size (microcephaly), short philtrum,
some authors (Fryns et al., 1996; Norio et al., and small cranial base dimensions are essential
1984) as a typical and early symptom of the features in Cohen syndrome. In addition, most
syndrome, was mildly evident from the neonatal patients had forward-inclined upper incisors and
period in our two patients and, apart from mild maxillary prognathia (Carey & Hall, 1978; Ozturk
hypotonia, was not associated with major neuro- & Weber, 1991). Head circumferences of Cohen
logical dysfunction (Balestrazzi et al., 1980; subjects were very small, in the order of mean
Carey & Hall, 1978). values for 5–6-year-old Finnish children and at
the level of 4 SD in Finnish head circumference age (Kivitie-Kallio et al., 2000). All except two
standards (Sorva et al., 1984). children aged 2 and 5 years of the 22 Finnish
Other craniofacial features, such as patients showed signs of the pigmentary retinop-
antimongoloid slant of the eyelids, high-arched or athy (Kivitie-Kallio et al., 2000). Early studies of
wave-shaped eyelids, long and thick eyebrows, Cohen syndrome patients showed that abnormal
prominent root of nose, short philtrum, prominent retinal findings and electroretinographic changes
upper central incisors, open mouth appearance, were present much earlier (Chandler et al., 2002).
maxillary hypoplasia, high and narrow palate, and Useful vision is usually preserved until the fourth
mandibular micrognathia, have been described decade (Kivitie-Kallio et al., 2000).
(Goecke et al., 1982; Kondo et al., 1990; Warburg, Retinal dystrophic changes were accompanied
Pedersen & Horlyk, 1990). by early night blindness. This symptom is com-
Despite variability in the facial appearance, monly seen in adolescents. In Cohen syndrome;
several specific features can be identified in ocular anomalies are also common finding
patients from different countries. Facial features including strabismus, hyperopia, astigmatism,
also seem to differ between populations. Finnish microphthalmia, coloboma of the iris, and, most
Cohen syndrome patients (81–100%) are described frequently, severe myopia. Recent reports also
as having a distinctive facial appearance including indicate involvement of the chorioretinal epithe-
wave-shaped eyelids, thick and high-arched lium (Mendez, Paskulin, & Vallandro, 1985;
eyebrows, long eyelashes, thick hair, low hairline, Norio et al., 1984).
high nasal bridge, flat philtrum, short upper lip, Myopia and astigmatism are common findings
prominent and broad upper central incisors, open in Cohen syndrome. Myopia was noted in 44% of
mouth, and micrognathia (Kivitie-Kallio & Norio, patients in the literature. Myopia in Cohen syn-
2001). The UK cohort was found to have a similar drome is mainly refractive in type and is due to
facial appearance as the Finnish, with the high corneal and lenticular power (Summanen
additional description of a beak-shaped nose, et al., 2002).
malar hypoplasia, and a grimace-like smile Strabismus was reported in 29% of patients
(Chandler et al., 2003). from literature review, with divergent strabismus
being more common than convergent (Fryns et al.,
Ophthalmologic 1996; Warburg et al., 1990). Chandler et al.
Cohen syndrome is also characterized by progres- (2002) reported strabismus in up to 80% of patients.
sive myopia and pigmentary retinopathy, as first Downslanting eyelids were present in 71% of
described in two of three patients by Cohen et al. patients, while 13% were reported to have ptosis.
(1973). Other reported ophthalmic features Lens opacities were present in 13 of 22 Finnish
include astigmatism, strabismus, microcornea, patients (Kivitie-Kallio et al., 2000). Small cortical
microphthalmia, sluggish pupillary reaction, iris opacities were noted in patients as early as 15 years
atrophy and oval pupil, lens opacities, lens sublux- of age; biomicroscopy and lens opacitometry show
ation, optic atrophy, bull’s-eye maculopathy, frequent incidence of early nuclear sclerosis in
coloboma of the retina or lids, ptosis, exophthal- patients with Cohen syndrome (Summanen et al.,
mos, poor vision acuity, nyctalopia, and constricted 2002). Older patients also had posterior subcapsu-
visual fields (Chandler & Clayton-Smith, 2002; lar cataracts, iris atrophy, and iridophacodonesis
Kivitie-Kallio et al., 2000). In the UK study, (Kivitie-Kallio et al., 2000).
however, a significant proportion of affected
adults were found to develop blindness with time Musculoskeletal
(Chandler et al., 2002). In the first report of this syndrome, all of the three
Retinal dystrophy was recorded by Cohen patients had lumbar lordosis, mild thoracic scoli-
et al. (1973) in their original description of the osis, cubitus valgus, genu valgum, and narrow
syndrome. The pigment deposits increase and hands and feet (Cohen et al., 1973). The hands
approach the posterior pole by 35–40 years of and fingers of Cohen patients were reported to be
long and slender (Kousseff, 1981; Norio et al., hypophyseal- gonadal axis were found. Kivitie-
1984). Since the first descriptions, the most com- Kallio et al. found no significant endocrinologic
mon abnormalities reported are kyphoscoliosis abnormalities in their patients with Cohen syn-
and pes calcaneovalgus (Norio et al., 1984; drome; however, they did not perform an oral glu-
North et al., 1985; Sack & Friedman, 1986). cose tolerance test in their obese cases for diabetes
The metacarpophalangeal pattern profile was or insulin resistance (Kivitie-Kallio et al., 1991).
characteristic: all measured bones of the hands Pirgon et al. reported that two patients showed C
were short, the medial and especially the distal the typical characteristics of Cohen syndrome
phalanges were the shortest, and the proximal with metabolic syndrome features of acanthosis
phalanges were relatively the longest. Their hands nigricans, hyperlipidemia, hypertension, and
and feet are small and narrow, as given in earlier marked hyperinsulinemia (Pirgon et al., 2006).
reports (Cohen et al., 1973; Norio et al., 1984).
Developmental Delay and Mental
Endocrine Retardation
In many previous studies, Cohen syndrome All patients had a global developmental delay of
patients have been reported to be short (Carey & variable degree and nonprogressive mental retar-
Hall, 1978; Cohen et al., 1973; North et al., dation. Intellectual impairment is considered to
1995). Short stature is a universal feature among be an essential criterion by some groups of
the Amish and Lebanese Cohen syndrome researchers (Kivitie-Kallio & Norio, 2001).
patients, but was seen in only 40% of the Finnish Mental retardation together with motor delay,
Cohen syndrome patients and 64% of the UK due to hypotonia, is present from early life in most
Cohen syndrome patients. Heights were highly reported cases of Cohen syndrome. The majority of
variable and ranged from 5.7 to 0.3 SD. Both patients have an IQ less than 50 (Goecke et al.,
impaired growth hormone (Massa et al., 1991) 1982), although there have been reports of children
and normal growth hormone secretion have been showing mild to moderate degree of retardation.
reported (Carey & Hall, 1978). Most reported cases of Cohen syndrome present
Mild truncal obesity was present in most with mental retardation accompanied by motor
patients at midchildhood, but that trait may be delay and hypotonia in early life. Patients are not
lacking in adult patients. Other studies have able to attend normal school; thus, they all need
described different frequencies of truncal obe- special schools. Mental retardation does not pro-
sity, from 17% to 100% in patients aged gress, and patients learn new things.
8 years (Chandler et al., 2003; Kivitie-Kallio
& Norio, 2001). Behavioral
Puberty in Cohen syndrome patients is mostly Cohen syndrome patients usually have cheerful
delayed (Kivitie-Kallio et al., 1999), although disposition and have not been associated with
they do reach sexual maturity. Delayed puberty maladaptive behavior. Language is possibly
has only been reported in the Finnish and UK lacking or severely impaired in infancy. Autistic
cohorts (77% and 40%, respectively). No endo- traits are found during childhood (Fryns et al.,
crine abnormalities are found. The other reported 1996). Children and young people diagnosed
endocrinologic study showed delayed onset of with Asperger’s syndrome have significant
puberty without luteinizing hormone and folli- social-communication difficulties and impaired
cle-stimulating hormone deficiency in Cohen empathy and theory of mind skills. These difficul-
syndrome (Balestrazzi et al., 1980). However, ties place them at risk of developing mental health
delayed puberty might be due to the obesity. problems, particularly anxiety, depression, and
Two girls, one with diabetes mellitus (Nambu obsessive-compulsive disorder.
et al., 1988) and the other with impaired glucose A recent study of cognitive and adaptive skills
tolerance test (Fuhrmann-Rieger et al., 1984), (Karpf et al., 2004) indicated that some individ-
have been noted. No abnormalities of the uals may have an IQ in the normal range, and
although some research (Kivitie-Kallio et al., associated with recurrent infections. While inter-
1999) has reported low levels of maladaptive mittent granulocytopenia is frequently described
behavior and high levels of self-direction, in the Finnish group (100%), UK group (77%),
responsibility, and socialization, there are also and was present in two Amish patients evaluated
accounts of greater behavioral disturbance for this problem with one additional child having
(Chandler et al., 2003). Fryns et al. (1996) symptomatic aphthous ulcers, it was not present in
reported autistic behavior patterns in four patients blood counts of any of the Lebanese Cohen syn-
and in a postal survey of 33 children and young drome patients. Importantly, no severe infections
adults with Cohen syndrome. were reported in association with this finding.
Reports from a number of parents belonging to Chandler et al. (2003) reported that stridor
the Cohen Syndrome Support Group in the UK had secondary to laryngomalacia was common in
indicated significant difficulties in social interac- infancy among the Jewish-type Cohen syndrome
tion; moreover, there were several cases of individ- patients and more significant laryngeal abnormal-
uals with Cohen syndrome also being diagnosed as ities were also reported, namely, laryngeal steno-
having autism. Howlin (2001) found that over half sis and vocal cord paralysis.
the sample had problems in social understanding,
communication, and ritualistic and stereotyped Cardiovascular
behaviors. Howlin et al. (2001) also suggested Numerous cardiac abnormalities have been
that although antisocial behaviors are rare, symp- reported. These include mitral valve prolapse in
toms of anxiety are common, and in some individ- two patients (Sack and Friedman, 1980; Mehes
uals, autistic-type features are marked. Their et al., 1988). Systolic murmur (grades II–IV) in
investigation of 45 individuals with Cohen syn- five of six patients (Norio et al., 1984) and
drome (age 4–48 years) found that although 57% a dilated descending aorta (Schlichtemeier et al.,
of the sample were reported as showing some 1994) have also been reported. Although 30% of
behavioral disturbance, problems related mainly the patients had systolic murmurs, echo studies
to anxiety and social interactions, marked antisocial revealed no abnormalities in their cardiac anatomy.
behaviors were rare.
Kivitie-Kallio and her colleagues (Kivitie-
Kallio & Norio, 2001) noted that “inappropriate Future Directions
interpersonal manners, stereotyped behavior and
odd mannerisms were not uncommon.” One of Management
their cases had also shown autistic behavior as an Early diagnosis of the syndrome is important for
infant, although this had improved after the age of appropriate counseling of families with one
3 years. In the Chandler et al. study (2003) of 27 affected child. Although most of the clinical find-
patients, 74% exhibited stereotyped behaviors, such ings are usually present from an early age, the
as spinning, and five cases (18%) were observed to diagnosis of Cohen syndrome is very difficult in
show autistic features (communication and social infancy, since the typical morphological stigmata
abnormalities and ritualistic and obsessive become more evident after the age of 6–8 years
behavior). (Fryns et al., 1996).
Newborns have low-normal weights, and the
Infections onset of obesity is generally in midchildhood
Many children with Cohen syndrome have recur- (Carey & Hall, 1978; Cohen et al., 1973). Severe
rent upper respiratory infections. However, patients obesity is rare, and some patients may not develop
have no fatal infections, and granulocytes seem to obesity at all (Friedman & Sack, 1982). The rela-
rise normally in cases of severe bacterial infections. tionship among the obesity, hypotonia, and
Several of the children had intermittent hypogonadism has not been clarified. Nutritional
granulocytopenia. The granulocytopenia is usually counseling for good long-term weight management
mild, not progressive, and does not seem to be should begin in early infancy to prevent the
inappropriate weight gain that would otherwise Beales, P. L., Warner, A. M., Hitman, G. A., Thakker, R.,
typically begin between 12 and 36 months of age. & Flinter, F. A. (1997). Bardet-Biedl syndrome:
A molecular and phenotypic study of 18 families.
Behavioral problems should be detected early Journal of Medical Genetics, 34, 92–98.
and treated appropriately with parental educa- Carey, J. C., & Hall, B. D. (1978). Confirmation of the
tion/training (including consistent limit setting) Cohen syndrome. Journal of Pediatrics, 93, 239–244.
and, if needed, consideration of counseling and/ Chandler, K. E., & Clayton-Smith, J. (2002). Does
or psychotropic medication. Developmental
a Jewish type of Cohen syndrome truly exist? Ameri-
can Journal of Human Genetics, 111, 453–454.
C
assessment should be performed routinely. Phys- Chandler, K. E., Kidd, A., Al Gazali, L., Kolehmainen, J.,
ical and occupational therapies should begin in Lehesjoki, A. E., Black, G. C., & Clayton-Smith, J.
infancy to facilitate the development of motor (2003). Diagnostic criteria, clinical characteristics, and
natural history of Cohen syndrome. Journal of Medical
milestones. Speech therapy is important in mon- Genetics, 40, 233–241.
itoring receptive-expressive language skills. In Cohen, M., Hall, B., Smith, D., Graham, B., & Lampert,
addition, appropriate educational intervention K. (1973). A new syndrome with hypotonia, obesity,
throughout the school years that addresses indi- mental deficiency, and facial, oral, ocular and limb
anomalies. Journal of Pediatrics, 83, 280–284.
vidual strengths and challenges as well as behav- Falk, M. J., Feiler, H. S., Neilson, D. E., Maxwell, K., Lee,
ioral issues can be effectively implemented in J. V., Segall, S. K., Robin, N. H., Wilhelmsen, K. C.,
both inclusion and self-contained classroom set- Tr€askelin, A. L., Kolehmainen, J., Lehesjoki, A. E.,
tings depending on individual needs. Wiznitzer, M., & Warman, M. L. (2004). Cohen syn-
drome in the Ohio Amish. American Journal of Med-
Long-term follow-up and clinical information ical Genetics, 128, 23–28.
on patients older than 40 years are rare in the Friedman, E., & Sack, J. (1982). The Cohen syndrome:
literature. Marked deterioration of visual func- Report of five new cases and a review of the literature.
tion, and even total blindness, can occur over Journal of Craniofacial Genetics and Developmental
Biology, 2, 193–200.
the age of 50 years (Seifert et al., 2006). Fryns, J. P., Leguis, E., Devriendt, K., Meire, F., Standaert,
Kyphoscoliosis can be observed in patients with L., Baten, E., & Van den Berghe, H. (1996). Cohen
Cohen syndrome as teenagers or adults, and this syndrome: The clinical symptoms and stigmata at
tends to be progressive through adult life. a young age. Clinical Genetics, 49, 237–421.
Fuhrmann-Rieger, A., Kohler, A., & Fuhrmann, W.
Appropriate management of children with (1984). Duplication or insertion in 15q11-13 associ-
Cohen syndrome requires collaborative efforts ated with mental retardation, short stature and obesity,
from the geneticist, neurologist, endocrinologist, Prader-Willi or Cohen syndrome? Clinical Genetics,
developmental-behavioral pediatrician, nutri- 25, 347–352.
Goecke, T., Majewski, F., Kauther, K. D., & Sterzel, U.
tionist, psychologist, psychiatrist, educational (1982). Mental retardation, hypotonia, obesity, ocular,
specialist, and the family. Once the diagnosis of facial, dental, and limb abnormalities (Cohen syn-
Cohen syndrome is confirmed, it is important for drome) report of three patients. European Journal of
the child to receive multidisciplinary care in addi- Pediatrics, 138, 338–340.
Hennies, H. C., Rauch, A., & Seifert, W. (2004). Allelic
tion to routine preventive health care from the heterogeneity in the COH1 gene explains clinical var-
primary care physician. iability in Cohen syndrome. American Journal of
Human Genetics, 75, 138–145.
Howlin, P. (2001). Autistic features in Cohen syndrome:
See Also A preliminary report. Developmental Medicine and
Child Neurology, 43, 692–696.
▶ Intellectual Disability Karpf, J., Turk, J., & Howlin, P. (2004). Cognitive, lan-
guage and adaptive behaviour skills in individuals with
a diagnosis of Cohen syndrome. Clinical Genetics, 65,
1–6.
References and Readings Katzaki, E., Pescucci, C., Uliana, V., Papa, F. T., Ariani,
F., Meloni, I., Priolo, M., Selicorni, A., Milani, D.,
Balestrazzi, P., Corrini, L., Villani, G., Bolla, M. P., Casa, Fischetto, R., Celle, M. E., Grasso, R., Dallapiccola,
F., & Bernasconi, S. (1980). The Cohen syndrome: B., Brancati, F., Bordignon, M., Tenconi, R., Federico,
Clinical and endocrinological studies of two new A., Mari, F., Renieri, A., & Longo, I. (2007). Clinical
cases. Journal of Medical Genetics, 17, 430–432. and molecular characterization of Italian patients
affected by Cohen syndrome. Journal of Human Mochida, G. H., Rajab, A., Eyaid, W., Lu, A., Al-Nouri,
Genetics, 52, 1011–1017. D., Kosaki, K., Noruzinia, M., Sadra, P., Ishihara, J.,
Kivitie-Kallio, S., Eronen, M., Lipsanen-Nyman, M., Bodell, A., Apse, K., & Walsh, C. A. (2004).
Marttinen, E., & Norio, R. (1999). Cohen syndrome: Broader geographical spectrum of Cohen syndrome
Evaluation of its cardiac, endocrine and radiological due to COH1mutations. Journal of Medical Genetics,
features. Clinical Genetics, 56, 41–50. 41, 87.
Kivitie-Kallio, S., & Norio, R. (2001). Cohen syndrome: Nambu, M., Oshima, Y., Kakiwchi, T., Hayakawa, Y.,
Essential features, natural history, and heterogeneity. Ito, T., Hasegawa, T., et al. (1988). Cohen’s syndrome
American Journal of Medical Genetics, 102, 125–135. with diabetes mellitus. Acta Paediatrica Japonica, 30,
Kivitie-Kallio, S., Summanen, P., Raitta, C., & Norio, R. 84–88.
(2000). Ophthalmologic findings in Cohen syndrome. Norio, R., Raitta, C., & Lindahl, E. (1984). Further delin-
Ophthalmology, 107, 1737–1745. eation of the Cohen syndrome; Report on chorioretinal
Kolehmainen, J., Black, C. M., Saarinen, A., Chandler, K., dystrophy, leukopenia and consanguinity. Clinical
Clayton-Smith, J., Tr€askelin, A. L., Kivitie-Kallio, S., Genetics, 25, 1–14.
Norio, R., Warburg, M., Fryns, J. P., de la Chapelle, A., North, K. N., Fulton, A. B., & Whiteman, D. A. (1995).
& Lehesjoki, A. E. (2003). Cohen syndrome is caused Identical twins with Cohen syndrome. American Jour-
by mutations in a novel gene, COH1, encoding nal of Medical Genetics, 58, 54–58.
a transmembrane protein with a presumed role in vesi- Ozturk, B., & Weber, H. P. (1991). Cohen-Syndrom Eigene
cle-mediated sorting and intracellular protein transport. Beobachtungund Literatur€ ubersicht. Monatschrift fur
American Journal of Human Genetics, 72, 1359–1369. Kinderheilkunde, 139, 844–848.
Kolehmainen, J., Norio, R., Kivitie-Kallio, S., Pirgon, O., Atabek, M. E., & Sert, A. (2006). Metabolic
Tahvanainen, E., de la Chapelle, A., & Lehesjoki, syndrome manifestations in Cohen syndrome:
A. E. (1997). Refined mapping of the Cohen syndrome Description of two new patients. Journal of Child
gene by linkage disequilibrium. European Journal of Neurology, 21, 536–538.
Human Genetics, 5, 206–213. Sack, J., & Friedman, E. (1986). The Cohen syndrome in
Kolehmainen, J., Wilkinson, R., Lehesjoki, A. E., Chan- Israel. Israel Journal of Medical Sciences, 22, 766–770.
dler, K., Kivitie-Kallio, S., Clayton-Smith, J., Schlichtemeier, T. L., Tomlinson, G. E., Kamen, B. A.,
Traskelin, A. L., Waris, L., Saarinen, A., Khan, J., Waber, L. J., & Wilson, G. N. (1994). Multiple coag-
Gross-Tsur, V., Traboulsi, E. I., Warburg, M., Fryns, ulation defects and the Cohen syndrome. Clinical
J. P., Norio, R., Black, G. C., & Manson, F. D. (2004). Genetics, 45, 212–216.
Delineation of Cohen syndrome following a large- Seifert, W., Holder-Espinasse, M., Kuhnisch, J., Kahrizi,
scale genotype-phenotype screen. American Journal K., Tzschach, A., Garshasbi, M., Najmabadi, H., Wal-
of Human Genetics, 75, 122–127. ter Kuss, A., Kress, W., Laureys, G., Loeys, B.,
Kondo, I., Nagataki, S., & Miyagi, N. (1990). The Cohen Brilstra, E., Mancini, G. M., Dollfus, H., Dahan, K.,
syndrome: Does mottled retina separate a Finnish and Apse, K., Hennies, H. C., & Horn, D. (2009).
a Jewish type? American Journal of Medical Genetics, Expanded mutational spectrum in Cohen syndrome,
37, 109–113. tissue expression, and transcript variants of COH1.
Kousseff, B. (1981). Cohen syndrome: Further delineation Human Mutation, 30, 404–420.
and inheritance. American Journal of Medical Genetics, Seifert, W., Holder-Espinasse, M., Spranger, S.,
9, 25–30. Hoeltzenbein, M., Rossier, E., Dollfus, H., Lacombe,
Massa, G., Dooms, L., & Vanderschueren-Lodeweyckx, D., Verloes, A., Chrzanowska, K. H., Maegawa, G. H.,
M. (1991). Growth hormone deficiency in a girl with Chitayat, D., Kotzot, D., Huhle, D., Meinecke, P.,
the Cohen syndrome. Journal of Medical Genetics, 28, Albrecht, B., Mathijssen, I., Leheup, B., Raile, K.,
48–50. Hennies, H. C., & Horn, D. (2006). Mutational spec-
Mehes, K., Kosztolanyi, G., Kardos, M., & Horvath, M. trum of COH1 and clinical heterogeneity in Cohen
(1988). Cohen syndrome: A connective tissue disorder? syndrome. Journal of Medical Genetics, 43, 22.
American Journal of Medical Genetics, 31, 131–133. Seifert, W., Holder-Espinose, M., Kuhnisch, J.,
Mendez, H. M. M., Paskulin, G. A., & Vallandro, C. Kohrizi, K., Tzschach, A., Garshasbi, M., et al.
(1985). The syndrome of retinal pigmentary degener- (2009) Exponded mutational spectrum in Cohen syn-
ation, microcephally and severe mental retardation drome, tissue expression, and transcript variants of
(Mirhosseini-Holmes-Walton syndrome): Report of COH1. Human Mutation, 30, 404–420.
two patients. American Journal of Medical Genetics, Sorva, R., Perheentupa, J., & Tolppanen, E. M., (1984). A
22, 223–228. novel format for a growth chart. Acta Paediatrica
Michaud, J. L., Héon, E., Guilbert, F., Weill, J., Puech, B., Scandinavica, 73, 527–259.
Benson, L., Smallhorn, J. F., Shuman, C. T., Buncic, Steinlein, O., Tariverdian, G., Boll, H. U., & Vogel, F.
J. R., Levin, A. V., Weksberg, R., & Brevière, G. M. (1991). Tapetoretinal degeneration in brothers with
(1996). Natural history of Alström syndrome in early apparent Cohen syndrome: Nosology with
childhood: Onset with dilated cardiomyopathy. Jour- Mirhosseini-Holmes-Walton syndrome. American
nal of Pediatrics, 128, 225–229. Journal of Medical Genetics, 41, 196–200.
Cohen, Donald J. 713 C
Summanen, P., Kivitie-Kallio, S., Norio, R., Raitta, C., & the neurobiological study of autism, initially
Kivela, T. (2002). Mechanisms of myopia in Cohen through his work in the 1970s and 1980s on
syndrome mapped to chromosome 8q22. Investigative
Ophthalmology & Visual Science, 43, 686–693. serotonin and monoamines in cerebrospinal
Tahvanainen, E., Norio, R., Karila, E., Ranta, S., fluid and later by developing cross-disciplinary
Weissenbach, J., Sistonen, P., & de la Chapelle, A. research collaborations at the Yale Child Study
(1994). Cohen syndrome gene assigned to the long Center and beyond. Under his directorship, the
arm of chromosome 8 by linkage analysis. Nature
Genetics, 7, 201–204. research program on autism at Yale broke new C
Velayos-Baeza, A., Vettori, A., Copley, R. R., Dobson- ground, among other areas, in nosology (through
Stone, C., & Monaco, A. P. (2004). Analysis of the the DSM field trials led by Fred Volkmar), phe-
human VPS13 gene family. Genomics, 84, 536–549. notypic definition (through Ami Klin’s eye track-
Warburg, M., Pedersen, S. A., & Horlyk, H. (1990). The
Cohen syndrome. Retinal lesions and granulocytopenia. ing paradigms), and neural substrates (through
Ophthalmic Paediatrics and Genetics, 11, 7–13. Robert Schultz’s imaging studies of the fusiform
gyrus). In addition, Cohen brought to autism
research his background in philosophy and psy-
choanalysis, as exemplified in his collaborations
Cohen, Donald J. on theory of mind with Simon Baron-Cohen, and
on the contributions of psychoanalysis to social
Andres Martin development with Linda Mayes.
Short Biography
Name and Degrees
Born in Chicago in 1940 to a humble family,
Donald J. Cohen, M.D. (1940–2001). Donald Cohen attended college at Brandeis Uni-
versity. He studied philosophy at Cambridge
before enrolling in medical school at Yale. He
Major Appointments (Institution, trained in pediatrics at Children’s Hospital Bos-
Location, Dates) ton and in psychiatry at the Massachusetts Mental
Health Center. During his time in Boston, he
Director, Yale Child Study Center, 1983–2001. worked with Ogden Lindsay in his operant con-
President, International Association of Child and ditioning laboratory. During the Vietnam War, he
Adolescent Psychiatry and Allied Professions, worked in Washington, D.C., as special assistant
1992–1998. to Edward Zigler, helping him in the develop-
ment of the Head Start program. Cohen was
recruited back to Yale in 1972 by Albert Solnit,
Major Honors and Awards whom he succeeded as director of the Yale Child
Study Center in 1983. At Yale, Cohen was able to
Doctorate Honoris Causa, Bar-Ilan University, integrate his background in philosophy, psycho-
1997. analysis, and neuroscience particularly on two
Lifetime Achievement Award, International “model” disorders: Tourette’s syndrome and
Meeting for Autism Research, 2001. autism. His early studies on monoamine metabo-
lites in serum and CSF were conducted at the
Children’s Clinical Research Center (CCRC) at
Landmark Clinical, Scientific, and Yale-New Haven Children’s Hospital. Cohen
Professional Contributions was codirector of the CCRC from the time of
his arrival at Yale until his succession by his
Donald Cohen was the leading American child close collaborator James Leckman in 1983.
psychiatrist of his generation and helped advance Cohen’s early studies on monoamine metabolites
C 714 Cohort Studies
were followed by his development of a rich Cohen, D. J., Caparulo, B. K., Shaywitz, B. A., & Bowers,
multidisciplinary research program for autism at M. B., Jr. (1977). Dopamine and serotonin metabolism
in neuropsychiatrically disturbed children. CSF
the Yale Child Study Center. Key collaborators in homovanillic acid and 5-hydroxyindoleacetic acid.
this program were Fred Volkmar (who eventually Archives of General Psychiatry, 34(5), 545–550.
would go on to lead it), Ami Klin, Robert Schultz, Cohen, D. J., Young, J. G., & Roth, J. A. (1977). Platelet
Rhea Paul, and George Anderson. In addition to monoamine oxidase in early childhood autism.
Archives of General Psychiatry, 34(5), 534–537.
a wide portfolio on neurobiological studies of Klin, A., & Cohen, D. J. (1994). The immorality of not-
autism, Cohen remained interested and made knowing: The ethical imperative to conduct research in
seminal contributions to theory of mind and the child and adolescent psychiatry. In J. Hattab (Ed.),
inner life of individuals with autism, as well as to Ethics in child psychiatry (pp. 1–17). Jerusalem:
Gelfen Publishing House.
the ethical imperative to conduct sound research Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D.
in vulnerable populations, including individuals (2002a). Visual fixation patterns during viewing of
affected with autism. Much of Cohen’s later naturalistic social situations as predictors of social
career was devoted to establishing international competence in individuals with autism. Archives of
General Psychiatry, 59(9), 809–816.
programs in child and adolescent psychiatry, Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D.
a focus that he developed as president of the (2002b). Defining and quantifying the social pheno-
International Association of Child and Adoles- type in autism. American Journal of Psychiatry,
cent Psychiatry and Allied Professions. 159(6), 895–908.
Klin, A., Sparrow, S. S., de Bildt, A., Cicchetti, D. V.,
Cohen, D. J., & Volkmar, F. R. (1999). A normed
study of face recognition in autism and related disor-
ders. Journal of Autism and Developmental Disorders,
References and Readings 29(6), 499–508.
Mayes, L. C., & Cohen, D. J. (1994). Experiencing self and
Edited Books others: Contributions from studies of autism to the psy-
Baron-Cohen, S., Tager-Flusberg, H., & Cohen, D. J. choanalytic theory of social development. Journal of the
(Eds.). (1994). Understanding other minds: Perspec- American Psychoanalytic Association, 42(1), 191–218.
tives from autism (1st ed.). New York: Oxford Univer- Schultz, R. T., Gauthier, I., Klin, A., Fulbright, R. K.,
sity Press. Anderson, A. W., Volkmar, F., et al. (2000). Abnormal
Baron-Cohen, S., Tager-Flusberg, H., & Cohen, D. J. ventral temporal cortical activity during face discrim-
(Eds.). (2000). Understanding other minds: Perspec- ination among individuals with autism and Asperger
tives from autism (2nd ed.). New York: Oxford Uni- syndrome. Archives of General Psychiatry, 57(4),
versity Press. 331–340.
Cohen, D. J., & Donnellan, A. M. (Eds.). (1987). Hand-
book of autism and pervasive developmental disorders
(1st ed.). Chichester: Wiley.
Cohen, D. J., & Volkmar, F. (Eds.). (1997). Handbook of
autism and pervasive developmental disorders Cohort Studies
(2nd ed.). Chichester: Wiley.
Volkmar, F. R., Paul, R., Klin, A., & Cohen, D. J. (2005).
Handbook of autism and pervasive developmental dis- ▶ Longitudinal Research in Autism
orders (3rd ed., Vol. 2). Chichester: Wiley.
Select Articles (In Reverse Chronological

Order) Collaborative Consultation
Anderson, G. M., Freedman, D. X., Cohen, D. J., Volkmar,
F. R., Hoder, E. L., McPhedran, P., et al. (1987). Whole
blood serotonin in autistic and normal subjects. Journal
▶ Role Release
of Child Psychology and Psychiatry, 28(6), 885–900.
Anderson, G. M., Horne, W. C., Chatterjee, D., & Cohen,
D. J. (1990). The hyperserotonemia of autism. Annals
of the New York Academy of Sciences, 600, 331–340.
Cohen, D. J. (2001). Into life: Autism, Tourette’s syndrome
Collaborative Intervention
and the community of clinical research. Israel Journal
of Psychiatry and Related Sciences, 38(3–4), 226–234. ▶ Role Release
Collaborative Program of Excellence in Autism 715 C
infrastructure, and resources focused on major
Collaborative Program of Excellence questions about autism. The research issues
in Autism addressed include advanced techniques of diag-
nosis and assessment, population genetics and
Alice Kau1 and Judith Cooper2 molecular biology, structural and functional
1
Intellectual and Developmental Disabilities brain imaging, animal models, behavioral and
(IDD) Branch, Eunice Kennedy Shriver National cognitive neuroscience, and focused interven- C
Institute of Child Health and Human tions, to elucidate the neurobiology of autism,
Development, Bethesda, MD, USA with the long-term goal of effective diagnosis,
2
NIDCD (National Institute on Deafness and treatment, and prevention. The CPEAs have
Other Communication Disorders), National linked scientists from the United States, Canada,
Institute of Health EPS – Executive Plaza South, Britain, and five other countries in the study of
400C, Rockville, MD, USA more than 2,200 families over 10 years. As
a result, the CPEAs have data on the genetic and
phenotypic characteristics of the world’s largest
Major Areas or Mission Statement group of well-diagnosed persons with autism.
The funding of the network ended in 2007 when
The mission of the CPEA network was to the NIH consolidated its funding for autism
increase empirical knowledge about autism research into other programs.
through the use of (1) multiple levels of interdis-
ciplinary investigation into the genetics, neurobi-
ology, and clinical aspects of autism; (2) rigorous Major Activities
phenotyping of research participants to support
network-wide studies of large numbers of partic- The CPEA network conducted basic and clinical
ipants; and (3) a collaborative process of sharing research on the possible genetic, immunological,
data, findings, and ideas to move the science neurobiological, and environmental causes of
ahead as quickly as possible. The purpose of autism. The network also investigated the
this network was to gain knowledge that could developmental course of autism and how specific
lead to prevention, treatment, and/or ameliora- brain structures were related to autism. These
tion of the disabling effects of autism on people undertakings required that each CPEA imple-
with autism and their families. ment a cohesive, site-specific, multidisciplinary
research program on the causes, brain substrates,
functional characteristics, and clinical develop-
Landmark Contributions ment of autism. In addition, each site participated
in a trans-network collaborative study for which
The CPEA network was created as result of no single site had sufficient expertise and/or par-
a congressionally mandated conference on the ticipant sample size. Network projects evaluated
State of the Science in Autism, which took the effectiveness of the hormone, secretin, in the
place in April 1995, to identify gaps in the knowl- treatment of autism (Owley et al., 2001; Unis
edge of autism and directions for future research. et al., 2002); the candidate autism genes, HOXA
The NICHD and the NIDCD joined together in and Reelin (Devlin et al., 2002, 2004); the onset
1997 to fund a 5-year project that consisted of of regression and measles-mumps-rubella vacci-
nine clinical centers that each had a unique focus nation (Richler et al., 2006); early regression in
of autism research. The CPEA network was social communication in autism (Richler et al.,
funded through an NIH Cooperative Agreement 2006); the heterogeneous association between
mechanism. Funding was secured in 2002 for Engrailed-2 and autism (Brune et al., 2008);
a second 5-year cycle. The primary goal of this familial autoimmune thyroid disease and regres-
program was to bring together expertise, sion in autism (Molloy et al., 2006); frontal lobe
C 716 Collaborative Teaming
function in people with autism (Ozonoff et al., programs of excellence in autism network. Journal of
2004); the relationship between head circumfer- Autism and Developmental Disorders, 34(2), 139–150.
Richler, J., Luyster, R., Risi, S., Hsu, W. L., Dawson, G.,
ence and autism (Lainhart et al., 2006); and Bernier, R., et al. (2006). Is there a “regressive pheno-
IQ-based subtypes of autism (Munson et al., type” of autism spectrum disorder associated with the
2008). measles-mumps-rubella vaccine? A CPEA study.
36(3), 299–316.
Unis, A. S., Munson, J. A., Rogers, S. J., Goldson, E. D.,
Osterling, J., Gabriels, R., et al. (2002). A randomized,
References and Readings double-blind, placebo-controlled trial of porcine ver-
sus synthetic secretin for reducing symptoms of
Brune, C. W., Korvatska, E., Allen-Brady, K., Cook, autism. Journal of the American Academy of Child &
E. H., Jr., Dawson, G., Devlin, B., et al. (2008). Het- Adolescent Psychiatry, 41(11), 1315–1321.
erogeneous association between engrailed-2 and
autism in the CPEA network. American Journal of
Medical Genetics Part B: Neuropsychiatric Genetics,
147B(2), 187–193.
Devlin, B., Bennett, P., Cook, E. H., Dawson, G., Jr.,
Gonen, D., Grigorenko, E. L., et al. (2002). No Collaborative Teaming
evidence for linkage of liability to autism to HOXA1
in a sample from the CPEA network. American
▶ Role Release
Journal of Medical Genetics, 114(6), 667–672.
Devlin, B., Bennett, P., Dawson, G., Figlewicz, D. A.,
Grigorenko, E. L., McMahon, W., et al. (2004). Alleles
of a reelin CGG repeat do not convey liability to
autism in a sample from the CPEA network. American
Journal of Medical Genetics. Part B, Neuropsychiatric
Collaborative Teaming Model
Genetics, 126B(1), 46–50.
Lainhart, J. E., Bigler, E. D., Bocian, M., Coon, H., ▶ Interdisciplinary Team
Dinh, E., Dawson, G., et al. (2006). Head circumfer-
ence and height in autism: A study by the collaborative
program of excellence in autism. American Journal of
Medical Genetics. Part A, 140A, 2257–2274.
Luyster, R., Richler, J., Risi, S., Hsu, W. L., Dawson, G., Colossal Commissure
Bernier, R., et al. (2005). Early regression in social
communication in autism spectrum disorders:
▶ Corpus Callosum
A CPEA study. Developmental Neuropsychology,
27(3), 311–316.
Molloy, C. A., Morrow, A. L., Meinzen-Derr, J., Schleifer,
K., Dienger, K., Manning-Courtney, P., et al. (2006).
Elevated cytokine levels in children with autism spec-
trum disorder. Journal of Neuroimmunology, 172(1),
Combat Disorder
198–205.
Munson, J., Dawson, G., Sterling, L., Beauchaine, T., ▶ Posttraumatic Stress Disorder
Zhou, A., Elizabeth, K. E., et al. (2008). Evidence for
latent classes of IQ in young children with autism
spectrum disorder. American Journal of Mental
Retardation, 113(6), 439–452.
Owley, T., McMahon, W., Cook, E. H., Laulhere, T., Combat Fatigue
South, M., Mays, L. Z., et al. (2001). Multisite, double-
blind, placebo-controlled trial of porcine
▶ Posttraumatic Stress Disorder
secretin in autism. Journal of the American
Academy of Child & Adolescent Psychiatry, 40(11),
1293–1299.
Ozonoff, S., Cook, I., Coon, H., Dawson, G., Joseph,
R. M., Klin, A., et al. (2004). Performance on
cambridge neuropsychological test automated battery
Combat Neurosis
subtests sensitive to frontal lobe function in people
with autistic disorder: Evidence from the collaborative ▶ Posttraumatic Stress Disorder
Comic Strip Conversations 717 C
bubbles, and other symbols. Through the
Comic Strip Conversations incorporation of these items into a conversation,
an individual with an ASD is provided a visual and
Brian Reichow concrete depiction of the conversation and/or
Child Study Center, Associate Research social situation. Providing this pictorial depiction
Scientist, Yale University School of Medicine, (representation) of an abstract social situation is
New Haven, CT, USA thought to capitalize on the improved C
processing of visual information that many
individuals with ASDs have. The exact mecha-
Definition nisms by which comic strip conversations and
other social narratives are effective remain
Comic strip conversations are a social narrative unknown.
that depicts or enhances a conversation or social
situation between two individuals by specifying the
underlying thought processes and/or communica- Goals and Objectives
tive exchanges using line drawings incorporating
thought bubbles, speaker bubbles, and other sym- Comic strip conversations aim to help an individ-
bols. “Comic strip conversations systematically ual with an ASD understand the underlying
identify what people say and do, and emphasize thought processes and/or communicative
what people may be thinking” (p. 1, Gray, 1994). exchanges that occur during conversations and
other social situations. Comic strip stories help
provide a concrete depiction of the expectations
Historical Background of individuals in specific social situations and the
impact that their actions can have on the thoughts
Comic strip conversations were first described by of others in that situation, thereby providing the
Carol Gray in 1994 (Gray, 1994) and are closely individual with ASD a scheme for improving their
related to Gray’s Social Stories. Since then, behavior in a social situation. Through the use of
little research has evaluated the efficacy of the thought bubbles (described later), one is able to
intervention, and little development beyond what explicitly show a person’s thoughts, thus provid-
was initially described by Gray has occurred. ing insight into their theory of mind, which is often
a difficult area for individuals with ASD. Because
comic strip conversations can provide this visual
Rationale or Underlying Theory representation of theory of mind, this is also often
a target of intervention.
A comic strip conversation is a type of social
narrative. Other types of social narratives include
Social Stories, cartooning, and Power Cards Treatment Participants
(Wragge, 2011). A social narrative is a written
description of various social situations that might Since there has been little empirical study of
be problematic for an individual with an ASD. The comic strip conversations, the following parame-
narrative helps explain what typically occurs in ters are based on recommendations based on the
a given social situation, thoughts other individuals intervention’s components and techniques.
might have, and how one is expected to act in Comic strip conversations are likely to be most
a given situation. Comic strip conversations beneficial to individuals who have higher
enhance a conversation between two individuals cognitive functioning skills across all ASD
by specifying the underlying thought processes diagnoses. Although young children (e.g., chil-
and/or communicative exchanges using line draw- dren younger than 5 years) might benefit from
ings incorporating thought bubbles, speaker comic strip conversations, the heavy emphasis on
C 718 Comic Strip Conversations
language and higher-order social thinking makes three children with ASDs. Rogers and Myles
school-age children, adolescents, and adults to be reported that comic strip conversations appeared
the ages of individuals who are likely to receive to be more effective (as measured by teacher
the most benefit. count of the number of redirections for desired
behavior) than social stories for helping a
14-year-old boy with Asperger’s disorder
Treatment Procedures navigate to PE class. Clearly, more research on
the efficacy of comic strip conversations is
Comic strip conversations are typically com- needed before the technique can be considered
pleted in a one-to-one child to therapist (teacher, an evidence-based practice.
parent, etc.) ratio. The intervention begins with
the adult engaging in small talk to strengthen
rapport. The child or therapist then begins the Outcome Measurement
conversation by drawing a social scene involving
multiple people. Multiple boxes (or pages) can be Comic strip conversations are typically writing
used if the scene involves multiple steps or situ- for individual children targeting specific
ations. Speaker bubbles can be used to indicate behaviors. Therefore, outcome measurement is
what people are saying in the scene, and thought likely to focus on behavioral measures of the
bubbles can be added to indicate what people are target behaviors. Since theory of mind is often
thinking (but not saying) during the scene. targeted, some measures of theory of mind
Thought bubbles provide a nice way for the (e.g., faux pas tasks, strange stories, false-belief
therapist to provide perspective of what tasks) might be used to assess the impact of the
people are likely to be thinking but not necessar- intervention technique on this construct.
ily saying during a situation exchange or interac-
tion. After the therapist feels the child has
processed the social situation and the perspec- Qualifications of Treatment Providers
tives of those involved, the therapist then can
ask the child to summarize the situation and pro- There are no formal qualifications (i.e., creden-
vide solutions to the problems the child is likely tials, licensure) necessary for using comic strip
to face when they later participate in similar conversations. There is a brief manual (Gray,
situations. 1994) providing basic guidelines for using the
intervention. Additional practice parameters
have also been published (Glaeser, Pierson, &
Efficacy Information Fritschmann, 2003; Rogers & Myles, 2001).
What is necessary is that the interventionist has
There have been no experimental studies knowledge about how social deficits in ASDs
presenting quantitative data demonstrating the are manifested and how autism can limit an
efficacy of comic strip conversations for students individual’s ability to interpret social situations
with ASDs. Two reports (Pierson & Glaeser, and function independently in a typical
2007; Rogers & Myles, 2001) presented brief social milieu and the ability to integrate that
descriptions of the perceived efficacy of comic knowledge into meaningful examples of how
strip conversations that were used to increase one can improve their social behavior. Parents,
prosocial behaviors of individuals with ASDs. psychologists, special education teachers, and
Pierson and Glaeser reported qualitative data speech-language pathologists are typical groups
suggesting comic strip conversations increased of interventionists that might use comic strip
peer interactions and decreased loneliness for conversations.
Common Disease-Common Variant Hypothesis 719 C
See Also
Commercial Hair Analysis
▶ Social Skill Interventions
▶ Social Stories ▶ Hair Analysis
▶ Theory of Mind
C
Common Disease-Common Variant
References and Readings Hypothesis
Glaeser, B. C., Pierson, M. R., & Fritschmann, N. (2003). Paul El-Fishawy

Comic strip conversations: A positive behavioural State Laboratory, Child Study Center,
support strategy. Teaching Exceptional Children,
36(2), 14–19.
Gray, C. (1994). Comic strip conversations:
Colorful, illustrated interactions with students with
autism and related disorders. Arlington, TX: Future Synonyms
Horizons.
Pierson, M. R., & Glaeser, B. C. (2005). Extension of
research on social skills training using comic strip CDCVH
conversations to students without autism. Education
and Training in Developmental Disabilities, 40(3),
279–284.
Pierson, M. R., & Glaeser, B. C. (2007). Using comic strip
Definition
conversations to increase social satisfaction and
decrease loneliness in students with autism spectrum The Common Disease-Common Variant Hypoth-
disorder. Education and Training in Developmental esis (CDCVH) is a hypothesis that proposes if
Disabilities, 42(4), 460–466.
a disease that is heritable is common in the pop-
Rogers, M. F., & Myles, B. S. (2001). Using social
stories and comic strip conversations to interpret ulation (a prevalence greater than 1–5%), then the
social situations for an adolescent with Asperger syn- genetic contributors – specific variations in
drome. Intervention in School and Clinic, 36(5), the genetic code – will also be common in the
310–313.
population. It makes this prediction for diseases
Wragge, A. (2011). Social narratives: Online training
module. In Ohio Center for Autism and Low Incidence whose genetic contribution is believed to
(OCALI), Autism Internet Modules, www.autisminter- come from multiple genes simultaneously, poly-
netmodules.org. Columbus, OH: OCALI. genic disorders. Autism is thought to be such
a disorder.
The CDCVH is based on evidence from evo-
lutionary theory, specifically that all humans
today descended from a small population of
Command roughly 10,000 individuals in Africa a relatively
short time ago, approximately 100,000 years ago.
▶ Mands Based on evidence about how frequently new
mutations enter the population, it states that the
extremely rapid population expansion that has
occurred over a short period disseminated disease
alleles (genetic changes or variations) that were
Comment common in the original population at a far greater
rate than new mutations have introduced such
▶ Protodeclarative alleles. Therefore, genetically influenced
C 720 Common Disease-Rare Variant Hypothesis
diseases that are common today should be the References and Readings
result of disease alleles that were common in the
original population and should still be common in Anney, R., Klei, L., Pinto, D., Regan, R., Conroy, J.,
Magalhaes, T. R., et al. (2010). A genome-wide scan
today’s population, as they would have been
for common alleles affecting risk for Autism. Human
widely distributed by the massive population Molecular Genetics, 19(20), 4072–4082.
explosion faster than new disease alleles could Borch-Johnsen, K., Burtt, N. P., Chen, H., Chines, P. S.,
be introduced. Daly, M. J., Deodhar, P., Ding, C. J., et al. (2008).
Meta-analysis of genome-wide association data
Several types of studies can be undertaken to
and large-scale replication identifies additional sus-
identify common genetic variants contributing to ceptibility loci for type 2 diabetes. Nature Genetics,
common disease. The most reliable of these is 40(5), 638.
called a genome-wide association study Chakravarti, A. (1999). Population genetics-making sense
out of sequence. Nature genetics, 21(Suppl. 1), 56.
(GWAS). These evaluate common genetic varia-
El-Fishawy, P., & State, M. W. (2010). The genetics of
tions, often in the form of single nucleotide poly- autism: Key issues, recent findings, and clinical impli-
morphisms (SNPs), at every gene in the genome cations. Psychiatric Clinics of North America, 33(1),
simultaneously. Such studies have reproducibly 83–105.
Iyengar, S. K., & Elston, R. C. (2007). The genetic basis of
identified common genetic risks for a wide range
complex traits: Rare variants or “common gene, com-
of common medical conditions. However, there mon disease”. Methods in molecular biology, 376, 71
have only been a small number of cases in which (Clifton, NJ).
these common genetic variations explain Reich, D. E., & Lander, E. S. (2001). On the allelic
spectrum of human disease. Trends in Genetics,
a substantial proportion of the overall predicted
17(9), 502.
genetic risks for the disorder. As a result, some Wang, K., Zhang, H., et al. (2009). Common genetic
have put forth a competing hypothesis, the Com- variants on 5p14. 1 associate with Autism spectrum
mon Disease-Rare Variant Hypothesis, that states disorders. Nature, 459, 528–533.
Weiss, L. A., Arking, D. E., & The Gene Discovery
that common diseases may be explained by
Project of Johns Hopkins & the Autism Consortium
a multiplicity of individually rare disease alleles (2009). A genome-wide linkage and association
in the population. scan reveals novel loci for autism. Nature,
With regard to autism, several GWAS studies 461(7265), 802–808.
have been conducted, and, so far, three SNPs
have been found that meet criteria for signifi-
cance, taking into account the fact that the entire
genome has been evaluated simultaneously.
However, none of the three studies replicate the Common Disease-Rare Variant
others’ findings, and combining the data from all Hypothesis
three decreases the evidence for any one of these
genetic markers being associated with autism Paul El-Fishawy
spectrum disorders. While it is expected that State Laboratory, Child Study Center,
common genetic polymorphisms carry risks for Yale University, New Haven, CT, USA
ASD, there is not yet agreement that any partic-
ular variation or gene has been definitively
identified. Definition
The Common Disease-Rare Variant Hypothesis

See Also (CDRVH) hypothesizes that if a disease with
genetic causes is common in the population (a
▶ Common Disease-Rare Variant Hypothesis prevalence greater than 1–5%), then the genetic
▶ DNA causes – specific genetic errors (genetic variants
▶ Genetics or disease alleles) – will not necessarily be found
▶ Genome-wide Association to be common in the population as suggested by
Common Disease-Rare Variant Hypothesis 721 C
the competing Common Disease-Common Vari- contributing biological effects that are much
ant Hypothesis (CDCVH) but rather will be com- larger than those so far associated with common
prised of a multiplicity of risk alleles, each of variants. For example, current estimates are that
which is individually rare in the population. It 5–10% of affected individuals carry large de
makes this prediction for diseases whose genetic novo copy number variations (CNVs) that sub-
contribution is believed to come from multiple stantially increase the risk for ASD (and other
genes simultaneously, polygenic disorders. neurodevelopmental disorders). In addition, C
Autism is thought to be such a disorder. a measurable proportion of individuals with
The CDRVH states that common polygenic ASD can be found to have mutations in FMRP,
disorders may reflect the convergence of multi- TSC-1, TSC-2, or other rare so-called monogenic
ple, rare variations in the same gene (allelic forms of autism. Finally, with the advent of new
heterogeneity) or multiple genes (locus heteroge- DNA sequencing technology, it is anticipated
neity). Given a sufficiently large number of dis- that additional individuals will be found carrying
ease alleles that could be involved, individually rare and de novo single nucleotide variants
rare mutations could accumulate in the popula- (SNVs) contributing relatively large risks.
tion and account for a significant proportion All told these findings provide substantial evi-
of a common disorder. Such variation could dence in favor of the CDRVH in a proportion of
be transmitted from generation to generation individuals with social disability. It is
or occur as new mutations (also known as important to recall, however, that in
de novo mutation). The latter would give rise a genetically heterogeneous disorder such as
to a pattern of inheritance prevalent in autism, the contribution of rare variants does not
autism, where cases are often sporadic (only rule out the potential contribution of common
a single child is affected in a family) and identical variants, either with respect to etiology or as a
(monozygotic) twins share the disorder much factor modifying other genetic and environmen-
more frequently than nonidentical (dizygotic tal risks.
twins).
Proponents of the CDRVH have recently been
able to cite considerable empiric evidence See Also
supporting this hypothesis. First, to date, it has
been difficult to confirm the presence of common ▶ Candidate Genes in Autism
variants contributing risk for ASD. Several con- ▶ Common Disease-Common Variant
temporary well-controlled association studies Hypothesis
have implicated biologically plausible candidate ▶ Copy Number Variation
genes, including the MET oncogene, Contact- ▶ DNA
Associated Protein Like 2, Cadherin 9 and ▶ Genetics
Cadherin 10, Semaphorin 5A, and MACRO
domain containing 2 (State & Levitt, 2011).
However, at present, the field has not reached References and Readings
a clear consensus about which of these genes or
loci carry definitive risks. More importantly, El-Fishawy, P., & State, M. W. (2010). The genetics of
were all of these association signals to confirmed, Autism: Key issues, recent findings, and clinical impli-
cations. The Psychiatric Clinics of North America,
they would nonetheless account for only a small 33(1), 83–105.
proportion of the predicted genetic contribution Iyengar, S. K., & Elston, R. C. (2007). The genetic basis of
to ASD. Perhaps, more importantly, to date, stud- complex traits: Rare variants or “common gene, com-
ies of rare variation have begun to demonstrate mon disease?”. Methods in molecular biology, 376, 71.
Clifton, NJ.
that a measurable proportion of the ASD-affected Ji, W., Foo, J. N., et al. (2008). Rare independent muta-
population carries very rare genetic mutations, tions in renal salt handling genes contribute to blood
either in the structure or sequence of the DNA, pressure variation. Nature Genetics, 40(5), 592.
C 722 Communication and Symbolic Behavior Scale
Reich, D. E., & Lander, E. S. (2001). On the allelic can be utilized as a baseline for evaluation. The
spectrum of human disease. Trends in Genetics, evaluator samples the child’s communicative
17(9), 502.
State, M. W., & Levitt, P. (2011). The conundrums of behaviors in structured and unstructured play-
understanding genetic risks for autism spectrum disor- based activities in the child’s natural environ-
ders. Nature Neuroscience, 14(12), 1499–1506. ment. Communicative temptations, sharing
books, symbolic play, language comprehension,
and constructive play activities are utilized to
encourage spontaneous communicative and play
Communication and Symbolic behaviors. Ideally, the sample is videotaped,
Behavior Scale so as to continue natural interactions during the
assessment and to ensure accurate scoring and
Hope Morris analysis. This test takes approximately I hour to
Communication Sciences and Disorders, administer and 1 hour to score the videotape. The
The University of Vermont, Burlington, Caregiver Questionnaire takes about 15 min to
VT, USA complete.
The Communication Symbolic and Behavior
Scales-Developmental Profile (CSBS-DP;
Synonyms Wetherby & Prizant, 2002) is the companion
test to the CSBS that is designed to evaluate
CSBS; CSBS-DP communication and symbolic abilities of children
in the same age range as the CSBS-Normed Edi-
tion. However, this test is intended as a guide to
Description indicate areas that may need further assessment
or to monitor behavior change. This test includes
The Communication Symbolic and Behavior a one-page Infant-Toddler Checklist for screen-
Scales-Normed Edition (CSBS; Wetherby & ing, a four-page Caregiver Questionnaire, and
Prizant, 1993) is a norm-referenced, standardized Behavior Sample, which is a shorter, more
test designed to assess infants, toddlers, and pre- streamlined version of the CSBS-Normed Edi-
schoolers that are at risk for communication tion. It should be noted that the CSBS-DP should
delays. In addition, this measure is used to estab- not be used alone for decisions about program
lish a profile of communicative, symbolic, and planning. The CSBS-Normed Edition is
social-affective functioning of a child, to monitor a more in-depth tool and is designed for
behavior change over time, and to provide a making program-planning decisions. The
direction for intervention. The assessment sur- CSBS-DP takes about 30 min to administer, and
veys both language skills and symbolic develop- the Behavior Sample can be scored during the
ment, including gestures, facial expressions, and sample or videotaped. The Infant-Toddler
play, using 22 5-point rating scales (18 in the Checklist can be completed in 5–10 min, and
communicative domain, 4 in the symbolic the Caregiver Questionnaire can be completed
domain). This measure can be used with infants in about 20 min.
and toddlers with functional communication ages
of 6–24 months and children up to 72 months
exhibiting atypical development. It can be admin- Historical Background
istered by a speech-language pathologist (SLP),
psychologist, early interventionist, and other pro- In 1986, the passage of the Education of
fessional trained to work with developmentally the Handicapped Act, Amendments of 1986
young children. As a part of this assessment, (PL 99-457) provided funds to states that chose
parents or caregivers complete a Caregiver Ques- to develop and implement early identification and
tionnaire, providing background information that intervention services for infants and toddlers
Communication and Symbolic Behavior Scale 723 C
beginning in 1991. This included children that other included temptations. Reciprocity and
were at high risk or children up to their third social-affective signaling are also assessed as
birthday that had identified disabilities, including a part of this tool. Addition of these areas of
delays in speech and language. Often, speech- assessment was based on the work of Stern
language delay is the first symptom of develop- (1985) and Tronick (1989) in socioemotional
mental delay that parents or professionals notice. development. The communication sample pro-
Unfortunately, however, early identification was vides a way to measure expressive language C
compromised by the limited number of standard- abilities, and a small measure of language
ized tools for assessing very young children. comprehension was also added. These items
Early identification of these delays or lack of were adapted from the work of Miller, Chapman,
speech-language development is crucial, as typi- Branston, and Reichle (1980). Play skills, both
cal early language development occurs between symbolic and constructive, were included in
12 and 20 months of age. The detrimental effects the sample, and toy sets were chosen for
of early speech and language disorders on later children that were developmentally appropriate
development of peer relations, educational suc- for children 8 months to 24 months. The devel-
cess, as well as emotional and behavioral development of the symbolic scales was influenced by
opment have also been well documented in the the model for emergence of symbols
research (Prizant et al., 1990). Most formal tests (Bates, 1979) and based on theories of Piaget
used to measure children’s communication abili- (Wetherby, 1991).
ties are clinician-directed and focus on the child The CSBS-DP (Wetherby & Prizant, 2002)
as a responder. There were few tests available Infant-Toddler Checklist and the CSBS-DP Care-
that sampled communication, especially commu- giver Questionnaire were adapted from the CSBS
nicative intent, in a naturalistic way. Communi- Caregiver Questionnaire (Wetherby & Prizant,
cation sampling is needed to supplement formal 1993) and from research on the MacArthur Com-
testing for children who are preverbal or at an municative Development Inventories (CDI;
early verbal communication stage (Wetherby, Fenson et al., 1993, 1994). Studies indicate that
Cain, Yonclas, & Walker, 1988). Therefore, the parent report is a reliable measure of communi-
CSBS was developed to allow for an informal cation development, and a checklist format was
communication sample. With the implementa- chosen, as this method is more accurate than
tion of PL 99-457, it was critical that clinicians a diary or free-form format (Fenson et al.,
utilize informal sampling procedures in their 1993). The items on the CSBS-DP Caregiver
assessment process. Questionnaire were based on the CSBS-Normed
The sampling procedures were developed and Edition Caregiver Questionnaire (Wetherby &
refined over a 10-year period. Pragmatic and Prizant, 1993). The questions on the CSBS-DP
social interactive theories from the 1970s Caregiver Questionnaire are meant to gather
and 1980s (Bloom & Lahey, 1978) were utilized similar information to that which is gathered
to make changes to the sampling procedures. Pro- from the Behavior Sample. The words expressed
cedures including the presentation of communi- and understood were based on the work of Fenson
cative temptations or structured situations that et al. (1994) and were the first 36 words reported
encourage or entice a child to communicate with highest frequency on the MacArthur CDI.
were adapted from informal procedures to sample The CSBS-DP Behavior Sample was based on
communication (Wetherby & Prizant, 1989). the CSBS Behavior Sample (Wetherby &
This included an assessment of both communica- Prizant, 1993). However, it was modified by
tive functions and communicative means. Shar- reducing the length of the sample. The scoring
ing books, which was a temptation originally procedures were reduced from 23 to 20 scales,
reported by Wetherby and Prutting (1984), was which simplified the scoring and enabled the
later considered separate from the communica- evaluator to score during the observed interac-
tive temptations, as it is less structured than the tions. Nineteen of the 20 scales were derived
C 724 Communication and Symbolic Behavior Scale
from the CSBS; however, the gaze/ of 0.91 for the entire sample and 0.84 for children
point-following scale was added based on at the multiword stage. Stability, the consistency
research findings from Mundy, Kasari, Sigman, of the test and retest results for individual test
and Ruskin (1995). participants whose performance has not changed,
is provided. Test-retest scores are provided for all
age intervals, including shorter intervals (less
Psychometric Data than 2 months) and longer intervals (greater
than 2 months). Correlations between the test
The CSBS-Normed Edition (Wetherby & and retest scores for the shorter and longer inter-
Prizant, 1993) was developed and tested over val subgroups are also provided. Taken together,
several years with both normally developing chil- this information indicates that the CSBS pro-
dren and children with language delays. This duces relatively stable rankings when children
research edition of this test was standardized in make significant improvements over shorter
1990 and 1991. The videotaped samples were periods of time. Interrater reliability coefficients
scored by a group of raters that were trained by are also provided. Raters following the CSBS
the authors. Before beginning the rating for the training steps can achieve good agreement with
norming study, they rated two additional tapes to other raters and experienced raters. Standard
calibrate with ratings of an experienced coder. errors of measurement (SEMs) are provided for
The samples were taken for 282 children from all cluster standard scores and communication-
24 sites in the United States. The norming sample composite scores, along with details on confi-
was weighted for scaling and norming analyses. dence ranges. Demonstration of validity is
Information about the sample provided in the provided, including face validity/ecological
manual includes age in months, linguistic stage, validity, criterion-related validity, and construct
gender, race, and Spanish origin. Since the CSBS validity. Further, a complete assessment of
was intended to monitor a child’s progress over gender differences in test outcomes is included
several months, one-third of the sample were in the manual. Studies of the CSBS demonstrate
retested once within 2–3 months of the first sensitivity and valid norms (Goodwyn & Cruz,
administration. 1997) and suggest that the instrument has good
Norms were developed by making the 22 predictive validity (McCathren, Yoder, &
scales comparable by converting individual raw Warren, 2000).
scores to a common metric based on the sample. The CSBS-DP (Wetherby & Prizant, 2002)
This was done by deriving percentile ranks of raw Preliminary Research Edition was developed
scores on each scale based on the frequency dis- and field tested with children younger than
tributions of these scores for the weighted sample 24 months of age and was standardized between
between 8 and 24 months of age. Cluster scores 1997 and 2000. Collection of Infant-Toddler
were established that were based on summing of Checklists, Caregiver Questionnaires, and
the scaled scores. The scaled scores for the 18 Behavior Samples was used to derive norms.
communication scales were summed to create Raters were trained in the same way as was uti-
a larger cluster score, the communication com- lized for the norming of the CSBS. A total of
posite. The communication score and all cluster 2,188 Infant-Toddler Checklists, 790 Caregiver
scores are expressed as percentile ranks. Means Questionnaires, and 337 Behavior Samples were
and standard deviations of raw scores and sums of included for the standardization sample from
scaled scores by language age and total eight sites in the United States and two sites in
unweighted scores are provided in the manual. Canada. A majority of the United States’ sample
Reliability of this measure is reported using four was recruited primarily from Tallahassee,
common methods. Internal consistency, the Florida; therefore, the sample is not nationally
degree to which the parts of the instrument mea- representative. Information about the sample by
sure the same characteristic, yielded a coefficient age, gender, race and ethnicity, and parent age
Communication and Symbolic Behavior Scale 725 C
and ethnicity is included in the manual. Norms child’s functioning in less structured environ-
were procedurally derived in the same way as the ments. The authors suggest that activities that
CSBS. All reliability measures including internal contain increased communicative demands
consistency, SEMs and confidence intervals, test- should be planned with the child’s strengths in
retest reliability, and interrater reliability are mind. Naturalistic activities that allow for gener-
included in the manual. Validity measures alization of learning and communication skills
including content, face, construct, criterion, con- are also recommended. Since the CSBS-DP C
current, and predictive validity are provided. The (Wetherby & Prizant, 2002) is intended as
CSBS-DP shows good reliability and validity, a guide to indicate areas that may need further
indicating it is a good screening and evaluation assessment or to monitor change in behaviors, the
tool for use with children between 6 and CSBS-DP should not be used alone for decisions
24 months of age. Recent research indicates the about program planning.
concurrent and predictive validity of this instru-
ment to be strong, and the findings support the use
of this instrument in the screening and evaluation See Also
of young children (Wetherby, Goldstein, Cleary,
Allen, & Kublin, 2003). ▶ Early Intervention
▶ MacArthur-Bates Communicative
Development Inventories, Second Edition
Clinical Uses ▶ Mullen Scales of Early Learning
▶ Normative Data
The CSBS-Normed Edition (Wetherby & ▶ Reciprocal Communication/Interaction
Prizant, 1993) was designed to be used for early ▶ Standardized Tests
identification of children who have or are at risk
for developing communication impairment. In
addition, it was intended to establish a profile of References and Readings
communication, symbolic, and social-affective
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and communication in infancy. New York: Academic.
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Bloom, L., & Lahey, M. (1978). Language development
tion needs, to prioritize intervention goals, and and language disorders. New York: Wiley.
to monitor progress. In the manual, there are Education of the Handicapped Amendments Act of 1986,
guidelines for using the results of this profile in Public Law 99–457, 100 Stat, 1145, (1986).
Fenson, L., Dale, P., Reznick, S., Thal, D., Bates, E.,
intervention planning, goal setting, and designat-
Hartung, J., et al. (1993). MacArthur communicative
ing intervention contexts. Areas addressed development inventories: User’s guide and technical
include expanding the use of social-affective sig- manual. San Diego, CA: Singular.
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cation and symbolic behavior scales. Assessment for
of communicative functions, increasing the
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enhancing symbolic level. The use of this profile predictive validity of the communication composite of
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of Early Intervention, 23(1), 36–46.
challenges in the areas listed above and to pro-
Miller, J., Chapman, R., Branston, M., & Reichle, J.
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goals. It is suggested that the communicative stages V and VI. Journal of Speech and Hearing
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Mundy, P., Kasari, C., Sigman, M., & Ruskin, E. (1995).
to design-focused activities utilizing develop- Nonverbal communication and early language acqui-
mentally age-appropriate toys and objects. The sition in children with Down syndrome and normal
child’s behavior displayed during the structured development. Journal of Speech and Hearing
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C 726 Communication and Symbolic Behavior Scales – Developmental Profile
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observations of spontaneous communication in autis-
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Disorders, 20(4), 437–453. current skills in speech, language, syntax, seman-
Tronick, E. (1989). Emotions and emotional tics, morphology, and pragmatics. As communi-
communication in infants. American Psychologist,
44, 112–119. cation is often an area of difficulty for children
Wetherby, A. (1991). Profiling pragmatic abilities in with autism, assessment of communication is
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practice issues (pp. 249–281). San Diego, CA:
Singular. municative success. The goal of communication
Wetherby, A., Cain, D., Yonclas, D., & Walker, V. (1988). assessment is to evaluate a child’s current level of
Analysis of intentional communication in normal chil- communicative skills across various settings and
dren from the prelinguistic to the multiword stage. with different partners. Ideally, the data obtained
The Journal of Speech and Hearing Disorders, 31,
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Wetherby, A., Goldstein, H., Cleary, J., Allen, L., & plan the most effective and functional course of
Kublin, K. (2003). Early identification of children treatment, given each individual’s needs and
with communication disorders: Concurrent and pre- abilities. Factors included in the assessment of
dictive validity of the CSBS developmental profile.
Infants and Young Children, 16(2), 161–174. communication are engagement and attention
Wetherby, A., & Prizant, B. (1989). The expression skills, nonverbal behaviors and gestures, as well
of communicative intent: Assessment guidelines. as speech and language form and content.
Seminars in Speech and Language, 10, 77–91.
Wetherby, A., & Prizant, B. (1993). Communication and
symbolic behavior scales. Chicago, IL: Applied
Symbolix. See Also
Wetherby, A., & Prizant, B. (2002). Communication and
symbolic behavior scales-developmental profile. ▶ Grammar
Wetherby, A., & Prutting, C. (1984). Profiles of commu- ▶ Paralinguistic Communication Assessment
nicative and cognitive-social abilities in autistic ▶ Pragmatics
children. Journal of Speech and Hearing Research, ▶ Prelinguistic Communication Assessment
27, 364–377. ▶ Speech
▶ Syntax
Communication and Symbolic References and Readings

Behavior Scales – Developmental
Profile Drew, A., Baird, G., Taylor, E., Milne, E., & Charman, T.
(2007). The social communication assessment for
toddlers with autism (SCATA): An instrument to
▶ Infant/Toddler Checklist measure the frequency, form and function of
Communication Disorder/Communication Impairment 727 C
communication in toddlers with autism spectrum dis- See Also
order. Journal of Autism and Developmental Disor-
ders, 37, 648–666.
Ogletree, B. T., Pierce, K., Hard, W. E., & Fischer, M. A. ▶ Alternative Communication
(2001–2002). Assessment of communication and ▶ Assistive Devices
language in classical autism: Issues and practices. ▶ Voice Output Communication Aids
Hammill Institute on Disabilities, 27(1&2), 61–71.
Paul, R. (2007). Language disorders from infancy through
adolescence: Assessment and intervention (3rd ed.).
C
St. Louis, MI: Mosby Elsevier. References and Readings
Wetherby, A. M., & Prizant, B. M. (1999). Enhancing
language and communication development in autism: Beukelman, D. R., & Mirenda, P. (2005). Augmentative
Assessment and intervention guidelines. In and alternative communication: Supporting children
D. B. Zager (Ed.), Autism: Identification, education, and adults with complex communication needs. Balti-
and treatment (2nd ed., pp. 141–174). Mahwah, NJ: more: Brooks Publishing.
Lawrence Erlbaum.
Communication Disorder
Communication Board
▶ Speech/Communication Disabilities
Vannesa T. Mueller
Speech-Language Pathology Program,
University of Texas at El Paso College of Health
Science, El Paso, TX, USA Communication Disorder/
Communication Impairment
Synonyms Kailey MacNeill

Communication Sciences and Disorders,
Assistive device; Augmentative and alternative The University of Vermont, Burlington,
communication (AAC) device; No-tech commu- VT, USA
nication device; Picture board
Synonyms
Definition
Communication impairments
A communication board is a low-tech communi-
cation aid that is used in the field of augmentative
and alternative communication (AAC). Typi- Short Description or Definition
cally, a grid with pictures on it is created, printed,
and then affixed to something like a sturdy manila A communication disorder is a developmental or
envelope. This type of assistive communication acquired impairment which generally affects
device is best for individuals with limited verbal language, speech, and/or hearing (National
output who are either preliterate or nonliterate. Institute on Deafness and Other Communication
The communication board user will point to pic- Disorders [NIDCD], 2010). The American
tures to communicate wants and needs, to make Speech-Language-Hearing Association (ASHA)
comments, or to ask questions. See Beukelman (1993) describes communication disorders more
and Mirenda (2005) for a detailed description of specifically, as impacting one’s ability to
no- and low-tech communication devices and “receive, send, process, and comprehend con-
their implementation. cepts or verbal, nonverbal and graphic symbol
C 728 Communication Disorder/Communication Impairment
systems (p. 2).” These impairments may include, Communication Disorder/Communication Impair-
but are not limited to, problems with fluency, ment, Table 1 Communication disorders
articulation, phonology, voice, auditory Speech Language Hearing
processing, pragmatics, syntax, semantics, mor- Articulation Receptive language Sensorineural
phology, and hearing loss (American Speech- disorders disorder hearing loss
Language and Hearing Association [ASHA], Fluency Expressive language Conductive
disorders disorder hearing loss
2008; NIDCD, 2010, Rochester Hearing and
Voice Mixed receptive- Mixed hearing
Speech Center [RHSC], 2011). Communication disorders expressive language loss
disorders generally fall on a continuum of sever- disorder
ity, ranging from relatively mild to profound Specific language
depending on the complexity of the impairment impairment
and which processes of communication are ASHA (2008), NIDCD (2010), RHSC (2011)
affected (ASHA, 1993). Individuals may present
with a single communication disorder or with Disabilities Act (IDEA), 1,460,583
a combination of various communication (24.1%) are receiving services for speech and/or
disorders. Depending on the nature of each indi- language disorders (ASHA, 2008). It is important
vidual’s impairment, a communication disorder to consider that this statistic does not account for
may be a primary disability or it may be second- children receiving speech and/or language ser-
ary to other disabilities (ASHA, 1993). vices secondary to another disability such as
A communication disorder or impairment is one autism spectrum disorders (ASD), children who
of the core deficits identified for individuals with do not qualify for services through the IDEA, for
an autism spectrum disorder (American Psychi- children who have not yet been identified, or
atric Association, 2000). children outside of the United States. As with
many disorders and diseases, the number of indi-
viduals identified and diagnosed with communi-
Categorization cation disorders continues to grow with
increasing knowledge, awareness, and skills of
Rather than being a disorder that can be catego- professionals and the general public.
rized into a group with other like disorders, com- It should be noted that for children to qualify
munication disorder is a category unto itself. for an autism diagnosis, they must exhibit
Communication disorders include impairments a qualitative impairment in communication
associated with speech, language, and/or hearing, which may be manifested by one or more of the
as outlined in Table 1. following: (1) delay in, or total lack of, the devel-
opment of spoken language (not accompanied by
an attempt to compensate through alternative
Epidemiology modes of communication such as gesture or
mime); (2) in individuals with adequate speech,
Given the complexity of communication disor- marked impairment in the ability to initiate or
ders and the endless possibilities for presenta- sustain a conversation with others; (3) stereotyped
tions, it is difficult to identify a specific cause or and repetitive use of language or idiosyncratic
origin. A wide variety of epidemiological studies language; and/or (4) lack of varied, spontaneous
have been conducted on the topic of communica- make-believe play or social imitative play appro-
tion disorders, and as the prevalence of related priate to developmental level (American Psychi-
disorders increases, the interest in identifying the atric Association, 2000). Therefore, all children
factors associated with such disorders continues with autism will have communication disorders
to expand. Recent prevalence rates found that of of varying degrees that affect their ability to
the 6,068,802 children in the United States being understand, produce, and/or use communication
served in public schools under the Individuals in an effective and efficient manner.
Communication Disorder/Communication Impairment 729 C
Natural History, Prognostic Factors, and That being said, there are many clinical features
Outcomes that have been identified to facilitate early detec-
tion, diagnosis, and treatment (ASHA, 2008;
Identification of communication disorders in Diehl, 2003; Drew, Baird, Taylor, Milne, &
children can be especially complex, as symp- Charman, 2007). Speech disorders can be char-
toms, particularly those related to speech and acterized by atypical articulation of speech
language, do not typically present in the early sounds, impaired fluency of speech, as well as C
months of life. Furthermore, disorder character- impaired voice production and/or quality
istics vary with each unique child (Ogletree, (ASHA, 2008). Language disorders can present
Pierce, Harn, & Fischer, 2002). That being said, in various forms but are typically known to affect
research has acknowledged factors that may play the comprehension or use of an individual’s
a role in determining prognosis, including family language in both verbal and written forms.
history of communication disorders or learning Within the category of language disorders, indi-
impairments, low socioeconomic status (SES), as viduals can experience difficulties with the form
well as familial hardships, such as single-parent of language, including phonology, morphology,
households or parental substance abuse (Johnson, and syntax, the content of language, otherwise
Beitchman, & Brownlie, 2010). Further known as semantics, as well as the function of
addressing issues of prognosis, research indicates language, which is often referred to as pragmat-
that individuals who had early language impair- ics. Disorders associated with hearing include
ments are more likely to experience unfavorable varying degrees of hearing loss, which can affect
adult outcomes than those who had early speech a person’s ability to detect, comprehend, or dis-
impairments (Johnson et al., 2010). criminate the sounds of speech (ASHA, 2008).
Studies addressing outcome of communica- As indicated above, communication disorders
tion disorders intervention have been mixed, in can present with any combination of impairments
part due to the breadth of the topic. However, associated with speech, language, and/or hearing.
with improved identification and treatment tech- In consideration of the various presentations of
niques, therapy outcomes appear to be relatively communication disorders as well as the impor-
positive, especially for those who were identified tance of early identification and treatment, it is
early and received intervention (ASHA, 2008). important for parents and caregivers who suspect
While intervention for communication disorders a communication disorder to seek the guidance
often yields improvements, occasionally even and support of a certified speech-language
complete remediation, it is essential to consider pathologist. Such a clinical professional
the additional confounding factors that may can then determine if an evaluation and later
inhibit the treatment of individuals with condi- treatment is warranted (ASHA, 2008).
tions such as autism. Given that autism falls on
a spectrum and each person experiences varying
levels of cognitive, linguistic, social, and behav- Evaluation and Differential Diagnosis
ioral functioning, it is difficult to make
a definitive statement regarding outcome As with most disorders, early and accurate iden-
(Howlin, Goode, Hutton, & Rutter, 2004). tification and diagnosis are essential components
in effective intervention of communication disor-
ders. Furthermore, since children with autism
Clinical Expression and have difficulties with one or multiple components
Pathophysiology of communication, early assessment of commu-
nication skills is often necessary to appropriately
Communication disorder is an incredibly broad address the needs of these children and ensure
category, including multiple sub-disorders future communicative success. The goal of com-
related to speech, language, and/or hearing. munication assessment is to evaluate a child’s
C 730 Communication Disorder/Communication Impairment
current level of communicative skills across var- also fulfilling the personal and clinical needs of
ious settings and with different partners (Ogletree the child and their family. Such approaches range
et al., 2002). Assessments utilized in the evalua- from behavioral techniques, which target the
tion process can be standardized or nonfunctional and social behaviors related to com-
standardized tools. Standardized measures, often munication, to augmentative and alternative
in the form of tests, require, as the name implies, communication aids, which utilize both high-
standard administration and scoring to ensure and low-tech aids to facilitate communication
consistent and accurate interpretation of results. (Diehl, 2003; Paul, 2008).
Non-standardized measures, such as observations
and caregiver interviews, as well as some tests,
allows a clinician to obtain information in See Also
a flexible and sometimes more functional man-
ner. Ideally, both standardized and non- ▶ Expressive Language
standardized data are obtained throughout the ▶ Expressive Language Disorder
assessment process and can be used to plan the ▶ Language Disorder
most effective and functional course of treatment, ▶ Pragmatic Communication
given each individual’s needs and abilities ▶ Pragmatic Language Impairment
(Ogletree et al.; Wetherby & Prizant, 1999). ▶ Receptive Language Disorders
There are a great deal of components considered ▶ Semantic Pragmatic Disorder
in the evaluation process that allow for identifi- ▶ Social Communication
cation of disorders as well as differential diagno- ▶ Speech Impairments
sis. Some components of communication that are ▶ Speech/Communication Disabilities
often assessed are ability to engage, attention ▶ Verbal Communication
skills, nonverbal behaviors, and gestures, as
well as form, content, and use of speech and
language. References and Readings
Amerian Psychiatric Association. (2000). Diagnostic and

Treatment statistical manual of mental disorders (Test Rev.
4th ed.). Washington, DC: Author.
American Speech-Language and Hearing Association.
Equally as significant as early identification, (1988). Definitions of communication disorders and
early intervention is an important consideration variation (Relevent paper). Available from www.
when addressing communication skills. Account- asha.org/policy
American Speech-Language and Hearing Association.
ing for the individualized presentation of each (1993). Prevention of communication disorders
child with autism and given the varying levels (Position statement). Available from www.asha.org/
of skills and abilities, communication interven- policy
tion should be based on information obtained American Speech-Language and Hearing Association.
(2008). Incidence and prevalance of communication
throughout the assessment process (Ogletree disorders and hearing loss in children. Available from
et al., 2002). Communication intervention often www.asha.org/research/reports/children
seeks to improve skills associated with the form, Diehl, S. F. (2003). Autism spectrum disorder: The con-
function, and content of the communicative act, text of speech-language pathologist intervention. Lan-
guage, Speech, and Hearing Services in Schools, 34,
as well as engagement and attention skills, 177–179.
nonverbal behaviors, and gestures (Paul, 2008). Drew, A., Baird, G., Taylor, E., Milne, E., & Charman, T.
As communication skills fall on a continuum, (2007). The social communication assessment for
there are a plethora of different intervention toddlers with autism (SCATA): An instrument to
measure the frequency, form and function of commu-
approaches available. Generally, clinicians nication in toddlers with autism spectrum disorder.
should choose an intervention method which is Journal of Autism and Developmental Disorders, 37,
supported with evidence-based research while 648–666.
Communication Intention Inventory 731 C
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004). Description
Adult outcome for children with autism. Journal of
Psychology and Psychiatry, 45(2), 212–229.
Johnson, C. J., Beitchman, J. H., & Brownlie, E. B. (2010). The Communicative Intention Inventory (CII) is
Twenty-year follow-up of children with and without an observational system for recording children’s
speech-language impairments: Family, educational, early intentional communication, including ges-
occupational, and quality of life outcomes. American tural, vocal, and verbal communicative behav-
Journal of Speech-Language Pathology, 19(1), 51–65.
National Institute on Deafness and other Communication iors, while the child is engaged in a free-play C
Disorders. (2010). Examples of communication disor- situation with a caregiver.
ders. Available from www.nidcd.nih.gov/health/ The CII is designed to support the clinician in
voice/speechandlanguage observing and coding the intentional communi-
Ogletree, B. T., Pierce, K., Harn, W. E., & Fischer, M. A.
(2002). Assessment of communication and language in cation of children functioning at the 8–24-month
classical autism: Issues and practices. Assessment for developmental level. Intentional communication
Effective Intervention, 27(1&2), 61–71. is defined as a child’s goal-oriented, purposeful
Paul, R. (2008). Interventions to improve communication. reasons for vocalizing, gesturing, and speaking.
Child and Adolescent Psychiatric Clinics of North
America, 17(4), 835–854. Often, particularly in the preverbal period,
Rochester Hearing and Speech Center. (2011). Types of children’s intentions must be deduced by their
communication disorders: Facts and figures. Avail- behaviors in relation to objects and people. It is
able from http://www.rhsc.org/files/communication- these preverbal intentions, and their expression in
disorders
Wetherby, A. M., & Prizant, B. M. (1999). Enhancing the use and coordination of gestures, vocaliza-
language and communication development in tion, and gaze, that serve as the communicative
autism: Assessment and intervention guidelines. foundation for the emergence of language.
In D. B. Zager (Ed.), Autism: Identification, education,
and treatment (2nd ed., pp. 141–174). Mahwah, NJ:
Lawrence Erlbaum.
Wrong Diagnosis. (2011). Prevalence statistics for Historical Background
types of communication disorders. Available from
www.wrongdiagnosis.com/c/communication_disorders/ When Drs. Truman Coggins and Robert Carpen-
prevalence-types
ter of the University of Washington first intro-
duced the Communicative Intention Inventory
(CII) in 1981, the assessments available for
describing child’s communicative intent were
Communication Impairments limited. The existing measures at that
time included a small number of intentional cat-
▶ Communication Disorder/Communication egories used for describing children’s behaviors,
Impairment inadequately described the categories presented,
and provided no information to support the
reliability of the categories. The authors therefore
attempted to develop the CII with good
Communication Intention Inventory content and construct validity (i.e., with catego-
ries that are believed to adequately reflect
Sarita Austin instances of early intentional communication
Laboratory of Developmental Communication and the range of communicative functions
Disorders, Yale Child Study Center, New Haven, involved in it).
CT, USA The eight intentional categories included in
the CII are:
1. Comment on action
Synonyms 2. Comment on object
3. Request for action
CII 4. Request for object
C 732 Communication Intention Inventory
5. Request for information into one of the CII’s eight intentional categories
6. Answering a request for information can be scored. Specifics on how to handle
7. Acknowledging that a previous gesture or repetitions of gestures, vocalizations, and
utterance was received verbalizations are also addressed.
8. Protesting
Administration Psychometric Data

The authors suggest that the free-play session
with child and caregiver should be videotaped The Communicative Intention Inventory (CII)
through a two-way mirror and monitored in was designed as a criterion-referenced measure
a control room by an individual familiar with of the intentional communication of a child and
the CII. Although this is a criterion-referenced thus compares each child’s performance in com-
measure, the authors indicated that the record- parison to a standard or objective, rather
ing should be approximately 45 minutes in than a normative sample. The eight intentional
length if the clinician would like to do compar- categories included were selected based on
isons against the preliminary data they reported their content and construct validity. The CII
for the measure. Stimulus materials should includes categories that are believed to ade-
include a variety of toys and books that allow quately reflect instances of early intentional com-
the child to create a variety of activities. No munication and the range of communicative
other distracting material should be in the functions involved in it based on the existing
assessment room, and only the child and care- literature in early intentional communication.
giver should be present during the recording. The categories included are believed to be neces-
A familiar caregiver is believed to support sary for the acquisition of future conversational
obtaining a representative sample of the child’s discourse skills.
communicative functioning regardless of the The reported internal test reliability was .66,
familiarity of the testing environment. based on a sample of 16 monolingual, native
A written script is included to be read to the English-speaking typically developing children
caregiver prior to beginning the recording. The between 15 and 16 months of age in Piaget’s
purpose of the script is to inform the caregiver sensorimotor stage V. The authors believe the
of the reason for recording the session and to score was affected by the homogeneity of the
encourage them to follow the child’s lead while participants. Percentile ranks and standard devi-
refraining from interacting minimally or asking ation scores were also provided for frequency of
too many questions. demonstration of each of the eight intentional
categories in the same sample group.
Scoring In terms of inter-scorer reliability, 10 graduate
The authors of the CII suggest that the video be students in speech-language pathology programs
scored as soon as possible and ideally by the (who underwent CII’s outlined scorer training
person who monitored the recording. A training procedure and independently scored a recording
procedure for all scorers is also outlined to min- of 33 behavioral sequences) received a mean pro-
imize variability in scorer coding. Only intention- portion of correct coding of behavioral sequences
ally communicative behaviors are to be coded. score of .91. All judges also coded all four
Therefore, all coded behaviors must occur in behavioral sequences that did not demonstrate
a shared or joint activity. Criteria for what con- communicative intent as “unscorable.”
stitutes a joint activity are also described. Each Content validity was established based on the
instance of an intentionally communicative creation of the inventory format and behavioral
behavior is assigned to a single category and definitions founded on existing early communi-
given a score of 1. Only those behaviors that fit cative development research studies, language
Communication Intention Inventory 733 C
acquisition literature, and the authors’ observa- likelihood to occur in a clinical setting, and the
tions of parent–child interactions. When this ability to develop an operational definition for
measure was initially published in 1981, specific them. Within each intentional category, descrip-
studies were not undertaken to establish construct tions of some expected behaviors are presented
validity though the authors believed that indirect within subcategories (i.e., “gesture or gestural/
evidence (i.e., the existing literature on social vocal” and “verbal”) to indicate how the intention
development in children with autism spectrum was coded. For example, for the Comment on C
disorders, the literature on onset of intentionality Object category, “points to, looks toward, or
in children with typical development, and approaches entity may vocalize” (gestural or ges-
hypotheses regarding children’s performance on tural/vocal) and “extends arm to show entity in
the CII) supports the CII’s utility for assessing hand and produces a word” (verbal) are both
intentional communication behaviors. The included as specific behaviors that a child may
authors published a study 2 years later noting no exhibit.
significant difference in the performance of General descriptions of the criteria for
children with Down’s syndrome and children inclusion within the subcategories of “gesture
with typical development on the CII. or gestural/vocal” and “verbal,” and samples of
parent–child interactions for classification
practice are also provided.
Clinical Uses The CII allows the clinician to determine
which of the eight intentional categories are pre-
The Communicative Intention Inventory (CII) sent and the manner (i.e., gestural, vocal, or ver-
allows the clinician to describe a child’s early bal) in which they are expressed in order to
communicative behaviors across eight inten- determine if a child’s language difficulties are
tional categories. Communicative intent is specifically associated with their ability to use
believed to form the basis of later social interac- language effectively. The authors suggest that
tion, making the CII a potentially useful tool in further analysis may be done regarding
determining intervention goals and predicting other aspects of language, such as productivity,
future social functioning based on a child’s by applying information from existing
performance on the measure. The CII was specif- language acquisition literature. The authors
ically designed to observe and code the inten- remind the clinician that the percentile ranks
tional communication of children functioning and standard deviations reported for the 16 chil-
between Piaget’s sensorimotor stages IV dren with typically development are not intended
and VI. As research in language acquisition to be used as referenced norms but are simply
supports the idea that nonverbal expression of provided to describe the behavior patterns in that
early communicative intentions precede and particular group and aid the clinician’s
may support the development of future conversa- interpretations.
tional skills, the authors suggest that the CII
might also be useful with nonverbal children
with and without cognitive delays both as an See Also
initial assessment tool and a measure of response
to therapy. ▶ Communicative Functions
These eight intentional behaviors (i.e., com- ▶ Communicative Intent
ment on action, comment on object, request for ▶ Intentional Communication
action, request for object, request for informa- ▶ Piagetian Stages
tion, answering, acknowledging, and protesting) ▶ Pragmatic Communication
were selected based on their frequency of use ▶ Pragmatic Language Impairment
among children in the sensorimotor stage, their ▶ Pragmatics
C 734 Communication Intentions

Communication Interventions
Adams, C. (2002). Practitioner review: The assessment of
language pragmatics. Journal of Child Psychology
Patricia Prelock
and Psychiatry, 43, 973–987. doi:10.1111/1469-
7610.00226. Communication Sciences & Disorders, Dean’s
Adams, C., Green, J., Gilchrist, A., & Cox, A. (2002). office, College of Nursing & Health Sciences,
Conversational behaviour of children with Asperger University of Vermont, Burlington, VT, USA
syndrome and conduct disorder. Journal of Child
Psychology and Psychiatry, 43, 679–690.
Austin, J. L. (1962). How to do things with words.
New York: Oxford University Press. Definition
Bates, E., Benigni, T., Bretherton, I., Camaioni, D., &
Volterra, V. (1979). The emergence of symbols:
Early identification and intervention are key fac-
Cognition and communication in infancy. New York:
Academic Press. tors when addressing communication skills.
Coggins, T., & Carpenter, R. (1981). The communicative Upon completion of a comprehensive communi-
intention inventory: A system for observing and cation assessment, it is important to address any
coding children’s early intentional communication.
communication deficits identified. As each child
Applied PsychoLinguistics, 2, 235–251.
Coggins, T., Carpenter, R., & Owings, N. O. (1983). with autism presents with varying levels of skills
Examining early intentional communication and abilities, communication intervention should
in Down’s syndrome and nonretarded children. Inter- be based on individualized information obtained
national Journal of Language & Communication
throughout the assessment process. Communica-
Disorders, 18(2), 98–106.
Creaghead, N. (1984). Strategies for evaluating and tion intervention should focus on improving
targeting pragmatic behaviours in young children. skills associated with the form, function, and
Seminars in Speech and Language, 5, 241–252. content of the communicative act, as well as
Dore, J. (1979). Conversational acts and the acquisition
increasing engagement and attention skills, non-
of language. In E. Ochs & B. Schiefflin (Eds.),
Developmental pragmatics. New York: Academic verbal behaviors, and gestures. Given that com-
Press. munication skills often fall on a continuum, there
Fey, M. E. (1986). Language intervention with young are a variety of different intervention approaches
children. Boston: College Hill.
available, each of which originates from one of
Halliday, M. (1975). Learning how to mean. London:
Edward Arnold. many philosophies. Such philosophies range
Klecan-Aker, J. S., & Lopez, B. (1984). A clinical taxon- from behavioral techniques that target the
omy for the categorization of pragmatic language functional and social behaviors related to com-
functions in normal pre-school children. Journal of
munication to augmentative and alternative com-
Communication Disorders, 17, 121–131.
Klecan-Aker, J. S., & Swank, P. (1988). The use munication aids, which utilize both high- and
of a pragmatic protocol with normal pre-school chil- low-tech aids to supplement communication, to
dren. Journal of Communication Disorders, 21, naturalistic approaches that seek to foster com-
85–102.
munication in the natural environment, including
Ninio, A., Snow, C. E., Pan, B. A., & Rollins, P. (1994).
Classifying communicative acts in children’s interac- home, school, the job setting, and community-
tions. Journal of Communication Disorders, 27, based activities.
157–188.
Roth, F., & Spekman, N. (1984). Assessing the pragmatic
abilities of children: Part I. Organizational framework
and assessment parameters. The Journal of Speech and See Also
Hearing Disorders, 49, 2–11.
▶ Consequence-Based Interventions
▶ Developmental Intervention Model
▶ Developmental-Pragmatic Approaches/
Communication Intentions Strategies
▶ Early Intensive Behavioral Intervention (EIBI)
▶ Communicative Functions ▶ Early Intervention
Communicative Acquisition in ASD 735 C
▶ Functional Ecological Approach expressed – has long been understood to be
▶ Hanen Approach an area of core impairment in ASD, and research
▶ Home-Based Programs has uncovered deficits in communication
▶ Language Interventions development within the first year of life for
▶ Natural Environment children who go on to develop ASD. These
▶ Self-Management Interventions difficulties are usually persistent, continuing to
▶ Social Interventions affect both verbal and nonverbal aspects of C
▶ Speech Therapy communication throughout the lifespan.
▶ Structured Behavioral Interventions
Natural History, Prognostic Factors, and

References and Readings Outcomes
Diehl, S. F. (2003). Autism spectrum disorder: The context Prior to the development of language, typically
of speech-language pathologist intervention. Language,
developing infants make a number of communi-
Speech, and Hearing Services in Schools, 34, 177–179.
Ogletree, B. T., Pierce, K., Harn, W. E., & Fischer, M. A. cative achievements starting only months after
(2002). Assessment of communication and language in birth. They attend preferentially to their
classical autism: Issues and practices. Assessment for caregivers’ face (Bushnell, 2001) and speech
Effective Intervention, 27(1&2), 61–71.
(DeCasper & Fifer, 1980), and by 3 months
Paul, R. (2008). Interventions to improve communication.
Child and Adolescent Psychiatric Clinics of North of age, infants smile reciprocally (Emde,
America, 17(4), 835–854. Gaensbauer, & Harmon, 1976). By the end of
the first year, they produce early speech sounds
and perhaps even single words, use gestures to
direct others’ attention, and follow social cues
Communication Services conveyed in movements and gaze (Fenson,
Dale, Reznick, & Bates, 1994).
▶ Speech-Language Intervention In contrast, children who are later diagnosed
with ASD show broad deficits in early communi-
cation. Within the first year of life, children with
ASD show reduced social smiling and reciprocal
Communicative Acquisition in ASD engagement with partners (Zwaigenbaum et al.,
2005). Unlike typically developing toddlers,
Rhiannon Luyster young children with ASD do not preferentially
Department of Communication Sciences and attend to child-directed speech (Kuhl, Coffey-
Disorders, Emerson College, Boston, MA, USA Corina, Padden, & Dawson, 2005; Paul,
Chawarska, Fowler, Cicchetti, & Volkmar,
2007), instead preferring to listen to nonspeech
Short Description or Definition analog signal. They show delays and deficits in
the emergence of early gestures, joint attention,
The development of communicative skills begins and imitation (Mitchell et al., 2006; Shumway &
in the earliest months of life. Communication can Wetherby, 2009; Wetherby, Watt, Morgan, &
be conceived as any action that conveys informa- Shumway, 2007). These skills are all critical
tion to establish a shared understanding with developmental precursors to language, and defi-
another individual. It is comprised of a complex cits in these nonverbal abilities are associated
set of skills, including language, as well as with deficits in verbal competence (Luyster,
a number of nonverbal behaviors like gestures, Kadlec, Carter, & Tager-Flusberg, 2008).
facial expressions, and body posture. Communi- One of the earliest forms of vocal communica-
cation – whether verbally or nonverbally tion in infants is crying, and infants who go on to
C 736 Communicative Acquisition in ASD
receive an early ASD diagnosis have cries that are Golinkoff, & Tager-Flusberg, 2007); the children
qualitatively different than controls, showing more who experience more profound deficits in social
dysphonation and less modulation (Esposito & attention may not be able to successfully extract
Venuti, 2009). When the first speech sounds these cues for the purpose of language learning
emerge for young children, they are in the form of (Baron-Cohen, Baldwin, & Crowson, 1997;
canonical babbling. In infants and toddlers later Preissler & Carey, 2005). The importance of relat-
identified with ASD, these sounds may have edness with social partners for language develop-
unusual vocal qualities (Schoen, Paul, & ment has also been reported by studies finding an
Chawarska, 2011; Sheinkopf, Mundy, Oller, & association between parental responsiveness to
Steffens, 2000) or have a restricted consonant child interest and child language (McDuffie &
range (Wetherby et al., 2004). By around 1 year Yoder, 2010; Siller & Sigman, 2008).
of age, children with ASD are already falling A number of other cognitive biases have been
behind their unaffected peers in receptive and proposed as important mechanisms for learning
expressive language development, showing delays language, including the “noun bias” (by which
in the attainment of first words (Landa & Garrett- children map a novel word onto an unknown
Mayer, 2006; Mitchell et al., 2006; Zwaigenbaum object rather than an action or feature) and the
et al., 2005). Receptive language skills are particu- “shape bias” (which supports children in general-
larly impaired starting in the first few years of life izing words based on similarity of shape). Young
(Hudry et al., 2010; Weismer, Lord, & Esler, 2010) children with ASD seem to abide by the former,
and continuing into childhood. accurately mapping new words onto objects rather
The process of learning words is driven, at least than some other aspect of the visual scene
in part, by social engagement and attention (Swensen, Kelley, Fein, & Naigles, 2007). How-
(Baldwin et al., 2011; Baldwin & Moses, 2001; ever, they are less adept at following the shape
Tomasello & Barton, 1994). Longitudinal studies bias, failing to extend terms to same-shaped
have suggested that slowed development in objects (Tek, Jaffery, Fein, & Naigles, 2008).
language – especially receptive – for children Patterns of change over time in communica-
with ASD is partly a product of their overall tion development have been a focus of recent
difficulty with social engagement (Bopp, Mirenda, research. In general, children with ASD show
& Zumbo, 2009). Indeed, the aforementioned improvement in language and communication
tendency of children with ASD to direct their with age (Ballaban-Gil, Rapin, Tuchman, &
attention more toward nonspeech sounds than to Shinnar, 1996; Lord, Risi, & Pickles, 2004;
child-directed speech is associated with lower Paul, Chawarska, Cicchetti, & Volkmar, 2008).
expressive language development (Kuhl et al., However, a minority of children may experience
2005). Similarly, children with ASD who a period of loss early in life. This phenomenon –
showed greater physiological responsiveness to called “regression” – has been reported in several
child-directed speech at an initial evaluation retrospective and early home video studies (Baird
exhibited better communication skills 1 year later et al., 2008; Hansen et al., 2008; Lord, Shulman,
(Watson, Baranek, Roberts, David, & Perryman, & DiLavore, 2004; Werner & Dawson, 2005).
2010), pointing to a critical link between social The initial portrait of this developmental shift
attention and communicative development. was a sudden-onset loss that primarily affected
The question of how children with ASD, who language skills and occurred around the second
experience deficits in attending to social input, birthday. Conceptualizations have gradually
learn new words has been addressed in a variety broadened to reflect the wider range of social
of studies. Results generally suggest that children communication skills that seemed to be affected,
who are able to attend to the social cues of others including reciprocal engagement, social atten-
are able to use those cues to learn new words tion, and shared enjoyment (Baird et al. 2008;
(Franken, Lewis, & Malone, 2010; Luyster & Luyster et al., 2005). Interestingly, prospective
Lord, 2009; Parish-Morris, Hennon, Hirsh-Pasek, studies have also uncovered evidence for loss of
skills, but the characterization of this shift is written accounts of the disorder included observa-
somewhat different from the retrospective and tions of odd speech patterns (Kanner, 1943; 1946).
video review reports. Ozonoff and colleagues Individuals with ASD may use language without
noted a gradual deterioration in social communi- apparent meaning; for instance, they may
cation skills between 6 and 18 months of age repeat previously heard words or phrases (termed
(2010), and a similar pattern has been observed “echolalia”). This behavior can occur immediately
elsewhere (Bryson et al., 2007). after the child hears a word or phrase, or it C
The understanding and use of language require may be delayed by several hours or days. The
the mastery of a complex set of sounds and rules, former – “immediate echolalia” – appears to be
and individuals with ASD have been found to more common in individuals with limited language
experience difficulties at nearly every level of lan- (McEvoy, Loveland, & Landry, 1988). More
guage development. It is important to note that, advanced language users may incorporate chunks
although all individuals with ASD (by definition) of speech heard previously into their speech in
experience some sort of impairment in language a scripted fashion (Nadig, Lee, Singh, Bosshart,
and communication, any specific area of difficulty & Ozonoff, 2010). Examples of this could include
is not universal to the conditions. Despite these a phrase spoken by the parent earlier in the day
difficulties, more than two-thirds of individuals (e.g., “It’s snowing cats and dogs!”) or the intro-
with ASD eventually acquire spoken language ductory sequence to the Powerpuff Girls television
(Anderson et al., 2007; Turner, Stone, Pozdol, & show. Other individuals may make up words that
Coonrod, 2006) though it can range from do not have any conventional meaning (termed
single words to complex, fluent speech. Early “neologisms”) (Volden & Lord, 1991). For
emergence of language (particularly by age 3) is instance, a child might call all cups “tamots” or
a positive predictor of a number of outcomes referring to anything with stripes as “surry.” In
(Ben Itzchak & Zachor, 2009; Charman et al., individuals with more advanced language, speech
2005). It is associated both concurrently and longi- can be idiosyncratic, characterized by overly for-
tudinally with a variety of skills including joint mal use of words or unusual formation of sentences
attention (Adamson, Bakeman, Deckner, & (Nadig et al., 2010; Paul, Orlovski, Marcinko, &
Romski, 2009; Dawson et al., 2004; Sigman Volkmar, 2009). For instance, rather than simply
& McGovern, 2005), gesture use (Ingersoll & saying, “I like reading books,” the individual might
Lalonde, 2010; Luyster, Kadlec, Carter, & Tager- use more pedantic phrasing like, “I enjoy engaging
Flusberg, 2008; Smith, Mirenda, & Zaidman-Zait, in literary endeavors.” Idiosyncratic phrasing
2007), play (Mundy, Sigman, Ungerer, & Sherman, could include asking, “How many years are
1987; Sigman & McGovern, 2005), imitation you?” instead of “How old are you?” or referring
(Carpenter, Pennington, & Rogers, 2002; Charman, to rainbows as “color bows.”
Drew, Baird, & Baird, 2003; Stone, Ousley, & There have been some deficits reported in
Littleford, 1997), and cognitive skills (Luyster, vocabulary acquisition and use, although results
Kadlec, Carter, & Tager-Flusberg, 2008; Thurm, are not consistent. On the one hand, vocabulary
Lord, Lee, & Newschaffer, 2007). Furthermore, the knowledge across general categories (e.g., modi-
strength of early verbal skills is positively associ- fiers, nouns, predicates) seems to be indistinguish-
ated with response to treatment in young children able from typically developing controls (Charman,
with ASD (Ben Itzchak & Zachor, 2011). Drew, Baird, & Baird, 2003; Luyster, Lopez, &
Lord, 2007). However, usage of some specific
vocabulary types – such as mental state terms
Clinical Expression and (Tager-Flusberg, 1992), social-emotional identi-
Pathophysiology fiers (Hobson & Lee, 1989), or deictic terms
(Hobson, Garcia-Perez, & Lee, 2010) – may be
When language is acquired, it is often atypical in impaired in an individual with ASD. An example
a variety of ways. Indeed, some of the first of this is pronoun reversal, such that the individual
uses the term “you” instead of “I” or “me” or refers (Jones & Schwartz, 2009). Difficulty maintaining
to himself or herself in the third person (Lee, back-and-forth dialogue may also present as rigid-
Hobson, & Chiat, 1994). ity in language use, sometimes referred to as “ver-
The degree to which semantic and lexical orga- bal rituals.” This pattern of behavior is
nization is disrupted remains unclear. Children characterized by a need for a language to follow
with ASD do well on standardized vocabulary a certain predictable routine rather than flow natu-
tests (Kjelgaard & Tager-Flusberg, 2001) and gen- rally. This can consist of a compulsive sequence of
eralize terms in a usual manner. Some studies have utterances spoken by the child – an example might
reported that individuals with ASD form concep- be the need to recite book titles in alphabetical order
tual categories in a similar fashion to their typi- without interruption – or it could be the desire for an
cally developing peers (Tager-Flusberg, 1985), interchange to abide by a particular routine. For
while others reported differences in the connect- instance, the child might have a habit of saying,
edness of conceptual and lexical knowledge “Welcome boys and girls! The color of the day
(Dunn, Gomes, & Sebastian, 1996). One possible is. . .” and insist that the parent answer, “The color
explanation to this apparent discrepancy is the of the day is red!” to which the child responds,
suggestion that impairment may be specific to “And after red is. . .” and expects the parent to
certain kinds of conceptual categories (e.g., ani- answer “After red is orange!” and so on through
mate beings; Kelley, Paul, Fein, & Naigles, 2006). a series of colors. Any disruption of this specific
In general, grammar and syntax seem to follow pattern and phrasing is often distressing for the
a typical path of development (Tager-Flusberg, child, with the focus being on the need for language
Calkins, Nolin, & Baumberger, 1990; Waterhouse predictability rather than social usage.
& Fein, 1982). However, there is some indication The understanding and use of nonlinguistic
that the range of grammatical constructions communicative cues, such as prosody, gestures,
spontaneously used by individuals with ASD may facial expressions, and gaze, commonly present
be limited. Other difficulties have been noted, a challenge to individuals with ASD. Understand-
including morpheme omission and failure to ing and using language that hinges on these
correctly mark tense (Bartolucci, Pierce, & nonlinguistic cues (such as humor or irony) are
Streiner, 1980; Eigsti & Bennetto, 2009; Roberts, often impaired (MacKay & Shaw, 2004; Rundblad
Rice, & Tager-Flusberg, 2004). & Annaz, 2010; Wang, Lee, Sigman, & Dapretto,
The area of language and communication that is 2006) as is the use of a range of nonverbal cues. For
most universally disturbed is pragmatics, or the instance, the speech of individuals with ASD may
social use of language. For example, individuals sound robotic or monotone; in other cases, it may
with ASD may use language in restricted ways. have exaggerated ups and downs (Paul, Augustyn,
That is, whereas language is broadly used for Klin, & Volkmar, 2005; Peppé, Cleland, Gibbon,
a variety of purposes (making requests, as well as O’Hare, & Castilla, 2011; Shriberg et al., 2001).
sharing information, conveying interest, or Vocal atypicalities carry over from speech into
directing attention), individuals with ASD may laughter, which is restricted in range and variety
employ language predominantly to express their relative to controls, suggesting that individuals
own needs, wants, or interests and only minimally with ASD may not modulate their laughter for
for purely social purposes (Loveland, Landry, different communicative purposes (Hudenko,
Hughes, & Hall, 1988; Wetherby, Watt, Morgan, Stone, & Bachorowski, 2009). Difficulties with
& Shumway, 2007). As a result, maintaining recip- expressive prosody are accompanied by deficits
rocal conversations is often quite difficult for indi- in accurately interpreting the significance of
viduals on the autism spectrum, who experience others’ prosodic cues (Korpilahti et al., 2007;
impairments in turn-taking and using socially Rutherford, Baron-Cohen, & Wheelwright, 2002).
appropriate questions and statements (Capps, Individuals with ASD show decreased use of
Kehres, & Sigman, 1998; Loukusa et al., 2007; gestures, facial expressions, and gaze in communi-
Paul, Orlovski, Marcinko, & Volkmar, 2009) cative situations whether with or without language
use (Garcı́a-Pérez, Lee, & Hobson, 2007; Lord language impairment for individuals with ASD (De
et al., 2000; Loveland, Landry, Hughes, & Hall, Fossé et al., 2004; Herbert et al., 2005).
1988). Similarly, whereas the perception of ges- The centrality of communication, whether
tures facilitates language comprehension for typi- verbal or nonverbal, to our understanding of
cally developing individuals, individuals with ASD ensures that it will remain a primary focus
ASD experience a detriment in speech comprehen- of research and clinical endeavors in the years to
sion when the speaker uses concurrent gestures come. Strides continue to be made in standardiz- C
(Silverman, Bennetto, Campana, & Tanenhaus, ing definitions and measures (Tager-Flusberg
2010), indicating that verbal and nonverbal cues et al., 2010), an important step in unifying efforts
may not be processed as complementary pieces of and optimizing the applicability of research find-
a unified communicative message. ings to applied settings.
These observable abnormalities of communi-
cation and language are accompanied by atypical
structural characteristics of associated brain See Also
regions. Volumetric differences in areas underly-
ing social and emotion processing are associated ▶ Communication Assessment
with social communication impairments on ▶ Communication Disorder
behavioral measures (Kim et al., 2011; Mosconi ▶ Communicative Functions
et al., 2009; Parks et al., 2009; Schumann, Barnes, ▶ Language
Lord, & Courchesne, 2009). Similarly, structural ▶ Language Acquisition
differences have emerged in brain regions known ▶ Language Disorder
to be associated with language processing ▶ Language Tests
(McAlonan et al., 2005; Rojas et al., 2006), ▶ Speech
and some of these structural differences are asso-
ciated with variability in language for children
with ASD (De Fossé et al., 2004; Knaus et al.,
2009). References and Readings
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Waterhouse, L., & Fein, D. (1982). Language skills in CDI-III; CDIs; Infant form; MacArthur-Bates
developmentally disabled children. Brain and Lan- Communicative Development Inventories
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Watson, L. R., Baranek, G. T., Roberts, J., David, F. J., & (MCDIs); Toddler form
Perryman, T. Y. (2010). Behavioral and physiological
responses to child-directed speech as predictors of
communication outcomes in children with autism Abbreviations
spectrum disorders. Journal of Speech, Language,
and Hearing Research, 53(4), 1052–1064.
doi:10.1044/1092-4388(2009/09-0096) CDI-WG CDI-Words and Gestures
Weismer, S. E., Lord, C., & Esler, A. (2010). Early CDI-WS CDI-Words and Sentences
language patterns of toddlers on the autism spectrum
compared to toddlers with developmental
delay. Journal of Autism and Developmental Disor-
ders, 40(10), 1259–1273. doi:10.1007/s10803-010- Description
0983-1
Werner, E., & Dawson, G. (2005). Validation of the phe- 2nd Edition CDIs (2007)
nomenon of autistic regression using home videotapes.
Archives of General Psychiatry, 62(8), 889–895. The MacArthur-Bates Communicative Develop-
doi:10.1001/archpsyc.62.8.889 ment Inventories (CDIs) are standardized, norm-
Wetherby, A., Watt, N., Morgan, L., & Shumway, S. referenced, parent-report measures of early
(2007). Social communication profiles of children language and communication. All reference here
with autism spectrum disorders late in the second
year of life. Journal of Autism and Developmental pertains to the 2nd edition English-language pub-
Disorders, 37, 960–975. lication (Fenson et al., 2007), unless otherwise
Wetherby, A., Woods, J., Allen, L., Cleary, J., Dickinson, stated. A User’s Guide and Technical Manual
H., & Lord, C. (2004). Early indicators of autism (hereafter, Manual) accompanies three alternative
spectrum disorders in the second year of life.
Journal of Autism and Developmental Disorders, 34 test forms: CDI-Words and Gestures (CDI-WG),
(5), 473–493. United States. CDI-Words and Sentences (CDI-WS), and CDI-
Zwaigenbaum, L., Bryson, S., Rogers, T., Roberts, W., III. The 2nd edition Manual (Fenson et al., 2007)
Brian, J., & Szatmari, P. (2005). Behavioral manifes- updates and expands upon its predecessor (Fenson
tations of autism in the first year of life. International
Journal of Developmental Neuroscience, 23(2–3), et al., 1992), providing details around:
143–152. England. Theoretical rationale for the CDIs
History of development of the CDIs
The various sections and items on each test form
Administration and scoring of the forms and
interpretation based on normative data
Communicative Act Clinical and research uses of the CDIs
The Manual Appendix includes some
▶ Protodeclarative photocopyable forms which (a) facilitate the
▶ Protoimperative summary of an individual’s CDI scores and (b)
Communicative Development Inventories 745 C
guide the types of background data which might Endings (i.e., irregular nouns/verbs, and over-
be sought concurrently. regularizations). Within Word Combinations,
CDI-Words and Gestures. With a normative parents indicate whether their toddler at all com-
sample of 1,089 infants aged 8–18 months, the bines words, and if so, they transcribe the three
CDI-WG evaluates early comprehension and longest phrases/sentences recently produced.
production of language and nonverbal From these, the Mean length of Three Longest
communication. Several subsections are arranged sentences (M3L; see Manual pp. 22–23) is com- C
within two major parts. Part 1 evaluates infants’ puted (akin to Mean Length of Utterance
First Signs of Understanding, including whether [MLU]). Finally, parents report on their toddler’s
they have begun to respond to language (e.g., current level of Complexity, indicating which
recognizing own name) and whether they under- exemplar within each of 37 pairs of phrases best
stand commonly used phrases (e.g., “give it to matches the toddler’s current speech (e.g., “that
mommy”). Parents then report on infants’ my truck” vs. “that’s my truck”).
Starting to Talk (i.e., word/phrase imitation and CDI-III. A new addition, the relatively short
early object labeling). The Vocabulary Checklist CDI-III, was designed as an upward extension of
presents 396 words within 19 semantic categories the CDI-WS, using a normative sample of 356
(e.g., animal names, toys, etc.), and parents indi- children aged 30–37 months. Expressive vocab-
cate those words their infant “understands” and ulary is assessed with a 100-item Vocabulary
“understands and says.” Raw expressive vocabu- Checklist (around half of items overlap with
lary (i.e., all “understands and says”) and recep- CDI-WS items). Sentence Complexity is assessed
tive vocabulary (i.e., all “understands” or using 12 sentence pairs, and Language Use ques-
“understands and says”) can be totaled. tions (not included in the CDI-WS) assess aspects
Part 2 evaluates 63 communicative and sym- of comprehension, semantics, and syntax. Pilot
bolic Actions and Gestures, presented within five testing informed the retention of some appropri-
categories. Early Gestures include First Commu- ate items from the CDI-WS and the inclusion of
nicative Gestures (e.g., pointing and showing) other new items, and the upper age limit of 37
and Games and Routines, signaling emerging months was adopted given the substantive ceiling
intentional communication and social engage- scores observed beyond this age.
ment. Later Gestures include Actions with
Objects, Imitating other Adult Actions, and Spanish CDIs
Pretending to be a Parent, signaling the develop- While numerous other-language CDI adaptations
ing awareness of objects’ functional and repre- are currently underway (see section “Other Lan-
sentational uses. guage Adaptations”), two Spanish version CDIs
CDI-Words and Sentences. With a normative have progressed to the level of Manual publica-
sample of 1,461 toddlers aged 16–30 months, the tion. The Spanish (Mexican) version comprises
CDI-WS evaluates later aspects of language pro- a full-test pack, including a Users’ Guide and
duction, including expressive vocabulary, gram- Technical Manual (Jackson-Maldonado et al.,
mar, and syntax. Several subsections are again 2003), and accompanying CDI-WG and CDI-
arranged within two parts. Part 1 evaluates Words WS forms. A Spanish (European) version
Children Use, presenting a Vocabulary Checklist (Lopez Ornat et al., 2005) has been adapted
of 680 words arranged within 22 categories. Par- from the former.
ents indicate those words their toddler “under-
stands and says,” providing an expressive (but Additional Developments
not receptive) vocabulary count. How Children CDI Short Forms
Use Words considers reference to the past and Brief CDI-WG and CDI-WS forms (Fenson et al.,
future, etc. Part 2 evaluates Sentences and Gram- 2000) are mentioned within the 2nd edition Man-
mar, including Word Endings (i.e., regular plu- ual (Fenson et al., 2007; pp. 13–14), but not
rals, possessive forms, etc.), and Word Forms/ published alongside it. These are purchased
C 746 Communicative Development Inventories
directly from the authors (refer to See Also) and the English-language normative sample. This
present a subset of the appropriate Vocabulary included developmental trajectories of the vari-
Checklist items. Level 1 maps on to the CDI-WG ous CDI skills, and evaluation of the correspon-
for 8–18-month-olds, and two (alternate version) dence across skills domains, and consideration of
level 2 Short Forms map on to the CDI-WS for the impact of factors such as gender, birth order,
16–30-month-olds. Each form also enquires and social class on language development
about whether the child yet combines words. (Fenson et al., 1994).
Completion time is around 10 min, permitting The CDI Manual is currently in its 2nd edition
rapid assessment of vocabulary acquisition, and (Fenson et al., 2007). While the inventory forms
interview administration format can be used if have seen no substantive alteration, updates to the
needed (e.g., in cases of low parent literacy), Manual include an improved normative data set,
although normative data were collected using brief presentation of the Short Forms, and intro-
the standard checklist format. duction of the CDI-III. Instructions for adminis-
tering, scoring, and interpreting the CDIs were
Other Language Adaptations also expanded upon, and more details were
A CDI Advisory Board promotes (and included on the instrument psychometric proper-
authorizes) adaptation of the CDIs for other ties and on research and clinical application. As
non-English languages, some accompanied by undertaken with the original normative sample
normative data and all available for public use. (Fenson et al., 1992, 1994), the updated Manual
Section “See Also” contains more information, as also includes analysis of developmental trajecto-
does the Advisory Board website: http://www. ries and cross-domain correspondence, along
sci.sdsu.edu/cdi/ with some evaluation of the impact of other fac-
tors on language acquisition/development
(Fenson et al., 2007; see section “Psychometric
Historical Background Data”).
Interest in language development has a long his-

tory, and the current CDIs have evolved over 30 Psychometric Data
years (Fenson et al., 2007). Parent reports have
regularly informed child language and communi- Normative Samples
cative assessment, with diary studies common Normative data for the CDIs have been collected
early on. Into the 1970s and 1980s, research pro- in two phases. During initial instrument develop-
grams led by Elizabeth Bates and Leslie Rescorla ment, 659 CDI-WG forms and 1,130 CDI-WS
endeavored to develop more user-friendly ques- forms were completed (Fenson et al., 1992). In
tionnaire formats for parent report. Precursors to preparing the 2nd edition Manual (Fenson et al.,
the current CDIs were four earlier questionnaires; 2007), an additional 430 CDI-WG and 331 CDI-
the Communicative Development Questionnaire WS forms were collected. The authors sought to
(8–12 months), Language and Gesture Inventory increase the CDI-WG normative range up to
(12–18 months), Early Language Inventory 18 months, rather than just 16 months (as in the
(18–24 months), and Grammatical Development 1st edition). Increased sample diversity was also
Questionnaire (24–36 months). The 1st edition sought, to better align with US census records
CDI Manual, CDI-WG, and CDI-WS forms around ethnicity and parent educational level.
were published in 1992 (Fenson et al., 1992), Ethnic distribution of the 2nd edition normative
with Italian versions also developed and sample does better match US census records,
published around this same time (Caselli & albeit with fewer Hispanic respondents than
Casadio, 1995). A research monograph on early expected, likely due to the inclusion criterion of
communication development also appeared in English as the primary home language, for this
1994, presenting detailed analysis of data from sample. Parental education levels remain above
the US average, although good variability is Validity
included within the 2nd edition normative The Manual reports on face, content, conver-
sample: around 30% of respondents held a high- gent, concurrent, and predictive forms of valid-
school diploma or lower level of completed ity across the broad skills domains assessed
education (Fenson et al., 2007). Geographical within the CDI-WG and CDI-WS (Fenson
sampling (across US states) was also improved et al., 2007; pp. 102–114). Face validity is
for the 2nd edition. supported by the professional appearance of C
the checklist forms, along with the breadth and
Reliability depth with which language and communication
The Manual reports reliability in terms of internal skills are addressed in the assessment. The
consistency (IC) and test-retest reliability (TRT) authors feel that parents will consider the CDIs
across the broad skills domains assessed within as valid and comprehensive assessments of their
the CDI-WG and CDI-WS forms (Fenson et al., children’s abilities and thereby provide consid-
2007; pp. 99–102). These various Vocabulary ered responses. Content validity is evidenced in
Checklist components (CDI-WG comprehension the authors’ use of the language development
and production and CDI-WS production) all evi- literature to ensure inclusion of those
dence very strong IC, as do the CDI-WS sentence aspects of early language and communication
Complexity items. IC is lower, however, for CDI- development most important at the ages
WG Gestures items: while the Actions with assessed. While phonology and communicative
Objects and Imitating Other Adult Actions corre- pragmatics fail to be represented in the CDIs,
late quite highly together, those among the other the authors maintain that those aspects included
three sections are lower. TRT reliability is are given comprehensive coverage (Fenson
assessed across a maximum inter-assessment et al., 2007).
interval of 2 months, within a subgroup of the Convergent validity is evidenced from the
normative sample. CDI-WS expressive vocabu- observation of correlations between CDI scores
lary counts for 216 toddlers were very stable. and language/communication data obtained
CDI-WG receptive vocabulary counts and ges- through other methods (see Fenson et al., 2007,
ture scores were similarly stable for 137 infants, Chap. 4, and Fenson et al., 1994, for details). In
with the single exception of those aged 12 months brief, developmental trajectories across various
at initial assessment (see Fenson et al., p. 101 broad communication and language domains
for discussion). CDI-WG expressive counts evaluated in the CDIs are shown to increase con-
were also quite stable, except for infants aged sistently and regularly across ages assessed. Each
8–10 months at initial assessment (and skill domain assessed demonstrates an onset
likely due to floor effects at these young ages; around the age at which it would be expected
Fenson et al.). (given the broader literature), and rates of devel-
The authors acknowledge difficulties inherent opment correspond similarly to expectations
in assessing the reliability of a parent-report from past research. Individual variability simi-
instrument, including the possibility for halo larly corresponds to that which would be
effects and recall bias to impact upon IC and expected. Fenson et al. (2007) note some clear
TRT reliability estimates. Ideally, evaluation of exceptions, however, including the parents of
inter-rater reliability (IRR) would also be some 8-month-olds reporting greater receptive
included, but this requires availability of vocabularies, and other parents reporting much
a second respondent, equally familiar with the earlier onset of some pretense skills, than would
child’s abilities (frequently improbable). The be expected (see Manual, p. 103). On the whole,
authors argue, however, that strong evidence of however, evidence for convergent validity is sub-
validity (see below) presupposes robust reliabil- stantial. Fenson et al. (2007) argue that parents
ity, further strengthening the case for reliability and researchers appear to be observing and
of the inventories (Fenson et al., 2007). reporting upon the same development
phenomena irrespective of the research method expressive vocabulary counts was high for all
employed (i.e., CDI report vs. laboratory infants and toddlers aged above 11–12 months
experiment). at the first assessment, with best predictive power
Evidence for concurrent validity emerges observed at an initial 20-month assessment. Only
through the comparison of results from one test limited validity was shown for expressive skills
(i.e., parts of a CDI form) with those arising from in infants younger than 11–12 months and for
other similar assessments (e.g., formal language receptive skills (only assessable at two time
tests, naturalistic language samples, etc.). points for infants initially aged up to 12 months).
A measure’s evaluated concurrent validity is This pattern of findings is argued to reflect a true
influenced not only by its own indices of reliabil- lack of stability in the language skills of very
ity and construct validity but also by those of the young infants (a proposal supported by evidence
comparison measure. Furthermore, strong con- from other areas of the developmental literature;
current validity will only be evidenced when the see Fenson et al.), rather than a flaw of the CDI-
target and comparison measures assess an equiv- WG. CDI-WS grammatical complexity showed
alent skill, a potential problem for the CDIs. good predictive validity, particularly in children
Parent reports of child language draw on aged 20 months and older at initial assessment.
a wealth of knowledge about the child and daily
exposure to his/her communication and are CDI-III
sought for the very reason that they are unlikely CDI-III normative data yield from 356 children
to correspond perfectly language skills assessed aged 30–37 months. Given the relative recency of
using other means (e.g., during a formal one-off this form, only very limited psychometric data
test with an unfamiliar adult, or during are available, summarized in the Manual (Fenson
a relatively brief naturalistic language sample, et al., 2007; pp. 154–160). Educational levels of
Fenson et al., 2007). Notwithstanding, Vocabu- respondents diverge significantly from US census
lary Checklist counts show moderate-to-strong data, limiting the confidence with which scores
correspondence with other vocabulary and lan- for children from low socioeconomic back-
guage measures (see a tabulation of various study grounds can be validly interpreted.
results in Fenson et al., pp. 106–107). More lim-
ited, however, is the evidence around Gestures, CDI Short Forms
given the dearth of other accepted measures of The 2nd edition Manual (Fenson et al., 2007)
gesture to which CDI scores can be compared. refers only briefly to the CDI-WG and CDI-WS
These do, however, associate closely with for- Short Forms, available for purchase directly from
mally assessed aspects of language (i.e., compre- the authors (for details, “See Also”). Preliminary
hension; see Manual p. 109). CDI-WS normative data exist in a research publication
Complexity has been compared to spontaneous (Fenson et al., 2000), with short-form and full-
speech transcriptions, with CDI M3L and other form vocabulary counts highly intercorrelated.
complexity scores associated strongly with MLU The two (alternate version) level 2 Short Forms
during unstructured play (Fenson et al.). demonstrate important ceiling effects for toddlers
Predictive validity is considered in the 2nd older than 27–28 months, due to the abbreviated
edition Manual (Fenson et al., 2007), based on vocabulary list length containing only 100 words
a subset of the normative sample which com- (vs. 680 words in the full CDI-WS).
pleted a second inventory form 6 months after
initial assessment. For many, this entailed
a repeat assessment with the same form (i.e., 62 Clinical Uses
parents completed CDI-WG and 228 completed
CDI-WS twice). For 217 cases, the interval Administration and Scoring
necessitated initial use of the CDI-WG but fol- Administration of a full-version CDI form requires
low-up using the CDI-WS. Predictive validity of 20–40 min and should be self-explanatory to
parents. While normative data collection was such contention is more justified for parent
through postal return of forms, the Manual pro- reports on other aspects of child developmental
vides suggestions for clarifications to parents and skill; Fenson et al., 2007). Furthermore, the CDI
procedures for checking report accuracy (Fenson format aims specifically to reduce potential respon-
et al., 2007; pp. 15–18). Both the CDI-WG and dent bias, addressing current and emerging skills
CDI-WS forms have norms for 16–18-month- (rather than past abilities) and using a recognition
olds, and form selection will therefore depend (rather than recall) format to minimize the effects of C
on the purpose of current and possible future memory and item interpretation.
assessments (see pp. 12–13). Options for scoring
and obtaining normative CDI data (by hand Clinical Uses for the Parent-Report CDIs
or using automated methods) are discussed in The Manual presents potential clinical and
detail (pp. 18–34). The authors address issues research uses of the CDIs (Fenson et al., 2007,
around data interpretation for three subgroups pp. 40–46). While not uniformly accurate, and
(pp. 34–38): therefore inadvisably used in isolation of other
Children from low SES backgrounds (includ- information sources, CDIs should yield highly
ing where parental education is low) representative language characterization.
Children who are learning more than one Screening for language delay. Firm diagnosis
language of specific language impairment (SLI) is possible
Children who are older than the normative only from around 3 years. However, CDIs permit
group, but for whom language skills are within assessment of conventional early markers for
the assessable range of the CDIs such language disorder (Fenson et al., 2007).
Both “delay 3” (Rescorla, 1989) and “delay
Parent-Report Pros and Cons 3 + ” (Klee, Pearce, & Carson, 2000) criteria for
Parent reports are based on the everyday obser- identifying late talkers can be gauged with the
vation of child language and arguably produce CDIs and associated Basic Information Form
more ecologically valid results than otherwise (Manual Appendix). Not all late talkers will
obtainable (e.g., through formal/direct assess- develop enduring language problems. However,
ment, naturalistic language sampling, etc.). early identification of atypical developmental
CDIs benefit from the wealth of parent knowl- patterns may indicate further assessment and
edge and are unlikely to be negatively influenced ongoing monitoring. Rates of communication
by aspects of the child’s personality (e.g., shy- growth (able to be evaluated through repeated
ness) or mood on a given day (e.g., fussiness). CDI completion) better predict later language
Clinically, parent report is also time efficient and ability than do the results of any single assess-
cost effective; CDIs can be completed prior to ment (Thal, 2000). Delays in concurrent language
attendance at more costly clinic appointments comprehension and production accompanied by
(i.e., permitting better use of the consultation a failure to compensate with gestures signify
time) and can be completed at multiple time particularly high risk (Thal & Katich, 1996),
points (i.e., to facilitate developmental monitor- with each component addressed within CDI-
ing; Fenson et al., 2007). WG assessments.
Other biases may be inherent, however. Par- Characterizing special groups. While the CDI
ents may consistently over- or underreport their normative sample extends only to 30 months (37
child’s abilities, and the experience of complet- months for CDI-III), they can be used to evaluate
ing an inventory might influence later reports the skills of older children whose language falls
provided using the measure (i.e., through alter- within the range of assessed domains (i.e., devel-
ation of the parents’ behavior with, or subsequent oping vocabulary, emerging grammar, etc.). As
observation of, their child). However, such such, they are increasingly used clinically/for
a possibility has been evaluated for the CDI, research with individuals with autism spectrum
with minimal such influence observed (although disorders, Down syndrome, Williams syndrome,
and cleft lip/palate, among other groups (e.g., the CDI Advisory Board, a not-for-profit organisation
Charman, Drew, Baird, & Baird, 2003; Mervis supporting further development of the inventories.
Reference lists are included, concerning the various
& Robinson, 2000; Snyder & Scherer, 2004). inventory forms and versions, and dating from the
Normative scores are only interpretable where 1980s through early 2000s. Some relevant professional
older individuals’ raw scores fall at or below the organisations, conference groups, and research groups
30-month median level (Fenson et al., 2007). are listed, and a dedications page honours Elizabeth
Bates, a key CDI developer, who passed away in 2003.
Raw scores are therefore typically of greatest
interest (e.g., documenting how many raw
Other-Language Adaptations
words an individual understands/says). The website and Advisory Board play a key role in CDI
Intervention design and evaluation. CDI other-language adaptations. Guidelines are provided
results can identify specific intervention targets, for obtaining appropriate authorisation, and include
such as the promotion of vocabulary growth, requirements around the competence and resource-
availability necessary to undertake adaptation. Sug-
specific lack of comprehension skills, develop- gestions regarding the adaptation procedure are
ment of correct grammar, etc. Furthermore, the outlined in an unpublished manuscript http://www.
inventories can be used to evaluate/demonstrate sci.sdsu.edu/cdi/suggestions_adaptations.htm (Dale,
post-intervention change. The Manual notes Fenson, & Thal, 1993). Other-language adaptations
currently undertaken/underway are tabulated, and
some such intervention studies including samples entries include investigator contact details, project
of toddlers with expressive language delays, with website links, and publication reference lists (http://
cleft lip/palate, and following cochlear implant www.sci.sdsu.edu/cdi/adaptations_ol.htm).
(Fenson et al., 2007, p. 44).
Lex2005 Database
The Lex2005 Database (Dale & Fenson, 1996), available
on the CDI Website, (http://www.sci.sdsu.edu/cdi/
See Also lexical_e.htm) provides a month-by-month compila-
tion of normative data for all CDI receptive and
▶ Communication and Symbolic Behavior Scale expressive Vocabulary Checklist items (in each of the
▶ Communication Assessment English and Spanish [Mexican] versions). Users select
the language, specific measure (i.e., receptive/expres-
▶ Expressive Language sive), types of word (i.e., all, specified semantic
▶ Gestures groups, specified words), and ages of interest, and the
▶ Grammar database returns the proportion of children at each age
▶ Language reported to understand/say each word of interest.
▶ Language Acquisition
▶ Language Development Survey CDI Scoring Program (2004)
The website also allows users to download, free of charge,
▶ Language Tests the Scoring Program for the CDI (2004), with accom-
▶ Play panying user’s guide: http://www.sci.sdsu.edu/cdi/
▶ Pretend Play scoringp_download.htm. The program aims to facili-
▶ Preverbal Communication tate management of CDI data, including entry and
scoring, and interfaces with PCs running Microsoft
▶ Receptive Language Office 97 or higher. The website mentions CDI Scor-
▶ Receptive Vocabulary ing Templates (http://www.sci.sdsu.edu/cdi/scoring_t.
▶ Symbolic Play htm), and describes the types of scanner system
▶ Vocabulary required for automated scoring. Template configura-
tions are indicated to be ‘Coming Soon!’ However, like
most of the website, this page notes its most recent
update as February, 2006.
References
CDI Advisory Board and Website Caselli, M. C., & Casadio, P. (1995). Il Primo Vocabulario
Additional materials and information on the CDIs, includ- Del Bambino (Children’s early vocabulary). Milan,
ing contact details for purchasing the various publica- Italy: France Angeli.
tions and inventory forms, are available at: http:// Charman, T., Drew, A., Baird, C., & Baird, G. (2003).
www.sci.sdsu.edu/cdi. This site is administered by Measuring early language development in preschool
Communicative Functions 751 C
children with autism spectrum disorder using the P. S. Dale, & D. J. Thal (Eds.), Communication and
MacArthur communicative development inventory language intervention series (Advances in assessment
(Infant Form). Journal of Child Language, 30, of communication and language, Vol. 6, pp. 1–28).
213–236. Baltimore: Paul H. Brookes.
Dale, P. S., & Fenson, L. (1996). Lexical development
norms for young children. Behavior Research
Methods, Instruments, & Computers, 28, 125–127.
Dale, P. S., Fenson, L., & Thal, D. J. (1993). Development
inventories to additional languages. http://www.sci. Communicative Functions C
sdsu.edu/cdi/adaptations.htm
Fenson, L., Dale, P. S., Reznick, J. S., Bates, E.,
Sarita Austin
Thal, D. J., & Pethick, S. J. (1994). Variability in
early communicative development. Monographs of Laboratory of Developmental Communication
the Society for Research in Child Development, 59, Disorders, Yale Child Study Center, New Haven,
1–173. CT, USA
Fenson, L., Dale, P. S., Reznick, J. S., Thal, D. J., Bates,
E., Hartung, J. P., et al. (1992). MacArthur communi-
cative development inventories: User’s guide and
technical manual (1st ed.). Baltimore: Paul H. Synonyms
Brookes.
Fenson, L., Marchman, V. A., Thal, D. J., Dale, P. S.,
Communication intentions; Communicative intent
Reznick, J. S., & Bates, E. (2007). MacArthur-Bates
communicative development inventories: User’s guide
and technical manual (2nd ed.). Baltimore: Paul H.
Brookes. Definition
Fenson, L., Pethick, S. J., Renda, C., Cox, J. L., Dale, P. S.,
& Reznick, J. S. (2000). Short form versions of the
MacArthur communicative development inventories. Communicative functions refer to the purpose of
Applied PsychoLinguistics, 21, 95–115. gestural, vocal, and verbal acts intended to convey
Jackson-Maldonado, D., Thal, D. J., Marchman, V. A., information to others. Some communicative func-
Newton, T., Fenson, L., & Conboy, B. (2003).
tions include commenting, requesting, protesting,
MacArthur inventarios del desarrollo de habilidades
comunicativas. User’s guide and technical manual. directing attention, showing, and rejecting. Ges-
Baltimore: Paul H. Brookes. tures and vocalizations are often first observed as
Klee, T., Pearce, K., & Carson, D. (2000). Improving the an indication of intentionality in infants 8–9 months
positive predictive value of screening for developmen-
of age. It is at this point many infants appear to
tal language disorder. Journal of Speech, Language,
and Hearing Disorders, 43, 821–833. begin pursuing their intentions through interactions
Lopez Ornat, S., Gallego, C., Gallo, P., Karousou, A., with others. The development of communicative
Mariscal, S., & Martinez, M. (2005). MacArthur: functions has been described by Bates as occurring
Inventario de desarrollo comunicativo. Manual
in a sequence of three stages: perlocutionary,
y Cuadernillos. Madrid: TEA Ediciones.
Mervis, C. B., & Robinson, B. F. (2000). Expressive illocutionary, and locutionary.
vocabulary ability of toddlers with Williams syndrome The perlocutionary stage of intentionality
or Down syndrome: A comparison. Developmental begins at birth and is expected to continue until
approximately 8 months of age. During this
Rescorla, L. (1989). The language development survey:
A screening tool for delayed language in toddlers. The period, the infant focuses on objects and people
Journal of Speech and Hearing Disorders, 54, and attends, discriminates, and responds to stim-
587–599. uli through cries and coos. At this developmental
Snyder, L. E., & Scherer, N. (2004). The development of
level, the child does not possess the mental
symbolic play and language in toddlers with cleft
palate. American Journal of Speech-Language representational capacity to hold an intention in
Pathology, 13, 66–80. mind and convey it to another, but his behavior is
Thal, D. J. (2000). Late-talking toddlers: Are they at risk? interpreted and treated by caregivers as if it were
San Diego: San Diego State University Press.
intentional. As the predictability of interactions
Thal, D. J., & Katich, J. (1996). Predicaments in early
identification of specific language impairment: Does between the caregiver and child increases and
the early bird always catch the worm? In K. Cole, cognitive development progresses, infants begin
C 752 Communicative Intent
associating their actions with specific responses

from their caregivers. Between 8 and 12 months, Community Services
the illocutionary stage begins in which infants
begin using gestures and vocalizations coupled Naomi Davis
with eye gaze and often repeating or modifying 3-C Institute for Social Development, Cary,
communicative acts in an intentional way to NC, USA
convey a message. In this stage, intentional,
nonconventional gestures, such as tantrums, also
begin to appear. Finally, the locutionary stage Synonyms
begins with a child’s first meaningful word.
This final stage of intentionality development Community-based services
typically occurs at approximately 12 months of
age. During this stage, a child uses words in
conjunction with gestures, sounds, and gaze to Definition
convey, at first, a limited range of communicative
functions. As language and social-cognitive Community services include a range of programs
development proceed through the preschool and that are designed to meet the support and inter-
school years, a wider range of communicative vention needs of individuals with ASD and their
intentions is acquired. families. Services are delivered in community
settings (e.g., community centers, recreational
See Also facilities, religious organizations) and include
programs for individuals across the autism spec-
▶ Communication Intention Inventory trum and throughout the life span.
▶ Pragmatics The following list includes examples of com-
munity services:
• Case management
References and Readings • Life skills training
• Structured social opportunities
Austin, J. L. (1962). How to do things with words.
New York: Oxford University Press. • Employment training
Bates, E. (1976). Language in context: Studies in the • Community mentors
acquisition of pragmatics. New York: Academic Press. • Job counselors
Bates, E., Benigni, T., Bretherton, I., Camaioni, D., & • Respite caregiving services
Volterra, V. (1979). The emergence of symbols:
Cognition and communication in infancy. New York: • Recreational opportunities
Academic Press. Developmental Shifts in Service Use: Commu-
Owens, R. E. (2008). Language development: An nity service use often changes over time for indi-
introduction (7th ed.). Boston: Allyn & Bacon. viduals with ASD. Although children generally
Searle, J. (1965). What is a speech act? In M. Black (Ed.),
Philosophy in America. New York: Allen & Unwin receive their primary services through their
and Cornell University Press. school, many families also make use of additional
Wetherby, A. M., Cain, D. H., Yonclas, D. G., & community services such as respite caregiving
Walker, V. G. (1988). Analysis of intentional commu- services (i.e., periodic, short-term in-home sup-
nication of normal children from the pre-linguistic to
the multiword stage. Journal of Speech and Hearing port to relieve primary caregivers) and special-
Research, 31, 240–252. ized recreational activities to develop an area of
interest (e.g., art, sports) or to foster a successful
social experience (e.g., summer camps). Simi-
larly, adolescents can take advantage of commu-
Communicative Intent nity services to increase their independence and
preparation for the transition to adulthood (e.g.,
▶ Communicative Functions structured social activity groups, community
Community-Integrated Residential Services for Adults with Autism 753 C
mentors). For adults with ASD, specialized job
training programs and employment counseling Community Work Crew
may be utilized.
Obtaining Service: Local and national ASD ▶ Mobile Work Crew Model
organizations often compile lists of available
community services. These lists are intended to
aid families in obtaining the most relevant ser- Community-Based Services C
vices for their family member with ASD. Cost
and payment requirements vary across services ▶ Community Services
and by state, though many services may be avail-
able to individuals at low or no cost through
existing Medicaid funding. Community-Based Work Team
Research: In contrast to the accumulating
evidence base for traditional interventions for ▶ Mobile Work Crew Model
ASD, less work has been done to evaluate the
effectiveness of these varied community ser-
vices. Families typically report involvement
with multiple community services at a time to Community-Integrated Residential
address different needs. Services for Adults with Autism
Mark Sherry1 and Ernst VanBergeijk2

See Also 1
Department of Sociology and Anthropology,
University of Toledo, Toledo, OH, USA
▶ Independent Living 2
Vocational Independence Program, New York
▶ Living Arrangements in Adulthood Institute of Technology, Central Islip, NY, USA
▶ Residential Services
▶ Self-Help Skills
Definition
Community-integrated residential services are

References and Readings homes located in the community, rather than in
disability institutions, and are designed to promote
Hendricks, D. R. (2009). Transition from school to adult- the social inclusion of people with disabilities.
hood for youth with autism spectrum disorders:
They developed as a challenge to the historical
Review and recommendations. Focus on Autism and
Other Developmental Disabilities, 24, 77–88. segregation and exclusion of people with disabil-
http://www.ct.gov/dds/lib/dds/autism/pilot_program_ ities from the community. People along the autistic
outcome_study.pdf spectrum historically were institutionalized in seg-
Montes, G., Halterman, J. S., & Magyar, C. I. (2009).
regated state institutions, but the exposure of large-
Access to and satisfaction with school and community
health services for US children with ASD. Pediatrics, scale abuses in disability institutions and the
124, S407–S413. growth of the disability rights movement
Robinson, J., Reed, I., Shugrue, N., Kleppinger, A., & prompted large-scale deinstitutionalization.
Gruman, G. (2008). An evaluation of the autism pilot
program of the Division of Autism services of the CT
Department of Developmental Services. Report pre-
pared for the Connecticut Department of Developmen- Historical Background
tal Services.
Ruble, L. (2007). Community service outcomes for
Eugenics and Segregation
families and children with autism spectrum
disorders. Research in Autism Spectrum Disorders, 1, In the late nineteenth and early twentieth centu-
360–472. ries, eugenics and social Darwinism gained
C 754 Community-Integrated Residential Services for Adults with Autism
enormous popularity throughout the world. These resulted in mass genocide. People with disabil-
ideas suggested that disabled people carried ities were bussed into killing centers (rather than
defective genes, labeling groups of develop- concentration camps), and they were diagnosed
mentally disabled people (including people and killed on the day they arrived – a process
with autism) as “idiots,” “imbeciles” and which has been called “medicalized killing”
“morons” – or lumped together through the (Lifton, 2000, p. 14). Nazis sterilized 375,000
term “feeble minded” (Noll & Trent, 2004). people with disabilities and killed approximately
People who were “feeble minded” were blamed 275, 000 children and adults with disabilities
for all sorts of social problems, including (Kerr & Shakespeare, 2002, pp. 27–44).
petty thievery, vagrancy, alcoholism, prostitution
and illegitimate children – and they were
regarded as a “burden” on society. These ideas, Rationale or Underlying Theory
which are recognized as incredibly prejudicial
today, were justified as “scientific” by medicine The rationale of community-integrated residen-
and psychiatry at the time. Indeed, eugenics tial services for adults with autism stems from the
inspired a generation of scientists and was taught undercovering of the systemic and horrific abuses
in 44 universities throughout the United States. of congregate care in the late 1960s and early
The classification, pathologization, and devalua- 1970s typified by the Willowbrook case.
tion of disability were integral to the scientific Willowbrook State Hospital on Staten Island,
ideas of the time (Snyder & Mitchell, 2006). New York, became the symbol of the deinstitu-
As a result of such negative attitudes toward tionalization movement. The thought was that
disability, people with developmental disabilities if patients lived and worked in the community,
were removed from the community and housed there will be less of a chance of abuse occurring
in institutions for the “feeble minded.” because the eyes of the community were upon
The following summary of attitudes toward dis- the caretakers in the small group homes.
ability highlights the extent of prejudice at Furthermore, people with autism were
that time. Common attitudes included regarding warehoused in large state-operated psychiatric
people with disabilities as subhuman, sick, facilities along with individuals with serious
menacing, pitiful, and a burden (Wolfensberger, mental illness. This was an inappropriate
1975). placement. They received little or no treatment,
Institutionalization and sterilization were nor rehabilitation. Nor was the intervention or
linked in the eugenic agenda. By the 1960s, treatment specific to autism. By being integrated
over 60,000 people had been sterilized in the into the community, individuals with autism
USA (Kerr & Shakespeare, 2002). Segregated could learn adaptive behavior to become more
residential institutions and educational institu- independent than in a large institution.
tions were more results of eugenic ideas. Although the rationale for deinstitutionaliza-
In total, the effect of eugenics was to create tion of individuals with autism and other
a widespread sense that people with disabilities disabilities outlined above is moral and sound,
were inferior, and perhaps dangerous, so they another rationale for community-integrated resi-
should be kept away from the community and dential services for adults is economic. The cost
locked in institutions. of 24 hour care in a large state-run psychiatric
Eugenic ideas were also central to the Nazi facility is staggering. Current estimates are
ideology. Their belief in “building a better race” between $150,000 and $200,000 per year per
stemmed in large part from the eugenic idea that patient. Small community-integrated residential
it was possible to identify and eradicate those services, more commonly referred to as group
with “defective genes.” Under the Nazi eugenic homes, are a fraction of the cost of placement in
program, “racial cleansing” and mass euthanasia a state psychiatric facility.
Goals and Objectives be done to provide this individual with a high
quality of life?
The primary goal of any placement, whether it is
a community-integrated residential setting or not,
is safety. When evaluating a possible placement, Treatment Participants
an eye should be kept upon how the person with
autism will be kept safe. Questions to ask include Community-integrated residential services are is C
the following: (1) What are the staffing and generally not considered a treatment in the tradi-
supervision levels? (2) How is wandering tional sense under a medical model. It is, how-
prevented? (3) What is the staff training in ever, a social intervention involving a number of
the areas of (a) CPR, first aid, and the use individuals and agencies depending upon the age
of automatic external defibrillators; (b) medica- of the participant. As a part of the transition
tion management; (c) aggressive behavior planning process under IDEA, the IEP team
management; and (d) psychiatric emergencies may identify living in a group home as a goal
and crisis intervention? (4) How are the residents for the student with autism. The IEP team
transported to appointments and recreational consists of the student with autism or another
activities? (5) Are there any geographic disability, his or her parents, special educators,
features in the community that might be and representatives of agencies other than the
hazardous to a person with autism (e.g., proxim- school district. The representatives of other
ity to a highway, body of water, or railroad agencies can include either private not-for-profit
tracks)? social service agencies subcontracted by the state
The second set of goals should involve or state-run social service systems that are known
maximizing the person’s level of independence by a variety of acronyms. These can be state
and integration into the community. The residen- offices of Developmental Disabilities Services,
tial services should continuously be an opportu- Offices of Mental Retardation and Developmen-
nity for the person with autism to learn new tal Disabilities (OMRDD), or Offices for Persons
independent living skills and adaptive behavior. with Developmental Disabilities (OPWDD).
These skills may be vocational in nature such as (It should be noted that the term “mental
working or volunteering on a part-time basis. retardation” is now considered a derogatory
Or they may involve learning new skills like term and the preferred term is a “person
travel training skills. Instead of relying upon an with a developmental disability.”). These agen-
agency van to drive the person with autism to and cies will oversee the provision of residential ser-
from work or recreational activities, the person vices in the community. Other entities that may
can be taught how to use mass transit or call be involved include state offices of Vocational
a taxicab. Depending upon the skill level of the and Rehabilitative Services, Social Security
individual, it may involve learning pedestrian Administration, Medicaid, and Medicare pro-
skills. The person may learn to walk to and from grams, as well as physical and mental health
the group home to a nearby store. This further providers.
increases his or her level of community integra- Group homes will have a variety of staff that
tion and independence. are either permanently assigned to the home such
The final set of goals should revolve around as frontline workers or itinerant staff including
improving the person with autism’s quality of psychologists, social workers, nurses, occupa-
life. What can be done to increase the person’s tional therapists, recreational therapists, ABA
sense of connectedness? What can be done to specialists etc. The provision of services
foster their sense of self-advocacy? What kinds will vary from system to system. There are
of activities or foods can be made available to the no universally set standards for the provision
individual to bring joy to his or her life? What can of community-integrated residential services
for adults with autism. This will vary from state to scholars suggested that the residents of
state. Willowbrook be immediately placed in group
homes instead of the institution (Rothman &
Rothman, 2004).
Treatment Procedures The key principle of normalization has been
summarized in the following way: “. . . the most
Challenges to Institutionalization explicit and highest goal of normalization must
One of the major reasons why institutionalization be the creation, support, and defense of valued
was abandoned as the major policy for housing social roles for people who are at risk of social
people with disabilities was the public exposure devaluation” (Wolfensberger, 2004, p. 43).
of horrific abuses which were occurring in The philosophy of normalization was later
these institutions. Geraldo Rivera’s exposé on re-named “Social Role Valorization” and became
the Willowbrook State School, a school in Staten an incredibly popular approach to disability,
Island for people with developmental disabilities, spurring on community-integrated residential
helped to raise public awareness about this issue. living and giving a sense of what residential
The school was filthy, overcrowded, unsanitary, inclusion should look like.
and rife with physical and sexual abuse. In the Wolfensberger identified three consequences
words of one scholar, “Willowbrook (and by of the devalued social roles which had been
implication, other residential facilities of its attributed to people with disabilities. First, he
kind) resembled concentration camps. Lacking said that mistreatment is an effect of social
cleanliness, privacy, care, affection, and devaluation. This was his explanation for the
education, Willowbrook would soon become the abuse experienced by disabled people: their
nation’s touchstone for publicly funded devalued social roles encouraged people to treat
abuse and neglect” (Rothman & Rothman, them in ways that did not recognize their dignity.
2004, p. 445). A successful class action against Second, he said that negative treatment is
New York State followed this public exposure of connected to the forms of devaluation: when
inhumane treatment. people with disabilities are devalued as human
Another important element of the beings and regarded as animals, they were put in
Willowbrook case was the involvement of a cages in institutions. Similarly, people who are
group of scholars from Syracuse University. regarded as a menace will be surrounded
One leading scholar, Wolf Wolfensberger, by enclosures marked by locks, barred windows,
developed a theory of “normalization” which fences, and so on. Third, he said that how people
suggested that people with disabilities should be are treated greatly affects how they behave:
afforded every right that other citizens have – when people are continuously treated as
they should attend regular schools, live in normal “deviant,” they will tend to adopt a deviant
houses in regular communities, and be included identity, but if they are treated with respect and
in community activities such as leisure, recrea- dignity and are accorded valued social roles,
tion, and sporting events. This philosophy of they will adapt accordingly (Wolfensberger,
normalization became a springboard for one sec- 2004). The implication of this argument
tion of the disability rights movement who was that people with disabilities needed to be
strongly believed that institutions must be located in the regular community – where
dismantled and their residents should be returned people with valued social roles can be found –
to the community. Institutions had become like and that any institutions or patterns of behavior
incarceration, and they were totally inappropriate which diminished their humanity must be
for people with disabilities, who deserved removed.
every opportunity to live a normal life in the Wolfensberger believed that addressing the
community. In the context of the abuses occur- devalued social image of people with disabilities
ring at Willowbrook, Wolfensberger and other should occur alongside efforts to improve their
“competencies.” He suggested that these two procity in the 1970s to make the whole community
cesses were interconnected: more inclusive and accessible (Fleischer &
A person who is competency-impaired is highly at Zames, 2001).
risk of becoming seen and interpreted as of low The development of the self-advocacy
value, thus suffering image-impairment; a person movement by people with disabilities represented
who is image-impaired is apt to be responded to a fundamental shift in the ways in which disabil-
by others in ways that impair/reduce his/her
competency. . . a person whose social image is ity should be understood. No longer were doctors, C
positively valued is apt to be provided with expe- social workers, welfare workers, bureaucrats,
riences, expectancies and other life conditions or allied health professionals considered the
which generally will also increase his/her compe- “experts” on disability; people with disabilities
tencies, and a person who is highly competent is
also more apt to be imaged positively. were claiming this role for themselves.
(Wolfensberger, 2004, p. 45) Self-advocacy not only occurred among people
with physical disabilities; people with develop-
In conjunction with Social Role Valorization, mental disabilities also formed organizations
an approach to evaluating community residences such as People First where they asserted
and services was developed entitled “PASSING,” their rights to make important decisions
which stood for “Program Analysis of Service about their own lives (Shapiro, 1994).
Systems’ Implementation of Normalization There were significant differences as well as
Goals.” PASSING involved a questionnaire similarities between the approaches of the
which could be used to evaluate the extent to emerging disability rights movement and those
which residences and services promoted valued committed to the principles of Social Role
social roles. They were evaluated according to Valorization. One primary goal of the disability
whether the following features of the residence rights movement was to remove barriers in the
or service enhanced the social role and environment – whether those barriers are
competencies of people with disabilities: the physical barriers such as steps or attitudinal
physical setting of the buildings, the groupings barriers such as prejudice. But the assertion that
and relationships built into the process, the ways people with disabilities must be in charge of the
in which time was used and activities were entire process was not a part of the Social Role
structured, and other miscellaneous areas Valorization philosophy. It centered on human
(Syracuse University Training Institute for service and welfare professionals; the disability
Human Service Planning Leadership and Change rights movement mobilized people with disabil-
Agentry, 2007). ities themselves (Linton, 1998). Additionally,
At the same time as the philosophy of normal- Social Role Valorization suggested that people
ization and Social Role Valorization was being with disabilities try to conform to socially valued
developed, another key social change was occur- roles; the disability rights movement asserted
ring. The disability rights movement, modeled a completely different set of values from the rest
after the African American civil rights move- of society and argued that society should conform
ment, was beginning to develop and assert the to those values, not vice versa. Additionally,
right to independent living. The first Center for Social Role Valorization assumed that disability
Independent Living was formed in Houston in was generally a negative experience which
1972, and Berkeley and Boston developed should be minimized in order to allow the person
their Centers for Independent Living in 1974. to fit in to society; the disability rights movement
Berkeley developed its national reputation from began to promote disability pride, which empha-
its unique perspective – emphasizing peer sized and took pride in their differences rather
counseling, legal assistance, advocacy on access than minimizing them (Sherry, 2006).
issues, and leadership by people with disability. The development of the disability rights
For instance, disability advocates in Berkeley movement had major implications for the ways
were able to get curb cuts installed around their in which community residential programs
responded to the needs of people with disabilities. been effective when families have been
For instance, they had to begin with the assump- overwhelmed with the behavior of the individual
tion that people with disabilities are capable and (e.g., assaultive or wandering behavior) or when
did not need to be “fixed” or changed. Addition- the individual with autism’s parents have become
ally, residential services need to provide support too old and infirmed to care for their adult child.
to enable people with disabilities, including Further discussions regarding the efficacy of
people with cognitive and developmental the services are dependent upon the particular
disabilities, to control their own lives. outcome one is focusing upon.
Self-determination was now a key component of
residential decision making (Mackelprang &
Salsgiver, 1999). Outcome Measurement
The deinstitutionalization process, and the
growth of the disability rights movement, helped Outcome measurement is difficult to define in
make independent living and supported living in a traditional sense of a single intervention.
the community a reality for many people with Community-integrated residential services for
disabilities. Rather than being isolated from adults with autism provide a variety of interven-
their friends and families in institutions, tions across multiple domains of a person’s life.
people with disabilities are now living in the Some of the outcomes worth assessing are (1) the
community. Social inclusion, including level of independence a person attains and
community integration, allows people to make the amount of support and supervision he or she
friendships and develop relationships with others might need; (2) the ability of the individual to
and is a cornerstone of equal rights for people navigate through the community and use
with disabilities. mass transit; (3) the ability of the person to
self-advocate when dealing with social service
agencies, government entitlement programs, and
Efficacy Information health-care providers; (4) the skills necessary to
manage money, pay bills, and purchase items at
The efficacy of community-integrated residential a local store; and (5) the frequency and quality of
services is difficult to quantify because of the the person’s participation in community events,
multiple domains these services impact upon. It entertainment, and cultural festivities.
appears that these services were effective in mov- The literature is replete with references to
ing people with autism out of a warehousing sit- a person being on a spectrum or a continuum
uation (as was the case in the large-scale when describing their abilities and deficits.
congregate care) and into the greater community. Residential services likewise can be thought of
It is a widely held belief that this move decreased as being on a continuum. On one end of the
the amount of abuse and neglect that was inflicted continuum is large-scale congregate care which
upon individuals with autism in large psychiatric is generally reserved for the individuals who are
hospitals. Likewise, it is believed that the most severely impacted by symptoms of autism
deinstitutionalization movement allowed indi- or have behaviors that prevent them from being in
viduals with autism to receive more appropriate a less restrictive setting (e.g., aggressive/assault-
and autism-specific interventions that were ive behavior or self-injurious behavior). On the
empirically based. This led to better outcomes other end of the continuum is an individual
for individuals on the spectrum. who lives in the community with no formal orga-
Community-integrated residential services nization supporting his or her independence. This
have been effective is alleviating caregiver is done simply through informal support net-
overload and burn-out. These services have also works (e.g., friends, family, spouse, etc.).
In between the two extremes of the continuum of individual with autism into a group home or sim-
care are group homes, supervised apartments ilar type of facility.
where social service agency staff actually live
in the apartment complex and are available
24 hour a day/365 days a year for emergencies, See Also
and finally a situation where the individual with
autism lives completely integrated within the ▶ Group Homes C
community and social service agencies drop in ▶ Transition Planning
periodically to help with bill paying, home main-
tenance issues, and possibly assisting in dealing
with in-home emergencies (e.g., what to do if the References and Readings
circuit breaker is tripped; what do if a smoke
Fleischer, D. Z., & Zames, F. (2001). The disability rights
detector is going off, how and when to use a fire movement: From charity to confrontation. Philadel-
extinguisher, etc.). phia, PA: Temple University Press.
An adult with autism may move up and down Kerr, A., & Shakespeare, T. (2002). Genetic politics from
the continuum of care depending upon where he eugenics to genome. Cheltenham, England: New
Clarion Press.
or she is in the life cycle and how much interven- Lifton, R. J. (2000). The Nazi doctors: Medical killing and
tion he or she receives to mitigate the symptoms the psychology of genocide. Jackson, TN: Basic
of autism and any comorbid disorders. Books.
The ultimate outcome for any individual on the Linton, S. (1998). Claiming disability. New York:
New York University Press.
spectrum is to live in a residential setting that Mackelprang, R., & Salsgiver, R. (1999). Disability:
maximizes his or her independence and A diversity model approach in human service practice.
autonomy while simultaneously ensuring Pacific Grove, CA: Brooks/Cole Publishing.
a reasonable level of safety. Noll, S., & Trent, J. W. (2004). Introduction. In S. Noll &
J. W. Trent (Eds.), Mental retardation in America:
A historical reader (pp. 1–19). New York: New York
University Press.
Qualifications of Treatment Providers Rothman, D. J., & Rothman, S. M. (2004). The litigator as
reformer. In S. Noll & J. W. Trent (Eds.), Mental
retardation in America: A historical reader
The qualifications of treatment providers (pp. 445–465). New York: New York University Press.
providing community-integrated residential Shapiro, J. (1994). No pity: People with disabilities
services for adults with autism vary widely. forging a new civil rights movement. New York:
This is a reflection of a variety of state laws Random House.
Sherry, M. (2006). If I only had a brain: Deconstructing
governing the provision of residential services brain injury. New York: Routledge.
to persons with developmental disabilities. Snyder, S., & Mitchell, D. (2006). Cultural locations of
The treatment providers may be state employees disability. Chicago: The University of Chicago Press.
working for the Office for Persons with Develop- Syracuse University Training Institute for Human Service
Planning Leadership and Change Agentry. (2007,
mental Disabilities, or they may be employees of February). Overview of “Passing”: A tool for analyz-
a private not-for-profit social service agency. ing service quality according to social role valorization
There are for-profit entities that provide care criteria. Retrieved 23 May, 2011, from http://www.
for persons with autism. When looking for srvip.org/PASSING_overview005.pdf
Wolfensberger, W. (1975). The origin and nature of our
a community-integrated residential placement institutional models. Syracuse, NY: Human Policy
for an adult with autism, consumers should ask Press.
where the agency receives its auspice. Who Wolfensberger, W. (2004). Social role valorization:
licenses the facility? Who inspects and regulates A new term for the principle of normalization. In
D. R. Mitchell (Ed.), Special educational needs and
facility? How often are they inspected? These are inclusive education: Systems and contexts (pp. 42–50).
all important questions to ask prior to placing an New York: Routledge Farmer.
C 760 Comorbidity
much smaller, with the strongest associations

Comorbidity observed with seizure disorder and a handful
of strongly genetic conditions (Rutter, Bailey,
Fred R. Volkmar Bolton, & Le Couteur, 1994).
Director – Child Study Center, Irving B. Harris Evolving diagnostic concepts and research
Professor of Child Psychiatry, Pediatrics and findings have sometimes clarified the signifi-
Psychology, School of Medicine, cance or meaning of possible associations.
Yale University, New Haven, CT, USA For example, Kanner’s original impression
(1943) that persons with autism had normal intel-
lectual potential has been shown to be incorrect;
Definition although the pattern of cognitive and adaptive
abilities in autism is unusual, for many of chil-
The presence of a second (comorbid) condition in dren with autism, overall scores on cognitive
association with a previous one. testing are stable within the mentally retarded
range (Goldstein et al., 2008; Lord and Schopler,
1989). On the other hand, a substantial group of
Historical Background persons with autism have cognitive abilities in
the average or above average range and, with
The issue of comorbidity with autism has early diagnosis and intervention, the overall
assumed increasing importance in recent years; outcome (and levels of cognitive ability in adult-
it is intimately related to other issues including hood) appears to be improving (Howlin, 2007),
more general topics in diagnosis and classifica- suggesting that perhaps this association reflects
tion as well as the attempt to identify meaningful an aftereffect of autism rather than one more
approaches to subgrouping/subtyping autism. essentially connected in an etiological sense to
Clearly having any serious disability – such as autism. On the other hand, seizure disorders of
autism or intellectual disability – only acts to various types are frequently associated with
increase vulnerability to other problems. In the autism if the latter is strictly defined occurring
past, as in the field of intellectual disability, the in perhaps 20–25% of cases.
problem was complicated by the tendency of Issues relating to comorbidity for other psy-
autism to “overshadow” other difficulties (Rutter, chiatric conditions are complicated for several
1994; Volkmar & Klin, 2005). reasons. Firstly there is a major difference
between approaches to diagnosis in DSM-IV
and ICD-10. While both systems attempt to be
Current Knowledge comprehensive in coverage, ICD-10 comes from
a nosological tradition of searching for a single,
Autism has been reported to co-occur with parsimonious diagnostic label (i.e., a “top-down”
various other developmental, psychiatric, and approach more focused on syndromes rather than
medical conditions; however, often these associ- symptoms). Conversely DSM-IV and its prede-
ations are based on reports of single, or at best cessors have often seemed to encourage multiple
a handful of, cases and often fail to address the diagnoses (a “bottom-up” orientation that starts
more central question of whether associations are with symptoms and then moves toward catego-
observed at greater than chance levels. This has ries) (Ghaziuddin et al., 1992; Rutter, 2006;
been strongly illustrated in the literature on asso- Volkmar and Woolston, 1997; Volkmar &
ciations of medical conditions with autism where Woodbury-Smith, 2007). Clearly no single diag-
early efforts, based largely on case reports, nostic label conveys the totality of the individ-
suggested hundreds, if not thousands, of such ual’s difficulties, and while the multiaxial
associations (Gillberg, 1992), but more careful approach employed in both DSM and ICD helps
controlled studies suggested that this list is address this issue, tensions do remain regarding
Comorbidity 761 C
issues of additional diagnoses for persons with implications for treatment (McDougle et al.,
autism. Other issues arise given the changes that 1995). However, as Baron-Cohen (1989)
occur with developmental level and age. Issues of observed, it does appear that it is not possible to
assessment are also a consideration, e.g., what simply equate ritualistic phenomena of autism
would it mean to assess thought disorder in with the obsessions and compulsions more typi-
a mute individual with autism? cal of OCD. Similarly reports of association with
Other issues arise given that diagnostic sys- Tourette’s syndrome (chronic motor and vocal C
tems like DSM-IV and ICD-10 strive for logical tics) are of interest although data on whether or
consistency in their approach, i.e., typically some not such associations are more likely than would
form of hierarchical process is used so as not to be expected based on chance alone have yet to be
reduce diagnosis entirely to the level of presence/ collected.
absence of individual symptoms, e.g., since In recent years, considerable interest has cen-
stereotyped behaviors are a diagnostic feature of tered on the association of autism with
autism, it seems nonsensical to also give ADD/ADHD and the possible implications of
a diagnosis of stereotyped movement disorder to such an association for treatment. Early views,
most people with autism. as in DSM-III-R, questioned this association
Given these considerations, it is important to given the high frequency of attention problems
interpret reported associations with some caution in children with autism (particularly for social
– particularly if the association is based on case tasks) and what appeared to be, in general,
reports in large part. That being said, it is the case a poor response to stimulant medications
that a veritable host of conditions have been although more recent research has questioned
reported in individuals with autism. These this view while also noting the potential for
include hyperactivity, obsessive-compulsive higher levels of adverse reactions in this popula-
phenomena, self-injury, tics, and affective symp- tion (Aman, Farmer, Hollway, & Arnold, 2008;
toms (Brasic et al., 1994; Ghaziuddin & Greden, Jahromi et al., 2009). The issue may have even
1998; Ghaziuddin & Tsai, 1991; Ghaziuddin greater importance among children with the
et al., 1992; 1995; Jaselskis, Cook, Fletcher, & broader autism spectrum (Barkley et al., 2002);
Leventhal, 1992; Kerbeshian, Burd, Randall, attempts have been made to delineate specific
Martsolf, & Jalal, 1990; McDougle et al., 1995; subgroups of cases with problems in social inter-
Realmuto & Main, 1982; Rapoport, Chavez, action and attention (and other features, e.g.,
Greenstein, Addington, & Gogtay, 2009; White Hellgren, Gillberg, Bagenholm, & Gillberg,
& Schry 2011). Particularly in older and more (1994)).
able individuals, the presence of anxiety and
mood problems is quite frequent (White &
Schry, 2011). On the other hand, some disorders, Future Directions
notably schizophrenia, do not appear to be signif-
icantly increased in samples of individuals with Clearly the issue of comorbidity is an important
autism (Volkmar & Cohen, 1991). one and one where our understanding is likely to
In some cases, possible associations might significantly shift with advances in research.
have significance for treatment. For example, Complications arise from the dual, and some-
given the use of new pharmacological treatments times competing, needs for research-based diag-
such as the SSRIs, a possible overlap of autism nostic approaches and one focused more on
with obsessive-compulsive disorder would be of service delivery. In the United States in particu-
interest. Clearly phenomena suggestive of obses- lar, issues of diagnosis may have very significant
sions or compulsions are frequent (although implications for eligibility for services. The abil-
highly variable depending on sample selected ity in the coming years to more robustly identify
(Baron-Cohen, 1989; Mack et al., 2010; Rumsey, end phenotypes may help resolve some of the
Rapoport, & Sceery, 1985) and may have issues.
C 762 Comorbidity
Issues of comorbidity have become more rel- Gillberg, C. (1992). Subgroups in autism: Are there
evant as overall outcome in autism has improved behavioural phenotypes typical of underlying medical
conditions? Journal of Intellectual Disability
(in part because it becomes easier to document Research, 36(Pt 3), 201–214.
comorbid conditions using more traditional and Goldstein, G., Allen, D. N., Minshew, N. J., Williams, D. L.,
conventional assessments). A growing awareness Volkmar, F., Klin, A., et al. (2008). The structure of
of this problem will likely produce a substantial intelligence in children and adults with high functioning
autism [Comparative Study Research Support, Non-U.S.
increase in work in this area in the future. Gov’t Research Support, U.S. Gov’t, Non-P.H.S.].
Neuropsychology, 22(3), 301–312.
Hellgren, L., Gillberg, I., Bagenholm, A., & Gillberg, C.
See Also (1994). Children with deficits in attention, motor con-
trol and perception (DAMP) almost grown up: Psychi-
atric personality disorders at age 16 years. Journal of
▶ Diagnosis and Classification Child Psychology & Psychiatry & Allied Disciplines,
▶ DSM-IV 35(7), 1255–1271.
▶ ICD 10 Research Diagnostic Guidelines Howlin, P. (2007). The outcome in adult life for people
with ASD. Autism and pervasive developmental disor-
▶ Secondary Handicapping Conditions ders (pp. 269–306). New York: Cambridge University
Press.
Jahromi, L. B., Kasari, C. L., McCracken, J. T., Lee, L. S. Y.,
References and Readings Aman, M. G., McDougle, C. J., et al. (2009). Positive
effects of methylphenidate on social communication
Aman, M. G., Farmer, C. A., Hollway, J., & Arnold, L. E. and self-regulation in children with pervasive devel-
(2008). Treatment of inattention, overactivity, and opmental disorders and hyperactivity [Randomized
impulsiveness in autism spectrum disorders [Research Controlled Trial Research Support, N.I.H., Extramural
Support, N.I.H., Extramural Review]. Child & Adoles- Research Support, Non-U.S. Gov’t]. Journal of Autism
cent Psychiatric Clinics of North America, 17(4), & Developmental Disorders, 39(3), 395–404.
713–738, vii. Jaselskis, C. A., Cook, E. H., Jr., Fletcher, K. E., &
Barkley, R. A., Cook, E. H., Dulcan, M., Campbell, S., Leventhal, B. L. (1992). Clonidine treatment of hyperac-
Prior, M., Atkins, M., et al. (2002). Consensus state- tive and impulsive children with autistic disorder. Jour-
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chiatry, 11(2), 96–98. Kerbeshian, J., Burd, L., Randall, T., Martsolf, J., & Jalal, S.
Baron-Cohen, S. (1989). Do autistic children have obses- (1990). Autism, profound mental retardation and atyp-
sions and compulsions? British Journal of Clinical ical bipolar disorder in a 33-year-old female with a
Psychology, 28(Pt 3), 193–200. deletion of 15q12. Journal of Mental Deficiency
Brasic, J. R., Barnett, J. Y., Kaplan, D., Sheitman, B. B., Research, 34(Pt. 2), 205–210.
Aisemberg, P., Lafargue, R. T., et al. (1994). Clomip- Lord, C., & Schopler, E. (1989). The role of age at assess-
ramine ameliorates adventitious movements and ment, developmental level, and test in the stability of
compulsions in prepubertal boys with autistic disorder intelligence scores in young autistic children. Journal
and severe mental retardation. Neurology, 44(7), of Autism and Developmental Disorders, 19(4),
1309–1312. 483–499.
Ghaziuddin, M., & Tsai, L. (1991). Depression in autistic Mack, H., Fullana, M. A., Russell, A. J., Mataix-Cols, D.,
disorder. British Journal of Psychiatry, 159, 721–723. Nakatani, E., & Heyman, I. (2010). Obsessions and
Ghaziuddin, M., Ghaziuddin, N., et al. (1992). Comorbidity compulsions in children with Asperger’s syndrome or
of autistic disorder in children and adolescents. Euro- high-functioning autism: A case-control study [Com-
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events and depression in children with pervasive McDougle, C. J., Kresch, L. E., Goodman, W. K.,
disorders. Journal of Autism and Developmental Naylor, S. T., Volkmar, F. R., Cohen, D. J., et al.
Disorders, 25(5), 495–502. (1995). A case-controlled study of repetitive thoughts
Ghaziuddin, M., & Greden, J. (1998). Depression in chil- and behavior in adults. American Journal of Psychia-
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a case–control family history study. Journal of Autism Rapoport, J., Chavez, A., Greenstein, D., Addington, A.,
and Developmental Disorders, 28(2), 111–115. & Gogtay, N. (2009). Autism spectrum disorders and
Ghaziuddin, M., Weidmer-Mikhail, E., & Ghaziuddin, N. childhood-onset schizophrenia: Clinical and biologi-
(1998). Comorbidity of Asperger syndrome: A prelim- cal contributions to a relation revisited. Journal of the
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Research, 42(4), 279–283. 48(1), 10–18.
Competitive Employment 763 C
Realmuto, G. M., & Main, B. (1982). Coincidence of in which individuals are compensated for their
Tourette’s disorder and infantile autism. Journal of work. The compensation paid must be at or
Rumsey, J. M., Rapoport, J. L., & Sceery, W. R. (1985). above the set minimum wage, but not less
Autistic children as adults: Psychiatric, social, and than the wages paid to individuals who are not
behavioral. Journal of the American Academy of disabled and performing work that is the
Child Psychiatry, 24(4), 465–473. same or similar. The individual must be
Rutter, M. (1994). Comorbidity: Meanings and mecha-
nisms. Clinical Psychology: Science and Practice, employed in an integrated setting in which C
1(1), 100–103. the individual has the ability to interact with
Rutter, M. (2006). Autism: its recognition, early diagno- individuals who are not disabled (NYSED.gov,
sis, and service implications. Journal of Developmen- 2011).
tal and Behavioral Pediatrics, 27(2 Suppl), S54–58.
Rutter, M., Bailey, A., Bolton, P., & Le Couteur, A.
(1994). Autism and known medical conditions: Myth
and substance. Journal of Child Psychology & Psychi- Historical Background
atry & Allied Disciplines, 35(2), 311–322.
Volkmar, F. R., & Cohen, D. J. (1991). Comorbid associ-
ation of autism and schizophrenia. The American Historically, competitive employment was not
Journal of Psychiatry, 148(12), 1705–1707. considered a likely outcome for individuals with
Volkmar, F. R., & Klin, A. (2005). Issues in the classifi- autism spectrum disorders (Wehman, Revell, &
cation of autism and related conditions, Vol 1. In Brooke, 2003). Typically, individuals with
F. R. Volkmar, A. Klin, R. Paul, & D. J. Cohen
(Eds.), Handbook of autism and pervasive develop- disabilities were placed in segregated or sheltered
mental disorders (pp. 5–41). Hoboken, NJ: Wiley. vocational settings in which they
Volkmar, F. R., & Woodbury-Smith, M. (2007). Clinical worked among other individuals with disabilities
diagnosis of autism. Clinical manual for the treatment only to be supervised by non-disabled
of autism (pp. 1–26). Arlington, VA: American Psy-
chiatric Publishing. individuals (Lutfiyya, Rogan, & Shoultz, 1988).
Volkmar, F. R. & Woolston, J. L. (1997). Comorbidity of These sheltered settings were considered to be
psychiatric disorders in children and adolescents. transitional with the hopes that most
ST- An Einstein psychiatry publication, No. 14. In individuals placed in these environments would
S. Wetzler & W. C. Sanderson (Eds.) Treatment strat-
egies for patients with psychiatric comorbidity transition into competitive employment.
(pp. 307–322). An psychiatry publication, No. 14. However, Taylor in 2002 noted that only 3.5%
New York: Wiley. of those placed in sheltered work environments
White, S. W., & Schry, A. R. (2011). Social anxiety move on to competitive employment in any sin-
in adolescents on the autism spectrum. Social
anxiety in adolescents and young adults: Translating gle year.
developmental science into practice (pp. 183–201). In the opening of the Americans with Disabil-
Washington, DC: American Psychological ities Act (ADA) in 1990, Congress notes that
Association. society has had a tendency to segregate individ-
uals in important areas such as employment and
therefore states that “no covered entity shall
discriminate against a qualified individual
Competitive Employment on the basis of disability in regard to job applica-
tion procedures, the hiring, advancement, or dis-
David J. Krainski charge of employees, employee compensation,
Vocational Independence Program, New York job training, and other terms, conditions, and
Institute of Technology, Central Islip, NY, USA privileges of employment” (ada.gov, retrieved
2011). The passage of the ADA was to bring
about a greater integration of individual with
Definition disabilities in the workplace. According to
Blanck (2008), discrimination of individuals
Competitive employment is work that with disabilities has been reduced and more
is performed on either a full- or part-time basis opportunities have opened.
C 764 Complete Agenesis
Current Knowledge See Also
Available statistics on employment by individ- ▶ Sheltered employment

uals with disabilities vary. However, the National ▶ Supported employment
Survey of Americans with Disabilities
(2010) reports that 21% of individuals with dis-
abilities aged 18–64 had been employed with References and Readings
59% of the general population maintaining
employment. Data specific to individuals with Americans with disabilities act of 1990, as amended.
(2008). Retrieved May 27, 2011, from http://www.
autism spectrum disorders (ASD) are harder to
ada.gov/pubs/adastatute08.htm
find, but the information that is available suggests Blanck, P. (2008). “The right to live in the world”:
that those with ASD are less likely to be disability yesterday, today and tomorrow. Texas
employed compared to other disability groups. Journal on Civil Liberties and Civil Rights, 13,
367–401.
In 2009, the National Longitudinal Transition
Dew, D. W., & Alan, G. M. (2007). Rehabilitation of
Study 2 had found the following as it relates to individuals with autism spectrum disorders (Institute
individuals with autism spectrum disorder and on Rehabilitation Issues Monograph no. 32). Washing-
employment (www.nlts2.org): ton, DC: The George Washington University,
Center for Rehabilitation Counseling Research and
• 32.5% of young adults with autism spectrum
Education.
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average of 59% of all respondents. ment of people with disabilities. In J. H. Stone & M.
• 47.7% of youth with autism spectrum Blouin (Eds.), International encyclopedia of rehabili-
tation. Retrieved May 27, 2011, http://cirrie.buffalo.
disorders had worked for pay in the past 2
edu/encyclopedia/en/article/123/
years versus an average of 78.4% of all Lutfiyya, Z. M., Rogan, P., & Shoultz, B. (1988).
participants. Supported employment: a conceptual overview. Center
• 29% of young adults with autism spectrum on Human Policy, Syracuse University, Syracuse, NY.
Retrieved May 27, 2011, from http://thechp.syr.edu/
disorders were looking for work if currently
workovw.htm
unemployed compared to 47.7% of all New York State Education Department, ACCES-VR.
participants. (2003). Employment outcome policy (010.00P:
The study does not specify if those surveyed Employment Outcome Procedure), Albany, NY.
Retrieved May 27, 2011, from http://www.acces.
are in a competitive employment situation or
nysed.gov/vr/current_provider_information/vocational_
not. However, it is important to note that individ- rehabilitation/policies_procedures/0010_employment_
uals that are in competitive employment work a outcome/policy.htm#Definitions
greater number of hours per week and earn more Schaller, J., & Yank, N. K. (2005). Competitive employ-
ment for people with autism: correlates of successful
per week than individuals in noncompetitive closure in competitive and supported employment.
employment (Schaller & Yank, 2005). Rehabilitation Counseling Bulletin, 49(1), 4, 13.
Even though there is great benefit to the indi- Taylor, S. J. (2002, September 2). Disabled workers
vidual to be working in a competitive employ- deserve real choices, real jobs. Retrieved May 27,
2011, from http://www.accessiblesociety.org/topics/
ment situation, only about 15% of individuals
economics-employment/shelteredwksps.html
were doing so (Wehman et al., 2003). The rest Wehman, P., Revell, W. G., & Brooke, V. (2003).
were in a number of day habilitation services Competitive employment: has it become the: “first
that were noncompetitive, and oftentimes, these choice” yet? Journal of Disability Policy Studies,
14(3), 163–173.
individuals were not integrated with the
community.
Current research indicates that individuals
with ASD can work in a variety of community-
based businesses. However, majority of individ- Complete Agenesis
uals on the spectrum currently remain unem-
ployed (Dew & Alan, 2007). ▶ Agenesis of Corpus Callosum
Comprehensive Assessment of Spoken Language 765 C
language across contexts. The results of the
Complete Exhaustion CASL assessment provide value in measuring
linguistic skill among children with language
▶ Posttraumatic Stress Disorder delays and disorders as well as the competence
of individuals who are learning English as
a second language.
Each of the 15 CASL tests is constructed dif- C
®
Compoz Nighttime Sleep Aid [OTC] ferently and measures different aspects of oral
language. First, the Lexical/Semantic tests assess
▶ Diphenhydramine knowledge and use of words and word combina-
tions through five tests. Comprehension of Basic
Concepts measures the ability of young children
to comprehend words representing basic percep-
Comprehension tual and conceptual relations. Antonyms assesses
expression of a word that has the opposite mean-
▶ Listening Comprehension ing of a given word. Synonyms assesses the abil-
▶ Receptive Language ity to identify a word with the same meaning as
a given word. Sentence Completion measures the
ability to retrieve and express one of the few
appropriate words that fit the meaning of spoken
Comprehensive Assessment of sentence. Idiomatic Language measures the
Spoken Language expressive knowledge of a group of words that,
when used together, have a conventional mean-
Kristin Ratliff ing different from the literal meaning of the indi-
Research & Development vidual words.
Western Psychological Services, Torrance, Next, there are five Syntactic tests that assess
CA, USA knowledge and use of grammar (morphology and
syntax). Syntax Construction assesses the ability
to generate sentences using a variety of
Synonyms morphosyntactic rules. Paragraph Comprehen-
sion measures the comprehension of syntax
CASL through a series of narratives spoken by the
examiner. Grammatical Morphemes measures
the metalinguistic knowledge of the form and
Description meaning of the English language. Sentence Com-
prehension measures the ability to comprehend
The CASL is an oral language assessment battery meaning of the syntactic-structure organization
for individuals aged 3–21 years and is based on of sentences. Grammaticality Judgment assesses
a comprehensive theory of language. Consisting the ability to recognize and correct grammatical
of 15 tests, the CASL measures auditory compre- errors within sentences.
hension, oral expression, and word retrieval Then, four Supralinguistic tests measure com-
processes in four linguistic categories: Lexical/ prehension of complex language in which the
Semantic, Syntactic, Supralinguistic, and meaning is not directly available from lexical or
Pragmatic. The CASL battery provides an in- grammatical information. Nonliteral Language
depth evaluation of oral language processing measures the ability to comprehend figurative
systems, knowledge and use of grammatical speech, indirect requests, and sarcasm. Meaning
structures, ability to use language requiring from Context measures inference ability that does
higher-level processing, and adaptation of not require the examinee to use world knowledge.
C 766 Comprehensive Assessment of Spoken Language
Inference assesses the ability to integrate appro- each individual test, and starting pages
priate world knowledge that is not explicitly are marked for the appropriate age ranges. The
stated with information provided by the speaker. manual also provides procedural information,
Ambiguous Sentences assesses the ability to com- interpretation of the results specific to each of
prehend multiple meanings given sentences the 15 CASL tests, and technical properties
containing elements that can be interpreted in such as the description of test development, stan-
more than one way. Finally, Pragmatic Judgment dardization, reliability, and validity data.
measures awareness of the appropriateness of A separate Norms Book contains all the norma-
language and ability to modify language in relative tables for the CASL in order to convert raw
tion to the situation in which it is used. scores to standard scores and provides signifi-
The CASL is individually administered and cance values for comparing differences between
requires no reading or writing on part of the tests scores.
examinee. Each test can stand alone, and each
score can be reported as a standard score (mean of
100, standard deviation of 15, range of 40–160), Historical Background
percentile, normal curve equivalent (NCE), sta-
nine, and test-age equivalent. These scores allow Originally published in 1999, the CASL was
each test to be compared with every other test, developed by author Dr. Elizabeth Carrow-
both within a category and between categories, as Woolfolk as a comprehensive test of oral
well as between tests of comprehension, expres- language based on her Integrative Language
sion, and retrieval. Additionally, a global mea- Theory, ILT (Carrow-Woolfolk, 1988, 1994;
sure of oral language can be calculated from Carrow-Woolfolk & Lynch, 1981). ILT com-
a subset of representative tests to derive a CASL bines and relates the linguistic, cognitive, and
Core Composite. Examiners may also administer pragmatic aspects of language, which forms the
all of the tests appropriate for the child’s age to basis for the classification of the CASL tests. In
use as a comprehensive battery. Depending on this view, a comprehensive understanding of lan-
the students’ age, Index Scores may be computed guage must take into account both the meaning of
as representative measures of language catego- language and its form.
ries (Lexical, Syntactic, Supralinguistic; The content of language conveys meaning and
available for ages 7–21) and processing (Expres- is largely dependent on substantive words and
sive, Receptive; available for ages 7–10). Admin- word combinations. Words that refer to
istration time varies based on the examinee’s age a relatively specific category of things are con-
and the number of tests administered. When sidered lexical morphemes (vocabulary).
administering the Core Battery tests only, it Throughout the CASL, the term “semantics” is
takes approximately 30 min to test children used to describe the content of only the lexical
aged 3–5 years and 45 min to 1 h for older morphemes of language. Conversely, language
examinees. can be more abstract with a general meaning
The CASL has two record forms: Record that refers to a wide range of things (pronouns,
Form 1 is appropriate for children 3–6 years, prepositions). These are considered grammatical
and Record Form 2 is for those 7–21 years. morphemes (functors and inflections) which
Three self-standing test easels contain all of the along with syntax (word order and structure of
picture stimuli and item text, as well as adminis- language) represent the form or structure of the
tration and scoring procedures for each test. Gen- language.
eral testing information is provided in the easels Language can be ambiguous when word con-
as well, such as basal and ceiling criteria, allow- structions have multiple interpretations. Often an
ance of item repetition if the examinee appears to individual must use inference or contextual infor-
not understand the task, and prompting guide- mation to interpret an underlying nonliteral
lines for specific tests. Test easels are tabbed for meaning of language. This type of nonliteral
Comprehensive Assessment of Spoken Language 767 C
language is labeled supralinguistic, which rely on one another for meaning evolves gradu-
implies that the interpretation of an utterance ally, once the use of basic elements has matured.
extends beyond the literal meaning and requires The CASL procedures and content reflect the
higher-level analysis to comprehend. This cate- two distinct dimensions of language: knowledge
gory of language emerges later in development (structure, form, and content of language) and
and is an integral component in measuring lin- performance (internal systems used to compre-
guistic skill during adolescence. Additionally, the hend and express language). As a result, the C
relation of form and meaning is significantly CASL separates listening comprehension
influenced by context including social variables (Receptive Index) from oral expression (Expres-
(setting, age, relationship), linguistic variables sive Index). Although these two major processes
(type of discourse-conversation, a narrative, of language have common elements (e.g., they
a lecture), and personal variables (intention, both draw upon the same basic knowledge of
motivation, knowledge, and style of the sender). language structure and meaning), there is empir-
These contextual aspects of communication are ical evidence for their distinction (Carrow-
considered pragmatic and can affect not only the Woolfolk, 1985).
manner in which language is expressed but also
how it is interpreted.
The categorization of CASL tests follows the Psychometric Data
structure of the ILT. Lexical/Semantic tests
address the meaning of language (Basic Con- In developing the CASL, Dr. Woolfolk created
cepts, Antonyms, Synonyms, Sentence Comple- items that would elicit information not only about
tion, Idioms). The Syntactic tests address an individual’s language knowledge and compe-
meaning derived from the structure of language tency but the individual’s use of language and
(Syntax Construction, Paragraph Comprehen- functionality of communication as well. Initial
sion, Grammatical Morphemes, Sentence Com- items were piloted in 1992, and normative data
prehension, Grammaticality Judgment). The were collected between 1996 and 1997. The
Supralinguistic tests measure understanding and CASL was normed on a nationwide standardiza-
use of complex meanings that require analysis tion sample of 1,700 individuals, 3–21 years,
above that of lexical and syntactic meaning which matched the most current US Census data
(Nonliteral Language, Meaning from Context, (1994 Current Population Survey) on gender,
Inference, Ambiguous Sentences). The Prag- race/ethnicity, region, and mother’s educational
matic test measures understanding of language level. Additionally, CASL sampling procedures
that is dependent on context and social under- drew children from public and private schools
standing (Pragmatic Judgment). without respect to special education status. As
The theoretical distinction of these categories a result, children receiving various special edu-
is reflected in the developmental literature as cation services were represented in the normative
well. Children begin to use language at a lexical sample in approximately the same proportions
level and proceed to using two-word phrases and that occur in the US school population. The fol-
simple morphemes, such as prepositions. Gradu- lowing five major special education categories
ally, utterances lengthen by the addition of com- were included: Specific Learning Disability
plex morphemes and the use of structurally (3.4% of CASL sample), Speech or Language
advanced syntax, such as noun and verb agree- Impairments (1.5%), Mental Retardation
ment. Eventually children can adapt their lan- (0.6%), Emotional Disturbance (0.3%), and
guage to the needs and demands of the Other Impairments (0.4%).
environment. Only then do children begin to The CASL tests, Index Scores, and Core Com-
comprehend and express nonliteral language posites have high internal consistency and test-
and idioms. Comprehension and expression of retest reliabilities. Item analyses, including Rasch
complex language in which the utterance units scaling methods, were utilized to obtain the final
C 768 Comprehensive Assessment of Spoken Language
test items. For each age band (12 groups), all of contrast, the Language Delay, Language Impair-
the Core Composite reliabilities are in the .90s, ment, Emotional Disturbance, and both Learning
and the indexes range from.85 to .96. Test-retest Disability groups scored significantly lower than
reliability was assessed by administering the their matched control groups. Adolescents with
CASL twice (median 6 week interval) to 148 mild mental retardation scored approximately
randomly selected examinees in three age groups: two standard deviations below the mean on all
5–0 to 6–11 (41 cases), 8–0 to 10–11 (38 cases), CASL tests. For Hearing Impairment, the clinical
and 14–0 to 16–11 (69 cases). Results suggest group scored lower on all CASL tests (e.g., about
only a minor practice effect and provide strong one standard deviation below the mean); how-
evidence of the stability of CASL scores. ever, interpretation is limited due to a small sam-
Five criterion-related validity studies and ple size for this group.
eight clinical validity studies were conducted
during standardization, with over 600 partici-
pants. In the first group of studies, CASL scores Clinical Uses
were compared with four measures of oral
language (Test for Auditory Comprehension of The CASL can assist speech/language patholo-
Language-Revised [TACL-R]; Listening gists, psychologists, educational diagnosticians,
Comprehension and Oral Expression Scales of early childhood specialists, and other profes-
the Oral and Written Language Scales [OWLS]; sionals in measuring oral language processing
Peabody Picture Vocabulary Test, Third skills and knowledge in preschoolers through
Edition [PPVT-III]; Expressive Vocabulary Test young adults. The age-based norms are useful in
[EVT]) and a measure of cognitive ability (Kauf- identifying language impairments to meet the
man Brief Intelligence Test [K-BIT]). The requirements of Public Law 94-142 (now incor-
highest overall correlations are with the OWLS, porated into the Individuals with Disabilities
which assesses the same four linguistic categories Education Act [IDEA] reauthorized as Public
as the CASL. While the OWLS assessment has Law 105-17). Further, CASL standard scores
a wide-range approach, the CASL allows for an can be directly compared with many other tests
in-depth study of specific skills. For the clinical when using the available standard scores based
validity studies, performance of eight different on the common metric scale (mean of 100, stan-
clinical groups was examined: Speech Impair- dard deviation of 15).
ment, Language Delay, Language Impairment, The CASL assists clinicians in understanding
Mental Retardation, Learning Disability (Read- the relation between an individual’s score and
ing), Learning Disability (Undifferentiated), any delays or disorders in language. The presence
Emotional Disturbance, and Hearing Impair- of poor performance in one or more of the lan-
ment. Each clinical case was matched with guage categories may be indicative of a language
a case from the standardization sample on the disorder. Further, a significant discrepancy in
following variables: age, gender, race/ethnicity, performance among the categories may indicate
and SES as measured by the mother’s education a problem. For example, comparisons can be
level. Children in the matched control made between receptive and expressive tasks or
groups were not receiving any special services. between tasks highly dependent on retrieval and
The manual includes tables reporting the mean those that are not. In-depth qualitative informa-
and standard deviation of each clinical group tion from the CASL may also be used to identify
and the matched control groups as well as the the possibility of a disorder even though the
significance value of the difference between quantitative level of performance is not atypical.
groups. Clinicians are also able to create a profile of an
In general, the clinical group scored about the examinee’s oral language strengths and weak-
same as the control group on most of the CASL nesses across distinct categories of language.
tests for the Speech Impairment group. In The CASL can also provide a record of growth
Comprehensive Transition Program 769 C
in language skills and knowledge across a broad spectrum disorders: A comparison of a standard mea-
time span (3–21 years) through using the same sure with parent report. Communication Disorders
Quarterly, 29, 169–176.
instrument.
Communication deficits are often associated
with autism spectrum disorders (ASD). The
CASL can provide clinicians with in-depth
information about an individual’s knowledge C
and use of language, which may help to identify Comprehensive Transition Program
problem areas associated with ASD. For
example, the CASL can be used to identify defi- Paul Cavanagh
cits in expressive compared to receptive language New York Institute of Technology, Central Islip,
as well as problems in the use of language (e.g., NY, USA
pragmatics) as opposed to the content or form of
language (lexical/semantic and syntactic).
This may be particularly useful for high- Definition
functioning ASD individuals who often have
advanced lexical/semantic knowledge and syn- A Comprehensive Transition and Postsecondary
tactic skills, but relatively poor pragmatic skills Program is a college-based program for students
associated with difficulties in social interaction with an intellectual disability defined and created
(Paul & Wilson, 2009). Recent evidence suggests by the enacting of Public Law 110–135: the
that the Pragmatic and Supralinguistic areas Higher Education Opportunities Act (HEOA,
of the CASL are useful particularly in 2008). As defined in the law, a Comprehensive
documenting the difficulties that individuals Transition and Postsecondary Program is
with ASD have in communicating flexibly across “designed to support students with intellectual
contexts (Reichow, Salamack, Paul, Volkmar, & disabilities who are seeking to continue aca-
Klin, 2008). demic, career and technical, and independent liv-
ing instruction at an institution of higher
education in order to prepare for gainful employ-
ment” (HEOA, sec. 760). Such a program must
be offered by an institution of higher education
Carrow-Woolfolk, E. (1985). Test for Auditory Compre- and have an advising and curriculum structure.
hension of Language-Revised (TACL-R). Allen, TX: The curriculum must provide for the students
DLM Teaching Resources. with an intellectual disability to spend at least
Carrow-Woolfolk, E. (1988). Theory, assessment, and
one-half of their time on academic components
intervention in language disorders: An integrative
approach. Philadelphia: Grune & Stratton. with nondisabled individuals.
Carrow-Woolfolk, E. (1994). Learning to read: An oral A Comprehensive Transition and Postsecondary
language perspective of beginning reading. San Program is a program based at a college or technical
Antonio, TX: The Psychological Corporation.
school to assist students with an intellectual
Carrow-Woolfolk, E. (1999/2008). Comprehensive
assessment of spoken language. Los Angeles: Western disability, transitioning out of secondary educa-
Psychological Services. tion, who are not yet ready to enter the workforce
Carrow-Woolfolk, E., & Lynch, J. I. (1981). An integra- or to enroll full-time in a college or technical
tive approach to language disorders in children. San
school. The programs are designed to provide
Antonio, TX: The Psychological Corporation.
Paul, R., & Wilson, K. P. (2009). Assessing speech, lan- the necessary instruction and support in social
guage, and communication in autism spectrum functioning and independent living skills to
disorders, Ch. 7. In S. Goldstein, J. A. Naglieri, & S. enable the student to prepare for gainful
Ozonoff (Eds.), Assessment of autism spectrum
employment.
disorders (pp. 171–208). New York: Guilford Press.
Reichow, B., Salamack, S., Paul, R., Volkmar, F. R., & Institutions of higher education must apply to
Klin, A. (2008). Pragmatic assessment in autism the United States Department of Education in
C 770 Compulsiveness
order to have their program approved as

a Comprehensive Transition and Postsecondary Computed Axial Tomography (CAT)
Program. In order to be eligible to apply for
approval, the institution of higher education ▶ Computed Tomography
must already be approved to administer
Federal Financial Aid for its students. A student
enrolled in an approved Comprehensive Transi-
tion and Postsecondary Program is eligible for
Federal financial assistance under the Federal Computed Tomography
Pell Grant, Federal Supplemental Education
Opportunity Grants (FSEOG), and Federal Kevin A. Pelphrey
Work Study (FWS) programs. As opposed to Child Study Center, Yale University School of
the general requirements for a postsecondary stu- Medicine, New Haven, CT, USA
dent to be eligible for federal financial aid,
a student with an intellectual disability in an
approved transition program does not have to be Synonyms
enrolled for the purpose of obtaining a degree or
certificate and the student is not required to have Computed axial tomography (CAT); CT; X-ray
a high school diploma, a recognized equivalent of computed tomography
a high school diploma, or have passed an ability
to benefit test. However, the student must
be making satisfactory progress according to the Definition
institution’s published standards for students
enrolled in its comprehensive transition and Computed tomography is a medical imaging
postsecondary programs (34 CFR, } 668.233). method employing tomography created by
computer processing of X-ray images. A form
of digital geometry processing is used to generate
See Also a three-dimensional image of the inside of an
object from a large series of two-dimensional
▶ Individualized Transition Plan (ITP) X-ray images taken around an axis of rotation.
▶ Individuals with Disabilities Education Act This volume of data can then be manipulated via
(IDEA) computer algorithm to observe and measure
▶ Intellectual Disability bodily structures (including brain structures)
▶ Transition Planning based on their ability to block the X-ray beam.
▶ Transitional Living This was one of the first techniques available to
neuroscientists to study the structure of the living
human brain. As such, it was one of the first
References and Readings techniques to be used to study brain structure in
individuals with autism providing some of the
Higher Education Opportunities Act, Pub. L. No. 110–135 earliest insights into the neural systems affected
} 760, 34 CFR subpart O } 668.230–233.
by autism.
Compulsiveness See Also
▶ Perfectionism ▶ Magnetic Resonance Imaging

Computer-Based Intervention Assistive Technology 771 C
References and Readings regarding computer-based technology was
anecdotal and not systematic. These interven-
Damasio, H., Maurer, R. G., Damasio, A. R., & Chui, tions focused on learning a computer language
H. C. (1980). Computerized tomographic scan findings
(Goldenberg, 1979), playing a computer
in patients with autistic behavior. Archives of
Neurology, 37(8), 504–510. game (Frost, 1981), responsiveness (Geoffrion
Harcherik, D. F., Cohen, D. J., Ort, S., Paul, R., & Goldenberg, 1981), attention (Pleinis &
Shaywitz, B. A., Volkmar, F. R., et al. (1985). Romanczyk, 1983), and social skills (Panyan, C
Computed tomographic brain scanning in four
McGregor, Bennett, Rysticken, & Spurr, 1984).
neuropsychiatric disorders of childhood. American
Journal of Psychiatry, 142(6), 731–734. By the mid 1990s, approximately 45 commer-
cially available software programs were marketed
for children and young adults with autism. These
programs were created by a small number of
Computer-Based Intervention developers to target cause and effect and language
Assistive Technology and cognitive development. Higgins and Boone
(1996) described best practices for the creation of
Vannesa T. Mueller software for individuals with autism. The authors
Speech-Language Pathology Program, noted that the symptoms of autism manifest differ-
University of Texas at El Paso College of Health ently in each individual, so they encouraged edu-
Science, El Paso, TX, USA cators and others working with students with
autism to create their own computer-based inter-
ventions to implement specific strategies that are
Definition known to work with the students. Eighteen soft-
ware guidelines were provided for those who
Computer-based interventions are those that use wished to create software for children with autism.
technology in some form to provide an interac- The guidelines cover many aspects of software
tive, multisensory learning experience. Also design such as age appropriateness and principles
called computer-assisted instruction (CAI), this of repeated practice. Additionally, Higgins and
form of intervention is used to present informa- Boone (1996) provided tips and strategies related
tion, allow a user to practice certain skills repeat- to creating software for children with autism.
edly, or to test knowledge or comprehension. Recently, the field of computer-based inter-
ventions has seen a steady growth in the quantity
and creativity applied to this population. Virtual
Historical Background reality technology has been utilized to address
social difficulties and pragmatic impairments
Computers have been used with individuals with typically seen in individuals with autism (Self,
autism since the 1970s. Colby (1973) used Scudder, Weheba, & Crumrine, 2007), an elec-
a computer and keyboard to increase the sponta- tronic tutor has been developed to aid in vocabu-
neous verbalizations of children with autism. It lary development (Bosseler & Massaro, 2003),
was the intent of the researcher to allow the and robots have been created to target social
children to engage in free play with the computer interactions and joint attention (Robins,
system that was designed to say the names of Dautenhahn, Boekhorst, & Billard, 2005; Robins,
the letters the children typed or provide some Dickerson, Stribling, & Dautenhahn, 2004).
kind of visual reinforcer when a letter was Additionally, with the fervor over the Apple
typed. Thirteen out of the 17 participants in the IPod touch, IPad, and approximately 350,000
study showed increased language after the ther- apps that are available, much attention and spec-
apy. Throughout the rest of the 1970s and early ulation has been focused on the use of this new
1980s, most of the evidence that was published technology. GeekSLP.com is a blog designed for
C 772 Computer-Based Intervention Assistive Technology
speech-language pathologists focused on tech- case, the software is a tool to be used as part of
nology use. There is also a GeekSLP a rehabilitation package. It is the responsibility of
app available for the IPad which helps identify the intervener to help the individual with autism
apps that are appropriate for use by speech- to generalize the skills learned and practiced.
language pathologists in the clinical setting.
Treatment Participants
Due to their versatility, ability to be individual-
What human beings lack in patience, predictabil- ized, and recent availability (related to smaller
ity, and consistency computers make up for. size and lower price), computers and technology
Microcomputers were introduced in the interven- are being used to a much greater extent today than
tions of children with autism due to the finding ever before. Technology is a mainstay of the
that children with autism spent a large amount of general education curriculum as well as the
time playing with machines compared to playing special education curriculum. Because of this,
with human beings (Colby, 1973). Computer- computer-based interventions could be appropri-
based interventions have the ability to control ate for any individual.
where and how stimuli are presented to help
children with autism compensate for attentional
difficulties and problems with filtering tangential Treatment Procedures
or unnecessary information. Difficulty with
unpredictability is a common symptom of autism. The specific procedures vary by the computer-
Computer-based instruction can vary a routine or based intervention. Due to the variety of pro-
program in very small increments, helping an grams available and the myriad of difficulties
individual with autism to accept these changes they target, generalizations regarding treatment
and build tolerance for change. See Panyan procedures cannot be made.
(1984) for a discussion on the early rationale for
computer-based instruction for children with
autism. More recently, Blischak and Schlosser Efficacy Information
(2003) have argued that computer-based inter-
ventions can contribute in unique ways to the Computers have been used successfully in inter-
services provided to individuals with autism due ventions with individuals with autism (Chen &
to the cognitive styles and learning preferences of Bernard-Opitz, 1993; Colby, 1973; Higgins &
the population. Boone, 1996). Computers are predictable, cueing
can be systematically removed to promote inde-
pendence in a skill, and an individual can practice
Goals and Objectives skills in an environment which is nonjudgmental.
These factors have increased the likelihood of the
The goals of computer-based intervention are as success of an intervention which utilizes some
varied as the purposes for them. Recently, kind of computer-based intervention. The out-
a computer-based intervention can be found for come of research that compares computer-based
nearly every area of difficulty afflicting individ- intervention with teacher-based intervention
uals with autism from vocabulary to attention to favors computer-based intervention (Bernard-
pragmatic abilities. The ultimate goal for these Opitz, Ross, & Tuttas, 1990). Compared with
programs could be generalization of the skills traditional instruction, children with autism
learned to the individuals’ natural environment. have been shown to attempt more responses,
However, some programs aim at allowing the answer more questions correctly, and had
individual user practice at a certain skill. In this improved behavior and developed better literacy
Computer-Based Intervention Assistive Technology 773 C
skills with a treatment that consisted of effectiveness of the tool. Speech-language
computer-based instruction (Chen & Bernard- pathologists, occupational therapists, special
Opitz, 1993; Heimann, Nelson, Tjus, & Gillberg, educators, and autism specialists are all trained
1995). in the use of these types of tools and can help with
An underlying question in the above studies knowing which computer-based interventions
pertained to generalization. Can an individual would be most appropriate. These intervention-
with autism transfer the skills learned from ists can also help with monitoring the outcomes C
a computer-based intervention to real life? of the intervention and will know how quickly
A computer-based intervention used by Hertzroni cues and prompts can be faded to result in the
and Tannous (2004) was shown to generalize to most efficient and effective treatment.
the children’s natural classroom environment.
After children with autism were exposed to the
computer-based intervention that focused on See Also
the use of relevant utterances and reduction of
the amount of echolalic utterances, the children ▶ Academic Supports
produced more relevant speech and reduced the ▶ Education
number of immediate echolalic utterances
(Hertzroni & Tannous, 2004). A review of com-
puter-based intervention was recently published References and Readings
by Pennington (2010). In that review, the results
of 15 studies showed that targeted academic skills Bernard-Opitz, V., Ross, K., & Tuttas, M. L. (1990).
Computer assisted instruction for autistic children.
were acquired by the participants with autism
Annals of the Academy of Medicine, 19, 611–616.
spectrum disorders. Pennington (2010) concludes Blischak, D. M., & Schlosser, R. W. (2003). Use of tech-
that computer-based instruction is a promising nology to support independent spelling by students
area of intervention for this population. with autism. Topics in Language Disorders, 23,
293–304.
Bosseler, A., & Massaro, D. (2003). Development and
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Outcome Measurement lary and language learning in children with autism.
653–672.
Generalization of the target skills acquired from
Chen, S. H., & Bernard-Opitz, V. (1993). Comparison of
computer-based intervention to a naturalistic set- personal and computer-assisted instruction for chil-
ting is what should be measured as the outcomes dren with autism. Mental Retardation, 31, 368–376.
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treatment of language difficulties in non-speaking
tant for individuals to be able to acquire and
autistic children. Journal of Autism and Childhood
practice skills in the relative safety of a computer Schizophrenia, 3, 254–260.
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to use the skills in their everyday lives. for autistic children. In Proceedings of The Johns
Hopkins First National Search for Applications
of Personal Computing to Aid the Handicapped.
Los Angeles: IEEE Computer Society.
Qualifications of Treatment Providers Geoffrion, L. D., & Goldenberg, E. P. (1981). Computer-
based learning systems for communication-
handicapped children. Journal of Special Education,
Many of the commercially available computer- 15, 325–332.
based intervention software packages are easy to Goldenberg, E. P. (1979). Special technology for special
install and, their use is fairly intuitive. However, children. Baltimore: University Park Press.
for the computer-based intervention to truly have Heimann, M., Nelson, K. E., Tjus, T., & Gillberg, C.
(1995). Increasing reading and communication skills
an impact on the language or cognitive skills of
in children with autism through an interactive multi-
an individual with autism, a trained intervention- media computer program. Journal of Autism and
ist should prescribe their use and oversee the Developmental Disorders, 25, 459–480.
C 774 COMT
Hertzroni, O. E., & Tannous, J. (2004). Effects of

a computer-based intervention program on the com- Conduct Disorder
municative functions of children with autism. Journal
Higgins, K., & Boone, R. (1996). Creating individualized Ricardo Canal
computer assisted instruction for students with autism Clinical Psychology Department,
using multimedia authoring software. Focus on Autism University Institute on Community
and Other Developmental Disabilities, 11, 69–78.
Panyan, M. V. (1984). Computer technology for autistic Integration Universidad de Salamanca,
students. Journal of Autism and Developmental Salamanca, Spain
Disorders, 14, 375–382.
Panyan, M., McGregor, G., Bennett, A., Rysticken, N., &
Spurr, A. (1984). The effects of microcomputer
based instruction on the academic and social progress Synonyms
of autistic students. Paper presented at the CEC Tech-
nology in Special Education Conference, Reno, Behavioral disorder; Challenging behavior; Dis-
Nevada. ruptive behavior; Dissocial behavior; Problem
Pennington, R. C. (2010). Computer-assisted instruction
for teaching academic skills to students with autism behavior
spectrum disorders: A review of literature. Focus on
Autism and Other Developmental Disabilities, 25,
239–248. Short Description or Definition
Pleinis, A., & Romanczyk, R. G. (1983). Computer
assisted instruction for atypical children: Attention, per-
formance, and collateral behavior. Paper presented at the Conduct disorder (CD) is a behavioral distur-
Applied Behavior Analysis Conference, Milwaukee, WI. bance occurring in childhood and adolescence
Robins, B., Dautenhahn, R., Boekhorst, R. T., & characterized by a persistent and repetitive pat-
Billard, A. (2005). Robotic assistants in therapy
and education of children with autism: Can a small tern of behavior that violates the basic rights of
humanoid robot help encourage social interaction others or major age-appropriate societal rules.
skills? Universal Access in the Information Society, CD involves a number of problematic behaviors,
4, 105–120. including oppositional and defiant behaviors, and
Robins, B., Dickerson, P., Stribling, P., & Dautenhahn, K.
(2004). Robot-mediated joint attention in children antisocial activities (e.g., lying, stealing, running
with autism. Interaction Studies, 5, 161–198. away from home, truancy, physical aggression,
Self, T., Scudder, R. R., Weheba, G., & Crumrine, D. and coercive behaviors).
(2007). A virtual approach to teaching safety skills to People with autism spectrum disorders (ASD)
children with autism spectrum disorders. Topics in
Language Disorders, 27, 242–253. may have several problematic behaviors that
are also found in people with CD, such as hyper-
activity, impulsivity, aggression, difficulty with
following directions or being cooperative, and
COMT both conditions may share other features such as
deficit in attributing mental states, poor verbal
▶ Catechol-O-Methyltransferase abilities for describing affective states, or
reduced pragmatic skills. It is, however, rare
that both conditions occur together (i.e., as
comorbid conditions) (Simonoff et al., 2008).
While presenting problematic behavior in indi-
Conceptually Accurate Signed viduals with CD is considered to arise from
English (CASE) abnormal learning, problematic behavior of indi-
viduals with ASD can be explained by their dif-
▶ Manual Sign ficulties in developing social and communicative
▶ Sign Language skills.
Conduct Disorder 775 C
Categorization dimensions. The overt-nondestructive cluster
reflected the criteria for ODD, whereas the other
CD is classified in the Diagnostic and Statistical three clusters, with features more indicative of
Manual of Mental Disorders, Fourth Edition property and status violations, represented CD
(DSM-IV TR) (American Psychiatric Associa- symptoms (see Fig. 2).
tion [APA], 2000) within the Attention-Deficit For diagnosis of CD, the individual must have
and Disruptive Behavior Disorders group, which presented in the past 12 months “a repetitive and C
also includes Oppositional Defiant Disorder persistent pattern of behavior in which the basic
(ODD), Attention Deficit Hyperactivity Disorder rights of others or major age-appropriate societal
(ADHD), and Disruptive Behavior Disorder Not norms or rules are violated” (APA, 2000). Behav-
Otherwise Specified (see Fig. 1). However, the iors that must be present fall into the following
International Statistical Classification of Dis- four categories of aggressive behavior:
eases (ICD-10) (World Health Organization 1. Aggressive acts toward people or animals
[WHO], 1992) categorizes the ODD as 2. Destruction of property
a particular form of CD, usually occurring in 3. Deceit or theft
younger children, primarily characterized by 4. Violation of rules
markedly defiant, disobedient, disruptive behav- At least one of the above criteria must have
ior that does not include delinquent acts or the been presented during the last 6 months. More-
more extreme forms of problem behavior. On the over, the disturbance in behavior must cause clin-
other hand, dimensional classification systems, ically significant impairment in social, academic,
based on studies of factor analysis to cluster spe- or occupational functioning.
cific behavioral symptoms, place both disorders The age of onset determines the type of CD
within the group of externalizing disorders (see Fig. 1), and the severity depends on the
(Achenbach & Rescorla, 2001). damage caused to others. The behaviors that
There are several reasons for classifying CD characterize a mild severity include lying, tru-
and ODD as two different categories of disorders. ancy, and running away at night without permis-
First, age of onset for ODD (usually before age 8) sion. Moderate severity may include acts of
is always at an earlier age than the onset of CD, vandalism and theft without confrontation.
which can have a childhood onset (if at least one Severe cases include forced sex; physical cruelty;
symptom is present before 10 years old) or an and use of a weapon and breaking and entering.
adolescent onset (if no behavioral problems occur Recent studies indicate that a significant pro-
before the age 10). The second reason is that only portion of children with ASD may also be char-
a small group of children with ODD will develop acterized with ODD symptoms. For example, two
CD at later ages. Finally, the third reason is that, recent studies found that the percentage of chil-
although both disorders share behavioral charac- dren with ASD who meet DSM-IV criteria for
teristics of aggressiveness, aggressive behaviors ODD is 13% in the age group of 3–5 years and
are qualitatively different for each type of disor- 27% in the age group of 6–12 years according to
der. This distinction has been demonstrated by parental ratings, and when rates from teachers
Frick and colleagues (1993) who showed that CD were considered the numbers were 21% and
and ODD can be differentiated from 25% respectively (Gadow, DeVincent, Pomeroy,
a dimensional point of view. They conducted & Azizian, 2004, 2005).
a meta-analysis with 60 factors identifying two Problem behaviors that are most often identi-
bipolar dimensions: “destructive-nondestructive” fied in individuals with ASD are physical aggres-
behaviors and “overt-covert” behaviors. They sion, self-injury, destruction of property, arguing
concluded that most conduct problems could be nature, temper tantrums, and disruption. But
classified within these two orthogonal other behaviors, such as explosive behavior,
C 776 Conduct Disorder
DSM-IV
Attention-Deficit and Disruptive Behavior Disorders
Attention-Deficit Oppositional Disruptive Behavior

Conduct Disorder
Hyperactivity Defiant Disorder Disorder Not
(CD)
Disorder (ADHD) (ODD) Otherwise Specified
Childhood onset: One symptom

before 10 years old
Adolescent onset: No behavioral

problems occur berfore the age
ICD-10
Conduct Disorder (CD)
Conduct
Oppositional disorder
Unsocialized Socialized Other Conduct
Defiant confined
conduct conduct conduct disorder,
Disorder to the
disorder disorder disorders unspecified
(ODD) family
context
Conduct Disorder, Fig. 1 Classification of conduct disorder according to DSM-IV TR (APA, 2000) and ICD-10
(WHO, 1992)
running away, stubbornness, violation of rules, the greater the risk of problem behavior (Holden
defiant, threatening, or not to accept being guilty, & Gitlesen, 2006).
have also been identified as moderate or severe A common way of categorizing problem
conduct problems in people with ASD behaviors in people with ASD is based on the
(Lecavalier, 2006). Individuals with ASD present function of these behaviors in their natural con-
more problem behaviors than typically develop- text, but there are no systematic reviews about the
ing children, and overall levels of problem behav- possible functions that may play a role. In addi-
ior are positively correlated with severity of ASD tion, a behavior problem may have more than one
(Matson, Wilkins, & Macken, 2009). About one function. The most common functions that can be
third of individuals with intellectual disability found in the literature are attention-seeking,
(ID) who exhibit problem behavior have comor- avoiding, tangible benefit, or being alone (i.e.,
bid diagnosis of ASD (Myrbakk & von nonsocial, self-stimulatory, or automatic rein-
Tetzchner, 2008), and the more severe the ID, forcement). Avoiding pain or discomfort has
Conduct Disorder, Destructive
Fig. 2 Classification of
Property Damage Aggression
disruptive behaviors
(Adapted from Frick et al.
(1993))
Covert-Destructive
Overt-Destructive
Cruel to animals, steals, Assault, spiteful, cruel,
vandalism, fire setting, fights, blames others, C
lies bullies
Covert Overt
Nondestructive
Nondestructive
Covert-
Covert-
Runaway, truancy, Stubborn, angry,
substance use, swears, annoys, touchy, argues,
breaks rules defies, temper
Status violations Oppositional

Nondestructive
also been described as a possible function of impact in everyday activities, and several studies
problem behavior. suggest a high prevalence of aggressive behavior
in people with ASD, few studies have examined
the prevalence of maladaptive behaviors that
Epidemiology warrant a clinical diagnosis of CD in individuals
with ASD. Prevalence of problem behaviors
Rates of prevalence estimates of CD vary widely within the ASD population is relatively high.
depending on the methodology used in each study Most studies indicate that at least half of the
and on the ascertainment procedures. The disor- people with ASD exhibit behavior problems,
der is considered to be a common mental health with an estimated prevalence ranging between
problem in children and adolescents, and appears 35.8% and 94.3% (Kozlowski & Matson, 2012).
to have increased in the recent years. CD may be Lecavalier (2006) presented a study on preva-
higher in urban than in rural areas, and appears lence of problem behaviors of children and ado-
more often in boys than girls. Prevalence rates for lescents with ASD. In a sample of 303 children
the disorder in childhood and adolescence range and adolescents with ASD, he found that the
from 1% to 6% in nonreferred samples (Kim- proportion of children and adolescents who,
Cohen et al., 2005). In boys, the rates vary according to parents and teachers, showed “con-
between 6% and 16%, and in girls rates move duct problems” was 13.9% (parents) and 8.4%
between 2% and 9% (APA, 2000). Recent studies (teachers). Behavior problems rated by parents
show prevalence rates of 9.5% (12% for males and teachers as more frequent were stubbornness,
and 7.1% for females) (Nock, Kazdin, Hiripi, & temper tantrums, defiant behavior, arguing
Kessler, 2006). It seems that male–female ratios nature, not to accept being guilty, and explosive
might be stronger in childhood than in adoles- behavior. Stubborn behavior was rated as
cent-onset groups. a moderate or severe problem for 50.7% (parents)
Although individuals with ASD often exhibit and 44.4% (teachers). Also, temper tantrums,
behavior problems that could have a negative defiant behavior, not to accept being guilty, and
explosive behavior were classified with a high evidence suggesting that childhood-onset CD
frequency. Finally, aggressive acts, such as could be more related to personal and familial
attacking others, were observed by teachers in factors, whereas adolescent-onset could be more
14.3% and in 9.9% by parents. Both informants related to exposure to deviant peers and environ-
(parents and teachers) indicate physical fights as mental disadvantages associated with ethnic
moderate-to-serious problem for 5.3% of the minority status (McCabe, Hough, Wood, & Yeh,
sample. Property destruction was a moderate or 2001). Finally, CD in childhood is associated with
severe problem for 11–12% (according to infor- other problems, including the likelihood of repeat-
mation from parents and teachers respectively), ing a grade in school, be suspended or expelled
and threatening people was rated as a moderate- from school, an earlier age of onset of alcohol
to-severe problem for 4.5% (parents) and 7.6% dependence, and having to attend a greater number
(teachers) of the sample. The study also found of treatments for drug abuse (Hughes et al., 2008).
that lower adaptive skills were associated with There is not a single risk factor that determines the
greater problem behaviors among the sample. onset of the CD. Experts emphasize that the
Regarding high-functioning individuals with multiple risk factors mentioned above interact to
ASD, research and clinical observations suggest facilitate and perpetuate the disorder.
that a relatively large number of these individuals Problem behaviors play a critical role in ASD.
have behavioral problems at some point in their However, the heterogeneity of symptoms present
development. These symptoms may indicate the in persons with ASD (differences in cognitive
presence of ODD comorbid with ASD. They may functioning, or in adaptive behavior, the nature
also have symptoms of CD that are more severe and severity of autistic behaviors) and changes in
in school-age time than in preschool (Gadow the development difficult to understand how these
et al., 2005). individual differences affect the occurrence and
presentation of behavior problems beyond the
core symptoms that define the ASD population.
Natural History, Prognostic Factors, and Despite the differences, consequences of prob-
Outcomes lem behaviors are similar in most cases. These
behaviors prevent the development of social rela-
The onset of CD can occur very early, even at tionships (Matson, Neal, Fodstad, & Hess, 2010;
preschool age, although the most obvious symp- Myrbakk & von Tetzchner, 2008); place the indi-
toms usually occur between middle childhood vidual and their family members in very difficult
and middle adolescence. Onset is rare after age situations; and interfere with effective education
16. ODD is a common precursor to the child- (Carr, Taylor, & Robinson, 1991). Also, it has
hood-onset type. Other different factors affect been shown that the fact of problem behaviors
the onset of symptoms of CD. The scientific (specially aggressiveness) causing more distress
literature highlights three main factors: (1) per- to caregivers than the core autistic symptoms
sonal characteristics such as a difficult tempera- (Lecavalier, Leone, & Wiltz, 2006) is one of the
ment in early childhood, a callous-unemotional most important impediments to placement in less-
personality style (lack of empathy, remorseless- restrictive environments (Shoham-Vardi et al.,
ness, and shallow affected), propensity for risk- 1996); can also interfere with intervention efforts;
taking, low to threatening and emotional reac- and, if present during early childhood, are of par-
tions stimuli, reduced sensitivity to cues of ticular concern given that these are critical years
punishment, and low levels of conscience and for intervention. Thereby problem behaviors
moral development; (2) bad parenting practices impact the long-term prognosis.
such as harsh, punitive, abusive, and/or inconsis- Research on risk factors has provided some
tent discipline; and (3) repeated peer rejection and important data. Tonge and Einfeld (2003) studied
socializing with a deviant peer group (Hughes, a group of 118 children with autism in a period of
Crothers, & Jimerson, 2008). In addition, there is 8 years. Results indicated that 73.5% of children
with autism had behavioral alterations in away from home at night (with no objective rea-
a clinically significant range, with scores fairly sons to escape such as being abused) or truancy
stable over time. These researchers reported that before age 13.
children and adolescents with ASD are at high The clinical expression of problem behaviors
risk of severe and persistent behavioral distur- in ASD will depend on the subject’s age and on
bances beyond those that define the disorder. whether it is associated with ID individuals with
Matson et al. (2009) have studied the potential greatest deficits engaging in more severe problem C
causal factors of problem behaviors in children behaviors. Severity of ASD symptomatology
with ASD, showing that overall levels of problem affects the severity of problem behaviors. Also,
behavior were positively correlated with severity symptoms of other disorders such as attention-
of ASD (Matson et al., 2009). Lecavalier (2006) deficit hyperactivity disorder or Obsessive
in his epidemiological study found that lower Compulsive Disorder will affect the clinical
adaptive skills were associated with greater expression of conduct problems in people with
behavioral problems, but age and gender do not ASD. But it remains unknown whether the
seem to influence behavior problems. In a recent comorbidity of ASD with these disorders leads
study, Hartley, Sikora, and McCoy (2008) exam- to different clinical expressions of behavior prob-
ined a large sample of children with ASD, clas- lems. This is important to better understand the
sifying 27% of sample in the clinically significant pathophysiology of CD (and also of ASD). The
range on the CBCL Externalizing Problems neurobiological disorder of ASD results in diffi-
subscale, and 22% fell within the clinically sig- culties in social cognition with its own character-
nificant range on the aggression subscale. Results istics, such as the difficulty to infer mental states
indicated that externalizing problems were sig- and recognize (e.g., intentions, beliefs, desires,
nificantly correlated with poorer adaptive skills, etc.) in self and others, which can interact with
lower nonverbal cognitive functioning, and environmental factors leading to atypical behav-
poorer expressive language. Also Dominick ioral patterns and behavior problems.
Davis, Lainhart, Tager-Flusberg, and Folstein Some CD symptoms (such as physical aggres-
(2007) found that individuals with ASD with sion, lying, and stealing) are relatively common
low cognitive functioning and adaptive behavior in early childhood, and to distinguish them from
and with low-expressive language skills exhibit normal childhood behavior, the clinician must
more problem behavior than high-functioning take into account the frequency and persistence
individuals (Dominick et al., 2007). of problem behavior beyond the age of four. In
childhood, most of the manifestations are limited
to family and school contexts, but they affect the
Clinical Expression and overall functioning of the child. In adolescence,
Pathophysiology behavior problems tend to have more serious
consequences encompassing the whole adoles-
CD may manifest itself in various symptoms that cent’s social setting and including behavior prob-
are classified into four categories: aggression lems that are much more serious.
toward people or animals, destruction of property
without aggression, deception or theft, and seri-
ous violation of the social rules. These symptoms Evaluation and Differential Diagnosis
are behaviors that usually occur in early child-
hood. Many children commit acts of aggression, CD is a complex problem affecting multiple
break property of others, commit petty thefts, say domains of functioning and often showing a high
some lies, and violate some social rules. But in rate of comorbidity with other disorders. Assess-
the case of children who have a CD, all these ment requires a comprehensive approach
behaviors are very frequent and persistent, and encompassing the child, family, school, peers,
some appear in an age too early such as running and community factors. Well-trained professionals
should conduct assessments, to ensure the proper Treatment

treatment. Otherwise, the behavior problems will
continue or even worsen. A variety of treatment procedures have been
Language disorders and intellectual disability developed for children and adolescents with
usually found in ASD complicate the assessment CD, but only some have been shown to reduce
and diagnosis. Expressive difficulties in some CD behaviors. Intervention procedures seem to
cases make it difficult to determine the presence be more effective in children under 8 years, when
of many symptoms of DSM-IV. Even mild defi- behavior problems have recently begun and when
ciencies in language can make challenging the it includes a multimodal and multicomponent
study and identification of subtle differences in strategy, specifically adapted to the individual
emotions, health status (presence of pain or phys- needs (Hughes et al., 2008).
ical discomfort), or feelings of annoyance at The evidence-based recommendations
being unable to control own decisions. emphasize the need for a multi-component inter-
Assessment requires combining qualitative vention aimed at prevention and early interven-
and quantitative methods to obtain information, tion. The treatment mainly consists of
and collecting data from several sources such as psychological, educational, and social interven-
parents, teachers, and peers is mandatory. Infor- tions focusing on children, parents, and teachers.
mation from different sources should be compared Psychotropic medication and applied behavior
to detect and prevent possible biases caused by the analysis are the most frequently used treatments.
partial view of each reporter and for a better Child-directed interventions aim to improve
understanding of the disorder being evaluated. skills to manage anger and control of aggressive
Behavior rating scales can be completed by impulses, and improve empathy with others,
parents, teachers, and children to obtain compa- strengthening relationships with peers. With the
rable information. Clinicians and researchers family it is necessary first to ensure commitment
consider behavior rating scales a time-efficient and motivation, and then to begin training within
method of collecting reliable information and the family context and subsequently generalized
providing an assessment of several domains of to other places of the community (INSERM,
behavior, usually both on the healthy functioning 2005). Pharmacological treatment is appropriate
and the maladaptive. when used in the context of a comprehensive
Behavioral observation is a useful tool that is psychoeducational evaluation and provided as
normally used in assessing problem behaviors, part of a global treatment strategy (Connor,
both to describe the function (i.e., functional 2002).
assessment) of problem behavior and to monitor The best practice for psychoeducational treat-
treatment progress. Functional assessment is the ment of behavior problems should be based on
process of identifying the variables that predict principles and methods of positive behavior sup-
and maintain problem behavior. The literature port (Rogers & Vismara, 2008). That is, it should
review on the treatment of problem behaviors be a treatment that uses functional assessment to
suggests that interventions based on functional determine the function (or functions) of problem
assessment are more likely to produce the reduc- behavior. After identifying the function,
tion of problem behavior (Horner, Carr, Strain, a positive behavior support plan must be designed
Todd, & Reed, 2002). The process of conducting and implemented, aimed at teaching new func-
a functional assessment typically involves the tional behaviors that serve to replace the problem
following: (1) identifying the problem behavior; behavior. Horner et al. (2002) suggest that
(2) building hypotheses about the events that a support plan should take into account several
occasion and maintain problem behavior; (3) test- elements, and a few of those are as follows:
ing/confirming the functional hypothesis; and (1) Prevent behavior problems by organizing the
(4) designing an intervention based on the con- environment in order to experience less negative
firmed information (Horner et al., 2002). events, and greater accessibility of rewarding
activities. (2) If there are behavioral problems, problem behavior than medication alone in
conduct a functional assessment. (3) Build children with ASD.
a behavioral intervention to make the problem
behavior irrelevant, by teaching socially appro-
priate behaviors that make the person much more See Also
competent in the context and produce the same
effect in the context of the problem behavior. ▶ Behavior Analysis C
(4) Organize the consequences for appropriate ▶ Behavior Modification
behavior to compete with problem behavior, ▶ Behavior Plan
avoiding also the reinforcement of problem ▶ Behavioral Assessment
behavior. (5) Ensure that the procedures are ▶ Challenging Behavior
within the skills, resources, and values of those ▶ Maladaptive Behavior
who must implement them. ▶ Positive Behavioral Support
Parent training based on principles of
applied behavior analysis has great empirical
support. Successful programs for individuals
with ASD and problem behavior include
a parent training component usually based on Achenbach, T. M., & Rescorla, L. A. (2001). Manual for
principles of applied behavior analysis. Common ASEBA school-age forms & profiles. Burlington, VT:
parent training elements include teaching behav- University of Vermont, Research Center for Children,
ioral principles and management techniques, Youth, & Families.
Aman, M. G., McDougle, C. J., Scahill, L., Handen, B.,
role-playing, homework assignments, teaching Arnold, L. E., et al. (2009). Medication and parent
play and social skills, use of visual schedules, training in children with pervasive developmental dis-
and home visits or telephone consultation, orders and serious behavior problems: Results from
among others. a randomized clinical trial. Journal of the American
Academy of Child and Adolescent Psychiatry, 48(12),
Pharmacotherapy is common among individ- 1143–1154.
uals with ASD with behavior difficulties. The American Psychiatric Association. (2000). Diagnostic
most used agents include selective serotonin and statistical manual of mental disorders (test revi-
reuptake inhibitors, antipsychotics, alpha 2 sion) (4th ed.). Washington, DC: Author.
Carr, E. G., Taylor, J. C., & Robinson, S. (1991). The
adrenergic agonists, psychostimulants, and anti- effects of severe behavior problems in children on
convulsants. But empirical support for use of the teaching behavior of adults. Journal of Applied
these agents in ASD varies widely. A classic Behavior Analysis, 24(3), 523–535.
study on the use of Risperidone (McCracken Connor, D. F. (2002). Aggression and antisocial behavior
in children and adolescents: Research and treatment.
et al., 2002) concluded that this psychoactive New York: Guilford Press.
drug is effective and well tolerated for the treat- Dominick, K. C., Davis, N. O., Lainhart, J., Tager-
ment of tantrums, aggression, or self-injurious Flusberg, H., & Folstein, S. (2007). Atypical behaviors
behavior in children with ASD, although the in children with autism and children with a history of
language impairment. Research in Developmental
short period of the trial in this study limits infer- Disabilities, 28, 145–162.
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other atypical antipsychotics, is associated with Loeber, R., Hart, E. A., et al. (1993). Oppositional
adverse events, such as weight gain, and the sub- defiant disorder and conduct disorder: A meta-analytic
review of factor analyses and cross-validation in
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C 782 Confirmatory Factor Analysis
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(2010). The relation of social behaviours and challeng-
(AACAP) http://www.aacap.org
ing behaviours in infants and toddlers with autism
ConductDisorders.com http://www.conductdisorders.com
spectrum disorders. Developmental Neuroreh-
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2, 29–44.
Confirmatory Factor Analysis
Maughan, B., Rowe, R., Messer, J., Goodman, R., &
Meltzer, H. (2004). Conduct disorder and oppositional ▶ Latent Variable Modeling
Conners’ Continuous Performance Test 783 C
Congenital Aphasia Congenital Metabolic Diseases
▶ Childhood Aphasia ▶ Inborn Errors of Metabolism
C
Congenital Disorders Conners’ Continuous
Performance Test
Claudia Califano
Yale-New Haven Hospital, New Haven, Renee Folsom1 and Philip Levin2
1
CT, USA Semel Institute for Neuroscience and Human
Behavior, University of California Los Angeles
(UCLA) The Help Group/UCLA
Definition Neuropsychology Program, Los Angeles,
CA, USA
2
Congenital disorders are those disorders that are The Help Group – UCLA Neuropsychology
present at the time of birth and involve an abnor- Program, Los Angeles, CA, USA
mality of structure and/or function that has arisen
during development. Congenital disorders are not
necessarily genetic though do include genetic dis- Synonyms
orders. All genetic disorders are congenital as they
are present at birth even if they are not yet detected CCPT; CPT; CPT-II
at birth. Congenital disorders may arise as a result
of the intrauterine environment, errors in embry-
onic development, and infections. The outcome of Description
such disorders varies widely and is dependent upon
the disorder itself and the availability of possible The Conners’ Continuous Performance Test is an
postnatal treatments. Examples of congenital attention test for research and clinical settings
disorders include diseases such as cystic fibrosis, (Conners, 1995). It is used for measuring pro-
physical anomalies such as having a sixth finger on cesses related to vigilance, response inhibition,
the hand, metabolic diseases such as congenital signal detection, and other aspects of performance
adrenal hyperplasia, and trisomy 21 which is also (Conners, Epstein, Angold, & Klaric, 2003). The
known as Down syndrome. test is presented in a game-like format where 360
letters (approximately 1 in. in size and bold faced)
appear on the computer screen, one at a time, for
See Also approximately 250 ms. Respondents are required
to press the space bar or click the mouse button
▶ Chromosomal Abnormalities when any letter except the letter “X” appears on
▶ Genetics the screen (Conners & MHS Staff, 2000). The
▶ Inborn Errors of Metabolism CPT-II standard paradigm consists of six blocks,
with each block divided into three 20-trial sub-
blocks. Each sub-block has a separate inter-
References and Readings stimulus interval (i.e., the time in between the
letter presentations). The inter-stimulus intervals
Kliegman, R. (Ed.). (2007). Nelson textbook of pediatrics
(18th ed.). Philadelphia: Saunders Elsevier.
(ISIs) are 1, 2, or 4 s. The order of the three
Stocker, J., & Dehner, L. (Eds.). (2001). Pediatric pathology. different ISI conditions varies from block to
Philadelphia: Lippincott Williams & Wilkins. block (Conners et al., 2003). The CPTII can be
C 784 Conners’ Continuous Performance Test
completed in 14 min. The test can be administered et al. explain that Conners’ “not-X” CPT places
to participants 6 years of age and above. a greater demand on response inhibition due to
After the test session, the program generates the frequent responding interrupted by the occa-
a report that includes response times, omission sional nontargets (the less probable “X”) as
errors (i.e., when a response is not given after opposed to the more passive responding of the
a non-X appears on screen), commission errors conventional “X” task.
(i.e., when a response is given after an X appears Conners has since come out with an updated
on screen), change in reaction time speed and version of his CPT, the Conners’ Continuous
consistency as the test progresses, and change in Performance Test (2nd ed.; Conners’ CPT-II;
reaction time speed and consistency for different Conners & MHS Staff, 2000). The updated ver-
inter-stimulus intervals. Examination of the sion differs from the previous version in that it is
results by blocks and varying ISIs allows for the based on new and expanded norms that include
assessment of vigilance and the ability to adjust a large subsample of neurologically impaired
to changing tempo and task demands (Conners & individuals. This allows for comparison of
MHS Staff, 2000). responses to general population norms, ADHD
norms, and neurologically impaired norms. The
program itself includes validity checks to flag
Historical Background certain conditions that may adversely affect
CPT II administration and a Confidence Index
The continuous performance test was first intro- that enables the practitioner to gauge the certainty
duced by Rosvold and colleagues in 1956 (Spreen of the assessment/classification.
& Straus, 1998) to detect lapses of attention in
patients with petit mal epilepsy. In this early
version, the participants were required to press a Psychometric Data
key in response to a rare target, such as the letter
“X.” Subsequent CPTs have made changes to this The CPT-II normative data included 2,521 partici-
original paradigm including having the participants pants. Of this, 1,920 were healthy individuals from
press a key when the target letter is preceded by the general population, 378 were diagnosed with
another letter (e.g., “X” preceded by “A”) or upon Attention-Deficit/Hyperactivity Disorder (ADHD),
the second successive presentation of a letter (e.g., and 223 were adult individuals identified with some
S-S). There have also been variations with regard to type of neurological impairment (e.g., head injuries,
modality (i.e., visual or auditory), the type of stim- dementias). Normative data were collected from 30
uli (e.g., letters, numbers, colors, or geometric fig- sites in 16 states and three Canadian provinces. The
ures), and the type of data that are evaluated (e.g., multi-site, nonclinical data came from schools,
omissions, commissions, inter-stimulus interval, organizations, science centers, and controlled
measures of sensitivity; Spreen & Straus, 1998). research settings. The norms were divided into
Conners’ introduction of his version of the eight age groups. For children of ages 4 through
CPT in 1995 represented a departure from the 17, norms were provided in 2-year increments. For
more traditional CPT paradigm. In the earlier adults aged 18 and older, they were divided into
versions, participants typically sit passively three age groups (18–34, 35–54, and 55 +). The
while observing the presentation of nontarget applicability of CPT-II norms to Asian and African
stimuli and must respond to the occasional target American groups was also assessed. Scores for the
stimulus (usually an “X”). In Conners’ version, Asian group were consistent with those obtained in
which is also sometimes called the “not-X” CPT, the general population. However, the African
participants are asked to press a button on each American group made slightly fewer commission
trial (usually letters), except for the letter X. errors than the general population, and showed
Barkley (2006) notes that this task requires slightly better discriminatory power as measured
a different form of response inhibition. Conners by the statistic d prime. Overall, the general
Conners’ Continuous Performance Test 785 C
population norms were reportedly applicable to As predicted, the clinical groups performed signif-
these minority groups. In fact, there were no significantly worse than the nonclinical group. Compared
icant differences on the overall profile indexes to the ADHD group, the Neurological group made
(Conners & MHS Staff, 2000). significantly more omission errors, had signifi-
Three types of reliability information were pro- cantly slower reaction times, and was significantly
vided on the CPT-II manual: Split-half reliability, less consistent across the interstimulus intervals.
test-retest reliability, and standard error of mea- C
surement (Conners & MHS Staff, 2000). The split-
half reliability information from the original CPT Clinical Uses
was cited. These appeared adequate and ranged
from 0.66 to 0.95. Test-retest reliability was The CPT paradigm has traditionally been included
obtained using 23 participants in the standardiza- in evaluations for ADHD. Barkley (2006) states
tion of the CPT-II. The average interval between that, “A wide-ranging literature has shown it to be
administrations was 3 months. The test-retest reli- the most reliable of psychological tests for discrim-
ability estimates ranged from 0.05 to 0.92 with inating groups of children with ADHD from
most of the variables showing good consistency nondisabled children” (p. 377). Spreen, Risser,
across administrations. However, the Block and Edgell (1995) report that on a continuous per-
change and ISI change statistics have low test- formance task hyperactive children make more
retest correlations, suggesting that these variables errors of omission and of commission, show more
do not produce good consistency across adminis- rapid deterioration in performance than controls,
trations. When measures are combined into indi- and are less able to inhibit premature or repetitive
ces for ADHD and neurological assessment, the responding, indicating poor impulse control. Lezak,
test-retest reliabilities were excellent, 0.89 and Howieson, and Loring (2004) state that on the CPT,
0.92 respectively. Using the same test-retest data, adults with ADHD have a high reaction time vari-
it was also demonstrated that the CPT-II had no ability and higher rate of commission errors than
significant practice effect. In addition, information control subjects, which suggests that they have
on standard error of measurement and standard trouble inhibiting responses. According to Spreen
error of prediction for the various CPT-II measures and Strauss, the CPTs have also been shown to
across gender and age was presented. distinguish between normal controls and certain
Conners and the MHS Staff (2000) cited patient groups including adults with head injuries
research to support the clinical utility of the CPT. and children with conduct disorder, learning dis-
In a study based on the original standardization abilities, and those at high risk for schizophrenia. In
sample, significant differences were seen between addition, Barkley and Spreen and Strauss report
the ADHD group and other diagnoses across most that CPTs are sensitive to stimulant drug effects
of the CPT variables. The ADHD group responded among children and adolescents with ADHD.
more slowly, had greater variability of reaction Barkley has raised some concern about the
times, made more omission and commission errors, diagnostic utility of the Conners’ CPT, in particu-
and was more affected by changes in ISI. In similar lar, in ADHD assessments. Citing one study that
analyses using the updated CPT-II data, no signif- investigated associations between Conners’ CPT
icant difference was observed between ADHD and scores and several other measures, including par-
nonclinical groups; for all other analyses, there was ent and teacher ratings as well as neuropsycholog-
a large and significant difference between ADHD ical and achievement tests, Barkley reported that
and nonclinical groups with the ADHD groups the Conners CPT’s overall index failed to relate to
performing worse on all of the measures. For the parent and teacher ratings. In addition, only half of
adults aged 18 years and older, planned compari- those participants who met criteria for ADHD
sons were done to see if the nonclinical group “failed” the CPT. Barkley also reported poor dis-
differed from the clinical groups, and if the two criminant validity, in that children with a reading
clinical groups differed from each other. disability actually performed more poorly than
C 786 Conners’ Continuous Performance Test
children with ADHD. In another study on the deficit, whereas only two of eight subjects received
ecological validity of the CPT-II in a school- scores suggestive of an attention deficit. The
based sample, Barkley cited findings showing authors looked at this as a pattern that could be
nonsignificant relationships between CPT perfor- explored using a bigger sample. In the third study,
mance and three other kinds of measures (parent Corbett and Constantine (2006) compared children
ratings, teacher ratings, and classroom observa- with autism spectrum disorder (ASD) with those
tions). He also reported negative correlation that have been diagnosed with ADHD and typically
between IQ and omission errors on the CPT-II, developing children using the Integrated Visual and
suggesting that the CPT-II may measure letter Auditory Continuous Performance Test, another
recognition skills or phonological awareness version of a CPT. They found that children with
rather than impulsivity or inattention per se. ASD show significant deficits in visual and auditory
Despite these concerns, Barkley still holds that attention and greater deficits in impulsivity than
the CPT is the only psychological measure that children with ADHD or typically developing chil-
seems to directly assess the core symptoms of dren. The authors note that the findings suggest that
ADHD, namely, impulsivity and attention. How- many of the children with ASD demonstrate signif-
ever, he warns that if a child performs well on this icant ADHD-like symptoms. They point out that
measure, it does not indicate that the child is this study adds to the growing literature that calls
nondisabled or without ADHD because of the into question the current exclusionary practice of
high rate of false negatives (i.e., children who are offering a diagnosis of ADHD in pervasive devel-
rated by parents and teachers as having ADHD, but opmental disorders.
who obtain average scores on the test) associated Two other variables that might be relevant in
with CPTs. He joins Conners (2000) in reminding the performance of individuals with autism spec-
the clinician that the test provides one source of trum disorders on the CPT-II are anxiety and
information to be integrated with other sources intelligence. Conners and the MHS Staff
(e.g., self-report data, observer-based data, histori- presented data showing that anxiety may affect
cal information, interview data, and results from a participant’s CPT-II response style and lead to
other tests) in reaching a final diagnostic decision. response inhibition for physiological anxiety, and
The use of continuous performance tests in decrease in response inhibition for cognitive anx-
assessing children with autism spectrum disorders iety. In terms of intelligence, the manual included
is less common. Three studies were found but none two studies that showed nonsignificant correla-
of them used the Conners’ CPT-II. In the first study, tions between IQ as measured by the WISC and
23 children with autism were compared with two CPT performance. Still it was noted in the manual
control groups (one matched based on verbal men- that some individuals with severe cognitive
tal age and another based on performance mental impairment, agitation, or severe psychotic symp-
age) on several attention measures including three toms cannot be administered the CPT-II.
versions of the traditional CPT paradigm
(Pascualvaca, Fantie, Papageorgiou, & Mirsky,
1998). The results showed that none of the CPT See Also
versions differentiated between the groups. In the
second study, Schatz, Weimer, and Trauner (2002) ▶ Attention
explored the use of the Test of Variables of Atten- ▶ Attention Deficit/Hyperactivity Disorder
tion (TOVA) in assessing attention deficit symp-
toms in a group of eight children and young adults
with Asperger’s Syndrome (AS). The TOVA is
a continuous performance test that is similar to the
Conners’ CPT but with an additional auditory com- Barkley, R. A. (2006). Attention-deficit hyperactivity dis-
ponent. Five of eight subjects with AS received order: A handbook of diagnosis and treatment
scores that suggested the presence of an attention (3rd ed.). New York: The Guilford Press.
Conners’ Parent Rating Scale 787 C
Conners, C. K. (1995). Conners’ continuous performance asked to complete the Conners 3-P because of
test computer program: User’s manual. Toronto, ON: the shared symptoms between ADHD and autism
Multi-Health Systems.
Conners, C. K., & MHS Staff. (2000). Conners’ continu- spectrum disorders. The Conners 3-P was devel-
ous performance test (CPT II): Technical guide and oped by C. Keith Conners, Ph.D., who also
software manual. Toronto, ON: Multi-Health Systems. designed two related measures: the Conners’
Conners, C. K., Epstein, J. N., Angold, A., & Klaric, J. Teacher Rating Scales (CTRS), a teacher-report
(2003). Continuous performance test performance in
a normative epidemiological sample. Journal of Abnor- measure, and the Conners’ Self-Report Scales C
mal Child Psychology, 31, 555–562. (CSRS), a self-report measure for children and
Corbett, B. A., & Constantine, L. J. (2006). Autism and adolescents. Because these measures are meant to
attention deficit hyperactivity disorder: Assessing be used in conjunction, the family of Conners’
attention and response control with the integrated
visual and auditory continuous performance test. tests is considered to be a “multi-informant”
Child Neuropsychology, 12, 335–348. mode of assessment. This is valuable because it
Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). can yield information about children’s behaviors
Neuropsychological assessment (4th ed.). New York: in multiple settings. For example, asking a parent
Pascualvaca, D. M., Fantie, B. D., Papageorgiou, M., & to complete the Conners 3-P and asking a teacher
Mirsky, A. (1998). Attentional capacities in children to complete the Conners 3-T (for “teacher”) can
with autism: Is there a general deficit in shifting focus? shed light on how a child’s behavior may differ
Journal of Autism and Developmental Disorders, 28, between home and school.
467–478.
Schatz, A. M., Weimer, A. K., & Trauner, D. A. (2002).
Brief report: Attention differences in asperger syndrome.
Journal of Autism and Developmental Disorders, 32, Historical Background
333–336.
Spreen, O., Risser, A. H., & Edgell, D. (1995).
Developmental neuropsychology. New York: Oxford Gianarris, Golden and Greene (2001) provide
University Press. a detailed overview of the multiple versions of
Spreen, O., & Strauss, E. (1998). A compendium of neuro- the Conners’ Parent Rating Scales. The roots
psychological tests (2nd ed.). New York: Oxford Uni- of the Conners 3-P date back to the 1960s, when
versity Press.
C. Keith Conners, Ph.D., created behavior rating
scales based on his multiple observations of chil-
dren and adolescents with behaviors consistent
with what is now known as ADHD. He performed
Conners’ Parent Rating Scale factor analysis to determine how these behaviors
fit together and first published his findings in
Hillary Hurst 1970. One of the earliest aims of Conners’ work
Department of Psychology, University of was to track changes in children’s behavior fol-
Massachusett Boston, Boston, MA, USA lowing medication use. In 1973, Conners
released a 93-item checklist of behaviors that
came to be known as the original Conners’ Parent
Description Rating Scale. It was quickly adopted as
a diagnostic tool even though it did not have
The Conners’ Parent Rating Scale (CPRS) is a normative sample of the kind structured for
a parent-report measure that assesses children’s empirical support that is required to establish
problem behaviors, particularly symptoms of a new assessment tool today. It was not until
attention deficit hyperactivity disorder (ADHD) 1989 that Conners’ sample was formalized and
and related disorders (including oppositional expanded, and that the CPRS was published
defiant disorder and conduct disorder). At the and shared widely. In 1998, the CPRS-R (for
time of publication, the Conners 3-P (2008) is “revised”) was released, and in 2008, the third
the current version of the CPRS. Parents of chil- and most recent edition, the Conners 3-P, was
dren with autism spectrum disorders may be released. The Conners 3-P is currently available
C 788 Conners’ Parent Rating Scale
in English and Spanish. The similarities and dif- Anxious-Shy (long form only), ADHD Index
ferences between these versions are explored (long and short forms), Perfectionism (long
below in the section “Psychometric Data.” form only), and Conners’ Global Index
(long form only). The same subscales appear on
the CTRS-R with the exception of the Psychoso-
Psychometric Data matic subscale, which is not included. Both raw
scores and T scores are generally reported for
The format and response style of the measure each subscale; T scores are standardized scores
have remained quite consistent throughout with a mean of 50 and a standard deviation of 10.
the revisions of the Conners 3-P. In all three For example, a child with a T score of 50 on the
versions, the respondent (the parent completing Oppositional subscale would have about the
the measure) is asked to reflect on his or same level of oppositional behaviors as the aver-
her child’s actions over the past month and to age child his or her age in the normative sample.
respond to a series of items describing Higher T scores are associated with higher levels
mainly problem behaviors (e.g., “gets distracted of problem behaviors.
when given instructions to do something”). Internal consistency coefficients of the
For each item, the respondent is asked to mark 0 CPRS-R (in other words, measures of how well
(“not true at all/never/seldom”), 1 (“just a little the individual items of the measure “hang”
true/occasionally”), 2 (“pretty much true/often/ together and form the subscales listed above) for
quite a bit”), or 3 (“very much true/very the total sample range from .77 to .96. The test-
often/very frequent”) to describe the extent to retest reliability coefficients – a measure of how
which their child engages in or demonstrates the similarly a child will be rated shortly following
given behavior. an initial assessment with the CPRS-R – range
The Conners 3-P has a long-form version from .47 to .86. As previously discussed, the
(110 questions), a short-form version (45 of the CPRS-R is designed to be sensitive to changes
110 total questions), an ADHD Index (10 of in behavior, particularly following medication
the 110 total questions), and a Global Index use, and this might explain partially the lower
(10 of the 110 questions). Previous versions also test-retest reliability coefficients.
offered longer and shorter forms. There are cir- Some significant changes were made to the
cumstances in which one form would be prefera- CPRS-R to create the Conners 3-P. The pub-
ble over another; this largely has to do with the lishers of the Conners 3-P point to the large
reason for testing. For example, using the long- normative sample (n ¼ 1,200) that reflects the
form version of the Conners 3-P might be prefer- 2000 US Census information on race and ethnic-
able to using one of the shorter forms when ity, gender, and parental education level as par-
conducting an initial assessment. ticular strength of the measure. While the test
Revisions were made (e.g., transitioning from creators were careful to include a diverse norma-
the CPRS to the CPRS-R, and again from the tive sample in their development of the Conners
CPRS-R to the Conners 3-P) in order to 3-P, it is important to point out that the validity of
strengthen the psychometric properties of the the Conners’ tests in diverse cultures has not yet
instrument. Most available literature focuses on been established and represents an active area to
the psychometric properties of the CPRS-R and study. The Conners 3-P includes the use of 1-
the Conners 3-P. The CPRS-R contains the fol- year, instead of 3-year, age bands to compare
lowing subscales: Oppositional (long and short children’s scores to the normative sample (e.g.,
forms), Social Problems (long form only), 4-year-olds are now compared only to other
Cognitive Problems/Inattention (long and short 4-year-olds, instead of to 4-, 5-, and 6-year-olds).
forms), Psychosomatic (long form only), Also, the Conners 3-P includes optional com-
Hyperactivity (long and short forms), DSM-IV bined gender norms for boys and girls – the
Symptom Subscales (long form only), norms had been strictly separated by gender in
Conners’ Parent Rating Scale 789 C
the previous versions – and the combined norms coefficients (in other words, measures of how
can be helpful for understanding behavior within well the individual items of the measure “hang”
the context of settings, such as the classroom, that together and form the subscales listed above) for
are very frequently coed. The Conners 3-P also the overall content scales is.91 and for the DSM-
has a greater focus on differential diagnosis (or, IV-TR scales, .90. A breakdown of internal con-
in other words, teasing apart symptoms of ADHD sistency coefficients by Conners 3-P subscale are
from symptoms of related disorders) and this is the following: inattention ¼ .93, hyperactivity/ C
reflected in its normative sample. Additionally, impulsivity ¼ .94, learning problems ¼ .90,
the age range of the Conners 3-P, at 6–18 years executive functioning ¼ .92, aggression ¼ .91,
old, is slightly narrower than the age range, peer relations ¼ .85, ADHD Inattentive ¼ .93,
3–17 years, of the previous CPRS versions. The ADHD Hyperactive-Impulsive ¼ .92, Conduct
age range was extended to 18 years, 11 months to Disorder ¼ .83, and Oppositional Defiant Disor-
capture adjustment through the end of high der ¼ .83. The 2–4-week test-retest reliability
school; it was limited to 6 years, 0 months so coefficients – a measure of how similarly a child
that early experiences can be assessed more thor- will be rated 2 weeks and again 4 weeks follow-
oughly with a separate measure, the Conners ing an initial assessment with the Conners 3-P –
Early Childhood (EC). was also very good in the overall Conners’
The Conners 3-P contains the following sample (Cronbach’s alpha ¼ .71 to .98, with all
content scales: inattention, hyperactivity/ correlations significant at the p <.001 level).
impulsivity, learning problems, executive func- Inter-rater reliability coefficients (a measure of
tioning, aggression, and peer/family relations. It how likely two different respondents, such as
also contains four symptoms scales – ADHD a mother and father, or a parent and teacher, are
Inattentive, ADHD Hyperactive-Impulsive, to rate the same child’s behavior) in the overall
Conduct Disorder, and Oppositional Defiant Conners’ sample are also acceptable to excellent,
Disorder – that map onto the diagnostic criteria ranging from .52 to .94. Continuity between the
put forth in the Diagnostic and Statistical Manual CPRS-R and the Conners 3-P was demonstrated,
of Mental Disorders, fourth edition, text revision and tests of factorial, convergent, divergent, and
(DSM-IV-TR). New to the Conners 3-P include discriminant validity were also performed on the
validity scales (which indicate how a parent is Conners 3-P.
responding to the items and whether or not the
information he or she provides is interpretable),
screening items for childhood anxiety and Clinical Uses
depression, critical items (which require immedi-
ate follow-up by the researcher or clinician The Conners 3-P is a useful tool when a child is
administering the measure), and impairment experiencing behavioral difficulty at home or at
items (which indicate decreased functioning in school. The Conners 3-P may indicate whether
certain life areas, like social relationships). The a child’s symptoms are consistent with ADHD or
Conners 3-P is also notable for the way in which a related disorder. While it includes questions
it maps onto the Individuals with Disabilities about different symptoms in parent-friendly and
Education Act (IDEA); in other words, how accessible language, it does not elicit all of the
a child is rated by his or her parent on the Conners information that would be needed to make
3-P might carry implications for the services he a formal diagnosis. It is important to note that
or she is eligible to receive in school. a high score on the Conners 3-P alone is not
Both test-retest reliability and internal consis- sufficient to diagnose a child; instead, it is only
tency have been found to be very good for the one piece of information that clinicians will con-
Conners 3-P, and for the overall family of sider when making a diagnosis, if one is
Conners 3 assessments. According to data put warranted. If a child has a diagnosis, then the
forth by the publisher, internal consistency Conners 3-P can be used to track changes in his
C 790 Conners’ Teacher Rating Scale
or her behavior over time; this is especially intelligence. Journal of Intellectual Disability
important if a child receives intervention, medi- Research, 52(11), 950–965.
Gallant, S. (2008, February). Conners 3: Psychometric
cation, or special services to address his or her properties and practical applications. Paper presented
behavioral challenges. Sometimes, the Conners at the Annual Meeting of the National Association of
3-P is used in the absence of any behavioral School Psychologists, New Orleans, LA.
problems – it can be used as a screener, or in Gallant, S., Conners, C. K., Rzepa, S., Pitkanen, J.,
Marocco, M., & Sitarenios, G. (2007, August). Psy-
a routine manner. chometric properties of the Conners 3rd edition.
Because of the overlap between behaviors – Poster presented at the annual meeting of the Ameri-
particularly externalizing ones – associated with can Psychological Association, San Francisco.
ADHD and those associated with autism spectrum Retrieved from http://downloads.mhs.com/conners/
Psychometric_Properties_Conners_3rd_Edition.pdf
disorders, it is helpful to understand the function Gianarris, W. J., Golden, C. J., & Greene, L. (2001). The
of the Conners 3-P. Also, since autism spectrum Conners’ parent rating scales: A critical review of the
disorders sometimes coexist with intellectual dis- literature. Clinical Psychology Review, 21(7), 1061–1093.
abilities (ID), it is important to understand how the Politi, D. M. (2011). Conners 3rd edition: Introduction
and application. Retrieved from http://www.
psychometric properties of the Conners’ tests hold mspaonline.net/Conference2011/Politi2%20Power%
up among children with ID. Deb, Dhaliwal and 20Point.pdf
Roy (2008) undertook this research with the Sparrow, E. P. (2010). Essentials of Conners’ behavior
CPRS-R and the CTRS-R and found that parents assessments. Hoboken, NJ: John Wiley and Sons.
and teachers differed significantly in how they
rated children with ID (whereas significant corre-
lations between their reports would be expected,
based on previously published psychometric Conners’ Teacher Rating Scale
data). Also, the authors noted that some of the
items were not applicable to children with severe Hillary Hurst
or profound ID, and/or who were nonverbal (as Department of Psychology, University of
are some children with autism spectrum disor- Massachusett Boston, Boston, MA, USA
ders). These findings have implications for using
the Conners’ tests to assess children with known
autism spectrum disorders and ID. Description
The Conners’ Teacher Rating Scale (CTRS) is

See Also a teacher-report measure that assesses children’s
problem behaviors, particularly symptoms of
▶ Attention Deficit/Hyperactivity Disorder attention deficit hyperactivity disorder (ADHD)
▶ Conners’ Teacher Rating Scale and related disorders (including oppositional
defiant disorder and conduct disorder). At
the time of publication, the Conners 3-T (2008)
References and Readings is the current version of the CTRS. Teachers of
children with autism spectrum disorders or
Conners, C. K., Parker, J. D. A., Sitarenios, G., & Epstein, suspected autism spectrum disorders may be
J. N. (1998). The revised Conners’ Parent Rating Scale asked to complete the Conners 3-T because of
(CPRS-R): Factor structure, reliability, and criterion
validity. Journal of Abnormal Child Psychology,
the shared symptoms between ADHD and autism
26(4), 257–268. spectrum disorders. The Conners 3-T was devel-
Conners, K. C. (2008). Conners 3rd edition. Toronto, oped by C. Keith Conners, Ph.D., who also
Ontario, Canada: Multi-Health Systems. designed two related measures: the Conners’
Deb, S. S., Dhaliwal, A. J., & Roy, M. M. (2008). The
usefulness of Conners’ rating scales-revised in screen-
Parent Rating Scales (CPRS), a parent-report mea-
ing for attention deficit hyperactivity disorder in chil- sure, and the Conners’ Self-Report Scales (CSRS),
dren with intellectual disabilities and borderline a self-report measure for children and adolescents.
Conners’ Teacher Rating Scale 791 C
Because these measures are meant to be used in revisions of the Conners 3-T. In all three versions,
conjunction, the family of Conners’ tests is con- the respondent (the teacher completing the mea-
sidered to be a “multi-informant” mode of assess- sure) is asked to reflect on his or her student’s
ment. This is valuable because it can yield actions over the past month and to respond to
information about children’s behaviors in multiple a series of items describing mainly problem
settings. For example, asking a teacher to complete behaviors (for example, “leaves seat when he/
the Conners 3-T and a parent to complete the she should stay seated”). For each item, the C
Conners 3-P can shed light on how a child’s behav- respondent is asked to mark 0 (“not true at all/
ior may differ between home and school. never/seldom”), 1 (“just a little true/occasion-
ally”), 2 (“pretty much true/often/quite a bit”),
or 3 (“very much true/very often/very frequent”)
Historical Background to describe the extent to which their student
engages in or demonstrates the given behavior.
The Conners 3-T shares a great deal of history The Conners 3-T has a long-form version
with the Conners 3-P. The roots of these assess- (115 questions), a short-form version (41 of the
ments date back to the 1960s, when C. Keith 110 total questions), an ADHD Index (10 of
Conners, Ph.D., created behavior rating scales the 110 total questions), and a Global Index
based on his multiple observations of children (10 of the 110 questions). Previous versions
and adolescents with behaviors consistent with also offered longer and shorter forms. There
what is now known as ADHD. He performed are circumstances in which one form would be
factor analysis to determine how these behaviors preferable over another; this largely has to do
fit together and first published his findings in with the reason for testing. For example, using
1970. One of the earliest aims of Conners’ work the long-form version of the Conners 3-T might
was to track changes in children’s behavior be preferable to using one of the shorter forms
following medication use. In 1973, Conners when conducting an initial assessment.
released a 93-item checklist of behaviors that Revisions were made (e.g., transitioning from
came to be known as the original Conners’ Parent the CTRS to the CTRS-R, and again from the
Rating Scale. It was quickly adopted as CTRS-R to the Conners 3-T) in order to
a diagnostic tool even though it did not have strengthen the psychometric properties of the
a normative sample of the kind structured for instrument. Most available literature focuses on
empirical support that is required to establish the psychometric properties of the CTRS-R and
a new assessment tool today. It was not until the Conners 3-T. The CTRS-R, like the CPRS-R,
1989 that Conners’ sample was formalized and contains the following subscales: Oppositional
expanded, and that the CTRS, along with the (long and short forms), Social Problems (long
CPRS, was published and shared widely. In form only), Cognitive Problems/Inattention
1998, the CTRS-R (for “revised”) was released, (long and short forms), Hyperactivity (long and
and in 2008, the third and most recent edition, the short forms), DSM-IV Symptom Subscales (long
Conners 3-T, was released. The Conners 3-T is form only), Anxious-Shy (long form only),
currently available in English and Spanish. ADHD Index (long and short forms), Perfection-
The similarities and differences between ism (long form only), and Conners’ Global
these versions is explored below in the section Index (long form only). Unlike the CPRS-R, the
“Psychometric Data.” CTRS-R does not contain the Psychosomatic
subscale. Both raw scores and T scores are
generally reported for each subscale; T scores
Psychometric Data are standardized scores with a mean of 50 and
a standard deviation of 10. For example, a child
The format and response style of the measure with a T score of 50 on the Oppositional subscale
have remained quite consistent throughout the would have about the same level of oppositional
C 792 Conners’ Teacher Rating Scale
behaviors as the average child his or her age in the The Conners 3-P contains the following
normative sample. Higher T scores are associated content scales: inattention, hyperactivity/
with higher levels of problem behaviors. impulsivity, learning problems, executive func-
Internal consistency coefficients of the tioning, aggression, and peer relations. It also
CPRS-R (in other words, measures of how well contains four symptoms scales – ADHD Inatten-
the individual items of the measure “hang” tive, ADHD Hyperactive-Impulsive, Conduct
together and form the subscales listed above) Disorder, and Oppositional Defiant Disorder –
for the total sample range from .77 to .96. The that map onto the diagnostic criteria put forth
test-retest reliability coefficients – a measure in the Diagnostic and Statistical Manual of
of how similarly a child will be rated shortly Mental Disorders, fourth edition, text revision
following an initial assessment with the (DSM-IV-TR). New to the Conners 3-T include
CPRS-R – range from .47 to .86. As previously validity scales (which indicate how a teacher is
discussed, the CPRS-R is designed to be sensitive responding to the items and whether or not the
to changes in behavior, particularly following information he or she provides is interpretable),
medication use, and this might explain partially screening items for childhood anxiety and
the lower test-retest reliability coefficients. depression, critical items (which require immedi-
Some significant changes were made to the ate follow-up by the researcher or clinician
CTRS-R to create the Conners 3-T. The pub- administering the measure), and impairment
lishers of the Conners 3-T point to the large items (which indicate decreased functioning in
normative sample (n ¼ 1,200) that reflects certain life areas, like social relationships). The
the 2000 US Census information on race and Conners 3-T is also notable for the way in which
ethnicity, gender, and parental education level it maps onto the Individuals with Disabilities
as particular strength of the measure. The Education Act (IDEA); in other words, how
Conners 3-T includes the use of 1-year, instead a child is rated by his or her teacher on the
of 3-year, age bands to compare children’s scores Conners 3-T might carry implications for the
to the normative sample (e.g., 4-year-olds are services he or she is eligible to receive in school.
now compared only to other 4-year-olds, instead Both test-retest reliability and internal consis-
of to 4-, 5-, and 6-year-olds). Also, the Conners tency have been found to be very good for the
3-T includes optional combined gender norms Conners 3-T, and for the overall family of
for boys and girls – the norms had been strictly Conners 3 assessments. According to data put
separated by gender in the previous versions – forth by the publisher, internal consistency coef-
and the combined norms can be helpful for ficients (in other words, measures of how well the
understanding behavior within the context of individual items of the measure “hang” together
settings, such as the classroom, that are very and form the subscales listed above) for
frequently coed. The Conners 3-T also has the total sample range from .77 to .97. The
a greater focus on differential diagnosis (or, in 2–4-week test-retest reliability coefficients –
other words, teasing apart symptoms of ADHD a measure of how similarly a child will be rated
from symptoms of related disorders) and this is 2 weeks and again 4 weeks following an initial
reflected in its normative sample. Additionally, assessment with the Conners 3-T – was also very
the age range of the Conners 3-T, at 6–18 years good (Cronbach’s alpha ¼ .71 to .98, with all
old, is slightly narrower than the age range, correlations significant at the p < .001 level).
3–17 years, of the previous CTRS versions. The Inter-rater reliability coefficients (a measure of
age range was extended to 18 years, 11 months to how likely two different respondents, such as
capture adjustment through the end of high a mother and father, or a parent and teacher, are
school; it was limited to 6 years, 0 months to rate the same child’s behavior) are also accept-
so that early experiences can be assessed more able to excellent, ranging from .52 to .94. Conti-
thoroughly with a separate measure, the Conners nuity between the CTRS-R and the Conners 3-T
Early Childhood (EC). was demonstrated, and tests of factorial,
Conners’ Teacher Rating Scale 793 C
convergent, divergent, and discriminant validity spectrum disorders, it is helpful to understand
were also performed on the Conners 3-T. the function of the Conners 3-T. Also, since
autism spectrum disorders sometimes coexist
with intellectual disabilities (ID), it is important
Clinical Uses to understand how the psychometric properties of
the Conners’ tests hold up among children with
The Conners 3-T is a useful tool when a child is ID. Deb et al. (2008) undertook this research with C
experiencing behavioral difficulty at school or at the CPRS-R and the CTRS-R and found that
home. The Conners 3-P may indicate whether parents and teachers differed significantly in
a child’s symptoms are consistent with ADHD or how they rated children with ID (whereas signif-
a related disorder. While it includes questions icant correlations between their reports would be
about different symptoms in user-friendly and expected, based on previously published psycho-
accessible language, it does not elicit all of the metric data). Also, the authors noted that some of
information that would be needed to make the items were not applicable to children with
a formal diagnosis. It is important to note that severe or profound ID, and/or who were nonver-
a high score on the Conners 3-T alone is not bal (as are some children with autism spectrum
sufficient to diagnose a child; instead, it is only disorders). These findings have implications for
one piece of information that clinicians will con- using the Conners’ tests to assess children with
sider when making a diagnosis, if one is warranted. known autism spectrum disorders and ID.
If a child has a diagnosis, then the Conners 3-T can
be used to track changes in his or her behavior over
time; this is especially important if a child receives See Also
intervention, medication, educational supports, or
other services to address his or her behavioral ▶ Attention Deficit/Hyperactivity Disorder
challenges. Sometimes, the Conners 3-T is used
in the absence of any behavioral problems – it can
be used as a screener, or in a routine manner. References and Readings
Frick, Barry, and Kamphaus (2009) note that
the Conners 3-T has several strengths that suit it Conners, K. C. (2008). Conners (3rd ed.). Toronto, ON:
Multi-Health Systems.
well for school-based assessments. For example,
Conners, C. K., Sitarenois, G., Parker, J. D., &
it focuses on ADHD and other disorders involv- Epstein, J. N. (1998). Revision and restandardization
ing externalizing behaviors that can interfere with of the Conners Teacher Rating Scale (CTRS-R): Factor
children’s school performance. Also, its short structure, reliability, and criterion validity. Journal of
Abnormal Child Psychology, 26(4), 279–291.
versions, with demonstrated validity and reliabil-
Cordes, M., & McLaughlin, T. M. (2004). Attention def-
ity, may be more accessible and user-friendly for icit hyperactivity disorder and rating scales with a brief
teachers in busy school environments. However, review of the Conners Teacher Rating Scale (1998).
the Conners 3-T has its drawbacks too, which International Journal of Special Education, 19(2),
23–34.
include minimal assessment of childhood depres-
Deb, S., Dhaliwal, A.-J., & Roy, M. (2008). The useful-
sion and anxiety, which frequently include inter- ness of Conners’ Rating Scales-Revised in screening
nalizing symptoms. Also, the normative sample for Attention Deficit Hyperactivity Disorder in
of the Conners 3-T is racially and ethnically children with intellectual disabilities and borderline
intelligence. Journal of Intellectual Disability
diverse, but not to the same degree as the Conners Research, 52(11), 950–965.
3-P. Additionally, there is little independent val- Frick, P. J., Barry, C. T., & Kamphaus, R. W. (2009).
idation of the Conners 3-T, aside from the data Clinical assessment of child and adolescent personal-
put forth by the instrument authors. ity and behavior (3rd ed.). New York: Springer.
Gallant, S., Conners, C. K., Rzepa, S., Pitkanen, J.,
Because of the overlap between behaviors –
Marocco, M., & Sitarenios, G. (2007, August). Psy-
particularly externalizing ones – associated with chometric properties of the Conners 3rd edition.
ADHD and those associated with autism Poster presented at the annual meeting of the
C 794 Consent
American Psychological Association, San Francisco. Current Law

Retrieved from http://downloads.mhs.com/conners/ General principles of consent are the same in all
Psychometric_Properties_Conners_3rd_Edition.pdf
Hale, J. B., How, S. K., Dewitt, M. B., & Coury, D. L. jurisdictions, though specific details of the doctrine
(2001). Discriminant validity of the Conners’ scales may vary. The right of consent requires several
for ADHD subtypes. Current Psychology: Develop- elements, including capacity (the patient is compe-
mental, Learning, Personality, Social, 20(3), 231–249. tent to make decisions), information (the patient is
Politi, D. M. (2011). Conners 3rd edition: Introduction
and application. Retrieved from http://www. informed of the benefits and risks), and voluntari-
mspaonline.net/Conference2011/Politi2%20Power% ness (the patient is not coerced into giving consent).
20Point.pdf Consent to medical treatment can be oral or written,
express, or implied. In some jurisdictions, statutes
specify the form that a patient’s consent must take.
Consent Consent is generally not required in certain circum-
stances, including emergencies, therapeutic privi-
Amanda E. Gordon lege, when the patient is incompetent, and when the
Quinnipiac University School of Law, Hamden, patient waives having to consent.
CT, USA A physician’s failure to obtain consent from
a patient prior to medical treatment can serve as
a factual predicate to a malpractice action.
Synonyms
ASD Application
Informed consent Patients with developmental disabilities, such as
ASD, may have cognitive, social, and mental impair-
ments that limit their ability to provide legal consent.
Definition Minors generally cannot give consent. Instead,
parents or legal guardians must give consent,
In General preferably with the child’s assent when feasible.
Consent is a voluntary agreement to participate in
medical treatment, procedure, or research. See Also
A physician or other health care provider must
obtain the consent of the patient or of someone ▶ Informed Consent
legally authorized to give consent for the patient
before initiating such activity. References and Readings
This requirement is based on the principle that
every individual of sound mind has a right to Canterbury v. Spence, 464F.2d 772 (D.C. Cir. 1972).
determine what shall be done with his own body
and to control the course of his medical treatment.
Standard Consequence-Based Interventions

The historical standard for legally sufficient dis-
closure was the customary disclose practices of Rebecca Munday
physicians in the community. The current stan- The Center for Children with Special Needs,
dard, however, is a more patient-oriented one. It Glastonbury, CT, USA
focuses on what material information about risks
a reasonable physician would believe
a reasonable patient would want to know to Definition
make a decision. It thus remains objective, but
with due regard for both the patient’s informa- Consequence-based interventions are implemented
tional needs and physician’s situation. in response to inappropriate behaviors. These
Constipation 795 C
interventions are designed to decrease the future Definition
likelihood of the inappropriate behavior occurring.
Interventions are determined based on the results of The definition of constipation varies among indi-
a functional behavior assessment. For a conse- viduals. To some, it is hard stools; to others, it is
quence-based intervention to be successful, it must large stools; and to many more, it is infrequent
be in response to the function of the behavior. stools. Because the word “constipation” has dif-
Often, antecedent and consequence-based interven- ferent meanings for different people, it has been C
tions are used in combination to decrease the prob- difficult to compile data on normal and abnormal
ability of inappropriate behavior occurring in the patterns in children (Schuster, 1984). Webster’s
future. Some examples of consequence-based inter- English Dictionary reads “a term used to describe
ventions are differential reinforcement and its var- the subjective complaint of passage of abnor-
iants, extinction, response cost, and redirection. mally delayed or dry, hardened feces, often
accompanied by straining and/or pain”
See Also (Webster’s ninth new collegiate dictionary,
1986). Guidelines of the North American Society
▶ Punishment for Pediatric Gastroenterology, Hepatology, and
▶ Reinforcement Nutrition similarly define constipation as “a delay
or difficulty in defecation, present for 2 or more
References and Readings weeks and sufficient to cause significant distress
to the patient” (Baker et al., 1999).
Anderson, C., & Long, E. (2002). Use of structured One can conclude then that normal stool fre-
descriptive assessment method to identify variables quency ranges from an average of four per day
affecting problem behavior. Journal of Applied
Behavior Analysis, 35, 137–154. during the first week of life to two per day at
Cooper, J., Heron, T., & Heward, W. (2007). Applied behav- 1 year of age. The normal adult range of three
ior analysis (2nd ed.). Hoboken, NJ: Pearson Education. per day to three per week is attained by 4 years of
Malott, R., Malott, M., & Trojan, E. (2000). Elementary age. These data reflect the average stool fre-
principles of behavior (4th ed.). Upper Saddle River,
NJ: Prentice-Hall. quency in normal infants and children in indus-
trialized countries, not in developing countries,
where the normal diet is rich in fiber and normal
stool frequency may be different.
Conservatorship Many experts believe that constipation is the
delay in defecation for approximately 2 weeks or
▶ Guardianship difficulty in defecation. The causes of constipa-
tion are many and may be organic or nonorganic;
medications can be a potential cause. Children
with ASDs can have sensory processing abnor-
Constipation malities and develop stool-withholding behaviors
or constipation related to altered pain responses.
Koorosh Kooros Even children with ASDs who have daily bowel
Pediatric Gastroenterology and Nutrition, movements may have retention of stool that is not
Children’s Medical Center, The University of evident to parents, teachers, or health care pro-
Texas Southwestern Medical Center at Dallas, viders. (Buie et al., 2010).
Dallas, TX, USA The evaluation of all children who present
with constipation should include a thorough med-
ical history and physical examination. Under-
Synonyms standing what the family or child means when
they use the term “constipation,” the frequency of
Dyschezia; Fecal impaction; Obstipation bowel movements, the consistency and size of
C 796 Consulting Teacher
stool, and the presence or absence of abdominal Buie, T., Fuchs, G. J., III, Furuta, G. T., Kooros, K., Levy, J.,
pain is important. A history of stool-withholding Lewis, J. D., et al. (2010). Recommendations for evalu-
ation and treatment of common gastrointestinal problems
behavior points more toward functional causes of in children with ASDs. Pediatrics, 125, S19–S29.
constipation. For children with ASDs, the physi- Schuster, M. M. (1984). Chronic constipation in children:
cal examination may not identify palpable stool, The need for hard data about normal stools. Journal of
and a careful rectal examination might not be Pediatric Gastroenterology and Nutrition, 3, 336–337.
Webster’s ninth new collegiate dictionary (1986).
feasible. Every attempt should be made to exam- Springfield (MA): Merriam-Webster, Inc.; Constipation;
ine the rectum, although at times it cannot be p. 281.
accomplished. The rectal examination enables
assessment of stool retention, anal tone, and
occult mass, as well as the presence or absence
of blood, and helps to reassure the family that the Consulting Teacher
child’s anatomy is normal. A plain radiograph of
the abdomen may reveal a rectal fecal mass not ▶ Itinerant Teacher
palpable on the abdominal examination, but due
to conflicting evidence for the accuracy of radio-
logic diagnosis of constipation, routine radiogra-
phy is not recommended. Diagnostic clues can Contactin-Associated Protein 2
help to identify some organic causes of constipa-
tion. Hirschsprung’s disease is common in chil- John D. Murdoch
dren with ASDs, and a history of delayed passage Child Study Center, Yale University School
of stool after birth should raise the suspicion of of Medicine, New Haven, CT, USA
aganglionosis. Anatomic abnormalities such as
an anterior displacement of anus, which is more
common in girls than boys, can be diagnosed by The gene CNTNAP2 encodes the protein
careful inspection of anal area. Drugs added to contactin-associated protein-like 2
behavior management for constipation are often (recommended UniProt name; also known as
beneficial. Mineral oil, magnesium hydroxide, Caspr2), a member of the neurexin superfamily,
lactulose, sorbitol, polyethylene glycol (PEG), and of a class of genes functioning in the nervous
or a combination of lubricant (mineral oil) and system as cell adhesion molecules and receptors
laxative is recommended for the daily manage- acting at the cell membrane (EntrezGene). This
ment of constipation in children. gene is less frequently referred to as AUTS15,
CDFE, CASPR2, PTHSL1, NRXN4, KIAA0868,
and DKFZp781D1846 (UniProt, BioGrid).
See Also
▶ Gastrointestinal Disorders and Autism Structure

▶ Leaky Gut Syndrome
CNTNAP2 is located at chromosome 7q35; the
genic region of this gene is quite large, spanning
References and Readings 2.3 MB (Nakabayashi & Scherer, 2001).
In humans, there is a single established isoform
Baker, S. S., Liptak, G. S., Colletti, R. B., Croffie, J. M., Di (or version of the gene) consisting of 24 exons.
Lorenzo, C., Ector, W., et al. (1999). Constipation in The final protein product is 1,331 amino acids. The
infants and children: Evaluation and treatment. protein spans the cell membrane one single time
A medical position statement of the North American
society for pediatric gastroenterology and nutrition.
(UniProt). The protein consists, in order, of
Journal of Pediatric Gastroenterology and Nutrition, a signal peptide (a short sequence directing
29, 612–626. the protein product where to go in the cell),
Contactin-Associated Protein 2 797 C
a FA58C domain (“cell surface-attached carbo- which both copies of a gene have been removed)
hydrate-binding domain”), two laminin of CNTNAP2 showed dysfunction in neuronal
G domains (common in extracellular proteins), migration (ectopic neurons occurring in the
an epidermal growth factor-like domain (also corpus callosum) and reduced numbers of
frequently found in extracellular proteins), interneurons (Peñagarikano, Abrahams, Herman,
a fibrinogen C-terminal domain, another laminin et al., 2011). One study has shown evidence of
G domain, another epidermal growth factor-like CNTNAP2 in rat forebrain synapses (Bakkaloglu, C
domain, another laminin G domain, a helical O’Roak, Louvi, et al., 2008), but it has not been
transmembrane domain (spanning the membrane definitively characterized as a synaptic molecule.
between the inside and outside of the cell), and
a cytoplasmic domain (the only portion of the
mature protein that is inside the cell). This trans- Pathophysiology
membrane and cytoplasmic end of the protein
also contains a putative band 4.1 homologues’ CNTNAP2 has been implicated in several
binding motif (common to neurexins as well psychiatric disease phenotypes, including
as syndecans and glycophorin C intracellular Tourette syndrome and obsessive-compulsive
C-termini, all of which are cell surface proteins) disorder (Verkerk, Mathews, Joosse, et al.,
(SMART, UniProt). 2003), but has received particular attention for
its possible association with autism. Initially,
linkage evidence suggested a language-linked
Function gene on chromosome 7q35 (Alarcon, Cantor,
Liu, et al., 2002; Alarcon, Yonan, Gilliam,
CNTNAP2 was first described by Poliak, Gollan, et al., 2005). A homozygous mutation in
Martinez, et al. (1999) and was shown to be CNTNAP2 was associated with a cortical dyspla-
a member of the neurexin superfamily that local- sia and focal epilepsy phenotype, resulting in
ized within juxtaparanodal regions of myelinated seizures, language and social impairments, men-
axons and clustering with potassium channels. tal disability, and autistic traits (Strauss,
The juxtaparanode is the region next to the Puffenberger, Huentelman, et al., 2006).
paranode, which is on either side of the node of CNTNAP2 was additionally implicated in multi-
Ranvier, an unmyelinated (unsheathed) region plex autism families by a linkage peak at 7q35
of the axon that allows for efficient signal and showed subsequent significant association
conduction. Homologs of CNTNAP2 are found with a single DNA base change, or single nucle-
as far back as insects (D. melanogaster, A. otide polymorphism (SNP) within the gene in an
gambiae) and nematodes (C. elegans) analysis of parent-affected child trios (Arking,
(EntrezGene), further implying important neural Cutler, Brune, et al., 2008). A fine-scale analysis
function. CNTNAP2 was shown to interact with of the 15 mb region (7q34-36) encompassing the
CNTN2 (TAG-1); in the absence of CNTN2, implicated 7q35 language region in 172 parent-
CNTNAP2 failed to localize at juxtaparanodes autistic child trios reinforced CNTNAP2 as an
and potassium channels did not accumulate autism candidate gene; follow-up analysis in
normally (Traka, Goutebroze, Denisenko, et al., 304 separate parent-autistic child trios showed
2003). The transcription factor FOXP2, itself association of a SNP in CNTNAP2 with age at
implicated in language function (EntrezGene), first spoken word, again underscoring a possible
was shown by Vernes, Newbury, Abrahams, connection to language phenotype as suggested
et al. (2008) to directly regulate CNTNAP2 by Vernes et al. (2008). Parallel work in this
expression. CNTNAP2 was also shown to have study showed CNTNAP2 expression very
higher expression in circuits involved in higher specific to brain circuits established as essential
cortical function, like language (Abrahams et al., for executive function in humans (Alarcon, Abra-
2007). A recent mouse knockout (an animal in hams, Stone, et al., 2008). Also in 2008,
C 798 Contactin-Associated Protein 2
large-scale resequencing of the CNTNAP2 gene References and Readings

in 635 autism cases and 942 unaffected controls
showed overrepresentation of rare deleterious Abrahams, B. S., Tentler, D., Perederiy, J. V.,
Oldham, M. C., Coppola, G., & Geschwind, D. H.
(i.e., changing the amino acid in a way that is
(2007). Genome-wide analyses of human perisylvian
predicted as harmful) mutations in autistic cerebral cortical patterning. Proceedings of the
patients compared with unaffected controls, but National Academy of Sciences of the United States of
not at a statistically significant level. A specific America, 104(45), 17849–17854.
Alarcon, M., Abrahams, B. S., Stone, J. L., et al. (2008).
mutation, I869T (the 869th amino acid changed
Linkage, association, and gene-expression analyses
from isoleucine to threonine), however, occurred identify CNTNAP2 as an autism-susceptibility gene.
four times in three unrelated families and was not American Journal of Human Genetics, 82(1),
seen in any controls, reaching statistical signifi- 150–159.
Alarcon, M., Cantor, R. M., Liu, J., et al. (2002). Evidence
cance. In each case, it was inherited from an
for a language quantitative trait locus on chromosome
ostensibly unaffected parent, suggesting again 7q in multiplex autism families. American Journal of
that idiopathic (nonsyndromic) autism may some- Human Genetics, 70(1), 60–71.
times involve harmful mutations in multiple neu- Alarcon, M., Yonan, A. L., Gilliam, T. C., et al. (2005).
Quantitative genome scan and ordered-subsets analy-
rological genes at once. A 2010 study described
sis of autism endophenotypes support language QTLs.
two siblings with a deletion spanning CNTNAP2 Molecular Psychiatry, 10(8), 747–757.
who showed mental retardation and language Arking, D. E., Cutler, D. J., Brune, C. W., et al. (2008).
delay (Sehested et al., 2010); a separate study A common genetic variant in the neurexin superfamily
member CNTNAP2 increases familial risk of autism.
described a boy with a complex chromosomal
American Journal of Human Genetics, 82(1),
rearrangement (pieces of chromosomes breaking 160–164.
off and rearranging spontaneously) disrupting Bakkaloglu, B., O’Roak, B. J., Louvi, A., et al. (2008).
CNTNAP2 who presented with speech delay and Molecular cytogenetic analysis and resequencing of
contactin associated protein-like 2 in autism spectrum
ASD (Poot, Beyer, Schwaab, et al., 2010). More
disorders. American Journal of Human Genetics,
recently, a rare, predicted deleterious CNTNAP2 82(1), 165–173.
variant was observed when 20 exomes of patients BioGrid. Retrieved from http://thebiogrid.org/
with autism were sequenced (O’Roak, Derziotis, EntrezGene. Retrieved from http://www.ncbi.nlm.nih.
gov/gene
et al., 2011), perhaps acting in concert with
Nakabayashi, K., & Scherer, S. W. (2001). The human
a FOXP1 mutation in that patient. Finally, contactin-associated protein-like 2 gene (CNTNAP2)
a report of a mouse model with both copies of spans over 2 Mb of DNA at chromosome 7q35.
the mouse homolog of CNTNAP2 knocked out Genomics, 73(1), 108–112.
O’Roak, B. J., Derziotis, P., et al. (2011). Exome sequenc-
(Peñagarikano et al., 2011) described mice with
ing in sporadic autism spectrum disorders identifies
deficits in the 3 ASD core features, in addition to severe de novo mutations. Nature Genetics, 43(6),
epileptic seizures (reminiscent of Strauss et al., 585–589.
2006) and hyperactivity. The evidence in Peñagarikano, O., Abrahams, B. S., Herman, E. I., et al.
(2011). Absence of CNTNAP2 leads to epilepsy, neu-
CNTNAP2 to date, as well as the implication of
ronal migration abnormalities, and core autism-related
several other neurological genes (e.g., NLGN3, deficits. Cell, 147(1), 235–246.
NLGN4 X-linked, SHANK3, NRXN1) involved Poliak, S., Gollan, L., Martinez, R., et al. (1999). Caspr2,
neuron and synapse structure and development, a new member of the neurexin superfamily, is local-
ized at the juxtaparanodes of myelinated axons and
means that further research on CNTNAP2 will
associates with K+ channels. Neuron, 24(4),
undoubtedly continue and, hopefully, better eluci- 1037–1047.
date its precise role(s) in autism spectrum disorders. Poot, M., Beyer, V., Schwaab, I., et al. (2010). Disruption
of CNTNAP2 and additional structural genome
changes in a boy with speech delay and autism spec-
trum disorder. Neurogenetics, 11(1), 81–89.
See Also Sehested, L. T., Mller, R. S., Bache, I., Andersen, N. B.,
Ullmann, R., Tommerup, N., et al. (2010). Deletion of
▶ Neuroligins 7q34-q36.2 in two siblings with mental retardation,
language delay, primary amenorrhea, and dysmorphic
▶ SHANK 3
Contingency Contracting 799 C
features. American Journal of Medical Genetics. Part approaches to the treatment of autism spectrum
A, 152A(12), 3115–3119. disorders. For example, discrete trial teaching
SMART (Simple Molecular Architecture Research Tool).
Retrieved from http://smart.embl-heidelberg.de/ includes the presentation of an antecedent (an
Strauss, K. A., Puffenberger, E. G., Huentelman, M. J., instruction, often referred to as a discriminative
et al. (2006). Recessive symptomatic focal epilepsy stimulus when it comes to occasion, a specific
and mutant contactin-associated protein-like 2. The response under specific conditions), the learner’s
New England Journal of Medicine, 354(13),
1370–1377. response, and the presentation of reinforcement. C
Traka, M., Goutebroze, L., Denisenko, N., et al. (2003).
Association of tag-1 with caspr2 is essential for the
molecular organization of juxtaparanodal regions of See Also
myelinated fibers. The Journal of Cell Biology,
162(6), 1161–1172.
UCSC Genome Browser. Retrieved from http://genome. ▶ Negative Reinforcement
ucsc.edu/ ▶ Operant Conditioning
UniProt. Retrieved from http://www.uniprot.org/ ▶ Positive Reinforcement
Verkerk, A. J., Mathews, C. A., Joosse, M., et al. (2003).
CNTNAP2 is disrupted in a family with Gilles de la
Tourette syndrome and obsessive compulsive
disorder. Genomics, 82(1), 1–9. References and Readings
Vernes, S. C., Newbury, D. F., Abrahams, B. S., et al.
(2008). A functional genetic link between distinct Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).
developmental language disorders. The New England Basic concepts. In J. O. Cooper, T. E. Heron, &
Journal of Medicine, 359(22), 2337–2345. W. L. Heward (Eds.), Applied behavior analysis
(2nd ed., pp. 24–46). Upper Saddle River, NJ: Pearson.
Skinner, B. F. (1969). Contingencies of reinforcement:
A theoretical analysis. New York, NY: Meredith.
Contingencies of Reinforcement
Dennis Mozingo
Department of Pediatrics, University of
Rochester Medical Center Contingency Contracting
Solandy Forte
Definition The Center for Children with Special Needs,
Contingencies of reinforcement, in their simplest
form, are comprised of antecedents (events that
occur immediately before a behavior), responses Definition
or behaviors, and consequences (events that
occur immediately after a behavior). The term A contingency contract is a positive intervention
contingencies refers to the relationship or that specifies the behavioral, social, or academic
interrelationship (Skinner, 1969) between these expectations to be completed in order to access
events. Reinforcement refers to consequences that reinforcement. A contract is typically developed
increase the probability of the behavior occurring by the client(s) and the individual providing
again under similar circumstances. Thus, contin- treatment. A clear definition of the task(s), to be
gencies of reinforcement describe an antecedent- completed by the client(s), is outlined, a criterion
behavior-consequence link in which the conse- is established, and a reinforcer is identified.
quence increases the likelihood that a behavior The contract must also monitor individual or
will occur again in the presence of an antecedent. group progress after obtaining the baseline level
Contingencies of reinforcement are a key compo- of performance. The implementation of these
nent in applied behavior analysis (ABA) contracts can target behaviors that are client or
C 800 Control
group specific. An example of a contingency

contract is a token economy system which spec- Conversational Manner
ifies the target behavior to increase, tokens to be
delivered, and the reinforcer as secondary for Sarita Austin
exhibiting the target behavior and also specifies Laboratory of Developmental Communication
a variety of highly preferred reinforcers to earn in Disorders, Yale Child Study Center, New Haven,
exchange for the tokens. Contingency contracts CT, USA
are widely used across a variety of settings
including home, community, classroom, and
clinical settings. Definition
Conversational manner refers to the extent to

See Also which an individual is able to make clear, concise,
and orderly contributions to conversation.
▶ Positive Reinforcement The maxim of manner is one of four conversa-
▶ Token Economy tional maxims (general truths or rules of conduct)
that guide cooperative conversation in everyday
life, as identified by the twentieth century linguis-
References and Readings tic philosopher, Herbert Paul Grice. The other
three conversational maxims include the maxims
Koegel, L. K., Singh, A. K., & Koegel, R. L. (2010). of quality (providing truthful information),
Improving motivation for academics in children
with autism. Journal of Autism and Developmental
quantity (providing sufficient, but not excessive
Disorders, 40(9), 1057–1066. information), and relation (providing relevant
Skinner, B. F. (1953). Science and human behavior. information). Failure to adhere to one of
New York: MacMillan. these maxims in conversation may lead to the
communication breakdowns, such as those that
often occur with individuals with autism spec-
Control trum disorders (ASD) during discourse. Alterna-
tively, purposeful violations of the maxim may
▶ Neurotypical create what Grice called “implicature,” the use of
the violation to convey a message that differs
from the literal content of the utterance. For
example, a young woman who violates the
Controlled Oral Word Association maxim of relevance when asked out on a date
by saying “Exams are coming up” forces the
▶ Verbal Fluency young man asking to consider that while, on the
surface, the exam schedule does not literally
answer his question, the implicature he is to
draw is that she means to turn down the date
Controlling Prompt and is offering a plausible excuse in order to
avoid directly saying “no” and embarrassing or
▶ Hand-Over-Hand Assistance hurting him.
The existing literature on language use and
conversational skills in individuals with ASD
indicates that appropriately modifying conversa-
Conversational Discourse tional manner based on listener and context may
present a challenge in this group. Individuals
▶ Discourse Management with ASD may present ambiguous or
Copy Number Variation 801 C
disorganized statements without taking into
account the interests or knowledge of their Copy Number Variation
listeners.
A. Jeremy Willsey
Department of Genetics, Yale University School
See Also of Medicine, New Haven, CT, USA
C
▶ Discourse Management
Synonyms
References and Readings CNVs
Fine, J., Bartolucci, G., Szatmari, P., & Ginsberg, G.

(1994). Cohesive discourse in pervasive developmen-
tal disorders. Journal of Autism and Developmental
Definition
Disorders, 24(3), 315–329.
Frith, U. (1984). A new look at language and communi- Copy number variations (CNVs) are deletions or
cation in autism. International Journal of Language & duplications of DNA, typically defined as includ-
Communication Disorders, 24(2), 123–150.
ing 1,000 base pairs of DNA. Deletions and
Ghaziuddin, M., & Gerstein, L. (1996). Pedantic speaking
style differentiates Asperger syndrome from duplications smaller than this are called “indels.”
high-functioning autism. Journal of Autism and The presence of CNVs in phenotypically normal
Developmental Disorders, 26(6), 585–595. individuals was not appreciated until 2004 with
Grice, H. P. (1975). Logic and conversation. In D. Davidson
& G. Harman (Eds.), The logic of grammar. Encino,
landmark papers by Iafrate and Sebat (Iafrate
CA: Dickenson Press. et al., 2004; Sebat et al., 2004). Like single nucle-
Paul, R. (1984). Responses to contingent queries in otide polymorphisms (SNPs), CNVs are part of
adults with mental retardation and pervasive develop- the normal variation between two individuals and
mental disorders. Applied PsychoLinguistics, 5,
may either be inherited from parents or appear de
349–357.
Surian, L., Baron-Cohen, S., & van der Ley, H. (1996). novo.
Are children with autism deaf to Gricean maxims? The importance of CNVs for ASD was first
Cognitive Neuropsychiatry, 1(1), 55–71. noted in 2007 by Sebat (Sebat et al., 2007). This
study focused on large de novo CNVs (i.e., not
present in either parent). These large de novo
CNVs were found to be more common in children
with autism compared to children without. In this
Convulsion initial study, the authors also demonstrated an
increased rate of de novo CNVs in simplex
▶ Seizure autism families compared to multiplex autism
families. This finding has been replicated multi-
ple times (Marshall and Scherer, 2012) with de
novo CNVs found in 5–10% of children with
Cooing ASD from families with no other affected indi-
viduals compared with 1.5% in unaffected con-
▶ Vocalization trols. The overall contribution of transmitted
CNVs and small de novo SNVs to ASD risk
remains to be definitively characterized.
Since the recognition of their importance in
Cooperative Groups ASD, multiple studies have aimed to identify
specific regions of DNA in which CNVs contrib-
▶ Group Work and Class Discussions ute risk. The best characterized CNVs include
C 802 Co-regulation
16p11.2 which has been found in 1% of children

with autism compared with <0.1% in unaffected Corpus Callosum
individuals.
Thomas Frazier1 and Antonio Hardan2
1
Research Center for Autism, The Cleveland
See Also Clinic, Cleveland, OH, USA
2
▶ 16p11.2 Sciences, Stanford University, Stanford, CA, USA
▶ 7q11.23 Duplications
▶ CATCH 22 (Chromosome 22q11 Deletion
Syndrome) Synonyms
▶ Chromosomal Abnormalities
▶ Common Disease-Rare Variant Hypothesis Colossal commissure; Interhemispheric white
▶ DNA matter tract
▶ Genetics
▶ Karyotype
Definition
References and Readings The corpus callosum (CC) is the largest

interhemispheric fiber tract of the brain. It con-
Iafrate, A. J., Feuk, L., Rivera, M. N., Listewnik, M. L., sists of more than 180 million neural fibers that
Donahoe, P. K., Qi, Y., Scherer, S. W., et al. (2004).
Detection of large-scale variation in the human
connect homologous and heterotopic regions of
genome. Nature genetics, 36(9), 949–951. the left and right hemispheres. The CC is
doi:10.1038/ng1416. typically divided into subregions from anterior
Marshall, C. R., & Scherer, S. W. (2012). Detection to posterior using either a three-region or seven-
and characterization of copy number variation in
region system. Table 1 presents the three broad
autism spectrum disorder. Methods Mol Biol., 838,
115–35. subregions and a common subdivision scheme by
Sebat, J., Lakshmi, B., Malhotra, D., Troge, J., Lese- Witelson, either of which may be used to refer to
Martin, C., Walsh, T., Yamrom, B., et al. (2007). subregions of the corpus callosum. The Witelson
Strong association of de novo copy number mutations
scheme includes seven specific subdivisions: the
with autism. Science, 316(5823), 445–449.
doi:10.1126/science.1138659. rostrum, genu, rostral body, anterior midbody,
Sebat, J., Lakshmi, B., Troge, J., Alexander, J., Young, J., posterior midbody, isthmus, and splenium; this
Lundin, P., Månér, S., et al. (2004). Large-scale scheme is often used in research studies.
copy number polymorphism in the human genome.
The CC is topographically organized with
Science, 305(5683), 525–528. doi:10.1126/
science.1098918. specific regions connecting fibers originating
from defined brain regions. For example, fibers
originating in prefrontal cortex cross the CC in
the genu, while fibers starting from the occipital
and inferior temporal regions cross at the level of
Co-regulation the splenium. These regions of the corpus
callosum contain connecting fibers important for
▶ Mutual Regulation many different cognitive functions including
attention, memory, language, and other specific
abilities. Developmentally, the CC shows
a U-shaped pattern with early increases in volume
Corneal Reflex and integrity through adolescence and early
adulthood, followed by later reductions. Based
▶ Eyeblink Reflexes on its anatomy and functional roles, the CC has
Corpus Callosum 803 C
Corpus Callosum, Table 1 Common subregions or seg- provided impetus for examining this brain struc-
ments of the corpus callosum ture in autism.
Anatomical Individuals with complete or partial absence
Region label Cortical region(s) of the corpus callosum as a result of abnormal
Broad regions development (agenesis) may exhibit social and
Anterior Frontal lobe Prefrontal cortex communication deficits reminiscent of autism
Body Frontal, parietal Premotor, supplementary
and result in a diagnosis of Asperger’s syndrome C
lobes motor, sensory, and
posterior parietal cortex or pervasive developmental disorder not other-
Posterior Temporal, Superior and inferior wise specified. However, agenesis of the corpus
parietal, temporal, posterior parietal, callosum is not a characteristic or common find-
occipital lobes visual and secondary ing in autism, and agenesis of the corpus callosum
occipital cortex
is part of many other congenital syndromes with
Witelson
a wide range of etiologies including fetal cyto-
1 Rostrum Caudal/orbital prefrontal,
inferior premotor megalovirus infection. The basis of the clinical
2 Genu Prefrontal overlap between ASD and agenesis of the corpus
3 Rostral body Premotor, supplementary callosum and vice versa is under investigation.
motor
4 Anterior Motor
midbody See Also
5 Posterior Somesthetic, posterior
midbody parietal
▶ Corpus Callosum Abnormalities in Autism
6 Isthmus Superior temporal, posterior
parietal
7 Splenium Occipital, inferior temporal
Fame, R. M., MacDonald, J. L., & Macklis, J. D. (2010).

Development, specification, and diversity of callosal
been conceptualized as an index of the develop- projection neurons. Trends in Neurosciences, 34(1),
ment of structural and functional connectivity of 41–50. doi:S0166-2236(10)00147-5 [pii] 10.1016/j.
tins.2010.10.002.
the hemispheres. Giedd, J. N., Blumenthal, J., Jeffries, N. O., Rajapakse,
J. C., Vaituzis, A. C., & Liu, H. (1999). Development
Relevance to ASD of the human corpus callosum during childhood and
Many research studies have investigated the size adolescence: A longitudinal MRI study. Progress in
Neuro-Psychopharmacology & Biological Psychiatry,
of the corpus callosum and its segments in 23(4), 571–588. doi:S0278584699000172 [pii].
autism. The most consistent finding has been Hardan, A. Y., Minshew, N. J., & Keshavan, M. S. (2000).
that the corpus callosum is not involved in the Corpus callosum size in autism. Neurology, 55(7),
early overgrowth that occurs in the rest of the 1033–1036.
Hasan, K. M., Kamali, A., Iftikhar, A., Kramer, L. A.,
brain in the first few years of life. Hence, studies Papanicolaou, A. C., & Fletcher, J. M. (2009). Diffu-
have reported that the corpus callosum does not sion tensor tractography quantification of the human
differ in size between those with and without corpus callosum fiber pathways across the lifespan.
autism. When CC size is considered in relation Brain Research, 1249, 91–100. doi:S0006-8993(08)
02516-X [pii] 10.1016/j.brainres.2008.10.026.
to total brain volume, the corpus callosum is Paul, L. K., Brown, W. S., Adolphs, R., Tyszka, J. M.,
disproportionately small in those with autism. Richards, L. J., & Mukherjee, P. (2007). Agenesis of
Other studies have investigated the size of the the corpus callosum: Genetic, developmental and
subregions with variable results in terms of functional aspects of connectivity. Nature Reviews
the subregions that are smaller in comparison to Witelson, S. F. (1989). Hand and sex differences in the
controls. This observation, as well as the role of isthmus and genu of the human corpus callosum.
the CC in connecting many brain networks, has Brain, 112, 799–835.
C 804 Corpus Callosum Abnormalities in Autism
Corpus Callosum Abnormalities

in Autism
Thomas Frazier1 and Antonio Hardan2

1
Research Center for Autism, The Cleveland
Clinic, Cleveland, OH, USA
2
Sciences, Stanford University, Stanford,
CA, USA
Definition
Corpus callosum (CC) abnormalities in autism Corpus Callosum Abnormalities in Autism,

generally refer to reductions in the midsagittal Fig. 1 Total corpus callosum and Witelson subdivisions.
size, volume, or integrity of the CC in individuals Subdivision 1: rostrum in black; subdivision 2: genu in
yellow; subdivision 3: rostral body in pink; subdivision 4:
with autism spectrum disorders. anterior midbody in aqua; subdivision 5: posterior
midbody in green; subdivision 6: isthmus in deep blue;
subdivision 7: splenium in red. Subdivisions 1 and 2 are
Historical Background the most anterior subdivisions and connect frontal regions.
Subdivision 7 is the most posterior and connects occipital
and inferior temporal regions
Over the last few decades, case reports have been
published supporting an association between par-
tial or complete agenesis or other abnormalities example, studies by Piven et al. (1997) and
of the CC and social deficits. While not all indi- Hardan et al. (2000) identified reduced
viduals with agenesis of the corpus callosum midsaggital area of the corpus callosum in indi-
meet full DSM criteria for autism spectrum dis- viduals with autism. Supporting these more
orders, they often show behavioral, cognitive, recent studies, a meta-analysis of ten total studies
and functional patterns reminiscent of autism, from 1987 to 2007 was completed examining
particularly individuals with complete agenesis both the total CC and Witelson subdivisions
(Paul et al., 2007) (Fig. 1). (see Fig. 2 below). Although three of the ten
The first careful examination of the CC in studies conducted over this time period did not
autism using magnetic resonance imaging was find a significant reduction of the CC in autism,
published by Gaffney, Kuperman, Tsai, Minchin, when considered together, this pool of studies
and Hassanein (1987). This study did not identify identified a highly significant reduction of the
significant differences in midsagittal CC area. overall CC in autism. Additionally, this meta-
However, the lack of significant findings was analysis found that the largest reduction occurred
likely due to a small sample size and the limita- in a subdivision of the CC called Witelson subdi-
tion of the early morphometric neuroimaging vision 3: Rostral body that is important for motor
methodologies. A series of more recent studies planning and also includes mirror neurons crucial
have found significant reductions of CC size to representing others’ behavior (see Fig. 1 for
examining a wide age range of individuals with a view of the whole CC and Witelson
autism and varying levels of cognitive subdivisions).
abilities (Hardan, Minshew, & Keshavan, 2000; As magnetic resonance imaging technology
Just, Cherkassky, Keller, Kana, & Minshew, has improved, more advanced imaging methods
2007; Manes et al., 1999; Piven, Bailey, Ranson, have been applied to the investigation of the CC
& Arndt, 1997; Vidal et al., 2006). For in autism. Results from these novel approaches
Corpus Callosum Abnormalities in Autism 805 C
Corpus Callosum 0.9
Abnormalities in Autism,
Fig. 2 Presents the 0.8
magnitude of reductions in 0.7
the total CC and Witelson
subdivisions in individuals 0.6
effect size (d)

with autism. Witelson
0.5
subdivision 3: rostral body
shows the largest reduction
C
0.4
0.3
0.2
0.1
0.0
total W1 W2 W3 W4 W5 W6 W7
Witelson Sub-Division
support previous findings. These studies have David, Wacharasindhu, & Lishman, 1993;
found decreased volume (Freitag et al., 2009; Fischer, Ryan, & Dobyns, 1992; Solursh,
Hardan et al., 2009; Keary et al., 2009; Mitchell Margulies, Ashem, & Stasiak, 1965; Williams,
et al., 2009) and density (Chung, Dalton, Goldstein, & Minshew, 2006).
Alexander, & Davidson, 2004; Spencer et al., The localization of the exact CC structural
2006; Waiter et al., 2005). Additionally, diffusion abnormalities has also been examined. While
tensor imaging investigations have also exam- most studies reported reductions in the total size
ined white matter water diffusivity and reported of the CC, recent investigations revealed
structural alterations (Alexander et al., 2007; reduction in the volume of its anterior and
Barnea-Goraly et al., 2004) of the CC and other posterior subdivisions (Chung et al., 2004;
related regions (Keller, Kana, & Just, 2007; Hardan et al., 2009) and decreased density of
Waiter et al., 2005). caudal regions (Spencer et al., 2006; Waiter et
al., 2005). These findings suggest corresponding
structural alterations in frontal and temporal
Current Knowledge regions and appear to be due to reductions of
the number of axons traveling between hemi-
Updated studies and reviews of small case series spheres (hypoplasia) rather than loss of axon
or small group studies of individuals with agene- integrity or atrophy (Chung et al., 2004). This
sis of the CC without intellectual disability have pattern is suggestive of early life abnormalities
provided further support for a relationship of the CC.
between the CC and autism. These observations Finally, the effect of development has also
suggest not only symptom and behavioral pat- been examined, with investigations suggesting
terns similar to what are seen in individuals with the existence of CC abnormalities in children
autism, but also alterations in thinking abilities with autism at a very young age (2–4 years old;
consistent with those seen in individuals with Boger-Megiddo et al., 2006) and their persistence
autism. For example, individuals with agenesis into adolescence and adulthood (Hardan et al.,
of the CC often show cognitive deficits, similar 2000; Just et al., 2007). This indicates that hypo-
what are observed in autism, such as problems plasia of the CC continues over time, along with
with abstract reasoning, deciphering nonliteral many autism symptoms (Lord et al., 2008; Piven,
language (metaphors, idioms, sarcasm, humor), Harper, Palmer, & Arndt, 1996; Seltzer et al.,
and generalization (Brown & Sainsbury, 2000; 2003).
C 806 Corpus Callosum Abnormalities in Autism
Future Directions of simultaneity to somatosensory stimuli. Journal of

Clinical and Experimental Neuropsychology, 22,
587–598.
Progress has been made to date in understanding Chung, M. K., Dalton, K. M., Alexander, A. L., &
the pathophysiology of the CC in autism, but Davidson, R. J. (2004). Less white matter
additional studies examining this structure, and concentration in autism: 2D voxel-based morphome-
white matter more generally, are needed to iden- try. Neuroimage, 23, 242–251.
David, A. S., Wacharasindhu, A., & Lishman, W. A.
tify the underpinnings of CC abnormalities and (1993). Severe psychiatric disturbance and abnormal-
how these abnormalities relate to the core fea- ities of the corpus callosum: Review and case series.
tures. Longitudinal studies of young children as Journal of Neurology, Neurosurgery and Psychiatry,
they grow may be a particularly powerful way to 56(1), 85–93.
Fischer, M., Ryan, S. B., & Dobyns, W. B. (1992).
uncover the pattern of development in the CC and Mechanisms of interhemispheric transfer and patterns
relate this pattern to changes over time in autism of cognitive function in acallosal patients of
symptoms. These studies should apply multi- normal intelligence. Archives of Neurology, 49(3),
modal imaging techniques, rather than only 271–277.
Freitag, C. M., Luders, E., Hulst, H. E., Narr, K. L.,
examining area or volume, to best identify abnor- Thompson, P. M., & Toga, A. W. (2009). Total brain
malities and provide a more comprehensive pic- volume and corpus callosum size in medication-naive
ture of how these abnormalities alter brain adolescents and young adults with autism spectrum
function. Finally, relating imaging findings to disorder. Biological Psychiatry, 66(4), 316–319.
doi:10.1016/j.biopsych.2009.03.011. S0006-3223(09)
genetic changes is an important but largely 00360-6 [pii].
unexplored avenue that will be fruitful for under- Gaffney, G. R., Kuperman, S., Tsai, L. Y., Minchin, S., &
standing the molecular changes contributing to Hassanein, K. M. (1987). Midsaggital magnetic reso-
CC abnormalities and developing new therapeu- nance imaging of autism. British Journal of Psychia-
try, 151, 831–833.
tics that might improve or prevent the develop- Hardan, A. Y., Minshew, N. J., & Keshavan, M. S. (2000).
ment of CC abnormalities in individuals with Corpus callosum size in autism. Neurology, 55(7),
autism. 1033–1036.
Hardan, A. Y., Pabalan, M., Gupta, N., Bansal, R., Melhem,
N. M., & Fedorov, S. (2009). Corpus callosum volume
in children with autism. Psychiatry Research, 174(1),
See Also 57–61. doi:10.1016/j.pscychresns.2009.03.005. S0925-
4927(09)00086-9 [pii].
▶ Corpus Callosum Just, M. A., Cherkassky, V. L., Keller, T. A., Kana, R. K.,
& Minshew, N. J. (2007). Functional and anatomical
cortical underconnectivity in autism: Evidence from
an FMRI study of an executive function task and
References and Readings corpus callosum morphometry. Cerebral Cortex,
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corpus callosum and cerebellum in mentally
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470–474. Departments of Psychiatry and Biometry, Yale
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Paul, L. K., Brown, W. S., Adolphs, R., Tyszka, J. M.,
Richards, L. J., & Mukherjee, P. (2007). Agenesis of The important concept of correlation will cover
the corpus callosum: Genetic, developmental and a number of important areas: defining features;
functional aspects of connectivity. Nature Reviews types of correlations; a brief historicity of the
Piven, J., Bailey, J., Ranson, B. J., & Arndt, S. (1997). concept; and multiple ways to look at the corre-
An MRI study of the corpus callosum in lation coefficient.
autism. American Journal of Psychiatry, 154(8),
1051–1056.
Piven, J., Harper, J., Palmer, P., & Arndt, S. (1996).
Course of behavioral change in autism: Definition
A retrospective study of high-IQ adolescents and
adults. Journal of the American Academy of Child Correlation refers to a statistical procedure that
and Adolescent Psychiatry, 35(4), 523–529. assesses the association between two variables
Seltzer, M. M., Krauss, M. W., Shattuck, P. T., Orsmond,
G., Swe, A., & Lord, C. (2003). The symptoms of that we will refer to as X and Y. Correlation
autism spectrum disorders in adolescence and adult- coefficients, symbolized as r, can vary
hood. Journal of Autism and Developmental Disor- between 1, 0, and +1. Positive correlations
ders, 33(6), 565–581. occur when Y increases as X increases and
Solursh, L. P., Margulies, A. I., Ashem, B., & Stasiak,
E. A. (1965). The relationships of agenesis of negative correlations occur when X increases as
the corpus callosum to perception and learning. Y decreases.
Journal of Nervous and Mental Disease, 141(2), When there is no association between the
180–189. X and Y variable, the size of r tends in the direc-
Spencer, M. D., Moorhead, W. J., Lymer, K. S., Job, D. E.,
Muir, W. J., & Hoare, P. (2006). Structural correlates tion of a 0 value. Finally, correlation rests
of intellectual impairment and autistic features in upon the assumption that there is no so-called
adolescents. Neuroimage, 33, 1136–1144. causative relationship between the X and
Vidal, C. N., Nicolson, R., DeVito, T. J., Hayashi, K. M., Y study variables.
Geaga, J. A., & Drost, D. J. (2006). Mapping corpus
callosum deficits in autism: An index of aberrant
cortical connectivity. Biological Psychiatry, 60,
218–225. Brief Historicity of the Correlation
Waiter, G. D., Williams, J. H., Murray, A. D., Gilchrist, A., Coefficient r
Perrett, D. I., & Whiten, A. (2005). Structural white
matter deficits in high-functioning individuals
with autistic spectrum disorder: A voxel-based As noted by Rodgers and Nicewander (1988), the
investigation. Neuroimage, 24(2), 455–461. concept of correlation was introduced, in 1885,
doi:10.1016/j.neuroimage.2004.08.049. S1053-8119(04) by Sir Francis Galton, who developed “the theory
00512-9 [pii].
Williams, D. L., Goldstein, G., & Minshew, N. J. (2006). of bivariate correlation” as well as the related
Neuropsychologic functioning in children with term “regression.” The concept of r, as we know
autism: Further evidence for disordered complex it today, was introduced a decade later by Karl
information-processing. Child Neuropsychology, 12 Pearson (1896). Again, from a historical perspec-
(4–5), 279–298. doi:10.1080/09297040600681190.
W6275407Q443855Q [pii]. tive, the Rodgers and Nicelander publication was
C 808 Correlation
written in celebration of the 100th Anniversary of study reaching an r value of 0.36 (Sparrow,
Galton’s critical contribution to the development Cicchetti, & Balla, 2005). By the same set of
of the correlation coefficient. clinical criteria, this represents a medium level
It is important to note also the more far- of clinical significance.
reaching significance of r when one realizes that In the next section, I shall discuss a multitude of
“Factor analysis, behavioral genetics models, different ways to understand the meaning and rather
structural equation models (e.g., LISREL), and far-reaching implications of the coefficient r.
other related methodologies use the correlation Thirteen were described by Rodgers and
coefficient as the basic unit of data” (Rodgers & Nicewander (1988); a 14th was added by Rovine
Nicewander, 1988, p. 61). In fact, as Henrysson and von Eye (1997); and a very general purpose
(1971) reminds us, three other correlation coeffi- r related index was developed and introduced by
cients can be accurately defined as special Rosental and Rubin in 1982. Each of these will be
instances of Pearson’s r coefficient: Spearman’s discussed in turn:
rho and the point-biserial correlation for ordinal Thirteen ways to interpret r (derived from
data; and the phi coefficient for nominal- Rodgers & Nicewander (1988)):
dichotomous data. 1. r as Pearson (1896) defined it, or as it is
typically applied, based upon raw score and
An Application of r average or mean values.
Let us assume that X refers to IQ level and Y to 2. r as a ratio of standard deviations.
Vineland overall adaptive behavior levels. 3. r as the standardized slope of the regression
Assume further that the study group is a random line.
representative sample of typically developing 4. r as the geometric average of the two regres-
10 year olds. Based upon many Vineland stan- sion slopes.
dardization samples, we know that the correlation 5. r as the proportion of variability accounted
will be of the order of about 0–0.20 between IQ for.
and the Adaptive Behavior Composite and this is 6. r as the average cross product of standardized
statistically significant at the 5% level of statisti- variables.
cal significance. What do we make of the corre- 7. r in relation to the angle between two stan-
lation of 0.20 between IQ and overall adaptive dardized regression lines.
behavior? Once again, the all important level of 8. r in relation to the angle between the two
clinical significance needs to be addressed, this variable vectors.
time in the form of criteria developed by Cohen 9. r as a rescaled variance of the difference
(1988), as expanded by Cicchetti (2008): between standardized scores.
Range of correlation: clinical significance 10. r as estimated from the balloon rule: Note
<0.10 Trivial that the “balloon” is formed by drawing an
0.10–0.29 Small ellipse around the scatterplot of the individ-
0.30–0.49 Medium ual X and Y values.
0.50–0.69 Large 11. r as a more formal representation of the bal-
0.70–1.00 Very large loon rule.
By these clinical criteria, the correlation of 12. r as related to test statistics from designed
0.20 between IQ level and overall adaptive experiments.
behavior level is considered small. It should be 13. r as the ratio of two means. A fourteenth way
noted that similar results occur for the Vineland to interpret r: (derived from Rovine & von
Domains, Daily Living Skills, Socialization, and Eye (1997))
Motor Skills. 14. r as the proportion of matches between stan-
As expected on the basis of the content of the dardized X and Y values.
items, the correlation between IQ and the Com- A fundamental biostatistical research question
munication Domain is somewhat higher, in one pertains to the extent to which some future
Correlation 809 C
researchers in the field of Autism Spectrum Dis- that receives psychotherapy), and a Control
orders will find some of these imaginative inter- Group (the one that does not receive
pretations of the correlation coefficient useful in psychotherapy).
providing further clinical insights into the vaga- The cells in the 2 2 BESD contingency
ries and vicissitudes of ASD disorders. table are expressed as four percentages, each
In the next section, I shall present some novel starting and ending at 50%. If the r is 0, then the
interpretations of the meaning of the correlation percentages remain unaltered and indicate 0 suc- C
coefficient r, as presented by Rosenthal and cess for the psychotherapy intervention. This
Rubin (1982). means that 50% of the subjects in the Treatment
Group show positive results and 50% do not. This
is no different than the results for the Control
The Binomial Effect Size Display (BESD) Group and makes perfect clinical sense in terms
of an r of 0.00 between X, reflecting the type of
A standard way of interpreting the clinical impor- treatment (Therapy or Not) and Y, reflecting the
tance of the size of a correlation coefficient, r, is outcome of the intervention (Success or Failure).
to simply square its value. This informs us about Now, in our application, the actual r ¼ 0.32.
how much of the explained variance in the The BESD will inform how much better than
Y variable can be attributed to the variance in a 0.00 r is one of 0.32.
the X variable. The result is expressed as Using the r ¼ 0.32 as a measure of Effect Size
a percentage score that will vary between 0% (e.g., Cohen, 1988; Rosnow, Rosenthal, & Rubin,
(a 0 correlation) and 100% (a perfect correlation, 2000), the r is divided in 2, with this value of 0.16
of either +1.00 or 1.00). Thus, a correlation of both subtracted and added to the 50% value in
size 0.32 would be viewed as very low or some- each of the two groups. This then represents the
what trivial, since it accounts for 0.32 squared, or amount of improvement provided by the treat-
only 10% of the explained variance in the ment intervention. In our example, this results
Y variable that can be predicted by the in percentages of (50% 16% ¼ 34%) and
X variable. This would leave as unaccounted (50% + 16% ¼ 66%), The result is now
variance a whopping 90%! And, in fact, this is interpreted to mean that the r between treatment
the reported success rate of psychotherapy, as and success rate of 0.32 indicates that psycho-
reported by Randolph and Edmondson (2000). therapy intervention has resulted in a 34–64%
While the traditional way of interpreting the increase in success rate, or 14% over the 50%
psychotherapy outcome study seems rather one would have expected if the therapy had no
wimpy, indeed, the work of Rosenthal and effect at all. As noted correctly and initially by
Rubin (1982) suggests otherwise. Using what Rosenthal and Rubin (1982), even though the r of
they referred to as a Binomial Effect Size Display 0.32 only explains 10% of the variance in success
(BESD), the authors cast a given correlation rate, when interpreted in a BESD context, the
between the X and Y variables into a 2 2 con- result can hardly be interpreted as of little clinical
tingency table, and the approach is applicable value.
whether the original data were derived from cat- In summarizing this section of the report,
egorical or continuous scales of measurement. I present, in Table 1, the results of comparing
the meaning and interpretation of the various
values of a correlation coefficient, r.
Applying the BESD to the Success of The table is constructed to show what happens
Psychotherapy Intervention to the values of r squared, the success of
a Treatment intervention, and the level of clinical
The reported r of 0.32, representing the success importance of the research result, as the correla-
of psychotherapy intervention, is now considered tion between the X and Y variable increases from
in the context of a Treatment Group (the one 0 to a perfect correlation of 1.00.
C 810 Correlational
Correlation, Value of r r squared BESD % success Clinical significance of r

Table 1 Comparing and
contrasting ways to <0.10 <0.01 <55 Trivial
interpret the meaning of the 0.10 0.01 55 Small
Pearson correlation 0.20 0.04 60 Small
coefficient, r 0.30 0.09 65 Medium
0.40 0.16 70 Medium
0.50 0.25 75 Large
0.60 0.36 80 Large
0.70 0.49 85 Very large
0.80 0.64 90 Very large
0.90 0.81 95 Very large
1.00 1.00 100 Perfect r
Concluding Comments Henrysson, S. (1971). Gathering, analyzing, and using

data on test items. In R. L. Thorndike (Ed.), Educa-
tional measurement (pp. 130–159). Washington, DC:
This report covers the correlation coefficient for American Council on Education.
determining the degree of linear relationship Pearson, K. (1896). Mathematical contributions to the
between a pair of variables designated as theory of evolution. III. Regression, heredity and
X and Y. It did not cover a number of related panmixia. Philosophical Transactions of the Royal
Society of London, 187, 253–318.
issues, not because they are not of research Randolph, J., & Edmondson, S. (2000). Using the binomial
importance in a larger sense, but, rather, because effect size display (BESD) to present the magnitude of
studies that focus upon curvilinear relationships effect sizes to the evaluation audience. Practical
among ASD-relevant variables are notable for Assessment Research and Evaluation, 10, 1–7.
Rodgers, J. L., & Nicewander, W. A. (1988). Thirteen
their absence in the field. Another way of stating ways to look at the correlation coefficient. The Amer-
this phenomenon is that the relationships we typ- ican Statistician, 42, 59–66.
ically study in ASD research are of a linear nature Rosenthal, R., & Rubin, D. B. (1982). A simple general
or quality. For similar reasons, this section on purpose display of magnitude of experimental effect.
Journal of Educational Psychology, 74, 166–169.
correlation has not focused on multiple Rosnow, R. L., Rosenthal, R., & Rubin, D. B. (2000).
correlation. Contrasts and correlations in effect-size estimation.
American Psychological Society, 11, 446–453.
Rovine, M., & von Eye, A. (1997). A 14th way to look at
the correlation coefficient: Correlation as the propor-
See Also tion of matches. The American Statistician, 51, 42–46.
Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005).
Vineland II: A revision of the Vineland adaptive
▶ Statistical Approaches to Subtyping
behavior scales: I. Survey form. Circle Pines, MN:
American Guidance Service.
Cicchetti, D. V. (2008). From Bayes to the just noticeable Correlational

difference to effect sizes: A note to understanding the
clinical and statistical significance of oenologic
▶ Qualitative Versus Quantitative Approaches
research findings. Journal of Wine Research, 3, 185–
193.
Cohen, J. (1988). Statistical power analysis for the behav-
ioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum
Associates.
Galton, F. (1985). Regression towards mediocrity in
Cortex
hereditary status. Journal of the Anthropological Insti-
tute, 15, 246–263. ▶ Cerebral Cortex
Cortical Language Areas 811 C
fissure, posterior to HG and lies on the superior
Cortical Deafness surface of the posterior STG. Many of these
regions are anatomically connected through the
▶ Verbal Auditory Agnosia arcuate fasciculus (AF), an axonal fiber bundle
that arches around the ventral part of the frontal
lobe and the posterior part of the temporal lobe.
Impairments in language and communication C
Cortical Language Areas feature are one of the defining characteristics of
autism spectrum disorders (ASD). Neuroimaging
Rajesh Kana and Constance Doss studies have found deviant functional brain
Department of Psychology, University of responses as well as altered anatomical organiza-
Alabama-Birmingham, Birmingham, AL, USA tion of the language cortex in people with ASD.
One of the main anatomical abnormalities
associated with the cortical language areas in
Synonyms ASD pertains to a reversed asymmetry in the
normally left hemisphere dominant structures.
Language cortex For instance, studies have found decreased gray
matter in Broca’s area in people with ASD in
comparison to typically developing individuals.
Structure Moreover, the right hemisphere homologue of
Broca’s area has been found to be much larger
Anatomical Organization of Language Cortex in 7–11-year-old children with ASD compared to
in Autism typically developing peers. Such findings are also
Cortical language areas are primarily centered supported by evidence from neuronal density and
around the perisylvian cortex, particularly in the neuronal volume in those with ASD. The differ-
left hemisphere. While the left posterior superior ences in asymmetry may be due to a difference in
temporal gyrus (LSTG, BA 22, Wernicke’s area) the number of neurons present or possibly how
has been attributed to decoding language, the left densely they are packed together.
inferior lateral prefrontal cortex (LIFG, BA 44/ Although there are consistent findings of
45, Broca’s area) has been associated with motor abnormal asymmetry of language association
expression of speech. In other words, Broca’s cortex in Broca’s area for individuals with ASD,
area is the language production center, whereas the picture is less clear for the relatively posterior
Wernicke’s area is the language comprehension language areas, such as Wernicke’s area and the
center. In addition to these primary centers, there PT. Typical individuals with leftward lateralized
are several other areas involved in processing language cortex generally also have leftward
language. For instance, the inferior parietal lateralization of the PT. However, there is evi-
lobule (IPL) has a critical role in processing lan- dence from PT tracings that suggests there is no
guage because it is located at the junction of the association between PT size or asymmetry and
auditory, visual, and somatosensory cortices. The the lateralization of language cortex. More recent
IPL also shares connections with several other research noted a significant enlargement of the
areas in the brain that are implicated in language PT in the right hemisphere of individuals with
processing. Other regions involved in language ASD. Other research, however, has contradicted
processing include the angular and supramarginal this finding by demonstrating reduced PT volume
gyri (both are part of IPL), the planum temporale in the left hemisphere in ASD and no difference
(PT), the insula, Heschl’s gyrus (HG), and the in the volume of Heschl’s gyrus. There is also
parietal operculum. Heschl’s gyrus is located evidence that suggests that PT asymmetry may be
within the Sylvian fissure, just anterior to the related to language impairment; it has been found
PT; whereas, the PT is located within the Sylvian that individuals both with ASD as well as typical
C 812 Cortical Language Areas
controls with language impairments have more which information is transferred from one area to
leftward PT asymmetry than individuals with the other. The arcuate fasciculus (AF) is a critical
no language impairment. Therefore, language white matter fiber tract for language as it
impairment may be an important variable in primarily connects the anterior and posterior
affecting or causing PT asymmetry. It is possible core language areas. While the direct segment
that age may be another factor that influences of the AF connects Wernicke’s area with Broca’s
the organization of this region. Studies show age- area, an indirect pathway connects these areas
related changes in the PT in both typically with the inferior parietal lobule. Specifically, the
developing individuals and in individuals with anterior segment of the indirect pathway connects
ASD, with both groups showing increased leftward Broca’s area with the inferior parietal lobule and
asymmetry in older than younger individuals. the posterior segment connects the inferior
The difference in asymmetry found in struc- parietal lobule with Wernicke’s area. The
tures like the PT and the STG in people with ASD functioning of the typical language network relies
may directly point to problems associated with heavily on the direct and indirect projections
auditory processing of language. Children from the AF connecting these areas. Microstruc-
with ASD have been found to process nonspeech tural differences in the organization and asymme-
sounds abnormally early in development try of AF found in people with ASD suggests that
which implies that the deficit may stem from atypical asymmetry in people with ASD may be
faulty organization of language processing areas affecting language ability. Another fiber tract
within the auditory cortex. For instance, that is important for language is the uncinate
decreased gray matter volume of the left STG fasciculus (UF), a hook-shaped fiber bundle
has been seen in children with ASD relative to that connects the anterior temporal lobe with
participants without ASD. In addition to the the orbital frontal cortex including the IFG.
alterations found in PT and STG, increased gray Abnormalities in the UF fiber organization in
matter volume of the auditory cortex in individ- individuals with ASD have recently been found
uals with ASD has been found in the in a Diffusion Tensor Imaging (DTI) study with
periamygdaloid cortex, the left middle temporal the people with ASD showing shorter length of
gyrus, and the right inferior temporal gyrus. the left UF fibers as well as increased length,
These anatomical alterations associated with volume, and density of the right UF. These alter-
language processing areas may be a key factor ations in fiber organization in AF and UF may
affecting language and communication difficul- underlie the functional abnormalities associated
ties in ASD. Many studies point to gray matter with processing language in people with ASD.
anomalies as the causal difference in language It may not be a coincidence that the asymme-
processing abilities of individuals with ASD. try seen in gray matter associated with language
Such abnormalities are mostly due to the volume, processing is also found in white matter in people
asymmetry, or neuronal organization of a region with ASD. The differences in hemispheric later-
rather than lesions of a certain region. alization in those with ASD need to be discussed
in the context of the structural integrity of the
Anatomical Connectivity of Cortical major white matter tract – the corpus callosum –
Language Areas that facilitates the communication between the
As previously mentioned, morphometry and two hemispheres. Reduced size of the midsagittal
lesion studies have found alterations in the area of the corpus callosum in people with ASD
volume and asymmetry of cortical language has been widely reported. Despite this relatively
areas in individuals with ASD. Such impairments consistent finding, the size of the subregions of
can have a significant impact on the organization the corpus callosum in those with ASD has been
and integrity of the anatomical connections found to vary as some researchers found the
among these regions. These connections, formed reduction to be centered in anterior subregions
by axonal fiber tracts, provide the mechanism by like the rostrum and genu and others in the body
of the callosum or in the splenium. In the context extent as seen in typically developing individ-
of language processing, the genu and the poste- uals. The alterations in functional specialization
rior midbody may be critical as the fibers pass in cortical language areas may result in different
through the former and connect the left and right patterns of recruitment of cortical regions,
frontal language areas and fibers passing through especially between the two hemispheres.
the latter connect the left and right temporal and
parietal language areas. Research findings Differential Recruitment of the Hemispheres C
indicate the involvement of the corpus callosum Perhaps mirroring the anatomical differences in
in understanding humor, prosody, and decoding the asymmetry of language association cortex,
the nonliteral meaning within context. These people with ASD have been found to recruit
complex linguistic functions may require com- more right hemisphere areas in language tasks.
munication between the two hemispheres that is In studies involving the processing of spoken
facilitated by the corpus callosum. Therefore, it is language in individuals with ASD, the main
possible that the alterations seen in the organiza- findings have consisted of abnormal frontal and
tion of the corpus callosum may constrain the temporal activations, as well as reversed
language abilities of individuals with ASD. laterality in some regions. Functional MRI scans
of babies (2–3 years old) during sleep have
reported an increase in activation of right
Function hemisphere regions in children with ASD. In
addition to the deficits seen in temporal
Functional Specialization of Language Cortex processing of speech in people with ASD, their
in ASD difficulty in processing spoken language in
Functional specialization and integration go the presence of noise was demonstrated by
hand-in-hand during brain development. Any examining cortical encoding of speech in chil-
faulty element in this delicate process can have dren. The left hemisphere is considered to be
a significant impact on how different brain responsible for processing the temporal aspects
regions respond to a given function. Abnormal of sound, such as encoding the sound properties
specialization of language association cortex in of speech. Therefore, sound features that activate
people with ASD has been reported by several higher order language processing areas may not
studies. For instance, individuals with ASD may be representing the characteristics of the sound
have a faulty early perception of language due to that are required in order to engage left hemi-
impaired feature extraction, such as the correct sphere areas which are important in language
decoding of phonemes or auditory language processing and for causing language to lateralize
encoding. This may result in the left hemisphere to the correct hemisphere. Several other fMRI
language areas not receiving the proper input that and PET studies examining auditory processing
would allow for them to develop normally. When also found that people with ASD had less tempo-
this normal input is not processed correctly early ral lobe activation and less activation that was
in the pathway, the brain does not receive lateralized to the left.
accurate feedback that allows for the normal Other aspects of auditory processing, such as
maturation of language cortex. In other words, phonemic and prosodic variations in the context
deviant cognitive processing of external stimuli of spoken word, have also been found to be
in those with ASD may cause a secondary neuro- accomplished differently in people with ASD.
biological assault, which in turn may result in They have abnormal functional lateralization
altered specialization of cortical areas. Due to within the left temporal area when processing
language specialization occupying abnormal phonemes. This is indicative of the fact that
regions of the cortex in people with ASD, when left hemisphere dominance is not
those areas may not be capable of functionally established, language impairments are more
supporting language processing to the same prominent. Impairments in the processing of
prosody (pitch, rhythm, and stress patterns of sentences when compared to controls. The
language), have been reported in low- and in pattern of activation that is evident from these
high-functioning people with ASD. Research studies suggests that the differences in recruit-
shows that people with ASD are worse than typ- ment of language areas as well as a possible
ically developing controls at understanding the compensatory processing may be due to
stress differences within words. At the neural a spillover effect from the left hemisphere.
level, while individuals with ASD show In addition to the activation of brain areas for
decreased recruitment of the left superior tempo- accomplishing a task, the functional connectivity
ral sulcus in response to vocal sounds, they dis- (synchronization of brain activation across
play typical activation in response to nonvocal activated areas) is critical in solving complex
sounds. Correct processing of prosodic informa- cognitive tasks. For instance, there is significant
tion has been found to help initiate language functional connectivity between Broca’s and
acquisition and to help understand the mental Wernicke’s areas when listening to speech in
states of others. Therefore, difficulty with pros- typically developing individuals. Brain responses
ody can have a significant impact in understand- in complex language tasks in people with ASD
ing and using language in social situations. have been found to be characterized by weaker
connectivity among core regions. Weaker
Differential Functional Activation and functional connectivity in ASD has been reported
Functional Connectivity of Core in tasks of active and passive sentence compre-
Language Areas hension, sentence imagery, and in discourse
Semantic and discourse processing (auditory processing. Such weak connections are usually
or visual) have also resulted in altered found between regions that are critical for the
brain responses in people with ASD. In tasks of task at hand, for example, there is a weaker
sentence comprehension, Wernicke’s area is connection between Broca’s area and IPL in sen-
more activated and Broca’s area is less activated tence imagery, and between Broca’s and
in people with ASD; whereas an opposite trend is Wernicke’s areas in sentence comprehension.
observed in typical individuals. This pattern of In people with ASD, connections between the
brain response (increased activation in parietal and temporal lobes allow for their
Wernicke’s area) may suggest an increased increased reliance on this area for processing,
reliance on word meaning and less emphasis on perhaps as an alternate route, along with reduced
integrating words at the sentence level to arrive at connections between Broca’s and Wernicke’s
meaning. This differential recruitment of core areas. Therefore, functional connectivity may
language areas has also been found at both the play an equally important role in language
sentence level as well as at the word level in those processing as does functional activation.
with ASD. Broca’s area has been proposed as
a vital component of language processing, espe- Compensatory Strategies
cially for mediating semantic integration and for Despite widespread reports of altered recruitment
the unification of the components needed for of cortical regions for language comprehension,
processing language. Weakened integrative many studies fail to find a pronounced difference
capacities have been reported in ASD in tasks in task performance in people with ASD
that target contextual processing in semantic suggesting the possible use of compensatory
anomalies. When examining the integration of strategies. One such mechanism may be an
speaker information, Broca’s area is not activated increased reliance on right hemisphere areas.
as highly by individuals with ASD as it is by Additional recruitment of right hemisphere
typically developing participants. Yet, individ- brain regions is usually seen in typically
uals with ASD showed increased activation in developing individuals when task demands
the right hemisphere homolog to Broca’s area are increased and when higher-level language
while comprehending speaker-incongruent processing is needed. In studies of discourse
processing and in detection of communica- Research has also found weaker synchronization
tive intent, it has been found that people with between language (left inferior frontal) and
ASD show increased right hemisphere activation spatial (superior parietal) areas in people with
in the homologues of core language areas. Such ASD as compared to typically developed
tasks are complex and may require the involve- controls which further suggests focal or modular
ment of a network of coarse semantic processing, processing as opposed to integrative processing
coherence monitoring, text integration, spatial that is seen in control participants. Such findings C
imagery, and perspective taking. While any infer- were also supported by computational modeling
ence may elicit a right hemisphere response in techniques suggesting low level perception in
people with ASD, only certain inferences, which individuals with ASD is superior and accessed
are extremely difficult, may elicit that pattern in easily compared to higher-level “top-down”
typical controls. This spillover effect has been cognitive processing.
demonstrated in other studies involving linguistic
stimuli of differential difficulty in typical
individuals and in story comprehension. Lesion Conclusion
studies have shown that damage to the left tem-
poral pole causes difficulties in recalling stories This entry describes the anatomical and func-
whether they are spoken or written. This occurs tional organization of cortical language areas
even when participants have normal sentence and the abnormalities associated with them in
comprehension skills and normal working people with ASD. In addition, it also deals with
memory. When listening to stories in particular, the ways in which cortical language areas partic-
people with ASD activate the left temporal pole ipate and communicate with one another in ASD.
which is involved in recalling linguistic content. The functional abnormalities seen in key
They also activate the right temporal pole which language areas (Broca’s and Wernicke’s areas)
is involved in encoding and storing the prosodic as well as the differences in the organization of
and pragmatic aspects of the story. This finding language association cortex in ASD may produce
was also demonstrated when the subjects were notable difficulties in language and communica-
required to read the stories. These areas were tion. Explaining any cognitive function in ASD is
recruited when the task demand increased, in difficult, as it may reflect the complexity of the
contrast to simple lexical and semantic disorder itself. The organization of language
processing of single words. Therefore, these association cortex during brain development and
studies suggest that individuals with ASD may the potential problems associated with it may
show bilateral activation regardless of difficulty. affect subsequent functional and anatomical spe-
Increased recruitment of relatively more pos- cialization. It is not clear whether the abnormal
terior cortical language areas is another alternate organization is neurobiological or is in turn the
neural route seen in those with ASD. In sentence result of a secondary assault on the brain by early
comprehension studies involving high and low deviant behaviors in children with ASD, or both.
visual imagery, greater recruitment of parietal Nevertheless, it should be noted that the brain of
regions was found in participants with ASD an individual with ASD, perhaps like the typical
irrespective of the presence of high or low imag- brain, adapts in certain ways to compensate for
ery content. Similar results were also found with weaker connections and altered organization.
increased occipital activation in individuals Such adaptations, reflected in neuroimaging
with ASD during semantic decision making studies of language, may involve increased right
tasks with a decrease in activation of the frontal hemisphere recruitment, and an increased recruit-
verbal areas. These findings are also in line with ment of relatively posterior language areas as
Temple Grandin’s view of “thinking in pictures” well as visuospatial areas. Such atypical use
by recruiting visual and visuospatial regions to of brain resources for solving cognitive and
assist complex cognitive or linguistic processing. linguistic tasks may be a cause or a consequence
of the altered organization and/or the difference takes place in early childhood is not seen in
in connectivity seen in individuals with ASD. children with ASD. Although high levels of
Another factor that may complicate this topic is blood serotonin are found in children with ASD,
the heterogeneity seen in the ASD population in it seems that they have below normal levels
general and in their language abilities in within their brains. It has been proposed that
particular. Learning about the organization, certain binding proteins (Mbd1) that are compo-
recruitment, and connectivity of cortical nents of the “methylation-mediated epigenetic
language areas in ASD should facilitate gene regulation system” could be an underlying
researchers as well as clinicians in making factor in the dysfunctional serotonergic system
informed decisions and plans for language- seen in ASD. Studies show that mice who were
based intervention in people with ASD. missing this gene exhibited autistic like charac-
teristics. Abnormalities in other neurotransmit-
ters, such as the N-Acetyl Aspartate (NAA) and
Pathophysiology in glutamate were also reported in people with
ASD. Together, these pathophysiological factors
The path of physiology of ASD is increasingly could play a significant role in causing disruption
complex, perhaps reflecting the intriguing nature in the typical functioning of the brain in individ-
of the syndrome itself, with abnormalities found uals with ASD.
in several brain structures and in neurochemicals
on a cellular level in cortical and subcortical
structures. Significant cerebral hypo-perfusion See Also
(decrease of blood flow within the brain) has
been widely reported in individuals with ASD ▶ Auditory Cortex
especially in bilateral superior temporal cortices. ▶ Functional Connectivity
This decrease in blood flow has been found to be ▶ Language Disorder
more prevalent as the age of the child increases. ▶ Neuroanatomy
A decrease in blood flow to the temporal lobes ▶ Pragmatic Language Impairment
has been proven to cause impairments in commu- ▶ Prosody
nication, decreased language development, and ▶ Theories of Language Development
auditory processing problems. The decreased ▶ Verbal Comprehension
blood flow has been hypothesized to be a result
of vessels within the brain constricting rather than
dilating which can lead to hypoxia and result in
cell death. The constriction of blood vessels has
been attributed to inflammation in the cortex of Bauman, M. L., & Kemper, T. L. (1995). Neuroanatomi-
individuals with ASD. Abnormalities have also cal observations of the brain in autism. In J.
been reported in neuronal migration in postmor- Panksepp (Ed.), Advances in biological psychiatry
(pp. 1–2). New York, NY: JAI Press.
tem cases of people with ASD along with abnor-
Boddaert, N., Belin, P., Chabane, N., Poline, J. B.,
mal minicolumn pathology, disrupted neuronal Barthélemy, C., Mouren-Simeoni, M. C., et al.
development, and glial cell abnormalities. Many (2003). Perception of complex sounds: Abnormal pat-
of these abnormalities can have a significant tern of cortical activation in autism. American Journal
of Psychiatry, 160, 2057–2060.
impact on the organization of the brain in ASD. Catani, M., Jones, D. K., & Ffytche, D. H. (2005).
Abnormalities in neurochemistry can also lead Perisylvian language networks of the human brain.
to problems in normal development of the brain. Annals of Neurology, 57, 8–16.
For instance, neurotransmitters like serotonin Dawson, G., Finley, C., Phillips, S., & Galpert, L. (1986).
Hemispheric specialization and the language abilities of
regulate neurogenesis, synaptogenesis, neuronal
autistic children. Child Development, 57, 1440–1453.
removal, and differentiation. Normal high De Fossé, L., Hodge, S. M., Makris, N., Kennedy, D. N.,
serotonin synthesis and synaptogenesis that Caviness, V. S., Jr., McGrath, L., et al. (2004).
Cortisol, Serum 817 C
Language-association cortex asymmetry in autism and
specific language impairment. Annals of Neurology, Cortical Rewiring
56, 757–766.
Diehl, J. J., Bennetto, L., Watson, D., Gunlogson, C., &
McDonough, J. (2008). Resolving ambiguity: ▶ Plasticity, Neural
A psycholinguistic approach to understanding prosody
processing in high-functioning autism. Brain and Lan-
guage, 106, 144–152.
Harris, G. J., Chabris, C. F., Clark, J., Urban, T., Aharon,
C
I., Steele, S., et al. (2006). Brain activation during Cortisol, Serum
semantic processing in autism spectrum disorders via
functional magnetic resonance imaging. Brain and George M. Anderson
Cognition, 61, 54–68.
Herbert, M. R., Harris, G. J., Adrien, K. T., Ziegler, D. A., Laboratory of Developmental Neurochemistry,
Makris, N., Kennedy, D. N., et al. (2002). Abnormal Yale Child Study Center, Yale University,
asymmetry in language association cortex in autism. New Haven, CT, USA
Annals of Neurology, 52, 588–596.
Just, M. A., Cherkassky, V. L., Keller, T. A., &
Minshew, N. J. (2004). Cortical activation and syn-
chronization during sentence comprehension in high- Synonyms
functioning autism: Evidence of underconnectivity.
Brain, 127, 1811–1821. Hydrocortisone
Kana, R. K., Keller, T. A., Cherkassky, V. L., Minshew,
N. J., & Just, M. A. (2006). Sentence comprehension
in autism: Thinking in pictures with decreased
functional connectivity. Brain, 129, 2484–2493. Definition
Kleinhans, N. M., M€ uller, R.-A., Cohen, D. N., &
Courchesne, E. (2008). Atypical functional lateraliza-
tion of language in autism spectrum disorders. Brain Cortisol is a stress hormone secreted into the
Research, 1221, 115–125. blood by the adrenal cortex of mammals. Its
Lord, C., & Paul, R. (1997). Language and communica- short-term effects of increasing metabolism,
tion in autism. In D. J. Cohen & F. R. Volkman (Eds.), increasing blood sugar, and decreasing inflamma-
orders. New York, NY: John Wiley. tion help the organism respond to stress and main-
Paul, R., Augustyn, A., Klin, A., & Volkmar, F. R. (2005). tain homeostasis. Long-term elevations in cortisol
Perception and production of prosody by speakers with can have a number of detrimental effects on
autism spectrum disorders. Journal of Autism and the body and, perhaps, on the brain. Cortisol
Redcay, E., & Courchesne, E. (2008). Deviant functional secretion by the adrenal is controlled by
magnetic resonance imaging patterns of brain adrenocorticotropic hormone (ACTH) secreted
activity to speech in 2–3-year-old children with autism by the pituitary, with ACTH secretion in turn
spectrum disorder. Biological Psychiatry, 64, controlled by corticotrophin-releasing hormone
589–598.
Rojas, D. C., Camou, S. L., Reite, M. L., & Rogers, S. J. (CRH) secreted by the hypothalamus. Cortisol
(2005). Planum temporale volume in children and exerts its peripheral and central effects by
adolescents with autism. Journal of Autism and binding to the glucocorticoid receptor (GCR)
Developmental Disorders, 35, 479–486. found on most cells. Cortisol has been measured
Tager-Flusberg, H. (1996). Brief report: Current theory
and research on language and communication in in the plasma, serum and urine of individuals
autism. Journal of Autism and Developmental Disor- with autism in order to assess their exposure to
ders, 26, 169–172. and response to stress, and their level of
arousal. When taken together, prior studies appear
to indicate that cortisol production is similar in
individuals with autism compared to controls.
However, there is some evidence that the normal
Cortical Remapping diurnal rhythm of cortisol secretion (highest in the
morning, lowest at night) might be altered in some
▶ Plasticity, Neural individuals with autism.
C 818 Cost-of-Care Liability
See Also care. But most states extend Medicaid benefits to

the “medically needy” who have sizeable health-
▶ Anxiety care needs but do not meet the Medicaid financial
eligibility requirements. Similarly, those disabled
with illnesses like autism spectrum disorder may
References and Readings qualify for Supplemental Security Income (SSI),
a federal program operated by the Social Security
Anderson, G. M., & Hoshino, Y. (2005). Neurochemical Administration. Like the medically needy, SSI
studies of autism. In F. R. Volkmar, A. Klin, R. Paul, &
recipients are eligible to receive Medicaid benefits
D. J. Cohen (Eds.), Handbook of autism and pervasive
developmental disorders (3rd ed., Vol. 1, even though they do not meet the financial eligi-
pp. 453–472). Hoboken, NJ: Wiley. bility requirements. Finally, states often offer pro-
Corbett, B. A., Mendoza, S., Abdullah, M., Wegelin, J. A., grams like residential care to the disabled without
& Levine, S. (2006). Cortisol circadian rhythms and
regard to the recipient’s economic situation. State
response to stress in children with autism. Psychoneur-
oendocrinology, 31(1), 59–68. services provided in these circumstances are often
Seltzer, M. M., Greenberg, J. S., Hong, J., Smith, L. E., accompanied by a cost-of-care liability. The
Almeida, D. M., Coe, C., & Stawski, R. S. (2010). recipient and the recipient’s family are liable for
Maternal cortisol levels and behavior problems in
the cost of the services to the extent that they are
adolescents and adults with ASD [research support,
N.I.H., extramural research support, Non-U.S. able to pay for them.
Gov’t]. Journal of Autism and Developmental Disor-
ders, 40(4), 457–469. Services and Settings
Tordjman, S., Anderson, G. M., McBride, P. A., Hertzig,
State cost-of-care liability statutes vary consider-
M. E., Snow, M. E., Hall, L. M., & Cohe, D. J. (1997).
Plasma beta-endorphin, adrenocorticotropin hormone, ably regarding the services subject to the claim
and cortisol in autism. Journal of Child Psychology and the financial criteria considered in determin-
and Psychiatry, 38(6), 705–715. ing ability to pay for care received. Some states
Zinke, K., Fries, E., Kliegel, M., Kirschbaum, C., &
impose cost-of-care liability only to institutional
Dettenborn, L. (2010). Children with high-functioning
autism show a normal cortisol awakening response or nursing home care, while others extend it to
(CAR) [research support, non-U.S. Gov’t]. home- or community-based services. The amount
Psychoneuroendocrinology, 35(10), 1578–1582. of the liability is uniformly based on the ability
to pay. So, the typical limit to cost-of-care
liability, regardless of the actual cost of the care
provided, is the recipient family’s monthly
Cost-of-Care Liability income, less sums like SSI payments, a personal
needs allowance, and health insurance premiums
John W. Thomas paid.
Quinnipiac University School of Law, Hamden,
CT, USA Financial Planning
Parent liability for care received by a child typi-
cally ceases in most, but not all, states when the
Definition child reaches the age of 18. The child’s liability,
however, continues to life’s end and, usually, on
In General to his or her estate upon death. As a result, parents
“Cost-of-care liability” refers to the obligation and estate planners may wish to take steps to
that many states impose upon some mentally ill minimize cost-of-care liability when devising
or disabled patients and their families to reimburse assets to a disabled child or in creating special
the state for the cost of treatment obtained through needs trusts. Income used for calculating cost-of-
state programs like Medicaid. Medicaid, for care liability, for example, includes payments
example, is the federal program enacted in 1965 received from a trust. Consequently, parents and
to assist the impoverished in obtaining medical their counsel may wish to consult their state’s
Course of Development 819 C
cost-of-care laws when determining the pay- Definition
ments to be made to the trust beneficiary.
Autism is a lifelong disorder characterized by
core problems in social communication and the
References and Readings presence of stereotyped and repetitive behaviors.
However, the manifestation of these problems
Begley, T. D. (2000). Representing the elderly or disabled can change over time. In many cases, the severity C
client: Forms and checklists with commentary. Val-
of autistic symptoms decreases with age; in
halla, NY: Warren, Gorham & Lamont.
Crowley, J. (2003). Medicaid medically needy programs: others, difficulties may become more evident as
An important source of medicaid coverage. Washington, individuals grow older. In adolescence and adult-
DC: The Kaiser Commission on Medicaid and the hood, many individuals also develop additional
Uninsured.
mental health problems, particularly related to
Hoyt, P. R., & Pollock, P. M. (2003). Special people,
special planning: Creating a safe legal haven for families anxiety and depression.
with special needs. Orlando, FL: Legacy Planning The course of development is highly
Partners. variable and often very difficult to predict. The
Krooks, B. A., & Hook, A. (2005). What attorneys need
to know about special needs trusts. Philadelphia:
most positive outcomes tend to be for individuals
ALI-ABA. Retrieved from http://files.ali-aba. who develop useful speech in childhood and have
org/thumbs/datastorage/lacidoirep/articles/EPCMJ_ an IQ in the normal range (i.e., 70+). Neverthe-
EPCMJ0510-KROOK_thumb.pdf less, even among this group, some individuals
Medicaid statue: 42 U.S.C. }1396, et seq. (2011).
remain highly dependent as adults. A good out-
Medicaid: A primer. (1999). Washington, DC: The Kaiser
Commission on Medicaid and the Uninsured. Medic- come also depends on the adequacy of interven-
aid regulations: 42 C.F.R. }430, et seq. (2011). tion and support available during child- and
Moore, R. J., & Landsman, R. M. (2000 & Supp. 2003). adulthood.
Planning for disability. Arlington, VA: The Bureau of
National Affairs.
Russell, L. M. (1983). Alternatives, a family guide to legal
and financial planning for the disabled. Lasalle, Can- See Also
ada: First Publication.
Russell, L. M., & Grant, A. E. (1995). Planning for the
future: Providing a meaningful life for a child with
▶ Adult Follow-Up Studies
a disability after your death (3rd ed.). Palantine, IL: ▶ Adulthood, Transition to
American Publishing. ▶ Comprehensive Transition Program
Schneider, A. (2002). The medicaid source book. Wash- ▶ Factors Affecting Outcome
ington, DC: The Kaiser Commission on Medicaid and
▶ Natural History
the Uninsured.
Supplemental security income regulations: 42 U.S.C. ▶ Outcome Studies
}1383c, et seq. (2011).
Course of Development References and Readings
Howlin, P. (2007). The outcome in adult life for

Patricia Howlin people with ASD. In F. R. Volkmar (Ed.), Autism
Institute of Psychiatry, King’s College of and pervasive developmental disorders (2nd ed.,
London, London, UK pp. 269–306). Cambridge: Cambridge University
Press.
Kanner, L. (1973). Childhood psychosis: Initial studies
and new insights (pp. 189–213). Washington, DC:
Synonyms V. H. Winston Sons.
Seltzer, M. M., Krauss, M. W., Shattuck, P. T., Orsmond,
G., Swe, A., & Lord, C. (2003). The symptoms of
Adult follow-up studies; Adulthood, transition to; autism spectrum disorders in adolescence and adult-
Factors affecting outcome; Natural history; hood. Journal of Autism & Developmental Disorders,
Outcome; Outcome studies 33, 565–581.
C 820 Court Decision (ASD Related)
IEP itself in accord with the United States

Court Decision (ASD Related) Supreme Court’s decision in Board of Education
v. Rowley. There, the Court held that the student
John W. Thomas must be provided with a fair process and that the
Quinnipiac University School of Law, IEP must be “reasonably calculated to enable the
Hamden, CT, USA child to receive educational benefits.”
ASD also plays a role in civil litigation
between private parties, including the tort litiga-
Definition tion contending that the MMR vaccine causes
ASD (Thomas, 2010). These cases, now totaling
Court decisions involving ASD occur in nearly 6,000, are being prosecuted under the
a number of legal contexts. Perhaps the most National Vaccine Injury Compensation Program
common decisions address the issue of insurance (Thomas). Individuals claiming an injury
coverage for the treatment of ASD. In the private from a covered vaccine must file a claim for
insurance context, the dispute often centers on “no-fault” compensation with the US Court of
coverage of behavioral therapies (Barner, 2009). Federal Claims. The claims are resolved not by
Insurers contend that these treatments are exper- juries but by special masters. To date, the
imental or are educational services rather than special masters have ruled against the plaintiffs
health services. Court decisions turn on both the on all six test cases, and all of those decisions
specific language of the policy at issue and the appealed to higher courts have been affirmed.
mandates of state laws (Barner, 2009). Court The Court of Claims has awarded compensation
decisions often also address the extent to which where the complaining child suffered from
early intervention, custodial services, and other a preexisting mitochondrial enzyme deficit
treatment modalities are covered by specific (Offit, 2008).
insurance policies. On February 22, 2011, the United States
Public health insurance also presents issues of Supreme Court ruled that the National Childhood
ASD treatment coverage. Decisions regarding Vaccine Injury Act (NCVIA) prohibits complain-
eligibility for coverage in Medicaid and other ants from filing lawsuits against vaccine manu-
governmental programs often depend on whether facturers. Rather, all such claims must be filed
a given intervention is classified as a mental with the special Federal Court of Claims
health treatment, physical health treatment, or a established under the National Vaccine Injury
neurodevelopmental therapy (Treatment, 2009). Compensation Program (Bruesewitz).
The educational setting provides another
major context for court decisions regarding
ASD. Litigation in this area often concerns the References and Readings
mandates of the federal Individuals with Disabil-
ities Education Act (IDEA). IDEA’s goal is “to Important ASD-Related Court Decisions
Board of Education of Hendrick Hudson Central School
ensure that all children with disabilities have District v. Rowley, 458 U.S. 176 (1982) (all children
available to them a free appropriate public are entitled to a Free Appropriate Public Education
education that emphasizes special education.” (FAPE)).
The statute also mandates the provision of Buckhannon v. West Virginia Dept. Health and Human
Resources, 532 U.S. 598 (2001) (prevailing parents
“related services designed to meet their unique may waive their right to recover attorney’s fees).
needs and prepare them for further education, Burlington School Committee v. Massachusetts Depart-
employment, and independent living.” Services ment of Education, 471 U.S. 359 (1985) (parents have
must be articulated in an Individualized Educa- a right to reimbursement for necessary private school
tuition).
tion Program (IEP). Litigation and resulting Cedar Rapids Community School District v. Garret F.,
judicial decisions depend on a court’s conclusion 526 U.S. 66 (1999) (schools must provide related
whether the process provided the student and the educational services regardless of cost).
Creak, Mildred 821 C
Irving Independent School District v. Tatro, 468 U.S. 883
(1984) (except for physician services, schools must Cranioscopy
provide all necessary supportive services).
Mills v. Board of Education of District of Columbia,
348 F. Supp. 866 (1972). (Children with disabilities ▶ Phrenology
have a right to a public education).
Pennsylvania Association for Retarded Children (PARC)
v. Commonwealth of Pennsylvania, 343 Fed.
Supp. 279, (1972) (Children with disabilities have
C
a right to a public education). Creak, Mildred
Schaffer v. Weast, 546 U.S. 49 (2005) (burden of persua-
sion lies with the party seeking relief). Adam Feinstein
Smith v. Robinson 468 U.S. 992 (1984) (parents
prevailing under IDEA are not entitled to an award of Autism Cymru and Looking Up, London, UK
attorney’s fees).
Major Appointments (Institution,

Location, Dates)
CP
Mildred Creak worked as assistant physician at
▶ Cerebral Palsy The Retreat, a mental hospital run by Quakers
in York, UK, 1924–1928.
Took up a post at the Maudsley Psychiatric Hos-
pital, London, 1929.
CPRS Appointed physician in psychological medicine
at the Hospital for Sick Children, Great
▶ Children’s Psychiatric Rating Scale Ormond Street, London, 1946–1963.

CPT Professional Contributions
▶ Conners’ Continuous Performance Test In the early 1960s, Mildred Creak chaired the
working party which established the landmark
nine-point criteria for the diagnosis of autism,
published in 1961. This work was based on
CPT-II a series of 100 children she had collected herself.
Creak suggested that autism, far from being
▶ Conners’ Continuous Performance Test caused by parental inadequacies, was primarily
due to genetic – or, as she put it, “constitutional” –
factors.
Craniognomy
Short Biography
▶ Phrenology
Born in Manchester, UK, in 1898, Mildred Creak
was an extraordinary figure in the history of child
psychiatry. She qualified as a doctor at University
Craniology College Hospital in London at the end of the First
World War. It was at the Children’s Department
▶ Phrenology of London’s Maudsley Psychiatric Hospital, from
C 822 Creativity
1929, that Creak helped to lay the clinical and individual in order for the skill or behavior to be
academic foundations for what is now one of evaluated and judged as mastered. Criterion
Britain’s leading centers for the study of child provides a defined and measurable answer to
psychiatric disorders. During the Second World questions about how and when an individual has
War, she joined the Women’s Army Corps as acquired a particular behavior or skill.
a doctor, serving part of her time in India. From Criterion is one of three essential components
1946 – when she joined the Hospital for Sick of a behavioral objective, which is a mandated part
Children in London’s Great Ormond Street – of a student’s individualized education plan (IEP).
until her retirement in 1963, she played A behavioral objective specifies a target behavior
a leading role in establishing the practice of to be taught to a student, the conditions under
child psychiatry in a pediatric setting. After her which the behavior will be taught, and finally, the
retirement, Creak lectured in Perth, Western Aus- criterion, how mastery of the behavior will be
tralia, and had a unit for autistic children named assessed. An individual might be expected to per-
after her there. She died in the UK in 1993 at the form a skill at a certain level of accuracy or inde-
age of 95. pendence across a certain amount of days, number
of times, or at a certain rate in order for the skill to
be considered mastered. Choices about criterion
References and Readings are to be made based on the skill being taught. For
example, an expectation of 80% accuracy may be
Creak, M. (1961). Schizophrenic syndrome in childhood: acceptable in showing mastery of a math skill on
Progress report of a working party. Cerebral Palsy
a math quiz. However, 80% accuracy would not be
Bulletin.
Feinstein, A. (2010). A history of autism: Conversations an acceptable criterion for teaching an individual
with the pioneers. Oxford, England: Wiley-Blackwell. how to cross a street because this means that the
student would be in danger of not making it across
the street 20% of the time.
Creativity
See Also
▶ Imagination
▶ Behavioral Objective
▶ Education
▶ Educational Interventions
Criterion ▶ Functional Goals
Juli Katon
Department of Special Education, University of
Maryland, College Park, MD, USA References and Readings
Alberto, P. A., & Troutman, A. C. (2009). Applied behav-

ior analysis for teachers (8th ed.). New York: Merril.
Synonyms Snell, M. E., & Brown, F. (2006). Instruction of students
with severe disabilities (6th ed.). Upper Saddle River,
Benchmark; Measure; Standard NJ: Pearson Education.
Definition
Criterion-Referenced Assessment
Criterion is a standard for minimally acceptable
performance of a specific behavior or skill by an ▶ Criterion-Referenced Testing
Cronbach’s Alpha 823 C
not yet achieved four-word sentences may be
Criterion-Referenced Testing seen as being severely behind in their expressive
speech compared with other 5-year-olds, whereas
Michael Berger a 2-year-old with such skills would be seen as
Department of Psychology, Royal Holloway within the typical range of development for their
University of London, Egham, Surrey, UK age. Used in this way, they should be subject to
the same quality standards noted for norm- C
referenced measures.
Synonyms
Criterion-referenced assessment; Criterion- See Also

referenced tests
▶ Autism Diagnostic Interview-Revised
Definition
Criterion-Referenced Tests References and Readings

Criterion-referenced tests are designed to assess
whether an individual has a particular set of com- Kaplan, R. M., & Saccuzzo, D. P. (2009). Psychological
testing: Principles applications and issues (7th ed.).
petencies or skills. They aim to answer questions
Belmont, CA: Wadsworth, Cengage Learning.
such as “Is this child able to use a spoon for
self-feeding or do up shoelaces?” or “Does this
individual use sentences of four or more words or
know how to subtract two numbers?” The focus
of interest is the presence or absence of the crite- Criterion-Referenced Tests
rion behavior and not, as in the case of norm-
referenced testing, how the individual functions ▶ Criterion-Referenced Testing
relative to some normative group.
Criterion-referenced measures may also be
used to determine whether the individual meets
the requirements for entry in special educational Cronbach’s Alpha
provision or for other decision processes. Psychi-
atric or other diagnoses are forms of criterion- Ellen Johnson
referenced testing, the presence or absence of Section of Social Work, Mayo Clinic, Rochester,
signs and symptoms of ASD constituting the MN, USA
criteria. Such uses of criterion-referenced test are
sometimes known as “high-stakes testing”
because of the major personal consequences of Synonyms
the outcome. In such uses in particular, including
for clinical purposes, it is critical that the tests Coefficient alpha
meet key criteria for quality (Kaplan & Saccuzzo,
2009); that the tester is competent in administra-
tion, scoring, and interpretation of the test; and that Definition
the testee was functioning as they typically do.
Criterion-referenced items can function as Cronbach’s alpha (a) is an estimate of reliability,
norm-referenced measures. For instance, devel- specifically the internal consistency, of a test or
opmental tests will have population norms on scale. It is widely used in psychological test con-
sentence length. Hence, a 5-year-old who has struction and interpretation (Cortina, 1993).
C 824 Cross Eye
When internal consistency is present in a test, it is

interpretable (Cronbach, 1951). Cronbach’s Cross-Training
alpha seeks to measure how closely test items
are related to one another and thus measuring ▶ Role Release
the same construct.
The formula for Cronbach’s alpha is as
follows:
Crystallized Intelligence
a ¼ ðn=ðn 1ÞÞ ð1 ðSsi 2 =sT 2 ÞÞ
Francesca Happé
where n is the number of items, si2 is the variance MRC Social, Genetic and Developmental
of the ith item, and sT2 is the total score variance Psychiatry Centre at the Institute of Psychiatry,
(Cronbach, 1951). King’s College of London, London, UK
When test items are closely related to one
another, Cronbach’s alpha will be closer to 1,
and when test items are not closely related Definition
to one another, Cronbach’s alpha will be
closer to 0. An a of 0.90–0.95 is desirable for Crystallized intelligence (abbreviated Gc) is
clinical interpretation of tests (Bland and Altman, reflected in a person’s general knowledge,
1997). vocabulary, and reasoning based on acquired
information. It is contrasted with fluid intelli-
gence (see ▶ Fluid Intelligence) as one of the
References and Readings two factors of general intelligence first proposed
by Cattell (1971). Crystallized intelligence is
Bland, J., & Altman, D. (1997). Statistics notes: conceptualized as the product of experience,
Cronbach’s alpha. British Medical Journal, 314, 572.
both cultural and educational, in interaction
Cicchetti, D. V., Lord, C., et al. (2008). Reliability of the
ADI-R: Multiple examiners evaluate a single case. with fluid intelligence; people with higher levels
Journal of Autism & Developmental Disorders, of fluid intelligence will generally amass learnt
38(4), 764–770. information faster, allowing higher crystallized
Cortina, J. (1993). What is coefficient alpha?: An
intelligence. Crystallized intelligence is mea-
examination of theory and applications. Journal of
Applied Psychology, 78, 98–104. sured by tests such as vocabulary and general
Cronbach, L. (1951). Coefficient alpha and the internal knowledge type assessments.
structure of tests. Psychometrika, 16, 297–334. In ASD, the profile of better performance than
Klin, A., Lang, J., et al. (2000). Brief report: Interrater
verbal IQ subtest scores may reflect, in part, dif-
reliability of clinical diagnosis and DSM-IV criteria
for autistic disorder: Results of the DSM-IV autism ferences between fluid and crystallized intelli-
field trial. Journal of Autism & Developmental gence. It has been suggested that standard
Disorders, 30(2), 163–167. IQ assessments underestimate intelligence
Russell, P. S. S., Daniel, A., et al. (2010). Diagnostic
compared to pure fluid assessments such as
accuracy, reliability and validity of childhood autism
rating scale in India. World Journal of Pediatrics, 6(2), Raven’s Progressive Matrices (Dawson,
141–147. Soulières, Gernsbacher, & Mottron, 2007). The
acquisition of skills and knowledge, as measured
by crystallized intelligence tests, may rely in part
on socially mediated learning and be hampered in
Cross Eye ASD by problems of social cognition
(Scheuffgen, Happé, Anderson, & Frith, 2000).
▶ Strabismus However, Bölte, Dziobek, and Poustka (2009)
CSBQ (Children’s Social Behavior Questionnaire) 825 C
suggested that discrepancies were small among
higher functioning ASD groups and CSBQ (Children’s Social Behavior
recommended use of Wechsler intelligence Questionnaire)
scales for comprehensive assessment of abilities
in ASD, perhaps supplemented by Raven’s Catharina Hartman1, Annelies de Bildt2 and
Matrices for lower functioning individuals. Ruud Minderaa1
Recent estimates from epidemiological samples 1
Department of Psychiatry, University of C
suggest that low measured IQ is not as common Groningen, University Medical Center
among people with ASD as previous figures Groningen, Accare, Groningen, The Netherlands
2
suggested; Charman et al. (2011) reported just Child and Adolescent Psychiatry, Accare,
over half their community sample of young peo- Accare, Groningen, The Netherlands
ple with ASD had IQ below 70, with less than
a fifth having IQ below 50, and almost a third of
the sample having IQ above 85. Improvements in Synonyms
understanding, recognition, and intervention may
have improved accessibility of appropriate edu- Children’s social behavior questionnaire
cation for children with autism, allowing more
individuals to come closer to fulfilling their learn-
ing potential. Abbreviations
ASD Autism spectrum disorders

See Also
▶ Fluid Intelligence Description

▶ Vocabulary
Children with an autism spectrum disorder
(ASD) form a heterogeneous group. The Chil-
dren’s Social Behavior Questionnaire (CSBQ)
References and Readings charts this heterogeneous behavior through 49
items rated by parents. These items are scored
Bölte, S., Dziobek, I., & Poustka, F. (2009). Brief report: on a three-point scale ranging from “does not
The level and nature of autistic intelligence revisited.
apply or occur” to “clearly or often applies.”
678–682. Items refer directly to DSM-IV criteria for autism
Cattell, R. B. (1971). Abilities: Their structure, growth, but also represent less severe variations of these
and action. New York: Houghton Mifflin. criteria as well as ASD-associated problems, such
Charman, T., Pickles, A., Simonoff, E., Chandler, S.,
Loucas, T., & Baird, G. (2011). IQ in children with
as executive functioning problems and disruptive
autism spectrum disorders: Data from the Special behavior in difficult social situations. The 49
Needs and Autism Project (SNAP). Psychological items aggregate into six problem dimensions
Medicine, 41, 619–27. which form the subscales of the CSBQ. Children
Dawson, M., Soulières, I., Gernsbacher, M. A., &
Mottron, L. (2007). The level and nature of
with ASD tend to vary in the extent to which the
autistic intelligence. Psychological Science, 18, problems captured by these subscales are present;
657–662. therefore, each child has his or her own problem
Scheuffgen, K., Happé, F., Anderson, M., & Frith, U. profile.
(2000). High “Intelligence”, low “IQ”? Speed
of processing and measured IQ in children with
Subscale names are abbreviated as social,
autism. Development and Psychopathology, 12, tuned, understanding, orientation, change, and
83–90. stereotypies and capture the following problems:
C 826 CSBQ (Children’s Social Behavior Questionnaire)
First, the subscale “social” measures aspects social, understanding, change, and stereotypies
related to social contact, social interest, and are summed.
social reciprocity. It refers to both initiation of
contact and reaction to social overtures by
others. Historical Background
Second, the subscale “tuned” measures behavior
related to daily adaptation to social situations. Parent-report questionnaires are cost- and time-
Examples of items are as follows: “overreacts efficient assessment tools in health practice and
to everything and everyone” and “does not research. The research program to develop the
know when to stop, goes on and on about CSBQ started for two reasons. First, the goal
things.” While instances of such behavior was to quantify the different dimensions on
may also be seen in typically developing chil- which children with an ASD tend to differ, thus
dren, the tuned subscale depicts the more tapping the heterogeneity in this group. The sec-
extreme form manifested by children with ond goal was to specifically include the milder
ASD. part of the ASD score distribution along with the
Third, children with high scores on the subscale more severe autistic behaviors in one and the
“understanding” have difficulties in under- same instrument, thus tapping the full ASD spec-
standing the rules of communication and the trum. The field lacked a questionnaire that tapped
social use of language (pragmatic communi- not only the severe behaviors seen in autism
cation). Sample items are as follows: “does not proper but also these milder and subtler variants
understand jokes” and “is extremely naive; of ASD. The inclusion of these (in addition to the
believes anything you say.” more severe autistic behaviors) in an instrument
Fourth, the orientation subscale refers to the abil- would be helpful in the diagnostic process of
ity to keep an overview of what goes on, what ASD, and even in case of a diagnosis outside
one is doing, and where one is headed. Sample the ASD spectrum, knowing the presence of
items are as follows: “gets lost easily” and such mild problems would be useful. Moreover,
“has difficulties doing two things the field lacked a questionnaire that summarized
simultaneously.” the heterogeneous problems seen in ASD by
Fifth, the items of the subscale “change” measure a number of meaningful problem dimensions
behavior when confronted with changes, along which children with an ASD show varia-
expressed as fear, panicking, resistance, and tion. The peaks and troughs on a profile of differ-
freezing. ent ASD problems would give insight into
Sixth, the items from the stereotypies subscale children’s specific clinical presentation within
tap the various repetitive sensorimotor behaviors ASD and provide clues for intervention.
seen in children with ASD such as making odd With these ideas in mind, the CSBQ was
movements with fingers and hands, smelling developed about 15 years ago (Luteijn, Jackson,
objects, and being unusually sensitive to certain Volkmar, & Minderaa, 1998). In its original
sounds. form, the CSBQ contained 96 items. Revised in
Both total CSBQ score and individual 2006, the 49-item CSBQ gained in specificity by
subscale scores can be used. The profile of scores removing problem items that were only margin-
on the six dimensions simultaneously reveals ally characteristic of ASD (Hartman, Luteijn,
which problem domains are predominantly pre- Serra, & Minderaa, 2006). Instrument develop-
sent in the child and which problem domains are ment is still in progress. For example, an adult
less prominent. The subscales “orientation” and counterpart of the CSBQ, the Adult Social
“tuned” are not specific for ASD, with similar Behavior Questionnaire (ASBQ), with both
scores in children with ADHD. Thus, if the aim a self- and other-report version, has been devel-
is to focus specifically on the most differentiating oped and currently is being validated (Horwitz
ASD core symptoms, scores on the subscales et al., 2012).
CSBQ (Children’s Social Behavior Questionnaire) 827 C
Psychometric Data groups come mostly from the four core autism
problem dimensions, i.e., social, understanding,
CSBQ scores are interpreted in relation to norm change, and stereotypies. Note however that
groups. Norms are available for boys and girls a combined diagnosis of ADHD and ASD is
and for six age groups between ages 4 and 18 for accompanied by significantly higher scores on
children from the general population. Gender- the tuned and orientation dimensions than
specific norms are also available for general a separate diagnosis of either ADHD or ASD, C
psychiatric child (4–11) and adolescent (12–18) suggesting that each condition has its own impact
population. From the general psychiatric popula- on the behaviors measured by these scales
tion, separate norms are available for three (Hartman et al., 2006). Further indices of crite-
subgroups: ADHD, PDD-NOS, and higher func- rion validity are an association of .75 for the
tioning autism, respectively. Further, there are CSBQ with the Autism Behavior Checklist
norms for children (4–11) and adolescents (Krug et al., 1980) (Hartman et al., 2007)
(12–18) with mild mental retardation and for and associations of around .40 for relevant sub-
children (4–18) with moderate mental retarda- scales with Theory of Mind ability (Blijd-
tion. These groups are split up further into sepa- Hoogewys, van Geert, Serra, & Minderaa,
rate norms for children with both mental 2008). For children with mental retardation,
retardation and ASD (Hartman, Luteijn, the CSBQ distinguishes between the profiles of
Moorlag, de Bildt, & Minderaa, 2007). the PDD group and the non-PDD group
Several factor analytic studies with varying (Hartman et al., 2006). A second study in children
item pools indicate that the six ASD problem with mental retardation showed that the contribu-
dimensions that are differentiated by the CSBQ tion of the CSBQ to a classification of ASD
are firmly anchored in the data (Hartman, Luteijn, was most specific for the problem dimensions
Serra, & Minderaa, 2006; Luteijn, Luteijn, Jack- “contact” and “stereotyped,” with high
son, Volkmar, & Minderaa, 2000a). That is, the coherence with classification methods of
ASD problem dimensions emerging from ADI-R, ADOS, and clinical DSM-IV-TR
the original item pool of 96 items and from the classifications.
revised version with the 49 items are highly For research purposes, the instrument has
similar. Additionally, the ASD problem dimen- proven useful in genetic (Nijmeijer et al., 2010,
sions emerged from a simultaneous factor analy- 2011), neurocognitive (Geurts, Luman & van
sis of the CSBQ with Child Behavior Checklist Meel, 2008; Rommelse et al., 2009), and behav-
items. The consistency in factor structure speaks ioral (de Bildt et al., 2005; Luteijn, Serra et al.,
to the construct validity of the problem 2000) studies, thus adding to its validity. For
dimensions. example, Nijmeijer et al. showed that the
Multiple studies have shown that the CSBQ COMT Val/Val genotype interacted with mater-
has good psychometric properties with regard to nal smoking during pregnancy in increasing ste-
test-retest and interrater reliability, internal con- reotyped behavior in two independent samples.
sistency of the scales (all reliability indices at As a second example, in a sample of 816 children
least .75), and good criterion validity both for from ADHD and control families, executive
high-functioning children and for children with functioning and motor impairments were corre-
mild to moderate mental retardation (de Bildt lated and cross-correlated in siblings to autistic
et al., 2005, 2009; Hartman et al., 2006; Luteijn, traits, suggesting that ADHD and ASD may pos-
Luteijn, et al., 2000a, 2000b). The CSBQ differ- sibly share familial/genetic EF and motor defi-
entiates between autism and PDD-NOS on the cits. The CSBQ has also aided in characterizing
one hand and PDD-NOS and ADHD on the (subthreshold) ASD problems in populations
other hand, with decreasing scores for these other than ASD such as ADHD (Nijmeijer et al.,
three conditions, respectively (Hartman et al., 2008) and delinquent groups (Geluk et al., 2011;
2006). The differences between these diagnostic ‘t Hart-Kerkhoffs et al., 2009). Finally, early
C 828 CSBQ (Children’s Social Behavior Questionnaire)
childhood assessments by community pediatric References and Readings

professionals were prodictive of CSBQ ratings
during adolescence (Jaspers et al., 2012). Blijd-Hoogewys, E. M., van Geert, P. L., Serra, M., &
Minderaa, R. B. (2008). Measuring theory of mind in
children. Psychometric properties of the ToM story-
books. Journal of Autism and Developmental Disor-
Clinical Uses ders, 38, 1907–1930.
de Bildt, A., Mulder, E. J., Hoekstra, P. J., Van Lang,
N. D., Minderaa, R. B., & Hartman, C. A. (2009).
The CSBQ may be used as a signaling, screening,
Validity of the Children’s Social Behavior Question-
or describing instrument for children aged 4–18 naire (CSBQ) in children with mental retardation:
and for all levels of functioning. Scores on the Comparing the CSBQ with ADI-R, ADOS, and clini-
CSBQ can be interpreted relative to norms based cal DSM-IV-TR classification. Journal of Autism and
on the general populations or 3norms based on
de Bildt, A., Serra, M., Luteijn, E., Kraijer, D., Sytema, S.,
general child psychiatric outpatient groups as & Minderaa, R. B. (2005). Social skills in children
well as on specific psychiatric groups such as with intellectual disabilities with and without autism.
autism or ADHD. Norms vary according to age, Journal of Intellectual Disability Research, 49,
317–328.
gender, and level of functioning.
Geluk, C. A. M. L., Jansen, L. M. C., Vermeiren, R.,
In the orienting stage of the diagnostic proce- Dorelijers, T. A. H., van Domburgh, L., de Bildt, A.,
dure, the score profile of the six subscales con- et al. (2011). Autistic symptoms in childhood
tributes to identifying whether or not the problem arrestees: Longitudinal association with delinquent
behavior. Journal of Child Psychology and Psychiatry,
behavior of the child is suggestive of ASD and
53, 160–167.
whether further diagnostic assessments should be Geurts, H. M., Luman, M., & van Meel, C. S. (2008).
focused on ASD. What’s in a game: The effect of social motivation on
Additionally, the CSBQ may be of value fur- interference control in boys with ADHD and autism
spectrum disorders. Journal of Child Psychology and
ther in the diagnostic process, clearly not in diag-
Psychiatry, 49, 848–857.
nosing ASD (which should be based on a more Hartman, C. A., Luteijn, E., Moorlag, A., de Bildt, A., &
extensive diagnostic procedure including obser- Minderaa, R. (2007). Manual for the CSBQ
vation and interviewing) but in complementing [Handleiding voor de VISK]. Amsterdam: Harcourt.
Hartman, C. A., Luteijn, E., Serra, M., & Minderaa, R. B.
these methods by adding additional information
(2006). Refinement of the Children’s social behavior
about the child’s clinical profile of problems questionnaire (CSBQ): An instrument that describes
along the six CSBQ problem domains. This the diverse problems seen in milder forms of PDD.
profile reveals the child’s major ASD Journal of Autism and Developmental Disorders, 36,
325–342.
problem areas as well as the domains that follow
Horwitz, E. H., Schoevers, R. A., Ketelaars, C. E. J., Kan,
normative development. This may add to the C. C., van Lammeren, A. M. D. N., Meesters, Y., et al.
diagnostic process as well as direct treatment Autism Spectrum Disorders (ASD) in adults assessed
choice. by self and other report: psychometric properties and
validity of the Adult Social Behavior Questionnaire
In children with a diagnosis outside the ASD
(ASBQ) (submitted).
spectrum, the CSBQ may reveal the presence of Jaspers, M., de Winter, A. F., Buitelaar, J. K., Verhulst, F.
subthreshold ASD problems which may be help- C., Reijneveld, S. A., & Hartman, C. A. (2011). Early
ful for choice of treatment. childhood assessments of community pediatric profes-
sionals predict autism spectrum and attention deficit
hyperactivity problems. Journal of Abnormal Child
Psychology.
See Also Krug, D. A., Arick, J. R., & Almond, P. J. (1980). Autism
screening instrument for educational planning.
Portland OR: ASIEP Education.
▶ Behavior Rating Scale (BRS)
Luteijn, E. F., Jackson, A. E., Volkmar, F. R., & Minderaa,
▶ Behavioral Assessment R. B. (1998). The development of the Children’s
▶ Pragmatic Communication Social Behavior Questionnaire: Preliminary data.
▶ Spectrum/Continuum of Autism Journal of Autism and Developmental Disorders, 28,
559–565.
▶ Stereotypic Behavior
CSF 5-HIAA 829 C
Luteijn, E. F., Luteijn, F., Jackson, A. E., Volkmar, F. R.,
& Minderaa, R. B. (2000a). The Children’s Social CSBS-DP
Behavior Questionnaire for milder variants of PDD
problems: Evaluation of the psychometric characteris-
tics. Journal of Autism and Developmental Disorders, ▶ Infant/Toddler Checklist
30, 317–330. ▶ Communication and Symbolic Behavior Scale
Luteijn, E., Luteijn, F., Jackson, S., Volkmar, F., &
Minderaa, R. (2000b). The children’s social behavior
questionnaire for milder variants of PDD problems:
C
Evaluation of the psychometric characteristics. Journal CSF
Luteijn, E. F., Serra, M., Jackson, A. E., Steenhuis, M. P.,
▶ Cerebrospinal Fluid
Althaus, M., Volkmar, F. R., et al. (2000). How
unspecified are disorders of children with a Pervasive
Developmental Disorder Not otherwise Specified?
A study of social problems in children with PDD-
NOS and ADHD. European Child & Adolescent CSF 5-HIAA
Nijmeijer, J. S., Arias-Vásquez, A., Lambregts-
Rommelse, N. N. J., Altink, M. E., Buschgens, George M. Anderson
C. J. M., Fliers, E. A, et al. (2011). QTL Linkage for Laboratory of Developmental Neurochemistry,
ASD symptoms in ADHD: Significant locus on Yale Child Study Center, Yale University, New
chromosome 7q11. Submitted.
Haven, CT, USA
Nijmeijer, J. S., Arias-Vasquez, A., Rommelse, N. J.,
Altink, M. E., Anney, R. J., Asherson, P., et al.
(2010). Identifying loci for the overlap between
ADHD and ASD using a genome-wide QTL linkage Synonyms
approach. Journal of the American Academy of Child
Nijmeijer, J. S., Hartman, C. A., Rommelse, N. J., Altink, Cerebrospinal fluid 5-hydroxyindoleacetic acid
M. E., Buschens, C. J. M., Fliers, E., et al. (2010).
Perinatal risk factors interacting with catechol
O-methyltransferase and the serotonin transporter
gene predict ASD symptoms in children with ADH.
Definition
Journal of Child Psychology and Psychiatry, 51,
1242–1250. Cerebrospinal fluid (CSF) levels of
Nijmeijer, J. S., Hoekstra, P. J., Minderaa, R. B., Buitelaar, 5-hydroxyindoleacetic acid (5-HIAA), the prin-
J. K., Altink, M. E., Buschgens, C. J., et al. (2008).
cipal metabolic end product produced from the
PDD symptoms in ADHD, an independent familial
trait? Journal of Abnormal Child Psychology, 37, neurotransmitter serotonin, are measured to
443–453. provide a global index of serotonin production
Rommelse, N., Altink, M. E., Fliers, E. A., Martin, N. C., in the brain. Taken together, studies of CSF
Buschgens, C. J., Hartman, C. A., et al. (2009). Comor-
5-HIAA in autism indicate that group mean levels
bid problems in ADHD: Degree of association, shared
endophenotypes, and formation of distinct subtypes. are not altered in autism.
Implications for a future DSM. Journal of Abnormal
Child Psychology, 37, 793–804.
‘t Hart-Kerkhoffs, L. A., Jansen, L. M., Doreleijers, T. A.,
See Also
Vermeiren, R. A., Minderaa, R. B., & Hartman, C. A.
(2009). Autism spectrum disorder symptoms in juve-
nile suspects of sex offenses. The Journal of Clinical ▶ Neurotransmitter
Psychiatry, 70, 266–272. ▶ Serotonin

CSBS Dhondt, J. L. (2004). Difficulties in establishing reference
intervals for special fluids: The example of
▶ Communication and Symbolic Behavior Scale 5-hydroxyindoleacetic acid and homovanillic acid in
C 830 CSF HVA
cerebrospinal fluid. Clinical Chemistry and Labora- Lam, K. S., Aman, M. G., & Arnold, L. E. (2006).
tory Medicine, 42(7), 833–841. Neurochemical correlates of autistic disorder:
Lam, K. S., Aman, M. G., & Arnold, L. E. (2006). Neu- A review of the literature. Research in Developmental
rochemical correlates of autistic disorder: A review of Disabilities, 27(3), 254–289.
the literature. Research in Developmental Disabilities, Narayan, M., & Anderson, G. M. (1993). CSF HVA in
27(3), 254–289. autism (in reply). Biological Psychiatry, 32, 746–747.
Narayan, M., Srinath, S., Anderson, G. M., & Narayan, M., Srinath, S., Anderson, G. M., & Meundi,
Meundi, D. B. (1993). Cerebrospinal fluid levels of D. B. (1993). Cerebrospinal fluid levels of
homovanillic acid and 5-hydroxyindoleacetic acid in homovanillic acid and 5-hydroxyindoleacetic acid in
autism. Biological Psychiatry, 33(8–9), 630–635. autism. Biological Psychiatry, 33(8–9), 630–635.
CSF HVA CT
George M. Anderson ▶ Computed Tomography

Laboratory of Developmental Neurochemistry,
Yale Child Study Center, Yale University, New
Haven, CT, USA
Culture and Autism
Synonyms Roy Grinker1, Tamara C. Daley2 and David

Mandell3
1
Cerebrospinal fluid homovanillic acid Anthropology, The George Washington
University, N.W. Washington, DC, USA
2
Westat, Durham, NC, USA
Definition 3
Center for Autism Research, The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
Cerebrospinal fluid (CSF) levels of
homovanillic acid (HVA), the principal meta-
bolic end product produced from the neurotrans- Definition
mitter dopamine, are measured to provide
a global index of dopamine production in the The understanding of autism can only be gained by
brain. Taken together, studies of CSF HVA in further examination of autism both across and
autism indicate that group mean levels are not within cultures. Careful attention to observed simi-
altered in autism. larities and differences will allow a better under-
standing of the disorder as well as better design and
development of interventions that are applicable to
See Also families of all backgrounds. This entry describes
research to date on how culture influences the epi-
▶ Dopamine demiology, diagnosis, and treatment of autism
▶ Neurotransmitter throughout the world, with a special focus on family
functioning, and disparities in diagnosis and care.

Dhondt, J. L. (2004). Difficulties in establishing reference
intervals for special fluids: The example of
While knowledge about autism is increasing rap-
5-hydroxyindoleacetic acid and homovanillic acid in
cerebrospinal fluid. Clinical Chemistry and idly throughout the world, there are to date few
Laboratory Medicine, 42(7), 833–841. scientific studies of the characteristics, prevalence,
Culture and Autism 831 C
and phenotypes of autism spectrum disorder reports, both of which can be heavily influenced
(ASD) outside of North America and Western by cultural attitudes about discipline and what
Europe and how culture, race, and ethnicity influ- kinds of behaviors are age appropriate. Estimates
ence the understanding and management of ASD. of autism may appear higher in a country with great
Researchers have long agreed that autism occurs in awareness among parents, educators, and clini-
families across races and socioeconomic back- cians and access to services or in which the national
grounds and, based on the presence of autism government mandates the use of autism as C
parent organizations in more than 100 countries, a diagnostic term. In contrast, estimates may be
there is clear evidence that a constellation of lower in a country with little awareness, few ser-
behaviors has been recognized as “autism” on vices, and lack of systematic surveillance through
every continent. Researchers are just beginning to research or administrative means. In the USA, for
study, however, the extent to which ASD varies example, school records of autism grew tremen-
both across and within cultures. While there appear dously following the 1991–1992 school year when
to be similarities in the onset and core symptoms of the U.S. Department of Education first introduced
ASD around the world, this remains an untested these terms to the American public school system
assumption. ASD experts to date are gradually (Newschaffer et al., 2005).
learning more about how cultural differences Research on the prevalence of ASD among
may influence its prevalence, diagnosis, treatment, children of immigrants dates back more than
presentation, course, and family function. 20 years. These studies have hypothesized
a range of possible explanations for what appears
to be higher rates in these children, including
Current Knowledge vulnerability to intrauterine infections and vita-
min deficiencies, among others (Dealberto, 2011;
Prevalence Gillberg, Andersson, Steffenburg, & Börjesson,
The received view is that the prevalence of autism 1987; Gillberg, Steffenburg, & Schaumann,
is consistent across races and cultures (Fombonne, 1991; Gillberg, Schaumann, & Gillberg, 1995;
2003). However, for many years, epidemiological Narayanan & Srinath, 1992). Conclusions from
studies were carried out primarily in North Amer- this work are limited by small sample sizes.
ica and Western Europe. Work from outside these While some researchers believe they do not sup-
areas was limited, with the notable exception of port an association, others note that maternal
Japan (e.g., Honda, Shimizu, Imai, & Nitto, 2005; birth abroad represents at least a marginal
Matsuishi et al., 1987; Sugiyama & Abe, 1989). In increase in risk of having a child with ASD
recent years, reports of prevalence have come from (Gardener, Spiegelman, & Buka, 2009).
Singapore (Bernard-Opitz, Kwook, & Sapaun, Recent work from the UK found a significant
2001), Iran (Samadi, Mahmoodizadeh, & association of risk for immigrant mothers, partic-
McConkey, 2011), China (Wong & Hui, 2008), ularly from the Caribbean (Keen, Reid, &
Oman (Al-Farsi et al., 2011), Venezuela Arnone, 2010). Similarly, data from the 3–4-
(Montiel-Nava & Pena, 2008), Sri Lanka (Perera, year-olds in the Somali community in the US
Wijewardena, & Aluthwelage, 2009), and Korea city of Minneapolis found the prevalence of
(Kim et al., 2011), among others. Most studies ASD to be as much as seven times higher for
provide prevalence estimates similar to those for Somali children than for non-Somali children,
the USA, although Kim et al. found more than although this ratio was observed to decrease dra-
twice the prevalence of US studies in South matically over time (Minnesota Department of
Korea. Prevalence studies have used a wide range Public Health, 2009).
of methods and are therefore difficult to compare to
one another. Moreover, autism epidemiologists Diagnostic Processes
face the difficult task of reliably defining cases Although researchers may use standardized
based on information from teacher and parent assessments and criteria – at the very least, The
C 832 Culture and Autism
Diagnostic Statistical Manual of Mental Disor- Clinicians may not make or record a particular
ders (DSM) and The International Classification diagnosis, and parents will not seek it, unless the
of Diseases (ICD) – to determine whether an diagnostic term is meaningful and in current use.
individual constitutes a “case” of autism, most For example, one report of the Navajo Indians of
physicians and psychologists are not integrated the American Southwest notes that autism is
into a research community and are likely to rely characterized as “perpetual childhood” (Connors
on past training and personal clinical experience. & Donnellan, 1995), and through the mid-1990s
Even with standardized criteria, considerable in India, it was not uncommon for clinicians to
subjectivity and differences in clinical assess- refer to children with autism as paagol, the Hindi
ments exist because the diagnosis depends on word for madness (Daley, 2004). In rural South
patient or caretaker narrative combined with Korea, the catch-all “brain disorder” can be used
behavioral observation rather than biological for children with disorders including traumatic
tests. Research in India (Daley & Sigman, brain injury, autism, epilepsy, speech and lan-
2002), Pakistan (Rahbar, Ibrahim, & Assassi, guage disorders, Down syndrome, and other
2011), and Nigeria (Bakare et al., 2009) shows clearly genetic disorders. In addition, many par-
that professionals can hold different beliefs about ents in South Korea prefer a RAD diagnosis to
the criteria that are important for diagnosis of autism because (1) it is believed to be a temporary
autism, and many have never even heard of the condition treatable by giving love and affection;
disorder. In South Korea, children that American (2) by blaming the mother, blame is deflected
clinicians might diagnose with autism are often away from the larger family, including the line-
diagnosed with reactive attachment disorder age and lineage ancestors; and (3) the diagnosis
(RAD), pejoratively referred to as “lack of love” makes sense in South Korea’s changing social
(aejǒng kyǒlpip), a term that parallels the older context, which includes the recent integration of
American concept of the “refrigerator mother.” mothers into the work force, thereby altering
Cross-cultural variations in diagnostic prac- family life and child care and justifying concern
tices for autism have been found, even among about mothers’ attachment to their young
communities whose scientific traditions are children (Grinker, 2007).
often assumed to be similar, such as the USA It is not clear whether diagnostic tools are
and western European countries. For example, sensitive to cultural differences, and while many
in the USA, the American Psychiatric Associa- autism screening and diagnostic tools may dem-
tion removed autism from the category of “psy- onstrate satisfactory properties, they should not
chosis” in 1980, but the French child psychiatric be assumed to have applicability in a given cul-
establishment, which uses its own indigenous ture without some level of validation. Items may
manual of mental disorders, the Classification need to be tailored to language impairment as it is
Française des Troubles Mentaux de l’Enfant et defined in particular languages and cultures. For
de l’Adolescent (CFTMEA), classified autism as example, the Modified Checklist for Autism in
a psychosis until 2004. French health profes- Toddlers (M-CHAT) has been translated into
sionals also conceptualize the etiology of autism more than 40 languages and tested in a number
differently from other European countries and of countries, including China, India, Sri Lanka,
consider the American classification of pervasive Egypt, Kuwait, Jordan, Oman, Qatar, Saudi
developmental disorders (PDDs) to be a product Arabia, Syria, Tunisia, and Lebanon. While
of Anglo-American culture. Since French health used in many countries, careful validation is not
professionals generally view autism as a problem always completed. In at least one location – Sri
that lies within family social relationships and Lanka – the tool demonstrated unacceptably low
with the mother-child relationship in particular, specificity (Perera et al., 2009). The authors site
there are only a few psychiatric or medical cen- both a lack of cultural relevance of some items, as
ters with expertise on autism as a genetic or brain well as a consistent pattern in which social and
disorder. communication impairments were not viewed as
an abnormality by the mothers. A “symptom” It must be emphasized that cultural variables,
such as poor eye gaze in a 2-year-old may be such as local conceptions of the normal and
seen as an impairment in one society but polite- abnormal, stigma, and attitudes about disclosure,
ness in another. Language is another example of cannot be easily measured, in large part because
the need to consider cultural practices and norms. there are so many cross-cultural differences in the
For example, while a commonly reported impair- norms of child rearing. The use of qualitative
ment associated with autism among English ethnographic methods, such as cultural consensus C
speakers is pronominal reversal, it occurs rarely analyses, provides systematic data on attitudes
in languages, such as Korean and Javanese, in toward health and illness that can be quantified
which pronouns are seldom used. Many East and converted into schematic models of shared
Asian languages use honorifics to denote the sta- beliefs (Romney, Weller, & Batchelder, 1986).
tus of the speakers in particular conversations and Researchers can then quantify levels of agree-
settings, so the inappropriate use of honorifics is ment among informants and identify both shared
an indicator of deficiencies in an individual’s cultural categories as well as intercultural
ability to understand the pragmatics of shifting differences.
referents and social context. Every geographic location and community
Within the USA, race, ethnicity, and socioeco- may demand different methods and types of
nomic status all play a role in which children are description. An ethnographic study of help-
identified as having autism. Mandell et al. (2002) seeking for ASD in the USA would likely focus
found that African-American children subse- primarily on the relationship between parents and
quently diagnosed with autism are at least health care providers, while the same study in
2.5 times less likely to receive a diagnosis at Kenya would likely focus on an extended-family
their first specialty visit than a white child with disease management group and how the family
autism. Work by Jarquin et al. (2011) found that negotiates a plurality of coexisting medical and
non-Hispanic Black children receive only the religious systems. In other words, although
most severe diagnosis of ASD, in contrast to autism appears to be universal, the contexts in
non-Hispanic White children who receive diag- which it occurs are distinctive.
nosis at all levels of severity. Using data collected
from states on the number of children eligible for Treatment
special education services under the category of The availability of providers and clinical services
autism, Morrier, Hess, & Heflin (2010) found sig- that are specific to ASD remains one of largest
nificant underrepresentation for Hispanic children challenges in most countries in the world. Inter-
in 95% of US states. Travers et al. (2011) were vention programs for children with ASD have
able to document that this particular finding has largely developed under conditions that are both
persisted between 1998 and 2006, while the like- culturally inconsistent and economically untena-
lihood of eligibility based on ASD varied across ble for most low- and middle-income countries.
time for other minority groups. Educational eligi- Indeed, researchers must also be aware of the
bility is clearly not equivalent to diagnosis, cultural fit of many interventions, especially for
although these findings are consistent with the minority groups within the USA. One interven-
recommendation by Mandell and Novak (2005) tion approach that is well known for its adaptabil-
to conduct research on “the complex relationship ity in a number of different countries is treatment
between culture and treatment, focusing on cul- and education of autistic and communication-
tural differences in the behavioral phenotype of related handicapped children or TEACCH
ASD, recognition of symptoms, interpretation of (Schopler & Mesibov, 2000), a training, services,
symptoms, families’ decisions regarding medical and research program that has been implemented
and educational interventions, and interactions in a wide range of countries, including Australia,
between families and the healthcare system” Brazil, Cambodia, Denmark, Iceland, Italy,
(2005, p. 114). Germany, Greece, India, Israel, Japan, Kuwait,
Mexico, New Zealand, the Netherlands, Republic countries, regardless of whether they are effec-
of Ireland, South Africa, Spain, Sweden, UK, tive. As is true for families throughout the world,
Venezuela, and Vietnam. The flexibility to create parents in Taiwan reported a willingness to try
new materials and the ability to apply the general anything that might work, from fortune tellers to
principles of the program have likely contributed vitamin supplements (Shyu, Tsai, & Tsai, 2010).
to its successful adaptation.
School- or classroom-based interventions are Family Functioning
only effective, however, if children with ASD Just as the impact of a child with autism on the
attend school. Many children with ASD and family varies widely within cultures, it also varies
other disabilities simply do not attend school at considerably across cultures. In many countries,
all. Estimates by the United Nations Children’s having a child with a disability of any type is
Fund (UNICEF) and the United Nations Educa- made even more challenging as a result of the
tional Scientific and Cultural Organization stigma associated with such a difference. Stigma
(UNESCO) place the percentage of children is generally defined as a form of branding of an
with disabilities living in developing countries individual in which a community devalues his or
who receive a basic primary education to be her social identity. In Korea, for example, despite
between 1% and 5%. In these countries, school- dramatic changes in autism awareness in all seg-
based opportunities are limited primarily to the ments of society, autism (chap’ae) continues to
urban areas, and even in these situations, children be a highly undesirable disability, and the diag-
with autism are typically in settings where pro- nosis is believed to be applicable primarily to
fessionals have little knowledge about effective children and adults with profound intellectual
practices specifically for children with ASD. In impairments. Other cultures provide pathways
Ghana, for example, classrooms were described that minimize stigma. In India, the recent positive
as “crowded, loud, and unpredictable” and “tran- portrayal of people with ASD on television and in
sitions between activities generally occurred films, even if inaccurate, has opened dialogue
without warning, after inconsistent durations about disability and has provided a point of cul-
and at varying times of the day” (Anthony, tural reference, and in some cases, pride (Singhal,
2009, p. 9), conditions which are both typical in 2010). In the USA, many people who have both
most low- and middle-income countries and also ASD and above-average intelligence, while fac-
challenging for many children with ASD. ing social challenges, still find gainful employ-
In the absence of laws and regulations that ment in the fields of engineering, computers, or
provide services, parents of children with ASD mathematics.
may engage in a high level of help-seeking and Within North America and Europe, the parent-
may use a combination of local healers, indige- ing experience of minority groups can involve
nous systems of medicine, medication, and additional challenges as a result of cultural dif-
Western treatments for ASD. In China, for exam- ferences. Kediye et al. (2009) described chal-
ple (Clark & Zhou, 2005), there is wide use of lenges faced by Somali parents, such as the
sensory integration therapies in addition to language barrier in communicating with key pro-
applied behavioral analysis (ABA). In India, fam- fessionals; a perception of racism and being
ilies have long relied on both special education judged; misguided advice from the general public
and traditional healing systems, such as the use of who assume poor parenting; and a sense of
Ayurvedic and homeopathic medicine (Daley, estrangement in the absence of extended family.
2002). They now also seek treatments for their However, it is important to recognize the wide
children that include hyperbaric oxygen cham- variability in experiences across minority groups.
bers, stem-cell replacement, Defeat Autism For example, Magaña & Smith (2006) found that
Now (DAN) diets, auditory integrated therapy, Latina mothers of children with ASD had signif-
and many others. Of course, such options are icantly better overall well-being than their
not available to most families and in most non-Latina counterparts and reported striking
differences in the degree to which Latina mothers ▶ Prevalence
held more positive beliefs about their children. ▶ TEACCH Transition Assessment Profile (TTAP)
Future Directions References and Readings
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Curriculum 837 C
of autism among five-year-old children in Iran. Autism. and sequence of topics, taught in schools.
Epub ahead of print 16(1), 5–14. The term core curriculum refers to the set of
Schopler, E., & Mesibov, G. B. (2000). Cross-cultural prior-
ities in developing autism services. International Journal courses and content typically required of all
of Mental Health, 29, 3–21. International Priorities for students in a school. In K-12 education, core
Developing Autism Services via the TEACCH Model. curriculum would usually include reading,
Shin, Y.-J., Lee, K.-S., Min, S.-K., & Emde, R. N. (1999). writing, mathematics, science, and social studies,
A Korean syndrome of attachment disturbance mim-
icking symptoms of pervasive developmental disorder. as well as the arts and physical education. C
Infant Mental Health Journal, 20(1), 60–76. Additionally, the term curriculum sometimes
Shyu, Y. I., Tsai, J. L., & Tsai, W. C. (2010). Explaining is applied within a particular domain (e.g., the
and selecting treatments for autism: Parental explana- reading curriculum or the math curriculum).
tory models in Taiwan. Journal of Autism and Devel-
opmental Disorders, 40(11), 1323–1331. Curricula within a particular domain include spe-
Singhal, N. (2010). The impact of the popular media on cific subtopics or component areas, with some
awareness: Aap Ki Antara. Paper presented at the sequencing of subtopics and skills. For instance,
International Meeting for Autism Research (IMFAR), a reading curriculum in the primary grades (K-3)
Philadelphia, 2010.
Stone, W. L. (1987). Cross-disciplinary perspectives on should address component areas such as phone-
autism. Journal of Pediatric Psychology, 12, 615–630. mic awareness, phonics, fluency, vocabulary, and
Sugiyama, T., & Abe, T. (1989). The prevalence of autism comprehension; within a component area, the
in Nagoya, Japan: A total population study. Journal of curriculum would address easier skills before
Travers, J. C., Tincani, M., & Krezmien, M. P. (2011). A more difficult ones. In the area of phonics,
multiyear national profile of racial disparity in autism for example, children would be taught to read
identification. Journal of Special Education, XX(X), 1–9. simple, one-syllable words before two-syllable
Wong, V. C. N., & Hui, S. L. H. (2008). Epidemiological words, and two-syllable words before complex
study of autism spectrum disorder in China. Journal of
Child Neurology, 23(1), 67–72. multisyllabic words. The term curriculum is not
synonymous with instructional program.
A curriculum could be implemented through the
use of one particular instructional program or set
Cumulative Incidence of programs, but it could also be implemented
through instructional activities developed by
▶ Incidence teachers or schools.
Cumulative Risk
Some countries, such as the United Kingdom,
▶ Incidence have a national curriculum which standardizes
specific course content by grade. Although the
United States has no national curriculum, virtu-
Curriculum ally all states have their own standards for impor-
tant academic domains such as mathematics or
Louise Spear-Swerling reading. These state standards provide some
Southern Connecticut State University, guidance to local school districts about what
New Haven, CT, USA state education officials view as important con-
tent for each grade level, K-12. Professional orga-
nizations and scholarly panels (e.g., the National
Definition Early Literacy Panel, the National Math Advi-
sory Panel) also provide guidance to educators
Broadly defined, a curriculum is the set of regarding important curriculum content. Never-
courses, including the specific course content theless, K-12 curricula can vary substantially
C 838 Curvature of the Spine
from one state to the next or even within a state, National Reading Panel. (2000). Teaching children to
across districts, meaning that curricular expecta- read: An evidence-based assessment of the scientific
research literature on reading and its implications
tions for children at a particular grade level also for reading instruction. Washington, DC: National
can vary substantially. Institutes of Health.
Future Directions
Curvature of the Spine
The Common Core State Standards Initiative
(www.corestandards.org), a state-led effort coor- ▶ Scoliosis
dinated by the National Governors Association
Center for Best Practices (NGA Center) and the
Council of Chief State School Officers (CCSSO),
has outlined evidence-based standards by grade
CVLT – Children’s Version
level for K-12 English/language arts and mathe-
matics. States choosing to adopt these standards
▶ California Verbal Learning Test, Children’s
would be addressing similar skills and content in
Version (CVLT-C)
their core curricula, which might lead to more
consistency across and within states in expecta-
tions for students in each grade.
CVLTC
See Also
▶ California Verbal Learning Test, Children’s
▶ Reading Version (CVLT-C)
▶ Written Language
References and Readings CVLT-C
National Council for Teachers of Mathematics. (2000). ▶ California Verbal Learning Test, Children’s
Curriculum and evaluation standards for school Version (CVLT-C)
mathematics. Reston, VA: Author.
National Early Literacy Panel. (2008). Developing early
literacy: The report of the National Early Literacy
Panel. Jessup, MD: National Institute for Literacy.
National Mathematics Advisory Panel. (2008). Founda-
tions for success: The final report of the National
Cylert
Mathematics Advisory Panel. Washington, DC:
US Department of Education. ▶ Pemoline
D
DA and personal hygiene, need to be performed on

a regular basis to maintain a reasonable level of
▶ Dynamic Assessment health and safety. Adaptive functioning, or an
individual’s ability to care for self and function
independently, is a primary consideration when
supporting individuals with autism and other dis-
Daily Activities abilities. Daily living skill activities include:
• Personal hygiene and grooming
▶ Daily Routines • Dressing and undressing
• Meal preparation and feeding
• Mobility and transfer
• Toileting
Daily Living Skills • Housekeeping
• Laundry
Aaron Stabel • Home safety
The M.I.N.D. Institute, University of California • Health and medication management
Davis Medical Center, Sacramento, CA, USA • Leisure time and recreation
Children’s abilities to care for themselves have
been found to correlate with intellectual function-
Synonyms ing and may be a strong predictor of future inde-
pendence (Carter, Gillham, Sparrow, & Volkmar,
Activities of daily living; Daily self-care 1996). Individuals who cannot independently carry
activities; Home living skills; Self-care; Self-help out these necessary self-help routines are at greater
risk for long-term institutionalization, require more
intensive living supports, and are less likely to be
Definition employed (Wehman & Targett, 2004). Assessing
adaptive functioning is required when measuring
The term “daily living skills” refers to a wide intelligence, diagnosing intellectual disability, and
range of personal self-care activities across determining appropriate treatment goals (Goodlin-
home, school, work, and community settings. Jones & Solomon, 2003). The most widely used
Most daily living skills, like food preparation instrument to assess adaptive behavior functioning

D 840 Daily Routines
is the Vineland Adaptive Behavior Scales (Spar-

row, Balla, & Cicchetti, 1984). Selecting skills to Daily Routines
teach should focus on the priority tasks required
for independent domestic and community living Kimberly Kroeger-Geoppinger
(Wehman & Targett, 2004; National Research Cincinnati Children’s Hospital Medical Center,
Council, 2001). Daily living skills are usually Cincinnati, OH, USA
taught using strategies from applied behavior anal-
ysis, specifically task analysis, shaping, chaining,
and positive reinforcement. Teaching individuals Synonyms
with autism to generalize learned tasks across set-
tings, people, and materials remains an important Activity schedules; Daily activities; Routine
aspect of intervention planning when teaching events; Schedules; Visual schedules
daily living skills.
Definition
See Also
Daily routine is a schedule, custom, or habit that is
▶ Adaptive Behavior known to occur similarly on a daily frequency.
▶ Adaptive Behavior Scales Daily routines are often preferred by children and
▶ Chaining adults diagnosed with autism in order to structure
▶ Functional Assessment and Curriculum for their day and provide predictability. Daily routines
Teaching Everyday Routines can be inherently known by the individual without
▶ Functional Life Skills support or review by an outside person, or are
▶ Independent Living scheduled out by another and presented verbally
▶ Positive Reinforcement or visually. Visual schedules are often used to act
▶ Task Analysis as an aid in conveying the day’s event and are
▶ Vineland Adaptive Behavior Scales often presented pictorially (as with picture icons)
or in written form (as in a checklist). Consistent
use of daily routines often helps reduce problem-
References and Readings atic behavior due to issues with transition from
activity to activity. Daily routines can be expanded
Carter, A. S., Gillham, J. E., Sparrow, S. S., & to teach and/or guide most events that occur daily
Volkmar, F. R. (1996). Adaptive behavior in autism. on a large scale (i.e., activities to occur from
morning to night) or for specific events (e.g.,
Goodlin-Jones, B. L., & Solomon, M. (2003).
Contributions of psychology. In S. Ozonoff, hand washing, putting away laundry).
S. J. Rogers, & R. L. Hendren (Eds.), Autism spec-
trum disorders: A research review for practitioners
(pp. 55–85). Washington, DC: American Psychiat-
ric Publishing.
See Also
with autism. Washington, DC: National Academy ▶ Adaptive Behavior
Press. ▶ Daily Living Skills
Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland
adaptive behavior scales. Circle Pines, MN: American
▶ Functional Assessment and Curriculum for
Guidance Service. Teaching Everyday Routines
Wehman, P., & Targett, P. S. (2004). Principles of ▶ Functional Life Skills
curriculum design: Road to transition from school ▶ Prompt Hierarchy
to adulthood. In P. Wehman & J. Kregel (Eds.),
▶ Prompting
Functional curriculum for elementary, middle, and
secondary age students with special needs (2nd ed., ▶ Visual Schedule
pp. 1–36). Austin, TX: Pro-Ed. ▶ Visual Supports
Deaf-Blind 841 D
DAS
Cohen, M. J., & Sloan, D. L. (2007). Visual supports for
people with autism: A guide for parents and profes-
▶ Differential Ability Scales (DAS and DAS-II)
sionals. Bethesda, MD: Woodbine House.
Etzel, B. C., & LeBlanc, J. M. (1979). The simplest treatment
alternative: The law of parsimony applied to choosing
appropriate instructional control and error-less learning
procedures for the difficult-to-teach child. Journal of
DAS-II
Autism and Developmental Disorders, 9, 361–382. D
Krantz, P. J., & McClannahan, L. E. (2010). Activity sched-
ules for children with autism: Teaching independent ▶ Differential Ability Scales (DAS and DAS-II)
behavior (2nd ed.). Bethesda, MD: Woodbine House.
Lott, J. D., & Kroeger, K. A. (2004). Self-help skills in
persons with mental retardation. In J. L. Matson,
R. B. Laud, & M. L. Matson (Eds.), Behavior modifi-
cation for persons with developmental disabilities: DDST
Treatment and supports (Vol. 2). New York: National
Association for the Dually Diagnosed.
▶ Denver Development Screening Test (DDST)
Daily Self-care Activities

Deaf-Blind
▶ Daily Living Skills
Jennifer McCullagh and Deborah Weiss
Department of Communication Disorders,
DAISI New Haven, CT, USA
▶ Detection of Autism by Infant Sociability

Interview Synonyms
Sensory impairment
DAMP
▶ Deficits in Attention, Motor Control, and
Perception Deaf-blind individuals have varying degrees of
a combination of both hearing and visual impair-
ments. In the United States, the legal definition
of blindness is 20/200 in the better eye. An
DAMP Syndrome individual with a threshold exceeding 90 dB
HL is considered to be deaf. Individuals who
▶ Deficits in Attention, Motor Control, and are deaf-blind have communication as well as
Perception mobility deficits. This dual sensory impairment
results in the inability to use one sensory modal-
ity to compensate for the other. Services
required for individuals who are deaf-blind are
DAP:IQ different than those required for individuals who
are either deaf or blind. Communication and
▶ Human Figure Drawing Tests language development are the primary deficits
D 842 Deaf-Blind
in individuals with deaf-blindness; however, is estimated to be small. Further, because

development of social-affective, cognitive, and etiological factors and symptoms such as
motor skills is also affected. Individuals with impaired social interaction and communica-
deaf-blindness also exhibit stereotyped behav- tion impairment are associated with both dis-
iors, similar to those seen in children with orders, it is challenging to differentially
autism spectrum disorders. diagnose between the two.
Categorization Natural History, Prognostic Factors, and

Outcomes
Deaf-blindness may be congenital or acquired
resulting in a heterogeneous population. It is The history of service for the population of indi-
important to differentiate between these two viduals with deaf-blindness is sharply divided
groups; those with congenital deaf-blindness between the pre- and post-rubella epidemic of
have additional handicaps and typically require 1964–1965. The first citations of education with
a substantially greater amount of rehabilitation, this population appeared in the mid-1800s with
including programs that are individually tailored Laura Bridgman described as the first deaf-blind
(Rönnberg & Borg, 2000). individual to learn language at the Perkins School
for the Blind. Helen Keller was an even more
recognized and influential figure in the success
Epidemiology of educating deaf-blind individuals. However,
even through the 1960s, limited education was
It is estimated that approximately 10,000 children available for this population, and individuals
(ages birth to 22 years) in the United States are were often placed in residential schools or asy-
classified as deaf-blind (Rönnberg & Borg, 2000; lums. Congressional legislation, approved in the
The National Consortium on Deaf-Blindness 1970s and beyond, which mandated education for
[NCDB], 2008). The adult deaf-blind population children with disabilities, had a significant effect
numbers are estimated at 35–40,000 individuals in advancing the education of this population
(Watson, 1993). (NCDB, 2012).
Congenital deaf-blindness may be caused
by hereditary or chromosomal syndromes and
disorders, prenatal or congenital complications, Clinical Expression and
complications of prematurity, and undiagnosed Pathophysiology
causes. Some common hereditary or chromo-
somal causes are CHARGE syndrome, Usher This severe sensory deficit results in communica-
syndrome, and Down syndrome. Cytomegalovi- tion disorders and subsequent handicaps in edu-
rus (CMV) and microcephaly are some prenatal cation, social and cultural development, and the
or congenital complications that may lead to acquisition of information. The tactile sense is
deaf-blindness. In the past, maternal rubella was commonly utilized by these individuals for com-
the leading cause of deaf-blindness. The majority munication as well as for feelings of security and
of cases of deaf-blindness are acquired; a variety control. Other methods of compensation include
of causes are responsible such as meningitis, use of the cutaneous senses and vibration for
inflicted brain damage, and aging of the sensory sound localization. Few studies have explored
organs (Rönnberg & Borg, 2000). the psychosocial aspects of being deaf-blind and
There have been very few reports on those that do typically focus on adaptation.
the combined disorders of autism and deaf- Depression in adolescents and psychosis has
blindness. The prevalence of deaf-blind indi- been reported (Rönnberg, Samuelsson, & Borg,
viduals with autism is unknown, although it 2002).
Deaf-Blind 843 D
Evaluation and Differential Diagnosis (1) communication skills, (2) cognitive develop-
ment, (3) social and emotional development,
The evaluation process for deaf-blindness is (4) motor and self-care skills, and (5) sensory
focused on determining the extent to which the development (Murdoch, 1986).
auditory and visual systems are impaired. Since Research conducted on communicative and
the characteristics of deaf-blindness are similar to linguistic treatment primarily focuses on the
those of autism spectrum disorders, determining “Tadoma” method in which the Tadoma user
if comorbid autism spectrum disorders exist can places his/her hand on the speaker’s face in
be challenging. These individuals are also typi- a proscribed position. Through the use of percep- D
cally difficult to test; therefore, identification is tual cues, skilled Tadoma users are able to
further complicated and standardized tests are achieve a relatively high level of comprehension
nonexistent (Vernon, 2010). There tends to be of spoken speech. Intelligibility of their speech
an overdiagnosis of autism in individuals with production is 60–70%; however, the rate of
deaf-blindness leading to unsuitable intervention speech is slower by about 50%. Other methods
(Hoevevnaars-van den Boom, Antonissen, & of communication include the T-code, sign
Vervloed, 2009). These authors studied 10 indi- language, and textured symbols (Rönnberg &
viduals with deaf-blindness and intellectual Borg, 2000).
disability in order to determine if they could
differentiate which of these individuals also
had autism (which had been previously diag- See Also
nosed). They utilized an instrument that they
had developed specifically for this purpose. ▶ Blindness
Results indicated the presence of a significantly ▶ CHARGE Syndrome
greater number of impaired behaviors among the ▶ Deafness
individuals with autism in reciprocity of social ▶ Sensory Processing
interaction, quality of initiatives to contact, ▶ Sensory Stimuli
and use of adequate communicative signals and
functions. The authors concluded that their
instrument has promise in terms of its utilization
in identifying individuals with autism within
the deaf-blind population. Operant conditioning Carvill, S. (2001). Sensory impairments, intellectual
techniques have also been used successfully in disability and psychiatry. Journal of Intellectual
the assessment of this population (Rönnberg & Disability Research, 45, 467–483.
Frith, U. (2003). Autism: Explaining the enigma. Malden,
Borg, 2000). MA: Blackwell Publishing.
Gense, M. H., & Gense, D. J. (2005). Autism spectrum
disorders and visual impairment. New York:
Treatment American Foundation for the Blind Press.
Hoevenaars-van den Boom, M., Antonissen, A., Knoors,
H., & Vervloed, M. (2009). Autism in deaf-blindness.
Treatment for deaf-blindness is typically focused Journal of Intellectual Disability Research, 53(6),
on improving the communication, self-help skills, 548–558.
and mobility of the individual. Since great variabil- McKay, V. (2010). Deaf-blindness and autism spectrum
disorder. Journal of American Deafness and
ity exists from individual to individual, it is imper- Rehabilitation Association, 44(1), 201–213.
ative to establish the degree to which either the Murdoch, H. (1986). Helping the deaf-blind child in class.
auditory system, visual system, or both can be British Journal of Special Education, 13, 75–77.
utilized to enhance communication. The predomi- Murdoch, H. (2000). Repetitive behaviours in children
with sensory impairments and multiple disabilities.
nant therapeutic model is behavior modification
DBI Review, 26, 7–11.
(Rönnberg & Borg, 2000). It is recommended Rönnberg, J., & Borg, E. (2000). A review and evaluation
that the curriculum addresses five main areas: of research on the deaf-blind from perceptual,
D 844 Deafness
communicative, social and rehabilitative perspectives. Categorization

Scandinavian Audiology, 30(2), 67–77.
Rönnberg, J., Samuelsson, E., & Borg, E. (2002).
Exploring the perceived world of the deaf-blind: On Degrees of Hearing Impairment in dB HL
the development of an instrument. International
Journal of Audiology, 41, 136–143. Normal 10 to +15
The National Consortium on Deaf-Blindness. (2008). Minimal 16–25
2007 National child count of children and youth Mild 26–40
who are deaf-blind. Monmouth: Teaching Research Moderate 41–55
Division. National Consortium on Deaf-Blindness.
Moderately severe 56–70
Retrieved January 2012 from http://www.nationaldb.
org/ Severe 71–90
Van Dijk, J., & Janssen, M. (1993). Deafblind children. In Profound 91+
H. Nakken (Ed.), Multi-handicapped children
(pp. 34–73). Rotterdam: Lemniscaat.
Watson, D., & Taff-Watson, M. (Eds.). (1993). A model
service delivery system for persons who are deaf-blind Epidemiology
(2nd ed.). Arkansas: University of Arkansas.
According to the National Institute of Deafness

and Other Communication Disorders (NIDCD,
2010), approximately 2–3 in every 1,000 children
Deafness born in the United States are born with deafness
or some degree of hearing impairment. Hearing
Jennifer McCullagh loss occurs in approximately 18% of 45- to
Department of Communication Disorders, 64-year-olds, 30% of 65- to 74-year-olds, and
Southern Connecticut State University, 47% of 75-year-olds and older. More systematic
New Haven, CT, USA research needs to be done regarding the incidence
and prevalence of deafness in the population
with autism.
Synonyms
Profound hearing impairment Natural History, Prognostic Factors, and

Outcomes
Short Description or Definition Individuals with severe-to-profound hearing loss

are not able to hear speech sounds and most
“Deafness” is a term that has varying definitions environmental sounds without amplification. If
but is characterized by severe-to-profound defi- individuals with this degree of hearing loss are
cits in the ability to hear. Deaf with a capital “d” not treated in the first year of life, severe speech
is a term used to describe individuals with severe- and language delays may occur. Furthermore,
to-profound hearing loss resulting in little to no learning and attention disorders may often arise.
usable hearing, even with the use of amplification Individuals with severe-to-profound hearing
devices (i.e., hearing aids, assistive listening impairment likely need hearing aids or cochlear
devices, etc.). Furthermore, individuals who are implants, speech and auditory training/therapy,
Deaf belong to the Deaf culture which uses and special education services.
American Sign Language (ASL) as their primary Prior to the onset of the Early Detection and
mode of communication. Deaf with a lowercase Intervention (EDHI) program in the late 1980s/
“d” refers to individuals with severe-to-profound early 1990s, children with hearing impairment
hearing loss who use amplification devices and were not typically diagnosed until age 2 or
use oral communication as their primary mode of 3 years when speech and language delays were
communication. apparent. Since the beginning of the EDHI
Deafness 845 D
program, children with hearing impairment are infection, meningitis, and encephalitis, or the
being identified and treated earlier which is cause may be unknown. Depending on the cause
important for speech and language development of the hearing loss, the impairment may, or may
(either spoken language or American Sign Lan- not, be progressive in nature. Once hearing
guage (ASL)). Early detection and intervention impairment is established, annual hearing evalu-
are critical because a sensitive period exists for ations are generally recommended.
speech and language development. The first few
years of life is when the foundation for speech
and language is established, and if this period is Evaluation and Differential Diagnosis D
missed due to an unidentified severe-to-profound
hearing loss, the child will not acquire speech The goal of hearing evaluations is to assess
and/or language. The development of oral speech the outer, middle, and inner ears. The audiologist
and language is possible with appropriate ampli- will first perform otoscopy to determine if the outer
fication or cochlear implantation in conjunction ear (pinna and external auditory meatus) and tym-
with speech and language therapy. panic membrane have normal appearances. Then
In postlingually deafened adults, appropriate tympanometry is completed to determine the status
amplification is critical to their ability to commu- of the middle ear. Finally, behavioral and/or elec-
nicate with spoken language. In order to perceive trophysiologic testing is completed to determine
what is being said, as well as monitor what their hearing sensitivity at the frequencies important for
own speech, these individuals need to be fit with speech. In behavioral testing, the goal is to com-
hearing aids, and/or assistive listening devices, or plete a pure-tone audiogram which is a graphical
with cochlear implants. depiction of the hearing thresholds of the octave
frequencies from 250 to 8,000 Hz. Speech reception
threshold and word recognition testing are also
Clinical Expression and done to determine threshold to speech stimuli as
Pathophysiology well as how accurately words are perceived.
The type of hearing evaluation one undergoes
Deafness occurs as a result of a sensorineural or depends on a number of factors, including age and
mixed (conductive and sensorineural) hearing ability to respond to the tonal and speech stimuli.
loss. Conductive hearing losses are those that Evaluation methods can be either behavioral or
occur due to pathology in the outer or middle electrophysiologic. Behavioral tests require the lis-
ear. Conductive hearing losses alone only result tener to respond in some way to the tonal or speech
in at most; moderate hearing losses, however, stimuli (i.e., raise hand, turn head, repeat back
in conjunction with sensorineural hearing losses words, etc.). Some examples of behavioral test
can result in severe-to-profound hearing loss. procedures are behavioral observation audiometry
Sensorineural hearing losses occur as a result of (BOA), visual reinforcement audiometry (VRA),
pathology (typically hair cell loss) in the cochlea conditioned play audiometry, and standard audi-
or auditory nerve fibers. ometry. Behavioral observation audiometry occurs
Deafness can be either congenital or acquired. when the audiologist plays tonal and speech stimuli
Congenital deafness can be the result of genetic through the sound field or headphones and then
factors, maternal illness, and/or infection. Some watches for a response from the individual. This
examples of syndromes associated with hearing response might be the cessation of crying or
impairment are CHARGE syndrome, Usher syn- cooing, eyes widening, or turning the head. Visual
drome, and Waardenburg’s syndrome. Examples reinforcement audiometry occurs when lighted
of maternal illness and/or infection include puppets positioned in boxes directly above the
rubella, cytomegalovirus (CMV), diabetes, hyp- left and right speakers in the booth are illuminated
oxia, syphilis, and toxemia. Acquired deafness when the stimulus is presented. This is done repeat-
may be the result of ototoxic medications, edly until the individual is trained to look in the
D 846 Declarative Memory
direction of the stimulus. During the actual testing, Prognosis, evaluation methods, and treatment of
the stimuli are presented and the light is turned on individuals with autism and deafness are contin-
only after the individual turns and looks toward the gent upon a number of factors. Some of these
light. In conditioned play audiometry, hearing factors include the severity of autism, etiology of
thresholds are obtained by using toys such as the hearing loss, comorbid disorders, mode of
blocks. For example, the individual is trained to communication, and candidacy for hearing aids
drop a block in a bucket every time they perceive and/or cochlear implants. Ultimately, a collabora-
the beeping sound. Finally, hearing thresholds tive approach should be taken when treating indi-
using standard audiologic procedures are obtained viduals with autism and deafness.
by having the individual raise their hand or push
a button every time they perceive the tonal stimuli.
Physiologic tests, like the otoacoustic emis- See Also
sions (OAEs) and auditory brainstem response
(ABR), do not require a behavioral response ▶ American Sign Language (ASL)
from the listener and are thus commonly used in ▶ Auditory Brainstem Response (ABR)
newborn hearing screenings, infant hearing tests, ▶ Auditory System
as well as hearing tests on individuals who are ▶ Cochlea
unwilling, or unable, to respond to behavioral ▶ Hearing
tests. Otoacoustic emissions are generated by
the hair cells in the cochlea, so if the hair cells
are absent or not functioning properly, the References and Readings
otoacoustic emissions will be absent or reduced.
Otoacoustic emissions are often used along with NIDCD, 2010. Quick statistics. Retrieved from http://
www.nidcd.nih.gov/health/statistics/quick.htm
ABR in populations, such as those with autism,
Justice, L. (2006). Communication sciences and
that cannot participate in behavioral testing, to disorders: An introduction. Columbus, OH: Pearson.
differentially diagnose cochlear hearing loss Northern, J., & Downs, M. (2002). Hearing in children
from neural hearing loss. (5th ed.). Philadelphia: Lippincott Williams & Wilkins.
Treatment Declarative Memory
In Deaf populations, no “treatment” is sought Naomi Schneider

since deafness is not considered a problem. College of Education and Human Ecology,
Individuals who are Deaf are taught American The Ohio State University, Columbus, OH, USA
Sign Language (ASL) and become immersed in
Deaf culture. These individuals use manual
communication to interact in society. Synonyms
Individuals who are deaf will often use hear-
ing aids and/or assistive listening devices. With Explicit memory
the advancement in technology, individuals who
do have a severe-to-profound hearing loss and
who do not receive benefit from amplification Definition
may get cochlear implants. Children as young as
12 months can receive cochlear implant surgery. Declarative memory is a type of long-term mem-
Either method (hearing aids or cochlear implan- ory and is memory for facts, data, words,
tation) must be combined with speech and etc. Declarative memory can be divided into
language therapy in order to train the system to three categories: episodic, semantic, and lexical.
listen as well as produce intelligible speech. Episodic memory includes memory for personal
Deep Pressure Proprioception Touch Technique 847 D
events or experiences. Episodic memory is Definition
primarily learned consciously and is linked to
a certain time and place. Examples include Decoding refers to the word recognition
specific events such as walking to the store or processes in which written words or print are
cooking dinner. Semantic memory refers to transformed into spoken words. This process is
general knowledge or facts, independent of expe- commonly referred to as “sounding out words.”
rience. Examples include facts about historical Proficient decoding requires rapid letter recogni-
events or types of cars. Lexical memory is the tion, knowledge of sound-letter correspondences,
knowledge for words. It has been observed that phonemic awareness, and word attack skills D
some individuals with autism have enhanced (i.e., analysis/segmenting and synthesis/blending
semantic and lexical memory abilities. of the letter-sound correspondences). Accurate
and fluent decoding allows for comprehension
of words both in isolation and in context.
See Also Many individuals with autism spectrum disor-
ders (ASD) are able to mentally represent at least
▶ Episodic Memory some single word meanings; that is, read words in
▶ Explicit Memory isolation and understand their meanings. Some
▶ Memory individuals with ASD spontaneously read words
▶ Semantic Memory with excellent proficiency at an unexpectedly
early age (referred to as hyperlexia); however, it
is the ability to read beyond decoding individual
References and Readings words (i.e., reading in context) that presents
greater difficulty for individuals with ASD.
Berger, K. S. (1998). The developing person through the
life span (4th ed.). New York: Worth.
Chapey, R. (2001). Language intervention strategies
in aphasia and related neurogenic communication References and Readings
disorders (4th ed.). Philadelphia: Lippincott Williams
and Wilkins. Huemer, S. V., & Mann, V. (2009). A comprehensive
Rathus, S. A. (1997). Essentials of psychology (5th ed.). profile of decoding and comprehension in autism spec-
Fort Worth, TX: Harcourt Brace. trum disorders. Journal of Autism and Developmental
Tager-Flusberg, H. (1985). The conceptual basis for Disorders, 40(4), 485–493.
referential word meaning in children with autism. Kamhi, A. G., Allen, M. M., & Catts, H. W. (2001). The
Child Development, 56, 1167–1178. role of the speech-language pathologist in improving
Ullman, M. T. (2004). Contributions of memory circuits decoding skills. Seminars in Speech and Language,
to language: The declarative/procedural model. 22(3), 175–184.
Cognition, 92, 231–270. Shanahan, T. (2006). The national reading panel report:
Practical advice for teachers. Retrieved from http://
www.learningpt.org/pdfs/literacy/nationalreading.pdf
Decoding Skills
Deep Pressure Proprioception Touch
Diana B. Newman Technique
Communication Disorders Department,
Southern Connecticut State University, Winifred Schultz-Krohn
New Haven, CT, USA Department of Occupational Therapy, San José
State University, San José, CA, USA
Synonyms Synonyms
Word recognition Wilbarger protocol

D 848 Deficits in Attention, Motor Control, and Perception
Definition
Deficits in Attention, Motor Control,
Deep pressure proprioceptive touch technique and Perception
(DPPT): Previously known as the Wilbarger Pro-
tocol, DPPT was developed by two occupational Fred R. Volkmar
therapists, Patricia and Julia Wilbarger, to Director – Child Study Center, Irving B. Harris
address sensory defensiveness. This technique Professor of Child Psychiatry, Pediatrics and
requires specific training and includes three Psychology, School of Medicine, Yale
parts where first a client’s arms, back, and legs University, New Haven, CT, USA
are brushed firmly with a soft bristled brush sim-
ilar to a surgical brush. Then joint compressions
are applied at specified joints throughout the Synonyms
body, and finally a sensory diet is prescribed to
address sensory defensiveness. This technique DAMP; DAMP syndrome
has been effectively used to reduce sensory
defensiveness and has been linked to bringing
Definition
salivary cortisol levels closer to normal values
in children with sensory processing deficits.
DAMP syndrome is a diagnostic concept devel-
The cortisol levels have been used as a measure
oped by Gillberg and colleagues in Sweden and
of stress in children, and with the use of the
used more frequently in Scandinavia. The term
DPPT, the levels of cortisol approached a normal
refers to a disorder in which aspects of attention
level. The recommended frequency for this
deficit disorder and motor coordination difficulties
technique is every 2 h during waking hours for
are present. A close link to PDD-NOS/autism spec-
2 weeks to see diminished sensory defensive
trum disorder has been suggested (Gillberg, 1993;
behaviors.
Kadesjoe & Gillberg, 1999). One complexity in
this regard is the potential for attentional difficulties
to lead to problems with peers and social interac-
References and Readings tion; this is particularly the case if some degree of
language difficulty is involved (Towbin, 2005).
Kimball, J. G., Lynch, K. M., Stewart, K. C., Issues of diagnosis can also be complex in children
Williams, N. E., Thomas, M. A., & Atwood, K. D. with significant intellectual disability, attentional,
(2007). Using salivary cortisol to measure the effects
of a Wilbarger protocol-based procedure on sympa- and motor problems, although it has been
thetic arousal: A pilot study. American Journal of suggested that the DAMP concept be restricted to
Occupational Therapy, 61, 406–413. cases where the individual has an IQ no lower than
Moore, K. M., & Henry, A. D. (2002). Treatment of adult the mild-moderate range of disability.
psychiatric patients using the Wilbarger Protocol.
Occupational Therapy in Mental Health, 18, 43–63.
Wilbarger, P. (1984, September). Planning an adequate See Also
sensory diet-application of sensory processing theory
during the first year of life. Zero to Three, 7–12.
▶ Attention Deficit/Hyperactivity Disorder
Wilbarger, P., & Wilbarger, J. (1991). Sensory defensive-
ness in children aged 2–12: An intervention guide for ▶ Developmental Coordination Disorder
parents and other caretakers. Santa Barbara, CA: ▶ Pervasive Developmental Disorder Not
Avanti Educational Programs. Otherwise Specified
Wilbarger, J., & Wilbarger, P. (2002). Wilbarger approach
to treating sensory defensiveness and clinical applica-
tion of the sensory diet. Sections in alternative
and complementary programs for intervention. References and Readings
In A. C. Bundy, E. A. Murray, & S. Lane (Eds.),
Sensory integration: Theory and practice (2nd ed.). Gillberg, I., Winnergard, I., & Gillberg, C. (1993). Screening
Philadelphia, PA: F.A Davis. methods, epidemiology and evaluation of intervention in
DeGangi-Berk Test of Sensory Integration 849 D
DAMP in preschool children. European Child & deficits so that the practitioner did not need to rely
Adolescent Psychiatry, 2(3), 121–135. on clinical judgment alone. At that time, there
Hellgren, L., Gillberg, I. C., Bågenholm, A., & Gillberg, C.
(1994). Children with deficits in attention, motor control were only measurements of motor functioning
and perception (DAMP) almost grown up: Psychiatric with no other instrument sufficiently sensitive to
and personality disorders at age 16 years. Journal determine if these motor issues were cause by an
of Child Psychology and Psychiatry, and Allied underlying sensory integrative difficulty.
Disciplines, 35(7), 1255–1271.
Kadesjoe, B., & Gillberg, C. (1999). Developmental coor- Once the items are scored, they are calculated to
dination disorder in Swedish 7-year-old children. establish an overall score of sensory integrative
Journal of the American Academy of Child and functioning (total test score), as well as a score D
Adolescent Psychiatry, 38(7), 820–828. within each of the following subdomains of sensory
Landgren, M., Pettersson, R., Kjellman, B., & Gillberg, C.
(1996). ADHD, DAMP and other neurodeve- integration:
lopmental/psychiatric disorders in 6-year-old children: 1. Postural control
Epidemiology and co-morbidity. Developmental Med- 2. Bilateral motor integration
icine and Child Neurology, 38(10), 891–906. 3. Reflex integration
Towbin, K. E. (2005). Pervasive developmental disorder not
otherwise specified. In F. R. Volkmar, A. Klin, R. Paul, The above subdomains were identified for
& D. J. Cohen (Eds.), Handbook of autism and pervasive inclusion "because of their clinical significance
developmental disorders. Hoboken, NJ: Wiley. in the development of sensory integrative
functions in the preschool child" (DeGangi &
Berk, 1983, p. 1). Table 1 outlines the compo-
nents of each subdomain.
DeGangi-Berk This tool was designed to be implemented by
occupational or physical therapy practitioners
▶ DeGangi-Berk Test of Sensory Integration given their training and educational background in
the interpretation of sensory integrative information
and test results. Therefore, it is suggested that
a practitioner outside of these fields (i.e., special
DeGangi-Berk Test of Sensory educators or motor development specialists) seek
Integration the assistance of an occupational or physical thera-
pist for the interpretation of the test scores.
Tara J. Glennon With a baseline understanding of sensory
Occupational Therapy, Quinnipiac University – processing, implementers should allow 2 h to
Hamden, CT and Center for Pediatric Therapy, learn the items prior to implementation. The assess-
Fairfield & Wallingford, CT, Hamden, CT, USA ment manual is easy to follow, and the specific
instructions for item implementation are outlined
with pictures to assist. A score of 0 through 1, 2, 3,
Synonyms or 4 is received depending on the child’s response
to each item and the quality of the performance
DeGangi-Berk; TSI indicating that the skill has been developed. The
higher the score indicates a more integrated, orga-
nized, or normal response. Lower scores qualify the
Description child’s responses, for example, unable to hold, loses
grasp, does not cross [midline], no resistance, slight
This assessment tool offers an objective method to moderate flexion of the elbow, etc.
to examine the sensory functioning of children The score tallies in each subdomain then result
aged 3–5 years. This 36-item assessment in a “normal,” “at risk,” or “deficient” score profile
published in 1983 intended to provide an objec- for a total test score, postural control score,
tive method to determine whether, and to what bilateral motor integration score, and a reflex
extent, a preschool child had sensory processing integration score (which is only counted toward
D 850 DeGangi-Berk Test of Sensory Integration
DeGangi-Berk Test of Sensory Integration, Table 1 TSI subdomains of sensory integration. All information taken
from TSI test manual (p. 1–2)
Sensory
integrative
subdomain Names of individual tests Description and significance
Postural • Monkey task • Stabilization of the next, trunk, and upper extremities
control • Side-Sit cocontraction • Muscle cocontraction of the neck and upper extremities
• Prone on elbows • Includes antigravity postures
• Wheelbarrow walk
• Airplane
• Scooter board cocontraction
Bilateral • Rolling pin activity • Emphasizes bilateral motor coordination
motor • Jump and turn • Includes components of laterality including trunk
coordination • Diadochokinesis rotation, rapid unilateral and bilateral hand movements,
• Drumming and crossing the midline
• Upper extremity control • Includes stability of the upper and lower extremities in
bilateral symmetrical postures and disassociation of
trunk and arm movements
Reflex • ATNR – asymmetrical tonic neck • Quadruped position to observe asymmetrical and
integration • STNR – symmetrical tonic neck symmetrical tonic neck reflexes and associated reactions
• Diadochokinesis of the upper extremities
the total test score). Score ranges for the varying wait for these secondary issues to arise, it
age ranges are provided on the score sheet was thought that intervention could addressed/
which makes scoring very clear. This criterion- remediated the sensory concerns before secondary
referenced assessment tool offers clinicians work- issues arose. This thought, based on sensory inte-
ing with this population of children a structured gration theory (Ayres, 1964, 1972, 1979), continues
and organized method to assess sensory integrative today. A fuller description of Ayres’ theory of sen-
functions in children with delays in sensory, sory integration can be found in the links below
motor, and perceptual skills, or children suspected titled Ayres, A. Jean, sensory processing, and sen-
of having learning problems. sory integration therapy.
Georgia DeGangi, PhD, OTR (occupational thera- DeGangi began developing test items in 1978, com-
pist who now practices in clinical psychology) and pleted psychometric studies, revised the test and the
Ronald Berk, PhD (professor of educational items, completed several rounds of reliability and
research at Johns Hopkins University at the time validity testing, and ultimately identified 73 items.
and authored the 1980 book titled: Criterion After additional item analysis, which discarded
Referenced Measurements: State of the Art) devel- items that did not well discriminate typical from
oped this objective tool to observe and measure the delayed children or were not sufficiently sensitive
sensory integrative processes in preschool children, to typical developmental in these age ranges, only
specifically the vestibularly based functions of pos- 36 items remained.
tural control, bilateral integration, and reflex inte- The test manual specifically outlines each step of
gration. It was thought that difficulties in sensory the sampling and statistical procedures. However, it
integrative processing in preschool children could should be noted that there were some sampling
result in fine or gross motor delays, poor balance, difficulties resulting in a disproportionate number
poor hand use, distractibility, and/or visual-spatial of 3–4-year-old children and a low sample popula-
organization later in the school years. Rather than tion (n). The authors therefore suggest that further
DeGangi-Berk Test of Sensory Integration 851 D
DeGangi-Berk Test of Sensory Integration, Table 2 DeGangi-Berk TSI assessment review form
Test name: DeGangi-Berk Test of Sensory Integration (TSI)
Author(s): Georgia A. DeGangi PhD, OTR and Ronald Berk, PhD
Publisher: Western Psychological Services, 625 Alaska Ave, Torrance, CA 90503; 800-648-8857
Technical information: 2 h of practice before administering
Age range(s): 3–5 years old
Assessment type: Criterion referenced
The following information was obtained from the TSI Manual
Reliability: D
1. Interobserver reliability: Two pairs of examiners were used. Difficulties with implementing repeat testing procedures
resulted in a low number in the sample and not fully representative of each age group (i.e., no 5-year olds). Intraclass
correlations were .80 and above for postural control, bilateral motor integration, and the total test; and coefficients for the
dependability of each observer ranged from .67 to .79 for those same categories. Reflex integration was low within each
pair of examiners as well as inconsistent between two pairs of raters.
2. Decision-consistency reliability: The po index of decision consistency was used determine "the proportion of children
classified as normal and delayed on repeated testings" indicating a degree of confidence for the decision (i.e., the stability
of the decisions). A sample of 23 "normal" and 6 "delayed" 3–5-year-old children (10 boys and 19 girls) were tested
twice during a 1-week retest interval. Utilizing three observers, the po estimates for the three subtests and the total test
ranged from 79–93% with the lowest in reflex integration. However, standard error was large and thought to be the result
of the small sample size.
3. Test-retest reliability: The Pearson correlation coefficients between test and retest scores for each subtest and the total
score for a period of 1 week ranged from .85 to .96. Postural control was the least stable with anticipation/familiarity with
the task thought to be an influence in the second testing, whereas bilateral motor integration and reflex integration,
requiring more automatic responses, were thought to be less susceptible to performance changes on test-retest.
Validity:
1. Content validity: A two-stage judgmental review occurred to determine test validity.
• Item-behavior congruence: Item-behavior congruence and representativeness was rated by eight judges (occupational
therapists). The degree of congruence between the items and the subdomain was rated either as poor, moderate, or high
for each item. A rating of "high" was obtained for all items in postural control and reflex integration, and for all but one
judge for bilateral motor integration.
• Representativeness: Twelve judges were asked: Is each collection of items representative of its respective subdomain
of behaviors? A score of "high" was obtained by all judges for postural control and 87% of the judges for the bilateral
motor integration and reflex integration (with the other 13% scoring as "moderate").
2. Construct validity: Construct validity evidence was found within the item, subtest, and test, and because the specific
use of the test score was to identify normal vs. delayed, this was the primary focus of the analysis. Total of 139 children in
the sample.
• Item validity: The effectiveness of each item was found by computing a discrimination index (DIS) displaying the
difference between the mean score for each item in the normal and delayed groups. Statistical significance was then
computed using a t test and the magnitude of the significance computer via effect size (d). Out of the original 73 test
items, 37 were taken out after item analysis since they did not discriminate between the groups of delayed and normal, or
were not sensitive to the normal developmental status of this population.
• Decision validity: The cut-off scores for this tool, and therefore the focus of these analyses, were to minimize the false
normal error rate as this was thought to be the most serious of errors. The total test and the three subtests’ error rate
ranged from 4 to 9%. The error rate for false delayed ranged from 10 to 26% for all test scores. Sensitivity and specificity
were calculated with scores of 71% and 85%, respectively, for the total test.
• Test structure: Moderately low subtest correlations (.39–.65) confirms that each subtest is measuring different
vestibularly based functions, thus supporting the structure of the test. The correlation of the subtests to sensory
integration as a whole ranges from .64 to .93. There was also support that the subdomains of postural control and bilateral
motor integration were more vital to overall sensory integration than reflex integration.
Testing procedures
Obtaining information: Thirty-six items should be administered individually and in one sitting; items should be
administered exactly as described in the order presented in the manual.
Time to administer: 30 min
Time to score: 10 min
Materials included in the test kit? _X_ yes ____ no
Additional materials needed: 10 15 ft space, table and chair, masking tape, pencil without eraser, switch-back
stopwatch, 3-ft-long wooden dowel, rolling pin, carpeted scooter board, plastic hula hoop, and floor mat
(continued)
D 852 DeGangi-Berk Test of Sensory Integration
DeGangi-Berk Test of Sensory Integration, Table 2 (continued)

Test name: DeGangi-Berk Test of Sensory Integration (TSI)
Is the tool easy to learn and administer? __X_ yes ____ no
How much training or practice is required? 2 h
Who can administer the test? Designed for implementation by occupational therapists and physical therapists; can be
implemented by special educators or motor development specialists but seeking an occupational or physical therapist to
interpret whether the score is recommended as they have training and education in sensory processing.
Is the manual easy to follow/understand? __X_ yes ____ no
Are the forms easy to follow/understand? __X_ yes ____ no
The forms are very clear, easy to follow while administering, and can be quickly scored in a very objective manner.
Domains: Postural control, bilateral integration, and reflex integration
research with a more representative sample would 4. There were high levels of classification consis-
improve the utility of the tool and the generalizabil- tency in the identification of the classification
ity of the findings. designated for each item.
Table 2 outlines the components of the 5. Test-retest reliability:
assessment process including the psychometric The results provided substantial evidence of the
procedures associated with the development of stability of sensory integrative functions for a
this criterion-referenced assessment tool. In 1-week re-test interval using a homogeneous
summary, the total test score can be used reliably preschool sample. (DeGangi & Berk, 1983,
p. 41).
and validly for screening decisions, and the
postural control score and bilateral motor
integration score can be used reliably and validly Clinical Uses
for diagnostic decisions based on the following
information: Any assessment tool should be used in combina-
1. Domain validity: The total test had a high tion with other tools in order to gain the most
degree of domain validity. comprehensive picture of a child’s functioning.
The DeGangi-Berk TSI was intended to provide
Consensus among therapists that the items measure
the behaviors they were designed to measure, information related to the three subdomains noted
and that the collection of items composing each above as these categories of sensory integrative
subtest was representative of the behaviors functioning were thought to have a strong impact
defined by the subdomains. (DeGangi & Berk, on the development of sensory integrative func-
1983, p. 40)
tions in the preschool child. The intent was to
2. Construct validity: administer this assessment to children with delays
• Total test score can be used for screening in sensory, motor, and perceptual skills, or to chil-
decisions with better that 80% accuracy dren suspected of having learning problems.
and a 9% false normal error rate. This tool continues to be utilized today in
• Postural control and bilateral motor integra- clinical practice as it is a structured and organized
tion subtests were extremely accurate. method to investigate the sensory processing
• Reflex integration was the least effective abilities in this age group.
subtest.
3. Interobserver reliability:
• Very reliable for postural control, bilateral See Also
integration, and total sensory integration
behaviors. ▶ Ayres, A. Jean
• Considerable subjectivity for reflex integra- ▶ Evaluation of Sensory Processing
tion behaviors. ▶ Occupational Therapy (OT)
Deixis 853 D
▶ Sensory Diet to have difficulty with spatial contrast deictic terms
▶ Sensory Integration and Praxis Test (“this/that,” “here/there”) into the early school age
▶ Sensory Integration (SI) Therapy years. This difficulty is thought to be related to the
▶ Sensory Processing shifting quality of the referents for these terms.
▶ Sensory Processing Assessment That is, “I” does not refer to any particular person,
▶ Sensory Processing Measure but to the person who happens to be talking at
▶ Sensory Processing Measure: Preschool a given time. When that person stops talking, the
(SPM-P) referent for “I” shifts to the next speaker. “Here”
▶ Test of Sensory Functioning in Infants refers not to a specific location, but rather to a place D
near the speaker. What is “here” for the speaker
may be “there” for the listener. This shifting refer-
References and Readings ence is thought to cause special difficulty for
speakers with ASD, due to their difficulties with
Ayres, A. J. (1964). Tactile functions: Their relations flexibility and change. But it is important to note
to hyperactive and perceptual-motor behaviour.
that young children with typical development can
American Journal of Occupational Therapy, 18,
6–11. also find these forms difficult.
Ayres, A. J. (1972). Sensory integration and learning
disorders. Los Angeles: Western Psychological
Services.
Ayres, A. J. (1979). Sensory integration and the child. Los
See Also
Angeles: Western Psychological Services.
DeGangi, G. A., & Berk, R. (1983). DeGangi-Berk Test of ▶ Pronoun Errors
Sensory Integration (TSI) manual. Los Angeles: Western ▶ Pronoun Reversal
Psychological Services.
▶ Pronoun Use

Deictic Terms
Bartolucci, G., & Albers, R. J. (1974). Deictic
categories in the language of autistic children.
Sarita Austin
Laboratory of Developmental Communication 4(2), 131–141.
Disorders, Yale Child Study Center, New Haven, Hobson, P. R. (2009). Personal pronouns and communi-
CT, USA cative engagement in autism. Journal of Autism
doi:10.1007/s10803-009-0910-5.
Hobson, P. R., Garcia-Perez, R. M., & Lee, A. (2009).
Synonyms Person-centered (deictic) expressions and autism.
40(4), 403–415. doi:10.1007/s10803-009-0882-5.
Deixis
Lee, A., Hobson, R. P., & Chiat, S. (1994). I, you, me and
autism: An experimental study. Journal of Autism and
Definition Owens, R. E. (2008). Language development: An
introduction (7th ed.). Boston: Allyn & Bacon.
Deictic terms are words whose meaning shifts

depending on the point of view of the speaker.
Examples of deictic terms include “this/that,”
“here/there,” “I/you,” and “my/your.” While
some personal pronoun contrasts (“I/you,” “my/ Deixis
your”) are expected to develop before 3 years of
age, many typically developing children continue ▶ Deictic Terms
D 854 DEL22q13.3 (Entrez Gene, OMIM, Uniprot)
Major Activities
DEL22q13.3 (Entrez Gene, OMIM,
Uniprot) DAP is public school program that presently
consists of affiliated programs in 6 of the 19 school
▶ SHANK 3 districts (Local Education Agencies, or LEA) across
the three counties in the State of Delaware, plus
other specialized services and supports provided
through the Office of the Statewide Director. As
a public school program, DAP’s services are fully
Delaware Autism Program funded by the LEA and the State Education Agency
(SEA), at no cost to parents. The six affiliated
Vince Winterling programs share many key elements, including:
Delaware Autism Program, Newark, DE, USA (a) programs for children 2 up until 21 years of
age, across the autism spectrum; (b) settings ranging
from full inclusion to separate classroom for chil-
Major Areas or Mission Statement dren with ASD, including extended school year
services; (c) reliance on teaching methods based
The Delaware Autism Program (DAP) is one of on principles of Applied Behavior Analysis
the largest public school programs in the (ABA), including PECS; (d) a high staff to student
United States specializing in educating children ratio to support more individualized teaching and
and adolescents with an Autism Spectrum Dis- community integration; (e) opportunities for parents
order (ASD). In 2010, it served more than 800 to create local Parent Advisory Committees (PAC)
students between 2 and 21 years of age, in to provide input to the LEA, SEA, and Office of
the full range of settings (residential programs, the Statewide Director; and (f) expectations that
separate schools and settings, and integrated staff complete a core training program, which
school and community sites) in six affiliated for teachers includes a 15 credit graduate teaching
school districts. DAP sites employ than 450 certificate in autism. Many of the programs also
staff, including teachers, assistants, specialists coordinate with other organizations (daycares,
(psychologists, speech language pathologists, vocational settings, institutes of higher education)
occupational therapists, nurses, etc.), and to provide community-based services. Three of the
administrative and support staff. six programs operate county centers which provide
services to students with more challenging educa-
tional and behavioral needs. Through an agreement
Landmark Contributions with the SEA, the Office of the Statewide Director
provides services across the state, including:
Elements of DAP have been described in various (a) management of extended educational services
book chapters (Battaglini & Bondy, 2006; (part-time residential programming in community-
Bondy, 1996; Bondy & Frost, 1994; Bondy & based settings) and extended support services
Frost, 1995; Doehring & Winterling, 2011). (in-home respite provided to parents for a nominal
The Picture Exchange Communication System co-pay); (b) leadership of various statewide com-
(PECS) (Frost & Bondy, 2000) was first devel- mittees that provide consultation to LEAs regarding
oped by Andy Bondy and Lori Frost during their educational programming, to coordinate parent
tenure at DAP, together with the involvement input from the PACs, and provide independent
of other DAP staff. Statewide directors have peer review of the assessment and intervention for
included Dr. Andy Bondy (1981–1997), Dr. students with very challenging behaviors; and (c)
Peter Doehring (1999–2008), and Dr. Vincent coordination of staff training specific to ASD. DAP
Winterling (2009–present). was established in 1976 after parents helped to pass
Delay, Deviance Versus 855 D
laws defining many of the core elements of
the program (specialized positions like the Delay, Deviance Versus
Statewide Director, specialized services like
extended educational and support services, Elizabeth Spencer
additional staffing, extended school year, statewide College of Education and Human Ecology,
committees, etc.). The Ohio State University, Columbus, OH, USA
See Also Definition D
▶ Applied Behavior Analysis Delay versus deviance refers to a debate about the
▶ Educational Interventions nature of development in autism and other
▶ Free Appropriate Public Education disorders. In general, a child who exhibits a devel-
▶ Individual Education Plan opmental delay follows a progression of develop-
▶ Local Educational Authority ment found in the general population, but progress
▶ Picture Exchange Communication System in development at a slower rate. In contrast, a child
▶ Regional Centers who exhibits deviance follows a progression of
▶ Statewide Service Programs development that is different both in rate and
sequence of progression. There is evidence to sug-
gest that children with autism may follow a devel-
opmental progression that includes elements of
References and Readings both delay and deviance. In many children with
autism, language development is often delayed but
Battaglini, K., & Bondy, A. (2006). Application of occurs in a progression similar to children with
the pyramid approach to education model in
a public school setting. In J. S. Handleman &
typical development. In other children, language
S. L. Harris (Eds.), School-age education pro- development may also include deviant character-
grams for children with autism (pp. 163–194). istics (e.g., echolalia). Many children with autism
Austin, TX: Pro-Ed. demonstrate deviance in the development of social
Bondy, A. (1996). What parents can expect from public
and pragmatic skills. For example, some children
school programs. In C. Maurice, G. Green, et al. (Eds.),
Behavioral intervention for young children with with autism demonstrate deviance in the develop-
autism: A manual for parents and professionals ment of social behaviors such as joint attention.
(pp. 323–330). Austin, TX: Pro-Ed.
Bondy, A., & Frost, L. A. (1994). The Delaware autistic
program. In S. L. Harris & J. S. Handleman (Eds.),
Preschool education programs for children with See Also
autism (pp. 37–54). Austin, TX: Pro-Ed.
Bondy, A. S., & Frost, L. A. (1995). Educational ▶ Speech Delay
approaches in preschool: Behavior techniques in
a public school setting. In E. Schopler, G. Mesibov,
et al. (Eds.), Learning and cognition in autism
(pp. 311–333). New York: Plenum Press. References and Readings
Doehring, P., & Winterling, V. (2011). The implemen-
tation of evidence-based practices in public Baron-Cohen, S. (1988). Social and pragmatic deficits in
schools. In B. Reichow, P. Doehring, D. V. autism: Cognitive or affective? Journal of Autism and
Cicchetti, & F. R. Volkmar (Eds.), Evidence-based Developmental Disorders, 18, 379–402.
practices and treatments for children with autism Carlisle, P. (2007). Progress in autism research.
(pp. 343–363). New York: Springer Science + New York: Nova Science.
Business Media. Charman, T., & Stone, W. (2006). Social and communi-
Frost, L. A., & Bondy, A. S. (2000). The picture exchange cation development in autism spectrum disorders:
communication system training manual. Cherry Hill, Early identification, diagnosis, and intervention.
NJ: PECs. New York: The Guilford Press.
D 856 Delayed Echolalia
Tager-Flusberg, H. (1981). On the nature of linguistic

functioning in early infantile autism. Journal of Autism Dementia Infantilis
VanMeter, L., Fein, D., Morris, R., Waterhouse, L., &
Allen, D. (1997). Delay versus deviance in autistic ▶ Childhood Disintegrative Disorder (Heller’s
social behavior. Journal of Autism and Developmental Syndrome)
Disorders, 27, 557–569.
Delayed Echolalia Dendrite
▶ Echolalia Claudia Califano

▶ Movie Talk Yale-New Haven Hospital, New Haven, CT,
USA
Delusion of Doubles Definition
▶ Capgras Syndrome A dendrite is one of the four main parts of neurons,

which also include the cell body, the axon, and the
axon terminals. The dendrite is the part of the neuron
that receives incoming signals from other neurons.
Delusion of Duplicates The signals come in the form of neurotransmitters
that cross the area of the synapse between one neu-
▶ Capgras Syndrome ron and another neuron’s dendrites. Neurotransmit-
ters bind to receptors on the dendrites, and then the
signal passes though the neuron to the cell body.
Dendrites may have extensive branching, and each
Delusion of Negative Doubles neuron often has multiple dendrites.
The number of dendrites and thus the number of
▶ Capgras Syndrome synapses vary with the functions of a neuron. The
dendrites of one neuron may receive signals from
thousands of other neurons. That one neuron then
integrates many signals received and responds
Delusion of Substitution accordingly.
▶ Capgras Syndrome
See Also
▶ Neuroanatomy
Delusional Hypoidentification ▶ Neurochemistry
▶ Neurotransmitter
▶ Capgras Syndrome ▶ Purkinje Cells

Demand Corwin, E. (2006). Handbook of pathophysiology (3rd ed.,
pp. 185–187). Philadelphia: Lippincott Williams &
▶ Mands Wilkins.
Denver Development Screening Test (DDST) 857 D
whose bar graphs are closest to but completely to
Denver Development Screening Test the left of the age line, indicating items that over
(DDST) 90% of typically developing children should be
able to do by that age. Any of these items not
Robin Hansen successfully completed are considered a delay;
Pediatrics, Center for Excellence in items where the age line passes through the
Developmental Disabilities, M.I.N.D. Institute/ 75–90% section of the bar graph which the child
UCDavis, Sacramento, CA, USA cannot accomplish are scored “cautions,” and an
algorithm for determining normal, abnormal (two D
or more delays), and questionable (two cautions
Synonyms or one delay) results is provided in the manual.
DDST; Denver II
Description The DDST is most important for its historical

background rather than as a currently
The Denver Developmental Screening Test, first recommended screening tool. It was the first
published in 1967 (Frankenburg & Dodds, 1967), developmental screening tool for young children
was one of the first screening tools developed to that was widely marketed to the primary care
identify young children at risk for developmental medical community as well as child care pro-
delay and disability. It’s format was similar to the viders and other child health professionals. It
construction of pediatric growth charts, with 105 played a significant role in widespread recogni-
developmental items for children from birth to tion of the importance of early identification and
6 years of age aligned chronologically along hor- intervention from a public health and primary
izontal age lines, divided into four discrete devel- care perspective. The role of parents as accurate
opmental domains: personal-social, fine motor- observers of their children’s behaviors was
adaptive, language, and gross motor. Bar graphs also recognized by the developers of the DDST
for each developmental item reflect the ages at and subsequent screening materials such as
which 25%, 50%, 75%, and 90% of typically the Denver Prescreening Developmental Ques-
developing children in the standardization sam- tionnaire and the Denver II. The DDST and
ple completed the task. Because of criticisms Denver II became widely used in the United
related to low sensitivity in identifying children States and internationally, being translated and
with speech and language delays, it was revised restandardized in many countries.
to add more language items, restandardized,
and remarketed as the Denver II in 1992
(Frankenburg, Dodds, Archer, Shapiro, & Psychometric Data
Bresnick, 1992), retaining a similar format to
the DDST. Both are administered by individuals The DDST was originally standardized on
who have trained to proficiency using training 1,036 children from Denver, age 1–72 months,
tapes/DVD or the administration manual, with with reported co-positivity scores of .92 and co-
standardized toys such as blocks, rattles, and negativity scores of .99, using the Bayley Mental
pictures included in the toolkit. It is estimated to and Psychomotor Scales and Stanford-Binet Intel-
take 10–20 min to administer and score. Several ligence Scales as criterion tests. Subsequent stud-
options regarding item administration were ies of concurrent and predictive validity, reviewed
developed and evaluated. The most commonly by Meisels (1989), found that while the specificity
used approach in primary care settings included remained high (.87–1.0), the sensitivity was unac-
administering at least three items in each domain ceptably low (.13–.46), particularly when children
D 858 Denver II
were reevaluated 14 months to 6 years later (.18). Denver II in developmental screening. Pediatrics, 89,
The Denver II was standardized on 2,096 children 1221–1225.
Johnson, C. P., & Myers, S. M. (2007). Identification and
0–6.5 years of age, half from Denver and half from evaluation of children with autism spectrum disorders.
rural Colorado. Inter-rater reliability and test-retest Pediatrics, 120, 1183–1215.
validity were reported to be .90 or greater Meisels, S. (1989). Can developmental screening tests
(Frankenburg et al., 1992). Subsequent studies identify children who are developmental at risk?
showed that, with these revisions, the Denver II
had acceptable sensitivity of .83 reported by
Glascoe et al. (1992), but specificity dropped to
.43, shifting concerns about the DDST failing to Denver II
identify children with significant delays to con-
cerns about overreferral of typically developing ▶ Denver Development Screening Test (DDST)
children using the Denver II.
Clinical Uses Denzapine
The Denver II is still marketed by Denver Devel- ▶ Clozapine

opmental Materials Inc. However, it is not
included in the most recent American Academy
of Pediatrics guidelines for general developmen-
tal surveillance and screening as a recommended Deoxyribonucleic Acid
tool (2006) nor in the AAP guidelines for ASD
screening (2007), as it has never been evaluated Paul El-Fishawy
as a screening tool for ASD. Its format, however, State Laboratory, Child Study Center, Yale
continues to be useful for pediatric educators as University, New Haven, CT, USA
a way of visually illustrating the importance of
assessing different developmental domains
simultaneously in individual children, of tracking Synonyms
development over time, and of showing the var-
iability in ages at which different developmental DNA
items “typically” occur.
Definition
References and Readings The instructions for the development and function-
ing of a living organism are contained in a molecule
American Academy of Pediatrics. (2006). Identifying
called deoxyribonucleic acid (DNA) which is
infants and young children with developmental
disorders in the medical home: An algorithm for a nucleic acid. The instructions are spelled out in
developmental surveillance and screening. Pediatrics, a sequence or code of four chemical units called
118, 405–420. nucleobases (or bases for short). These are adenine,
Frankenburg, W., & Dodds, J. (1967). The Denver
cytosine, guanine, and thymine, abbreviated as A,
developmental screening test. Journal of Pediatrics,
71, 181–191. C, G and T, respectively. DNA is contained within
Frankenburg, W. K., Dodds, J., Archer, P., Shapiro, H., & nearly every cell of the human organism. Certain
Bresnick, B. (1992). The Denver II: A major revision segments of the DNA molecule called genes
and restandardization of the Denver developmental
contain the code for creating the components of
screening test. Pediatrics, 89, 91–97.
Glascoe, F. P., Byrne, K. E., Ashford, L. G., Johnson, K. L., cells, most importantly, molecules called proteins
Chang, B., & Strickland, B. (1992). Accuracy of the (Alberts, Bray, et al., 2002). James Watson and
Depakene 859 D
Francis Crick described the molecular structure of Bailey, A., Le Couteur, A., et al. (1995). Autism as
DNA in 1953 (Watson and Crick, 1953). a strongly genetic disorder: Evidence from a British
twin study. Psychological Medicine, 25(1), 63.
DNA is passed from one generation to the next. Strachan, T., & Read, A. P. (2004). Human molecular
In humans, the DNA molecule is divided up into genetics. New York: Garland Press.
a set of smaller pieces corresponding to chromo- Watson, J. D., & Crick, F. H. C. (1953). Molecular struc-
somes. Humans inherit 23 chromosomes from ture of nucleic acids. Nature, 171(4356), 737–738.
each parent, 22 of them are referred to as auto-
somes and are numbered 1–22 and one is called a
sex chromosome and is either a chromosome X or Depade D
a chromosome Y. Thus, normal human cells con-
tain 44 autosomes and 2 sex chromosomes. The ▶ Naltrexone
chromosomes are paired in each cell. For example,
each cell will contain two copies of chromosome
1, one from the mother (the maternal chromo-
some) and one from the father (the paternal chro- Depakene
mosome). Each of a pair of autosomes will
generally contain the same genes. However, the Lawrence David Scahill
sequence of DNA at each of the genes will often Nursing & Child Psychiatry, Yale University
vary slightly between individuals, and it is also School of Nursing, Yale Child Study Center,
now clear that the structure of the chromosome, New Haven, CT, USA
so-called copy number variations (CNVs), is also
part of the normal complement of human genetic
variation. Synonyms
A change in the sequence or structure of DNA
which results in a deviation from the agreed upon Divalproex; Valproic acid
reference genome may be referred to in various
ways, including an allele, a variant, a variation, a
polymorphism, or a mutation. Typically, the word Indications
polymorphism is used when one is referring to a
change that is present in a percentage of the pop- Valproic Acid: Valproic acid is a simple carbonic
ulation and mutation is taken to mean that the acid. It is available in several preparations includ-
variation is rare and relates to a disease or ing divalproex and valproic acid. It appears
phenotype. to exert its beneficial effects by interfering with
the repetitive firing of neurons. This appears to be
especially relevant for its treatment of seizures.
See Also Valproic acid is approved for the treatment
of seizures, migraine, and for the treatment of
▶ Chromosomal Abnormalities bipolar disorder.
▶ Copy Number Variation
▶ Dizygotic (DZ) Twins
▶ Karyotype Clinical Use (Including Side Effects)
▶ Monozygotic (MZ) Twins
It has been studied in children and adults with
bipolar illness and appears to be an effective
References and Readings treatment. Valproic acid is often well tolerated,
but it can have a range of adverse effects.
Alberts, B., Bray, D., et al. (2002). The cell. New York: Sedation and gastrointestinal disturbance with
Garland Science. vomiting are common particularly at the start of
D 860 Department of Vocational Rehabilitation
treatment. Other more significant adverse effects disabilities (Rehabilitation Act of 1973, Public
include thrombocytopenia, pancreatitis, and Law 93–112 93rd Congress, H. R. 8070 September
rarely hepatotoxicity. These more severe adverse 26, 1973). In the act, every state arranges a bureau
effects require monitoring of drug level in the of vocational rehabilitation services. In NY State,
blood, platelet counts, amylase, and liver the office is frequently mentioned as VESID
enzymes. (VESID is an acronym for Vocational and Educa-
To date, valproic acid has not been well tional Services for Individuals with Disabilities).
studied in children or adults with autism spectrum In all states, the Department of Vocational
disorders. There are some open case studies Rehabilitation (DVR) delivers occupation ser-
suggesting benefit for aggression and agitation; vices and treatment to those with disabilities
however, these studies have not compared who want to work but experience obstacles to
valproic acid to placebo. work due to physical, sensory, and/or mental
disability. A DVR therapist works with every
person to develop an individually tailored strat-
See Also egy of services intended to aid them in reaching
their employment goal. The aid may contain, but
▶ Mood Stabilizers is not limited to, the following:
• Counseling and guidance
• Assessment services
References and Readings • Independent living services
• Assistive technology services
Kowatch, R. A., Strawn, J. R., & Danielyan, A. (2011). • Training and education
Mood stabilizers: Lithium, anticonvulsants and others.
Vocational and Educational Services for Indi-
In A. Martin, L. Scahill, & C. Kratochvil (Eds.),
Pediatric psychopharmacology: Principles and viduals with Disabilities within the New York
practice (pp. 297–311). New York: Oxford University State Education Department has accountability
Press. criteria for meeting the needs of individuals diag-
nosed with disabilities from early infancy
through old age, plus oversight of special educa-
tion services for pupils with disabilities aged
Department of Vocational 3–21. Each year VESID offers thousands of
Rehabilitation New Yorkers who have a disability a chance to
be independent through learning, preparation,
Oren Shtayermman and employment. In addition, VESID delivers
New York Institute of Technology Mental Health vocational rehabilitation services to eligible indi-
Counseling, Old Westbury, NY, USA viduals to prepare them for appropriate jobs.
These jobs might be in the competitive work
force, in private businesses, in supported employ-
Synonyms ment on employer sites, or in sheltered shops.
Moreover, VESID aids individuals with disabil-
Employment services; Office of rehabilitation; ities who are having trouble keeping their jobs.
Vocational counseling Offices of Vocational Services throughout the
country provide similar services and oversight.
Offices of Vocational Rehabilitation, or OVR,
Definition delivers vocational rehabilitation services to
support persons with disabilities to prepare for,
The Department of Vocational Rehabilitation is obtain, or maintain employment. The office also
a broad marker for an organization that provides offers services to qualified persons diagnosed with
services for persons identified with developmental disabilities, both directly and through a system of
Department of Vocational Rehabilitation 861 D
appropriate vendors. Services are provided on wheelchairs, and automobile hand controls can
a personalized base. The therapist, through face- be provided to achieve employment.
to-face interviews, helps clienteles in choosing Placement assistance: Counseling, job-seeking
their choice of occupational goals, services, and programs, job clubs, and job development used to
service providers. An Individualized Plan for upturn your skill to acquire a job.
Employment (IPE) is established, charting a voca- Assistive technology: Assistive technology
tional objective, services, providers, and responsi- includes a wide range of devices and services
bilities. Some services are subject to a Financial that can empower individuals with disabilities to
Needs Test (FNT) and could involve fiscal contri- make the most of employment, independence, D
bution by the client. Counseling and guidance, and integration into society. The office can help
diagnostic services, assessments, information and person with a disability in successfully choosing
referral, job development and placement, and and obtaining appropriate assistive technology.
personal services such as readers or sign language They can arrange for an adviser to assess the
interpreters are provided at no cost to the individ- situation and to make appropriate recommenda-
ual. Also, by law, OVR clienteles awarded tions. The office also functions and maintains
Social Security benefits for their disability Center for Assistive and Rehabilitation Technol-
(SSI, SSDI) are relieved from OVR’s Financial ogy (CART) at the Hiram G. Andrews Center.
Needs Test. There is no charge for evaluation and vocational
counseling services through OVR.
Types of Vocational Rehabilitation Services Support services: Additional services are
The OVR runs a variety of services to qualified provided for eligible persons if they are essential
applicants. Certain services can aid in overcom- to start and uphold occupation. Such services
ing or lessening the disability; others can may include:
directly support and prepare for a vocation. • Room, board, and transportation costs during
The services will be organized to meet distinct an evaluation or while completing a rehabili-
needs. tation program
The OVR services include: • Occupational tools, licenses, or equipment
Diagnostic services: Medical, psychological, • Home modifications, adaptive or special house-
and checkups and assessments used to improve hold equipment; van or car modifications,
understanding of the disability and needs for including special driving devices or lifting
specific types of services. devices
Vocational evaluation: Ability, interest, over- • Personal care assistance
all ability, academic exams, work tolerance, and • Job site modifications, independent living
“hands-on” job experience used to understand training
vocational potential. • Text telephone (TT), signaling devices, hear-
Counseling: Occupational therapy will help to ing aids, and interpreter services
better understand potential, to rely on abilities, to • Specialized services such as rehabilitation
set accurate vocational goals, to modify them teaching and orientation and mobility train-
once needed, to advance fruitful work ways, and ing for persons who are blind or visually
to initiate a fulfilling career. Counseling is obtain- impaired
able throughout rehabilitation program.
Training: Education to prepare for a job
including, but not limited to, basic academic, See Also
vocational/technical, college, on-the-job train-
ing, independent living skills, and personal and ▶ Americans with Disabilities Act
work adjustment training. ▶ Individualized Plan for Employment (IPE)
Restoration services: Medical services and ▶ Vocational Evaluator
gear such as physical and occupational therapy, ▶ Vocational Training
D 862 Depressive Disorder
References and Readings children) or diminished interest or pleasure in activ-

ities, and at least four of the following: significant
Government Accountability Office. (2005). Special edu- weight loss or weight gain; insomnia or
cation: Children with autism. Washington, DC: United
hypersomnia; psychomotor agitation or retardation;
States Government Accountability Office.
Hillier, A., Campbell, H., Mastriana, K., Izzo, M., fatigue or loss of energy; feelings of worthlessness
Kool-Tucker, A., Cherry, L., et al. (2007). Two-year or excessive or inappropriate guilt; diminished abil-
evaluation of a vocational support program for adults ity to think or concentrate, or indecisiveness; or
on the autism spectrum. Career Development for
recurrent thoughts of death, suicidal ideation with-
Exceptional Individuals, 30(1), 35–47.
M€uller, E., Schuler, A., Burton, B., & Yates, G. (2003). out a plan, or a suicide attempt or specific plan for
Meeting the vocational support needs of individuals with committing suicide. The symptoms must cause clin-
Asperger syndrome and other autism spectrum disorders. ically significant distress or impairment in social,
Journal of Vocational Rehabilitation, 18, 163–175.
occupational, or other important areas of function-
ing, and they must not be due to the direct effects
of a general medical condition, a substance,
Depressive Disorder a medication, or other treatment.
Dysthymic disorder includes the presence of
Betsey A. Benson and Whitney T. Brooks depressed mood for most of the day, for more days
Nisonger Center, UCEDD The Ohio State than not, as indicated either by subjective account or
University, Columbus, OH, USA observation by others, for at least 2 years (in chil-
dren and adolescents, mood can be irritable, and
duration must be at least 1 year) and at least two of
Synonyms the following: poor appetite or overeating, insomnia
or hypersomnia, low energy or fatigue, low self-
Depressive disorders; Dysthymia; Major esteem, poor concentration or difficulty making
depressive disorder; Mood disorders decisions, or feelings of hopelessness.
Depressive disorder not otherwise specified
includes disorders with depressive features that
Short Description or Definition do not meet the criteria for major depressive dis-
order but present with subthreshold symptoms that
Major depressive disorder cause clinically significant impairment or distress.
Dysthymia In the ICD-10 (WHO,1992), depressive disor-
Depressive disorders der is defined by the presence of at least one depres-
Mood disorders sive episode with the same key characteristics as
in the DSM-IV-TR, such as lowering of mood,
decrease in activity, decrease in capacity for enjoy-
Categorization ment, and difficulty in concentration. Somatic
symptoms, such as marked tiredness, sleep, and
According to the DSM-IV-TR (American Psychi- appetite disturbance are present, and ideas of guilt
atric Association [APA], 2000), depressive disor- or worthlessness, and suicidal thoughts are often
ders include major depressive disorder, dysthymic present. Depressive disorders are also categorized
disorder, and depressive disorder not otherwise by the severity and duration of symptoms, into mild,
specified. Major depressive disorder includes the moderate, severe, recurrent, or with psychotic
presence of a major depressive episode, with spec- symptoms. The ICD-10 differs in the classification
ifiers to indicate the severity and duration. Major from DSM-IV-TR by its lack of a specific number
depressive episodes involve symptoms that are pre- of symptoms required to meet criteria.
sent most of the day, nearly every day consisting of Dysthymia in the ICD-10 is defined similarly
either depressed mood (can be irritability in as in the DSM-IV-TR, with chronic depression of
Depressive Disorder 863 D
mood that is not sufficiently severe or prolonged provide initial estimates of the rate of depressive
to justify a diagnosis of severe, moderate, or mild disorders. Reviews of published research on
recurrent depressive disorder. However, the co-occurring depressive disorders in ASD have
criteria do not specify a period of 2 years but reported a wide range of prevalence estimates,
rather indicates that the symptoms must last at from 4% to 58% (Lainhart, 1999; Lainhart &
least several years. Other depressive disorders Folstein, 1994; Stewart, Barnard, Pearson,
include any other disorders that are not of suffi- Hasan, & O’Brien, 2006). The varied rates of
cient severity or duration to meet criteria for depressive disorders in the literature likely reflect
depressive disorder or dysthymia. the heterogeneity of the samples and different D
(Note: Major depressive disorder, dysthymia, methods of assessing depressive disorders. For
depressive disorder not otherwise specified, and example, the estimates differ depending on
other depressive disorders will be referred to whether psychiatric or community samples were
collectively as “depressive disorders” or “depres- used, which ASD subtype was included, the age
sion” throughout.) of participants, and whether psychiatric inter-
views or questionnaire assessment methods
were used. Many researchers posit a higher rate
Epidemiology of depressive disorders in ASD than in the gen-
eral population and suggest that the disorders
The occurrence of depressive disorders in individ- may be under-diagnosed (e.g., Ghaziuddin,
uals with autism spectrum disorders is likely 2005; Lainhart & Folstein, 1994).
affected by the same complex genetic and envi- In one of the first descriptions of children and
ronmental interactions seen in typically develop- adults with Asperger syndrome in a clinical set-
ing individuals (Ghaziuddin, 2005). However, the ting, about 1/3 of the adolescents (16 years and
impact of these factors is far less understood in ASD above) and young adults presented with clinical
due to the lack of systematic epidemiological stud- levels of depression (Wing, 1981). Other reports
ies. Family studies suggest a genetic component to describe depression as being the most common
the presence of depressive disorders in ASD, with psychiatric disorder in Asperger syndrome, with
rates of major depression increased in first-degree 15% of adults referred to a psychiatric setting
relatives of individuals with autism and parents of presenting with symptoms of depression (Tantum,
children with ASD exhibiting higher risk for 1991). Despite the findings of several clinical stud-
depressive disorders than parents of children with ies and the recognition of the risk for developing
other developmental disabilities (Ghaziuddin & depressive disorders in ASD, no population-based
Greden, 1998; Lainhart, 1999). Families of individ- prevalence studies with adolescents and adults
uals with ASD who present with depression at appear to have been completed.
clinical settings have a history of depression or There have been some promising studies exam-
suicide at a rate of 50–77% (Lainhart, 1999). Stress- ining the prevalence of depressive symptoms in
ful life events, including bereavement, peer victim- children with ASD, with larger, more representa-
ization, and loneliness, could also contribute to the tive samples. For example, a prevalence study
development of depressive symptoms in individuals of mood and anxiety symptoms among 9–13-
with ASD (Ghaziuddin, Alessi, & Greden, 1995; year-old children with Asperger syndrome and
Ghaziuddin, 2005). high-functioning autism included a community
Despite the recognition that depressive disor- standardization sample of 1,751 typically develop-
ders are relatively common in individuals with ing children (Kim, Szatmari, Bryson, Streiner, &
autism spectrum disorders, true prevalence rates Wilson, 2000). On a questionnaire of depression
are unknown because most studies have been symptoms, 16.9% of the ASD sample scored at
conducted with psychiatric samples rather than least two standard deviations above the population
population samples. However, these studies mean, suggesting a significantly higher rate of
depressive symptoms than in the community sam- currently unknown if more women with ASD
ple (Kim et al., 2000). present with depression than men, as is the
An Australian study examined emotional and case in the general population (Ghaziuddin,
behavioral problems in 4–18-year-old children 2005).
and adolescents diagnosed with ASD and with
youngsters diagnosed with intellectual disability
(learning disability) and no diagnosis of ASD Natural History, Prognostic Factors,
(Brereton, Tonge, & Einfeld, 2006). The ASD and Outcomes
group scored significantly higher on a measure of
depression than the non-ASD group. Age and IQ in The presence of depressive symptoms in individ-
the ASD group also affected depression scores. uals with autism spectrum disorders was noted
Older children (13 years or older) scored signifi- in the earliest descriptions of the disorders
cantly higher on the depression measure than (Asperger, 1944; Kanner, 1943; Wing, 1981).
the youngest age group (less than 6 years old), However, due to the lack of systematic popula-
and those with higher IQs scored higher than tion studies, the course of depressive disorders is
individuals with intellectual disability (learning not well understood.
disability). Numerous publications have noted that the
Standardized interview methods of assess- development of depressive disorders in adoles-
ment have been used infrequently in research on cents and adults with Asperger syndrome and
depression in ASD. Only one study was found to high-functioning autism in particular seems to
examine the prevalence rates of psychiatric be related to a developing awareness of “differ-
disorders in a community-derived sample using entness” from their peers and unsuccessful
a standardized interview measure (Simonoff, attempts to establish friendships and romantic
Pickles, Charman, Chandler, Loucas, & Baird, relationships (e.g., Ghaziuddin, 2005; Howlin,
2008). In this sample of children aged 1997; Wing, 1981). The presence of depressive
10–14 years, a surprisingly low rate of depressive symptoms in children with Asperger syndrome
disorders (1.4%) was found. and high-functioning autism has been found to be
When lifetime occurrence of depressive associated with higher rates of aggressive and
symptoms and a wider age range was included, oppositional behavior, along with poorer rela-
a higher rate of depressive disorders was found. tionships with teachers, peers, and family mem-
In a pilot study for the development of an bers when compared to children with ASD
ASD-specific psychiatric comorbidity interview without depressive symptoms (Kim et al., 2000).
conducted with 5–17-year-olds, 10% of a com- In general, the outcomes for adults with autism
munity sample with higher functioning ASD met spectrum disorders, with and without intellectual
criteria for at least one major depressive disorder disability (learning disability), have not been prom-
in their lifetime and 25% met criteria for sub- ising, with decreased opportunities for employment,
syndromal symptoms of depressive disorders independent living, and access to community ser-
(Leyfer et al., 2006). vices (Howlin, 2005). There is little information on
The prevalence of depressive disorders in the long-term outcome of persons with ASD and
the general population varies by age with more depressive disorders. However, clinicians report
adolescents and adults presenting with depression that the presence of co-occurring depressive disor-
than children (World Health Organization, 2001). ders can result in further impairment and disruption
Research on depressive disorders in ASD suggests in functioning, such as increased morbidity and
a similar pattern, with more adolescents and adults mortality, and a higher potential for drug interac-
with ASD presenting with depression than chil- tions due to multiple pharmacotherapy treatment
dren (e.g., Brereton et al., 2006; Martin, Patzer, (Ghaziuddin, 2005). Depressive illness can become
& Volkmar, 2000; Simonoff et al., 2008). It is chronic in some individuals, and a family history
of mood disorders seems to be associated with conclusions about differential risks of developing
a poorer treatment outcome (Ghaziuddin, 2005). depression in these groups (Howlin, 2005).
Individuals with Asperger syndrome and higher
functioning autism may present with depressive
Clinical Expression and symptoms differently than individuals with autis-
Pathophysiology tic disorder. They may be able to verbally describe
feelings of sadness and loneliness, while individ-
The presentation of depressive symptoms in ASD uals with more cognitive impairments may not be
shares many of the features seen in the general able to express themselves verbally and may pre- D
population, such as sadness and lack of interest in sent with more behavioral signs, such as irritabil-
formerly pleasurable activities, but individuals ity, aggression, and changes in sleep and appetite.
with ASD may also present with unique features, However, it is important to recognize that individ-
due to their restricted range of emotional expres- uals with higher functioning presentations of ASD
sion and difficulty in communication. While sad and intact language abilities may not be able to
mood and loss of pleasure in activities are defin- accurately describe their emotions and may pre-
ing characteristics of depressive disorders, indi- sent with atypical signs and symptoms of depres-
viduals with ASD are often referred to clinical sive disorders, such as irritability or bizarre
settings because of changes observed by others, ideation (Howlin, 2005).
such as facial expressions of sadness or misery, or The presence of other psychiatric disorders can
behavioral expressions, such as increased fre- also affect the presentation of depressive symp-
quency of crying, irritability, or problem behav- toms. The co-occurrence of mood and anxiety
ior (Stewart et al., 2006). Particular features that disorders is common in the general population,
must be assessed carefully in individuals with and research suggests that these disorders often
ASD include an increase in social withdrawal, co-occur in people with ASD (e.g., Lainhart,
changes in the character of stereotypic and repet- 1999). The presence of symptoms associated
itive behavior, and restricted interests, irritability, with anxiety, such as increased stereotypic behav-
and regression of skills (Ghaziuddin, 2005). iors, may make it more difficult to assess depres-
Other factors that are likely to affect the presen- sive disorders in individuals with ASD.
tation of depressive disorders in ASD include age,
gender, cognitive and verbal ability, other psychiat-
ric disorders, and other medical disorders. Younger Evaluation and Differential Diagnosis
children may be more likely to present with irrita-
bility than with sad or depressed mood, and this is The classification of psychiatric disorders in
recognized in the DSM-IV-TR criteria, which ASD has involved considerable controversy.
allows for substitution of irritability for depressed Many early researchers adopted a hierarchical
mood in children (APA, 2000). Research suggests approach to diagnosis and argued that psychiatric
an increase in depressive symptoms with age (e.g., disorders could not occur in individuals with intel-
Brereton et al., 2006). The risk of depression and lectual disability (learning disability) or autism
other psychiatric disorders may be higher in indi- spectrum disorders. A hierarchical approach con-
viduals with Asperger syndrome and higher func- ceptualizes symptoms that overlap with other dis-
tioning individuals with autism because their orders as part of the primary disorder, with little
relatively good cognitive and language skills may room for the diagnosis of co-occurring psychiatric
lead others to overestimate their abilities and put disorders. An alternative diagnostic approach to
more pressure on them to “fit in” with peers, while the hierarchical approach classifies all symptom
overlooking the severe difficulty they have in constellations that meet criteria for a particular
understanding social interaction. However, there is disorder and allows for identification of multiple
not enough evidence at this time to make any disorders (Simonoff et al., 2008). Despite the
controversy in the literature, many now agree that 30–70% of individuals with ASD functioning in
the full spectrum of psychiatric disorders can co- the ID (LD) range (Fombonne, 2005). The pres-
occur in ASDs (Ghaziuddin, 2005; Matson & ence of ID (LD) in this population has important
Nebel-Schwalm, 2007; Simonoff et al., 2008). implications for how depression is assessed in this
Despite the recognition that depressive disor- heterogeneous group. The diagnostic manual for
ders can and do occur in ASD, diagnosing them intellectual disability (DM-ID) proposed adapta-
in individuals with autism spectrum disorders tions to the DSM diagnostic criteria for persons
can be particularly difficult due to a variety of with intellectual disabilities based on clinical con-
factors, including an overlap between symptoms sensus (Fletcher, Loschen, Stavrakaki, & First,
of depressive disorders and features of ASD, such 2007). The DM-ID includes irritable mood as an
as poor eye contact, restricted affect, and lack of acceptable substitute for depressed mood for peo-
voice inflection. For example, it may be difficult ple with ID which the DSM-IV-TR includes in the
to determine whether the social withdrawal criteria for children (APA, 2000). The DM-ID
observed in an individual with autism is part of reduces the number of symptoms by one for diag-
the core social deficits of autism spectrum disor- nosing major depressive disorder, requiring four
ders or is symptomatic of a co-occurring mood symptoms instead of five if the individual has
disturbance. limited expressive language skills. The other
An important factor in making an accurate important adaptation is that the DM-ID allows
diagnosis of depressive disorders in ASD is hav- observer report for many symptoms (Charlot,
ing reliable information from multiple sources. If Fox, Silka, Hurley, Lowry, & Pary, 2007). This
the individual with ASD is able to provide infor- practice is compatible with clinical reports
mation about symptoms, it is important to assess concerning individuals with ASD in which most
these carefully. However, given the difficulties cases of depression are brought to clinical attention
that individuals with ASD have in expressing and by observations from caregivers rather than by
understanding emotions, it is also important self-report of the individual.
to obtain information from caregivers, teachers, While the alternative diagnostic criteria
and family members about typical patterns of put forth in the DM-ID represent an important
behavior. Reports by others may also be helpful step in the understanding of co-occurring psychi-
to interpret self-report of individuals with ASD. atric disorders in individuals with all types
The clinician needs to obtain a detailed picture of of developmental disabilities, there remains
the individual’s baseline levels of social activity, a lack of ASD-specific psychopathology assess-
interests, restricted and repetitive behavior, mal- ment methods. Many studies on depression in
adaptive behavior, and adaptive skills, in order to ASD have relied on scales or structured interviews
detect distinct differences in these areas that may designed for the general population or for individ-
indicate the onset of mood disturbance. Informa- uals with intellectual disability. Consequently, it is
tion obtained from parental report concerning difficult to determine if these measures are sensi-
developmental and social history, including tive to the characteristic features of ASD.
the presence of significant life events, and the A semistructured psychiatric interview was
results from prior assessments, such as medical developed to assess psychiatric disorders in chil-
and psychological evaluations, intelligence and dren and adolescents with ASD (Leyfer et al.,
adaptive behavior testing, can complete the diag- 2006). The Autism Comorbidity Interview –
nostic picture. A detailed physical examination is Present and Lifetime Version (ACI-PL) was mod-
recommended to rule out other possible causes of ified from the Kiddie Schedule for Affective Dis-
depressive symptoms such as thyroid disorders orders and Schizophrenia (KSADS, Chambers
(Ghaziuddin, 2005). et al., 1985). This measure aims to distinguish the
Intellectual disability (learning disability) core symptoms of ASD from symptoms of comor-
commonly co-occurs in ASD, with estimates of bid psychiatric disorders. It demonstrated good
reliability and validity, although the validation Asperger syndrome with resulting improvement
sample was limited to individuals with higher (Hare, 1997). Depending on the individual’s
functioning ASD. level of functioning and communication abili-
The further development of ASD-specific ties, CBT may be an appropriate treatment
screening measures and structured diagnostic choice. Further study is needed to determine
interviews is important to improve the accurate the effectiveness of CBT with individuals with
identification of depressive disorders in ASD and ASD and to identify the active components of
to gain access to specific, effective treatment. the treatment.
Social skills training, environmental modifica- D
tions, and behavioral interventions may have
Treatment a role in addressing depressive symptoms in indi-
viduals with ASD. Psychosocial interventions are
The treatment of depressive disorders in individ- often used in conjunction with medications to
uals with ASDs is largely pharmacological in treat depressive disorders.
nature, with antidepressant medication being
prescribed most often and selective serotonin
reuptake inhibitors (SSRIs), such as fluoxetine, See Also
sertraline, and fluvoxamine, showing the greatest
success in symptom reduction (Lainhart, 1999, ▶ Affective Disorders (Includes Mood and
Stewart et al., 2006). It is difficult to determine Anxiety Disorders)
if psychopharmacological treatments are being ▶ Antidepressant Medications
used in this population specifically to treat ▶ Anxiety Disorders
depressive disorders because a large percentage ▶ Cognitive Behavioral Therapy (CBT)
(30.5%) of individuals with ASD take one or ▶ Mood Disorders
more psychotropic medications (Aman, Van ▶ Serotonin Reuptake Inhibitors (SRIs)
Bourgondien, Wolford, & Sarphare, 1995). Anti-
depressants may be prescribed for repetitive or
compulsive behavior as well as for depressive
symptoms. A naturalistic study, which examined
Aman, M. G., Van Bourgondien, M. E., Wolford, P. L., &
psychotropic drug use among a sample of Sarphare, G. (1995). Psychotropic and anticonvulsant
109 individuals with high-functioning ASD, drugs in subjects with autism: Prevalence and patterns
reported that about a third of the participants of use. Journal of the American Academy of Child and
Adolescent Psychology, 34, 1672–1681.
were prescribed an antidepressant with about
one fourth taking an SSRI (Martin et al., 2000). and statistical manual (4th ed., Text Rev.). Washing-
Depression was identified as the reason for taking ton, DC.: Author.
psychotropic medication in about 30% of partic- Anderson, S., & Morris, J. (2006). Cognitive behaviour
therapy for people with Asperger syndrome. Behavioural
ipants. The response to antidepressants by
and Cognitive Psychotherapy, 34, 293–303.
patients with ASD is reported to be similar to Asperger, H. (1944). Die “Autistischen Psychopathen”
the general population (Ghaziuddin, 2005). Side im Kindesalter. Archiv fur Psychiatrie und
effects, if they are problematic, tend to be related Nervenkrankheiten, 117, 76–136.
Attwood, T. (2003). Cognitive behaviour therapy (CBT).
to other medical issues such as seizures.
In L. H. Willey (Ed.), Asperger syndrome in adoles-
There is increasing recognition that cognitive cence: Living with the ups, the downs and things in
behavior therapy may be an effective treatment between (pp. 38–68). London: Jessica Kingsley.
for psychiatric disorders in individuals with Brereton, A. V., Tonge, B. J., & Einfeld, S. L. (2006).
Psychopathology in children and adolescents with
Asperger syndrome (Anderson & Morris, 2006; autism compared to young people with intellectual
Attwood, 2003). Cognitive behavior therapy for disability. Journal of Autism and Developmental
depression has been used with individuals with Disorders, 36, 863–870.
D 868 Depressive Disorders
Chambers, W. J., Puig-Antich, J., Hirsch, M., Paez, P., Martin, A., Patzer, D. K., & Volkmar, F. R. (2000). Psy-
Ambrosini, P. J., Tabrizi, M. A., et al. (1985). The chopharmacological treatment of higher-functioning
assessment of affective disorders in children and pervasive developmental disorders. In A. Klin,
adolescents by semistructured interview. Test-retest F. R. Volkmar, & S. S. Sparrow (Eds.), Asperger
reliability of the schedule for affective disorders and syndrome (pp. 210–228). New York: The Guilford
schizophrenia for school-age children, present episode Press.
version. Archives of General Psychiatry, 42, 696–702. Matson, J. L., & Nebel-Schwalm, M. S. (2007). Comorbid
Charlot, L., Fox, S., Silka, V. R., Hurley, A., Lowry, M., & psychopathology with autism spectrum disorder in
Pary, R. (2007). Mood disorders. In R. Fletcher, children: An overview. Research in Developmental
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Dermamycin ® [OTC]
development and rates of disorders. Journal of Autism
and Developmental Disorders, 36, 849–861. ▶ Diphenhydramine
Desensitization 869 D
Dermatoglyphic Patterns Descriptive Research
Jessica L. Roesser ▶ Qualitative Versus Quantitative Approaches

Department of Pediatrics (SMD), University of
Rochester, School of Medicine and Dentistry,
Rochester, NY, USA
Desensitization
D
Definition 1 2
John T. Danial , C. Enjey Lin and
Jeffrey J. Wood3
1
Dermatoglyphics refers to the study of finger- Psychological Studies in Education, University
prints and handprints. Dermatoglyphic patterns of California, Los Angeles, Los Angeles,
are the unique ridges and whorls of the skin CA, USA
2
of the fingertips and palms. Each individual Departments of Education and Psychiatry,
person (even genetically identical twins) has University of California, Los Angeles,
a slightly different pattern of ridges and Los Angeles, CA, USA
3
whorls on the fingers, especially the tips and Departments of Psychiatry and Education,
palms. There can be unique patterns of the University of California, Los Angeles,
lines that cross the palms and fingers as well. CA, USA
The creases of the palms may be altered
in specific genetic syndromes. The dermato-
glyphic pattern of the fingerprint is determined Definition
prenatally. At this point, the literature on der-
matoglyphic patterns in children with ASD is Systematic desensitization refers to the
conflicting. The evidence does not indicate therapeutic technique of gradually exposing an
that there are differences in the ridges/whorls individual to increasingly difficult anxiety-
or palm prints of children with autism spec- producing conditions in an effort to help an indi-
trum disorders, although there may be differ- vidual reduce anxious responses in those situa-
ences related to associated or underlying tions by adopting more adaptive ways of coping.
genetic disorders. The closely related process of countercondition-
ing consists of coupling opposing, positive
responses (e.g., relaxation) to situations known
See Also to cause fear or anxiety. By substituting a new,
adaptive response to fearful settings, the individ-
▶ Down Syndrome ual learns to elicit a more appropriate reaction in
▶ Genetics fearful situations. The development of
▶ Physical and Neurological Examination a hierarchy of fearful conditions (i.e., consists of
identifying a range of situations from least to
most anxiety provoking) plays a key role in
this intervention by serving as a framework
References and Readings for gradual exposure. Anxiety-related situations
are introduced in a step-by-step process
Walker, H. A. (1979). A dermatoglyphic study of autistic beginning with the least challenging and
children. Journal of Autism and Developmental Disor-
ders, 7, 11–21. progressing to the more difficult. This technique
Zimmerman, A. W. (2008). Autism: Current theories and has been used effectively with children and adults
evidence (p. 193). Boston: Springer. with autism.
D 870 Desensitization
Historical Background emphasized that opposite responses to anxiety,

such as relaxation, could be utilized to diminish
Systematic desensitization originates from classi- anxiety. Though Wolpe acknowledged that other
cal conditioning theory. In 1920, John B. Watson responses also compete with anxiety (Wolpe,
demonstrated that fearful responses could be 1990a), he incorporated relaxation as the “recipro-
conditioned. Watson conditioned a fear of rats in cally inhibiting” response in his treatment through
an infant, referred to as “Little Albert,” by pairing gradual exposure. Wolpe’s seminal research on
the presence of a white rat with a sudden loud noise systematic desensitization provided a theoretical
(Watson & Rayner, 1920). Eventually the pres- explanation for the success of gradual approaches
ence of the rat by itself elicited a fear response through which the therapist determines the degree
that generalized to all furry objects. Watson pos- to which a patient is exposed to anxiety-provoking
tulated that emotional responses could be learned stimuli (Wolpe, 1961). He also developed the
and modified to generalize to a broader category of method of imagery construction within systematic
stimuli. The seminal work by Watson laid forth desensitization (having the client imagine fearful
evidence for the development of phobias. situations) to gradually expose clients to anxiety-
In response, Mary Carver Jones conducted provoking scenarios without confronting them
instrumental research examining the mechanisms directly to begin with. Systematic desensitization
in which fearful responses could be reduced and was reportedly successful for treating anxiety of
generalization of these new responses achieved nonpersonal stimuli (enclosed spaces, harmless
(Jones, 1924). She treated a young boy, “Peter,” animals, etc.) as well as interpersonal stimuli
whom she selected partially because of charac- (fears of specific people or fear of being criticized).
teristics (i.e., fear of white rats and other furry Also, Wolpe’s method treated fears that could not
animals and objects) he shared with “Little be brought into a therapist’s office such as complex
Albert.” In the experiment, Peter was gradually social situations in a community setting (Lang,
presented with increasingly difficult fearful 1966). Overall, the method adequately treated
situations while he was simultaneously engaged abstract fears and anxieties, which separated sys-
in a pleasant activity. Initially the rabbit was tematic desensitization from other treatments
presented a considerable distance away, and available at the time.
over a period of multiple sessions, it was gradu- While Wolpe originally incorporated imag-
ally moved closer to Peter. During each of these ined exposures during treatment, many clinicians
sessions, Peter received his favorite food that was now use in vivo exposures when implementing
presented to him by a friendly peer or adult in the systematic desensitization. These in vivo expo-
presence of the rabbit (Lang, 1966). Peter initially sures involve direct exposure to the actual fear-
demonstrated fearful responses to the rabbit inducing stimuli. Both imagined exposure and
but gradually exhibited that he was comfortable in vivo exposure produce diminished anxiety
by holding the rabbit on his lap and he ultimately levels in patients. With children, in vivo exposure
showed affection towards it. Through the process tends to be used more.
of gradual exposure, coupled with positive rein-
forcement (both through tangible rewards and
social praise), Jones effectively demonstrated Rationale or Underlying Theory
mechanisms through which fear could be reduced.
Building on the findings of Mary Carver Jones, Wolpe hypothesized that the underlying process
Joseph Wolpe developed and operationalized the at work during systematic desensitization is
method of systematic desensitization to treat cli- reciprocal inhibition. If a client can be taught
ents with anxiety and phobias, especially those to elicit a response oppositional to anxiety
connected to situations in which no real danger (e.g., relaxation) while in the presence of anxi-
was present (Wolpe, 1958). He based his method ety-evoking stimuli, then the anxiety response
on the principle of reciprocal inhibition, which weakens eventually leading to diminished or no
anxiety (Wolpe, 1958). Pairing such a response remediated in behavioral therapy. While some
with systematic presentations of increasingly models of the method utilize only imagined expo-
anxiety-provoking stimuli, fear responses gradu- sure and others incorporate exposure in natural-
ally diminish even in response to the most fearful istic contexts, the objective is to gradually
situations. weaken anxious responses to anxiety-evoking
The theory of habituation provides another stimuli and to minimize the probability of fears
explanation for the changes that occur during returning after being successfully treated
systematic desensitization (Antony & Stein, (Brewin, 2006). Modern research suggests that
2008; Watts, 1971). The longer and more often the “return of fear” phenomenon is most likely D
a client is exposed to anxiety-producing stimulus, to occur when exposure therapy is conducted
the less effect that stimulus is presumed to have. only in limited contexts (e.g., clinics), rather
When a person is exposed to anxiety-producing than also in the naturalistic settings where fear
stimuli without negative consequences (e.g., pet- is experienced in everyday life (Mineka,
ting a dog without getting bitten), negative Mystkowski, Hladek, & Rodriguez, 1999;
thoughts are challenged and new, more adaptive Mystkowski, Mineka, Vernon, & Zinbarg, 2003).
information is encoded (Antony & Stein, 2008).
As a client spends more time exposed to these
situations free from negative consequences, the Treatment Participants
person becomes “habituated” to the stimuli and
previously distressing situations no longer cause Systematic desensitization is appropriate to treat
unmanageable levels of anxiety. phobias or anxiety symptoms in both children and
Modern theorists also incorporate cognitive adults. Given that phobias and anxiety present
approaches to explain the success of systematic themselves in a range of populations, the process
desensitization in treating anxiety symptoms. has been effective in treating a variety of condi-
A retrieval competition theory posits that when tions (Brooks, Gibbs, Jenkins, & Mcleod, 2007;
clients are exposed to feared stimuli with no neg- Davis, May & Whiting, 2011; Frank et al., 1988;
ative consequences, they begin to form different Morrow, 1986). Research indicates particular
mental representations of these situations. Positive effectiveness in treating specific phobias (Gelder
aspects of the exposure such as free choice, rela- et al., 1967), such as with snakes (Lang & Lazovik,
tive safety, and perceived self-efficacy all contrib- 1963) or claustrophobia (Wolpe, 1961). System-
ute to the formation of new mental representations atic desensitization has also proven effective to
(Brewin, 2006). As exposures are repeatedly com- treat fears and anxieties in persons with cognitive
pleted, these more positive representations are limitations (Erfanian & Miltenberger, 1990) and
primed for retrieval and activated more quickly autism spectrum disorders (ASD) (Jackson &
than the original negative representations. King, 1982; Koegel, Openden, & Koegel, 2004;
Luiselli, 1978; Luscre & Center, 1996; Wood
et al., 2009).
Goals and Objectives
Systematic Desensitization and Autism
The overall goal of systematic desensitization is Spectrum Disorders
to reduce anxiety in feared situations. The Individuals with ASD often experience symp-
method aims at addressing fears and anxieties toms of fear and anxiety (Gillot, Furniss, & Wal-
through gradual exposures. Systematic desensiti- ter, 2001; White, Oswald, Ollendick, & Scahill,
zation can be used to treat a range of anxiety 2009). Many systematic desensitization interven-
symptoms, particularly phobias, from the specific tions among children with autism involve in vivo
(e.g., fear of snakes) to the abstract (e.g., fear of exposures within the actual setting (Koegel et al.,
embarrassment). In this way, phobias such as fear 2004; Luiselli, 1978; Luscre & Center, 1996;
of crowds or fear of public speaking can be Wood et al., 2009). Luiselli (1978) used in vivo
systematic desensitization to successfully treat continue to function on the principles of reciprocal

a child with autism who feared riding the school inhibition and/or habituation.
bus. Additionally, systematic desensitization sig- Before implementing an intervention using
nificantly reduced fear of dental visits in children systematic desensitization, a hierarchy of fears
with autism (Luscre & Center, 1996), and in is established. This hierarchy refers to a list of
another study, it was used to successfully elimi- various situations ordered from mildly to
nate fearful behaviors to common auditory stim- severely anxiety provoking (e.g., Wood &
uli (e.g., sounds from a vacuum, flushing toilets) Mcleod, 2008). For example, a mild anxiety-
in three children with autism (Koegel et al., inducing situation in a patient with a fear of
2004). snakes would be imagining a snake lying on the
Wood et al. (2009) incorporated systematic ground, while a severe anxiety-provoking situa-
desensitization as a component of their cognitive tion would be holding a small, defanged,
behavioral therapy. Children with autism moved nonpoisonous snake. The hierarchy delineates
through individually designed fear hierarchies in the full range of conditions that produce fear.
which they were presented with in vivo exposures The items on the hierarchy can be conceptualized
and received a variety of reinforcers for their as steps or levels that range from a continuum
participation. Immediately before and immedi- from least to most anxiety provoking. It is devel-
ately following each exposure, a therapist guided oped before implementing treatment because it
the client through conversations aimed at serves as a guideline for treatment goals (Lang,
restructuring negative thoughts with more adap- 1966). Treatment proceeds in a stepwise progres-
tive cognition. Case studies of this treatment are sion beginning with mild anxiety-producing situ-
given in Sze and Wood (2007, 2008), with anxi- ations and gradually addresses more severe
ety targets ranging from intrusive thoughts anxiety-producing scenarios on the hierarchy.
(worries and obsessions) to separation anxiety, The patient should exhibit and report diminished
social avoidance at school, and compulsive levels of anxiety before moving to the next step in
behaviors. the hierarchy. Employing a hierarchy during
These studies suggest that systematic desensi- treatment has shown to increase the effects of
tization is effective in treating anxious responses systematic desensitization (Morrow, 1986) and
in children with ASD. has been a constant component of systematic
desensitization since Wolpe first described the
treatment.
Treatment Procedures Incorporating relaxation into systematic desen-
sitization treatment produces substantial effects
Joseph Wolpe’s original treatment paradigm (Wolpe, 1958). The presence of a relaxation
remains at the foundation of systematic desensiti- response inhibits anxiety or fear arousal because
zation while some elements have been modified. it is inherently antagonistic to both (Lomont &
For example, current systematic desensitization Edwards, 1966). However, some research indi-
procedures now employ more in vivo exposure cates that relaxation training is an unnecessary
rather than imagined exposure when possible. In component to treatment (Agras et al., 1971).
fact, Wolpe himself utilized in vivo exposures While the degree of focus on relaxation may
when imagined exposure did not effectively treat vary, many systematic desensitization treatments
a patient’s symptoms (Wolpe, 1990a). Similarly, continue to include it as a component. Given that
though relaxation is used as a means of reciprocal it requires intensive focus, relaxation training in
inhibition (Graziano & Kean, 1968), other children may be challenging (King, Ollendick,
methods have been used as well such as positive Gullone, Cummins, & Josephs, 1990), especially
reinforcement (Koegel et al., 2004; Luiselli, 1978; in children with mental retardation or low-
Wood et al., 2009) and laughter (Jackson & King, functioning autism (Graziano & Kean, 1968). To
1982). All systematic desensitization treatments circumvent these challenges, immediate positive
reinforcement (praise, edibles, toys, etc.) may sub- Outcome Measurement
stitute as an adequate means of attaining reciprocal
inhibition and has been successful in treating anx- Abstract concepts such as “fear” and “anxiety”
iety in children with ASD (e.g., Wood et al., 2009). can be difficult to measure. As a result, outcome
This type of treatment paradigm often occurs when measurement varies across studies. One common
employing in vivo exposures rather than imagined method is to measure outcome by the number of
exposures. Luiselli (1978) used verbal praise and steps completed in a fear hierarchy. Many single-
edible treats for each successive step a child com- case methodological studies utilize this approach
pleted in riding the school bus. In a study of hyper- as a means of determining the success of treat- D
sensitivity to auditory stimuli in children with ment in ASD (Koegel et al., 2004; Luscre &
autism (Koegel et al., 2004), children’s favorite Center, 1996). Additionally, the occurrence of
snacks and verbal praise were used to reinforce anxious behavioral responses (e.g., crying, run-
the children during in vivo exposures. Similarly, ning away) has been measured using frequency
Luscre and Center (1996) employed individual- counts or calculated as percentages of occurrence
ized rewards (i.e., music, Play-Doh, fruit, etc.) within specific timed intervals using direct obser-
during and after exposures. Jackson and King vation or review of videotaped sessions (Koegel
(1982) found that laughter could be used as an et al., 2004).
effective means of inhibiting anxiety in a child Other measures include parent or patient
with autism suffering from a phobia of the sound report of anxiety symptoms (Kendall, 1994;
from flushing toilets. These studies indicate that Wood et al., 2009). These self-report measures
the effectiveness of systematic desensitization in are subjective ratings (King et al., 1990) and are
children with autism may be enhanced when pos- often used in conjunction with other measures. In
itive reinforcement or pleasant experiences are order to limit subjectivity, reports may be
coupled with anxiety-provoking situations. recorded using standardized anxiety scales such
as subjective units of distress scale, which is a
0–100-point scale usually administered with
Efficacy Information adults to assess their subjective anxiety levels
(Choy et al., 2007). When children are the sub-
The efficacy of systematic desensitization is well jects of treatment, measures of parent report are
documented (Chambless et al., 1998; Choy, Fyer, often obtained.
& Lipsitz, 2007; Wood et al., 2009). Since the Since changes in physical (somatic) responses
treatment requires individualization to the such as increased respiration, cardiac rate, blood
patient, there are numerous single-case studies pressure, or galvanic skin response (GSR) serve as
published (e.g., MacDonald, 1975; Sze & indicators of fear or anxiety, physiological mea-
Wood, 2007, 2008). However, studies have also sures may also be recorded as a means of indicat-
emphasized the effectiveness of systematic ing anxiety (Fisher, Granger, & Newman, 2009).
desensitization in larger sample sizes (e.g., All of these outcome measurements are intended
Frank et al., 1988; Wood et al., 2009). The degree to determine the remittance of anxiety behaviors.
of efficacy varies and is associated with the type
of phobia, the severity of symptoms, the length
of intervention, as well as individual attributes Qualifications of Treatment Providers
(e.g., treatment motivation) that is evidenced
across typically developing populations (Wolpe, Trained clinicians familiar with behavioral prin-
1990b) and children with ASD (Koegel et al., ciples and the treatment population have
2004; Sze & Wood, 2007, 2008). Despite these implemented systematic desensitization. Under-
variations, it seems that systematic desensitiza- standing the rationale of the treatment likely
tion is generally an effective treatment method in increases the effectiveness of how the treatment
treating anxious responses in ASD. is delivered. While therapists typically deliver
the treatment, there are resources available for Frank, E., Anderson, B., Stewart, B. D., Dancu, C., &
parents, teachers, and even patients themselves Hughes, C. (1988). Efficacy of cognitive behavior
therapy and systematic desensitization in the treatment
to learn to implement the treatment (Merrell, of rape trauma. Behavior Therapy, 19(3), 403–420.
2001); however, the efficacy of such implemen- Gelder, M. G., Marks, I. M., & Wolff, H. H. (1967).
tation has yet to be determined. Desensitization and psychotherapy in the treatment
of phobic states: A controlled inquiry. The British
Journal of Psychiatry, 113, 53–73.
Gillot, A., Furniss, F., & Walter, A. (2001). Anxiety
See Also in high-functioning children with autism. Autism, 5,
277–286.
▶ Cognitive Behavioral Therapy (CBT) Graziano, A. M., & Kean, J. E. (1968). Programmed
relaxation and reciprocal inhibition with psychotic
▶ Phobia children. Behavior Research and Therapy, 6, 433–437.
Hedberg, A. G., & Campbell, L. (1974). A comparison of
four behavioral treatments of alcoholism. Journal
of Behavior Therapy and Experimental Psychiatry, 5
References and Readings (3–4), 251–256.
Jackson, H. J. E., & King, N. J. (1982). The therapeutic
Agras, W. S. (1967). Transfer during systematic desensi- management of an autistic child’s phobia using laugh-
tization therapy. Behavior Research and Therapy, 5, ter as the anxiety inhibitor. Behavioural Psychother-
193–199. apy, 1, 364–369.
Agras, W. S., Leitenberg, H., Barlow, D. H., Curtis, N. A., Jones, M. C. (1924). A laboratory study of fear: The case
Edwards, J., & Wright, D. (1971). Relaxation in of Peter. Pedagogical Seminary, 31, 308–315.
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Psychiatry, 25(6), 511–514. dren: Results of a randomized clinical trial. Journal of
Antony, M. M., & Stein, M. B. (2008). Oxford handbook Consulting and Clinical Psychology, 62, 100–110.
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Brewin, C. R. (2006). Understanding cognitive behaviour adolescents with intellectual disabilities: Assessment
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Brooks, C. J., Gibbs, P. N., Jenkins, J. L., & McLeod, S. Koegel, R. L., Openden, D., & Koegel, L. K. (2004).
(2007). Desensitizing a pilot with a phobic response A systematic desensitization paradigm to treat hyper-
to required helicopter underwater escape training. sensitivity to auditory stimuli in children with autism
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Paul, G. L. (1966). Insight versus desensitization in
psychotherapy. Stanford, CA: Stanford University Press.
Sze, K. M., & Wood, J. J. (2007). Cognitive behavioral Desipramine is a tricyclic antidepressant. The term
treatment of comorbid anxiety disorders and social tricyclic refers to the three-ring structure of this
difficulties in children with high-functioning autism: class of antidepressant medications. These medi-
A case report. Journal of Contemporary Psychother-
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Sze, K. M., & Wood, J. J. (2008). Enhancing CBT for the they have been largely replaced by the SSRIs.
treatment of autism spectrum disorders and concurrent Desipramine has been used to treat depression
anxiety: A case study. Behavioural and Cognitive Psy- and attention deficit/hyperactivity disorder. Desip-
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ramine has highly selective norepinephrine reup-
Watson, J. B., & Rayner, R. (1920). Conditioned emo-
tional reactions. Journal of Experimental Psychology, take inhibitor properties.
3(1), 1–14. The tricyclic antidepressants have several adverse
Watts, F. (1971). Desensitization as an habituation phe- effects in common including dry mouth, urinary
nomenon: Stimulus intensity as determinant of the
retention, constipation, nausea, increased heart rate,
effects of stimulus lengths. Behaviour Research and
Therapy, 9(3), 209–217. dizziness, and, at higher doses, confusion. The tricy-
White, S. W., Oswald, D., Ollendick, T., & Scahill, L. clic antidepressants also carry some risk of altering
(2009). Anxiety in children and adolescents with the electrical conduction in the heart. They are well
autism spectrum disorders. Clinical Psychology
known to be fatal on overdose due to their potential
Review, 29, 216–229.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. for causing cardiac arrhythmia. Because of their
Stanford, CA: Stanford University Press. known toxicity at higher doses, treatment with tricy-
Wolpe, J. (1961). The systematic desensitization treat- clic antidepressants requires blood-level monitoring
ment of neuroses. Journal of Nervous and Mental
and electrocardiogram monitoring as well. Finally,
Diseases, 132, 180–203.
Wolpe, J. (1990a). Practice of behavior therapy. the tricyclic antidepressants are also vulnerable to
New York: Pergamon Press. drug-drug interaction. For example, some medica-
Wolpe, J. (1990b). Theme and variations: A tions such as SSRIs or certain antibiotics may inter-
behavior therapy casebook. New York: Pergamon Press.
fere with the breakdown of tricyclic antidepressant
Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K.,
Fujii, C., et al. (2009). Brief report: Effects of cognitive medications. The interference of metabolism of
behavioral therapy on parent-reported autism symptoms the tricyclic can cause a sharp increase in the blood
in school-age children with high-functioning autism. levels of the tricyclic antidepressants and increase
the vulnerability to toxic effects. The tricyclic
1608–1612.
Wood, J. J., & McLeod, B. (2008). Child anxiety disorders: medications have not been well studied in children
A treatment manual for practitioners. New York: Norton. or adults with autism.
D 876 Desyrel
See Also retrospective reports of social engagement from

their parents. It employs a conversational style
▶ Antidepressants masking when the interviewer moves from one
to another of DAISI’s 19 items. The interview
is designed to facilitate the development of
References and Readings a relationship between parent(s) and interviewer
so that honest/accurate replies are more likely. To
Martin, A., Scahil, L., & Christopher, K. (2010). Pediatric this end, DAISI involves sensitive probing with
situational prompts. Questions are ordered to
increase the likelihood that parents will be able
to give an initial positive response before having
to describe any negative responses on further
Desyrel detailed questioning. Rather than focusing
merely on discrete communicative skills, there
▶ Trazodone is a focus on the infant’s role in any interactive
flow of preverbal engagement.
The interview schedule is reproduced below
from an appendix within a paper by Wimpory
Detection of Autism by Infant et al. (2000) documenting DAISI’s initial
Sociability Interview published use. DAISI can take up to an hour to
administer and requires an understanding of typ-
Dawn Wimpory ical and autistic early social communication
School of Psychology, University of Wales rather than specific training. Although it was
Bangor, Gwynedd, UK originally designed clinical psychologists’ use
for clinical and research purposes, it has subse-
quently been successfully employed by a range of
Synonyms professionals and researchers.
Wimpory et al. (2000) retrospectively used of
DAISI DAISI with twenty 2–4-year-olds, prior to any
autism diagnoses being made, found 15 key items
differentiating the children who were subse-
Description quently diagnosed with autism from those with
nonautistic developmental delay. Distinguishing
DAISI is a semistructured detailed developmen- items include engaging in dyadic social interac-
tal history interview designed to elucidate tion (i.e., sociability in play with or without toys,
a child’s early sociability and communication. socially directing feelings of anger and distress,
It is for concurrent or retrospective use with frequency and intensity of eye contact, greeting
parents in clinical and research investigations, parents, waving, raising arms to be picked
particularly those concerning autism. Wimpory, up, enjoying lap games, preverbal turn-taking,
Williams, Nash, and Hobson (2000) provides and using noises communicatively) as well as
details of DAISI with an appendix clarifying its “triadic” social behavior, involving an object
schedule and criteria for positive and negative and another person (i.e., referential eye contact,
responses, as scored from verbatim parental pointing and following others’ points, offering
responses. and giving, and showing objects).
The instrument focuses on developmental The evidence from the study by Wimpory
progression in the manifestation of social engage- et al. (2000) indicated that infants with autism
ment in young preschool children with autism manifest a range of abnormalities suggestive
through a semistructured interview drawing out of profound limitations in social engagement.
Detection of Autism by Infant Sociability Interview 877 D
These abnormalities were specific to the group development. It has also been employed for
with autism and were not simply an expression of diagnostic purposes in clinical/educational set-
general developmental delays because they were tings for two decades.
not characteristic of the infancies of children in
the matched control group. Moreover, the abnor-
malities were both in the area of person-to-person Historical Background
nonverbal communication and interpersonal
contact and in triadic person-person-object inter- DAISI’s development was influenced by child
actions. In the former respect, it is notable that clinical training at Nottingham University’s Child D
the abnormalities extended to socially directed Development Research Unit, and particularly by
expressions of anger and distress as well as Professor Elizabeth Newson’s guidelines (1990).
signs of positive engagement. In the latter The originality of data published on DAISI,
respect, there were a majority of infants without by Wimpory et al. (2000) lies in the fact that the
autism but no infants with autism who were interview was carried out before any diagnosis was
reported to offer, give, show, or point to objects made; so the parents did not have any a priori
in relation to someone else. Finally, nearly all of assumption when recounting their child’s social
the infants in the control group, but not a single behavior.
child with autism, were said to have followed In this respect, the DAISI differs from earlier
another person’s point. questionnaires that were used with parents of
These findings are in keeping with autism affected children or adults, such as Dahlgren
theories that focus on impairments in primary and Gillberg (1989) and Wing (1969). The latter
intersubjectivity as well as recognize the impor- were completed after the diagnosis of autism had
tance of difficulties with secondary intersubjec- been made and after years of experience of the
tivity (Hobson, 1993; Newson, 1984; Rogers & person with autism, which might have influenced
Pennington, 1991; Wimpory et al., 2002). Con- the results. Also, despite the fact that question-
current use of the 15 key DAISI items that naires are concise and easy to use, they are less
Wimpory et al. (2000) found to be significant sensitive than interviews and provide less accu-
also determined significant group differences rate answers. These methodological limitations
between the infant siblings of autistic spectrum were a feature of almost all previous studies of
disordered (ASD) and typically developing this kind, even if the period recalled was not so
children as detailed below (Stone, McMahon, distant. The DAISI interview is designed to give
Yoder, & Walden, 2007). Stone et al. (2007) the impression of a natural conversation. There
also found significant correlation between total are opportunities for explanation, discussion, and
scores from the DAISI and a direct child measure provision of examples as part of the interchange.
of social-communicative functioning, The While previously published diagnostic instru-
Screening Tool for Autism in 2-Year-Olds. ments for young children with autism, such as
Findings from Wimpory et al.’s use of DAISI, the Parent Interview for Autism (PIA; Stone &
along those from other studies, determined 25 Hogan, 1993) and the revised Autism Diagnostic
key items for Dereu et al. in screening for ASDs Interview (ADI-R; Lord, Storoschuk, Rutter, &
(Dereu et al., 2010). They successfully evaluated Pickles, 1993), record impairments in social
the Checklist for Early Signs of Developmental relatedness, they do not focus exclusively on
Disorders (CESDD) in a population of almost early social engagement in young preschool
seven thousand 3–39-month-olds. In summary, children.
DAISI has been used for research retrospec- The DAISI interview was developed to over-
tively, with children who have autism or come several of the methodological issues that
nonautistic developmental delay and concur- were a feature of previous research involving
rently with infant siblings of children with retrospective parental accounts. For example, it
autistic spectrum disorders (ASD) and typical focuses on aspects of social engagement that are
D 878 Detection of Autism by Infant Sociability Interview
prominent in the behavior of typically developing Childhood Autism Rating Scales (CARS) scores
infants and thus identify what may be abnormal for the entire group (.891, p < .0001; Wimpory,
in the case of autism. In addition, interviewing 1995). For the subgroup with developmental
parents of young children with a specific focus on delay, DAISI total scores and CARS scores
the first 2 years of life means that recall is showed a significant negative correlation (Spear-
required over a relatively short period (e.g., over man rank correlation .86, p ¼ .001); this was
6–24 months in Wimpory et al., 2000). not significant for the group with autism (Spear-
man rank correlation .02, ns; Wimpory et al.,
2000). Within each group, there was a relatively
Psychometric Data small range of DAISI total scores. The significant
negative correlation in the case of control
The internal consistency of the DAISI was deter- (nonautistic developmentally delayed) individ-
mined using the Kuder-Richardson-20-statistic uals is of note because here the individuals who
(for dichotomous data) on retrospective use of were reported to show a number of social deficits
DAISI with parents of twenty 2–4-year-olds, on the DAISI (and thus achieved lower scores)
prior to any autism diagnoses (Wimpory, 1995). were also those who were given relatively high
This gave a standardized item alpha coefficient of scores for abnormality on the CARS.
0.9. Significant autistic versus developmentally Stone et al. (2007) concurrently employed the
delayed nonautistic group differences emerged 15 key DAISI items that the retrospective study
from analysis of variance on the total DAISI by Wimpory et al. had found significant (2000).
scores, F (1,18) ¼166.94, p < .0001. Stone et al. (2007) reported significant group
As indicated above, Wimpory et al. (2000) differences between infant siblings of 64 autistic
reported 15 key items that differentiated the infan- spectrum disordered and 42 typically developing
cies of children subsequently diagnosed with (TD) children (MD, 1.32; 95% Cl, 0.27–2.37).
autism (mean score ¼ 3.6, SD 2.4, range 0–7) Autistic siblings’ mean scores were 12.8 (SD
from those with nonautistic developmental delay 3.2, range 0–15), while TD siblings’ mean scores
(mean score ¼ 15.7, SD 2.5, range 13–19; Mann– were 14.4 (SD 1.2, range 10–15). Stone et al.
Whitney U ¼ 0, p < .0001). Distinguishing items, (2007) also found that DAISI total scores
computed on an item by item basis (with Fisher’s correlated significantly with:
exact one-tailed test), indicated impairments in fre- 1. CARS total scores (0.74, p < .01)
quency/intensity of eye contact (p < .0001*) and its 2. Mullen Scales of Early Learning subscores
referential use (p < .0001*); pointing (p < .0001*) (The Early Learning Composite; Visual
and following others’ points (p < .0001*); Reception, Expressive and Receptive Lan-
using noises communicatively (p < .0001*); guage; 0.46; 0.28; 0.41; 0.39, respectively,
preverbal turn-taking (p < .0004*); raising arms all at p < .01)
to be picked up (p < .0004*); offering and giving 3. Screening Tool for Autism in 2-Year-Olds
(p < .0004*); greeting (p < .005); showing total scores (STAT; 0.37, p < .01).
objects (p < .005); sociability during play with This last finding supports face validity for the
toys (p < .005); socially directing anger/distress DAISI as a parental report measure for broadly
(p < .010); sociability during play without toys similar child social-communication constructs
(p < .016); waving appropriately (p < .016); and that are directly assessed by the STAT.
enjoying lap games (p < .043). Asterisks indicate
specific items that individually discriminated
between the autistic and developmentally delayed Clinical Uses
nonautistic groups, following stringent Bonferroni
correction for multiple comparisons. The DAISI interview was designed for both clin-
For the above retrospective research, DAISI ical as well as research purposes. It has been
total scores correlated significantly with employed for multi-agency clinical/educational
diagnostic purposes in some services in England are later analyzed separately as aspects of socia-
and Wales for over two decades. The expanded bility and gestural communication.
clinical form includes items assessing the triad of Eye Contact (Item 1)
autistic impairments during both early and cur- Did he/she look at you more or less readily as
rent functioning, while the published form a baby (< 2 years) than he/she does nowadays?
focuses exclusively on aspects of sociability and Did his/her readiness to give eye contact
communication in infancy. Parental responses change at any stage (< 2 years)?
are recorded verbatim, and each item that corre- Key Question for Item 1: Did he/she have
sponds to a specific domain of behavior is scored difficulties in the frequency and/or intensity of D
as present or absent as indicated above, the eye contact? (This item and item 2 below are
interview relies on the relationship between the subject to a special scoring procedure: They are
interviewer and the parent so that accurate and scored as negative when direct observation of the
honest answers are more likely to be provided. child reveals poor eye contact at the time of
DAISI’s clinical advantage over standardized diagnosis and where parents report both that
diagnostic interviews is that it can be adminis- their child’s readiness to give eye contact has
tered much more quickly and affords a more con- not changed since infancy, and that they do not
versational experience, so assisting the clinician see eye contact as a problem for their child.)
in gaining a good rapport with clients within Soothability from Crying (Items 4 and 5)
routine diagnostic assessments. How would you stop him/her crying as
a baby?
The DAISI Schedule Key Question for Item 4: Could you stop him/
The following section identifies the specific her crying by picking him/her up? (Positive
domains of functioning assessed using the responses include those where this strategy
DAISI. Each domain contains a key question worked for at least a few months of infancy.)
(italicized in bold below) and may also have Key Question for Item 5: Could you stop him/
associated questions. These are designed to elicit her crying by just talking to him/her? (Positive
a comprehensive description of behavior relevant replies include communicative use of “baby
for the domain under consideration. The key talk,” i.e., employing singing, vocalizations, and
questions, identified by corresponding item num- facial expressions but no physical contact or
bers, are those used to determine DAISI scores, as movement. Negative responses include those for
outlined below. These key questions may be infants described as never interested in social
substituted by and/or preceded and/or followed interaction.)
by associated questions. This arrangement is Greeting, Requesting to Be Picked Up, and
designed to allow the interviewer to assist parents Waving (Items 3, 15, and 14, respectively)
both to gain confidence in answering the key What would he/she do when you went to his/
questions and to clarify their answers to those her cot after he/she had woken (naturally) from
questions. Responses to each key question (either a sleep? Where would he/she be looking?
direct or indirect via associated questions) deter- What would her/his face be like?
mine the score for its corresponding numbered Key Question for Item 3: Would he/she greet
DAISI item. Examples and criteria for positive you? (Positive responses include manifest
and/or negative replies are shown in regular ital- pleasure or excitement and/or appropriate facial
icized print in the section below. expression while looking toward parents. Negative
Questions are arranged below in the order most responses include a failure to look pleased on most
compatible with the flow of a natural conversation. occasions where there was potential for greeting.)
In this way, responses to more than one domain What would he/she do if he/she wanted to
may be recorded from one segment of conversa- come out of the cot or be lifted from the floor?
tion. For example, greeting and reaching up to be Would he/she touch you or the cot while
lifted up from a cot are juxtaposed although these reaching up as if to climb up/out physically?
D 880 Detection of Autism by Infant Sociability Interview
Did you need to offer your own arms for him/ prefer to play alone? (Positive responses include
her to lift his/her? descriptions of infants apparently happy for
Key Question for Item 15: Would he/she parents to play alongside them without parents
spontaneously lift her arms to be picked up? feeling excluded.)
(Positive responses cover spontaneous non- Would you need toys in order to play with
tactile gesturing including the support of him/her?
vocalization, eye contact, etc.) Key Question for Item 6: Could you amuse
Would he/she appear to notice if someone he/ him/her without toys (if say, you were together on
she knew well was leaving? a bus or in a doctor’s waiting room where no toys
What would he/she do? were available)? (Positive replies may include
Would he/she wave if they (or you) waved? chatting and/or singing, play with body parts,
Would he/she need you to tell him/her to wave etc.)
or to lift his/her hand for her? Showing, Offering and Giving, Referential
Would he/she wave spontaneously? Eye Contact, Pointing, and Following Points
How did he/she do it? (i.e., to distinguish from (Items 11, 10, 2, 12, and 13, respectively)
arm flapping) Did he/she sometimes want to draw your
Where would he/she be looking? attention to his/her toys?
Key Question for Item 14: Would he/she (Or did he/she seem too interested in them to
spontaneously and appropriately wave goodbye? share them with anyone else?)
(Positive responses cover spontaneous waving Key Question for Item 11: Would he/she show
with apparently appropriate communicative you things? (Positive replies include either hold-
intent, as indicated by context, looking toward ing an object up to another’s field of view or
the other’s face, etc. Negative responses include pointing to it and simultaneously looking at the
only brief acquisition of waving and/or waving other person. Such referential eye contact also
an arm for social or motoric stimulation scores positively on item 2, below. Communica-
without apparent understanding of its gestural tive pointing also scores positively on item 12,
significance.) below.) (Depending on responses to previous
Lap Games (Items 7 and 8) questions. . .)
What did he/she tend to do during lap games? What would he/she do if he/she wanted you to
Key Question for Item 7: Did he/she enjoy lap share his/her experience of a toy?
games?, e.g., “Round and round the garden,” Would he/she hold it up for you to see? Where
“Peek a boo.” (Negative responses included would he/she be looking?
a lack of interest in lap games.) Key question for Item 10: Would he/she offer
Would he/she watch you doing the actions? and give objects? (Positive replies include
Would he/she try to join in? pausing and looking to the recipient’s face before
How did he/she show his/her enjoyment? giving.)
Key Question for Item 8: Did he/she actively Would he/she give a toy (or other item) to
participate? (Positive replies require use of body you?
actions, e.g., imitative clapping.) Was this in response to a request or would it be
Social Engagement During Play With and spontaneous?
Without Toys (Items 9 and 6, respectively) Have you known babies who like to give
Would he/she be happy for you to play with something (e.g., a biscuit) to other people . . .
him/her? babies who give it very carefully, often breathing
How would he/she react if he/she was already heavily as they do so, and then they want it back
occupied with toys? as soon as they have given it?
Key Question for Item 9: Would he/she be Did he/she like to play giving and taking
happy for you to join in his/her play with toys or games like that or did he/she tend to “post” or
would he/she regard that as an intrusion and place objects on you instead?
Where would he/she be looking before and Teasing (Item 16)
during the act of giving? Did he/she understand “No” even if he/she
Key Question for Item 2: Would he/she look chose to ignore it?
both to where he/she was pointing and to you? Have you noticed some toddlers will still do
(Referential eye contact) what they have been told not to do (e.g., touch an
What would he/she do if he/she wanted some- electric switch) and will be smiling and looking
thing (e.g., a biscuit) out of reach? to their parents at the same time as if they are
(If reaching) How would he/she position his/ doing it again because they have been told not to
her fingers? do it? D
Where would he/she be looking? Was he/she a toddler who was interested in
Key Question for Item 12: Would he/she use doing that?
pointing communicatively? (Positive replies include Can you give examples? Where would he/she
eye- or finger-pointing to request and show items of be looking?
interest accompanied by eye contact. Negative What would his/her face be like as he/she did
responses include extension of index finger with no it?
apparent communicative intent.) Key Question for Item 16: Would he/she tease
What would he/she do if she saw something of you? (Negative responses include enjoyment of
interest like a plane, or an animal across the playful reprimands, such as being chased, rather
street? than manifesting playful provocation/teasing
(If reaching) How would he/she position his/ per se.)
her fingers? Can you think of other ways in which he/she
Where would he/she be looking? would tease you?
Did he/she take notice if you pointed at Preverbal Turn-Taking and Use of
something or did he/she tend to be preoccupied Vocalizations (Items 19 and 17, respectively)
with his/her own interests? Did he/she make baby noises?
What would he/she do if you pointed (at near (Positive responses enable progression to the
and far objects, e.g., an animal across the street, following questions.)
the correct hole for a puzzle piece, etc.)? Did he/she make these just for him/herself or
Key Question for Item 13: Could she follow did he/she seem to be making them for you to
your pointing gestures? listen to him/her?
Where would he/she look . . . toward your How did he/she show that they were for you?
finger or to where you were pointing? Where would he/she be looking?
Expressing Directed Anger and Distress Key Question for Item 19: Were his/her baby
(Item 18) noises communicative? (Negative responses
Did he/she have tantrums? include an absence of babbling or parental
Where would he/she be looking during these? inability to recall communicative use of babbling
What would he/she do if he/she was hurt? despite parental expectation that this occurs.)
Would he/she let you know how he/she was Have you noticed how some babies like you to
hurt? join in with their babbled noises, so that there is
Where would he/she be looking? a turn-taking pattern between you and them – as if
Key Question for Item 18: Would he/she the two of you are speaking another language?
appear to direct anger and/or distress with appar- (Positive answers are required before
ent communicative intent? (Negative responses proceeding.)
include toddlers who would avoid looking toward Was he/she the kind of baby who did that?
other faces during expressions of anger and/or Were you able to have babbling conversations
distress. Positive responses include toddlers who with him/her?
directed anger toward parents when feeling phys- Did he/she use his/her early words for
ical pain unrelated to parental behavior.) him/herself or for giving messages to you?
D 882 Detriment in Skill
Where would he/she be looking when using Journal of Autism and Developmental Disorders, 23,
them? 639–652.
Stone, W. L., McMahon, C. R., Yoder, P. J., &
Key Question for Item 17: Did he/she take Walden, T. A. (2007). Early social-communicative
turns before he/she could talk, e.g., with babbled and cognitive development of younger siblings of
noises? (Positive responses include turn-taking children with autism spectrum disorders. Archives of
flows established by (a) infants repeating a babbled Pediatrics & Adolescent Medicine, 161(4), 384–390.
Wimpory, D., (1995) Social engagement in preschool
noise as if with communicative intent apparently in children with autism. Unpublished doctoral thesis,
response to an adult’s imitations of those noises and University of Wales, Bangor, Gwynedd, UK.
(b) active silent participation in a flow of interaction Wimpory, D., Nicholas, B., & Nash, S. (2002). Social
using appropriate facial expressions and communi- timing, clock genes and autism: A new hypothesis.
Journal of Intellectual Disability Research, 46(4),
cative body actions during a period of mutism.) 352–358.
Wimpory, D., Williams, J. M. G., Nash, S., & Hobson,
R. P. (2000). Are infants with autism socially engaged?
See Also A study of recent retrospective parental reports.
30(6), 525–536.
▶ ADI-R Wing, L. (1969). The handicaps of autistic children-a
▶ CARS comparative study. Journal of Child Psychology and
▶ STAT Psychiatry, 10, 1–40.
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Pattyn, G., Schietecatte, I., et al. (2010). Screening for
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childhood apraxia of speech include vowel errors Gene expression, brain function, cognitive
or distortions, highly inconsistent speech errors, processes, behavior, and environmental factors
and inappropriate prosody. all involve multiple cross-level interactions, and
all are characterized by dynamic developmental
change over time. The study of any neurodeve-
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Developmental Change at the
Neural Level
Developmental Apraxia of Speech The brain is not static; it changes significantly

(DAS) after birth in terms of structure and function.
Functionally, one often witnesses the child
▶ Verbal Apraxia brain initially processing inputs bilaterally.
With development, however, neural networks
become increasingly specialized and localized
Developmental Change such that, for example, face processing starts
out bilaterally and becomes predominantly
Annette Karmiloff-Smith right lateralized, over developmental time, in
Birkbeck College, a network including the fusiform gyrus. Like-
London, UK wise, the processing of certain aspects of
language, for example, the use of, say, arti-
Definition cles, starts out bilaterally but becomes increas-
ingly left lateralized. By contrast, in some
Developmental change is the process of change that neurodevelopmental disorders, this progressive
occurs in human beings throughout development. fine-tuning of specialization and localization
D 884 Developmental Continuum (Principles of TEACCH)
of function fails to occur, and processing con- References and Readings

tinues to be bilateral, even when the relevant
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brain development? Developmental Cognitive Neuro-
science, 1(1), 7–21.
Developmental Change at the Karmiloff-Smith, A. (2009). Nativism versus neurocon-
Cognitive Level structivism: Rethinking the study of developmental
disorders. Special issue on the interplay of biology
and environment. Developmental Psychology, 45(1),
In the study of neurodevelopmental disorders, it 56–63.
is critical to differentiate between identical overt Karmiloff-Smith, A. (2010). Neuroimaging of the devel-
behavioral scores and the underlying cognitive oping brain: Taking “developing” seriously. Human
Brain Mapping, 31(6), 934–941.
processes that sustain them. For example, face
Karmiloff-Smith, A., Thomas, M., Annaz, D.,
processing may be proficient in a disorder, with Humphreys, K., Ewing, S., Brace, N., et al. (2004).
scores “in the normal range,” but the underlying Exploring the Williams syndrome face processing
cognitive processes rely on featural analyses, debate: The importance of building developmental
trajectories. Journal of Child Psychology and Psychi-
whereas in the typically developing child,
atry, 45(7), 1258–1274.
processing has moved from featural to configural
processing over developmental time.
Developmental Continuum
Developmental Change at the (Principles of TEACCH)
Environmental Level
Joyce Lum and Kristin Hodgson
The environment is not static either. In all UNC TEACCH Autism Program-Charlotte,
neurodevelopmental disorders, parents respond to Charlotte, NC, USA
the subtle differences in their atypical offspring,
and thus, the dynamics of parent-child interaction
change over time. For example, when learning Synonyms
language, the parents of typically developing chil-
dren tend to let their children temporarily make Individual differences in development
overgeneralizations (e.g., “dog” for all animals),
whereas parents of atypically developing children
tend to correct immediately in the fear, perhaps, Definition
that they otherwise may never learn the correct
term. However, overgeneralization often helps Childhood development is a dynamic process char-
the development of categories (e.g., “animal”), acterized by milestones and challenges that occur
and subtle differences in the ways in which the at particular ages. The interaction of typical devel-
environment responds to the atypical child may opmental issues with the autism spectrum is com-
give rise to the learning of individual exemplars plicated. A child with an autism spectrum disorder
rather than categories. (ASD) may achieve milestones earlier or later than
In conclusion, developmental changes must be typical peers, at an atypical rate, and in an atypical
taken into account at every level of analysis. order. The child may present a scattered skill pro-
file, which can be confusing to educators and others
working with the child, who may have elevated
See Also expectations for his overall behavior and skill level
based on performance in a domain of strength.
▶ Developmental Delay Similarly, the challenges that a child with ASD
▶ Developmental Milestones faces may mirror those of his typical peers (e.g.,
Developmental Coordination Disorder 885 D
entering school, coping with bullying, developing See Also
self-image, managing life changes) but may be
exaggerated or occur at a different point in devel- ▶ Clinical Assessment
opment. Awareness of the skill level and current ▶ Informal Assessment
needs of an individual with ASD facilitates the ▶ Treatment and Education of Autistic and
development of specific goals. Related Communication-Handicapped
Like individuals, families are dynamic and Children
follow a general developmental pathway. This is
true of families with typical children as well D
as those with ASD though, as with individual References and Readings
development, the challenges experienced by the
latter are likely to be exacerbated and the changes Marcus, L. M., Kunce, L. J., & Schopler, E. (2005).
Working with families. In F. R. Volkmar, R. Paul,
less linear. The particular needs of a family with
A. Klin, & D. Cohen (Eds.), Handbook of autism and
a child with ASD tend to correspond to the age of pervasive developmental disorders (3rd ed.,
the child. When the child is an infant/toddler, pp. 1055–1086). Hoboken, NJ: John Wiley & Sons.
families are recognizing developmental differ- Mesibov, G. B., Shea, V., & Schopler, E. (2006). The
ences and dealing with the impact of these on
New York: Springer.
the family. Early childhood tends to be a time Schopler, E. (1997). Implementation of TEACCH philoso-
for diagnosis of ASD and dealing with grief. In phy. In D. J. Cohen & F. R. Volkmar (Eds.), Handbook of
the middle childhood years, families focus on autism and pervasive developmental disorders (2nd ed.,
pp. 767–795). Hoboken, NJ: John Wiley & Sons.
school concerns, adaptive skills, and issues
Shea, V., & Mesibov, G. B. (2005). Adolescents and
related to puberty. In adolescence and adulthood, adults with autism. In F. R. Volkmar, R. Paul,
common themes center on collegiate, vocational, A. Klin, & D. Cohen (Eds.), Handbook of autism
and/or residential preparation as well as self- and pervasive developmental disorders (3rd ed.,
pp. 288–311). Hoboken, NJ: John Wiley & Sons.
advocacy and interpersonal supports. This pattern
of development is not universal, however. Just as
professionals must fully assess an individual to
ascertain skill level before implementing inter-
vention, they must understand the current family Developmental Coordination
interactions, challenges, needs, and foci so as to Disorder
have a greater impact on that family.
The developmental continuum is the basis for Fred R. Volkmar
one of the main principles of TEACCH, which is Director – Child Study Center, Irving B. Harris
that of family involvement in service delivery. In Professor of Child Psychiatry, Pediatrics and
working with clients, TEACCH understands that Psychology, School of Medicine,
the specific needs of the individual with ASD can Yale University, New Haven, CT, USA
be best met by recognizing the family’s needs and
by working simultaneously with the parents to
address them. TEACCH views parents and care- Synonyms
givers as the experts, advocates, and teachers for
their children and sees the professional’s role as Cerebral palsy; Dyspraxia
one of facilitator in helping the individual with
ASD to maximize their level of independence and
in helping family members gain additional tools to Short Description or Definition
be as effective as possible in their roles. The devel-
opmental continuum of individuals and of families Children who present marked difficulties with
must be the focus of assessment and intervention in motor movements have been known since ancient
order to most effectively serve in this capacity. times. Terms like “cerebral palsy” have been used
D 886 Developmental Coordination Disorder
in the past particularly to refer to situations where difficulties (e.g., hypoxia or severe prematurity).
these problems appear to relate to some specific Speech-language issues can be noted reflecting,
process, e.g., birth trauma. Although a medical in some cases, oral motor difficulties. Often a
etiology is sometimes seen, this is less likely in combination of some degree of developmental
cases that are less severe. The term “developmen- immaturity and a more specific motor vulnerabil-
tal coordination disorder” is currently used. ity is involved.
Categorization Evaluation and Differential Diagnosis
In DSM-IV, this condition is defined based on Neurological and specialized occupational and
the presence of motor difficulties greater than physical therapy evaluations are indicated if
expected (given age or developmental level) and motor difficulties are severe and/or significant.
not due some other condition like autism. Motor The presence of unusual movements, problems
difficulties are sometimes seen with other devel- with hyper- or hypotonia, and of specific neuro-
opmental problems, e.g., language or learning logical symptoms can also prompt referral.
disorders. Interestingly some work has been Various tests of gross and fine motor skills as
done on the constellation of social-emotional well as visual motor integration and of dexterity
difficulties, motor, and attentional problems (the can be administered. These help to document
DAMP syndrome, see Ehlers et al., 1997). areas of difficulty and establish baselines for
intervention. In some cases, use of auxiliary
aids/devices may be helpful, e.g., in children
Epidemiology with Asperger’s disorder who have problems
with cursive handwriting, use of a laptop to
The condition may be seen in up to 6% of teach keyboarding skills can be indicated.
children of school age. Boys are more frequently
diagnosed than girls (although various factors
may make it less likely that subtle difficulties in Treatment
girls lead to lower rates of referral).
Rehabilitative approaches are helpful. Both occu-
pational and physical therapy approaches can be
Natural History, Prognostic Factors, and used to address fine and gross motor problems.
Outcomes Within schools, adaptive physical education can
also be helpful.
Various factors determine outcome. Often the ulti-
mate outcome is best when motor difficulties are
mild and isolated (i.e., not associated with other See Also
developmental problems). Sometimes motor delays
can lead to other problems such as social isolation ▶ DAMP Syndrome
and, in turn, to anxiety and mood problems. ▶ Language Disorder
▶ Occupational Therapy (OT)
▶ Physical Therapy
Clinical Expression and
Pathophysiology
Motor skill difficulties can arise because of a host
of factors. These range from problems during and statistical manual of mental disorders (4th ed.).
pregnancy in the mother, birth trauma, perinatal Washington, DC: Author. Text revision.
Developmental Delay 887 D
Ehlers, S., Nyden, A., Gillberg, C., Sandberg, A. D., and adaptive development as the areas to assess for
Dahlgren, S. O., Hjelmquist, E., et al. (1997). Asperger a suspected disability. Children with autism often
syndrome, autism and attention disorders: A compara-
tive study of the cognitive profiles of 120 children. display delays in several of these areas, which may
Journal of Child Psychology & Psychiatry & Allied be the first warning signs that lead to further assess-
Disciplines, 38(2), 207–217. ment and evaluation. Assessing developmental
Gillberg, C., & Kadesjo, B. (2003). Why bother about delays should be a component of diagnosing autism
clumsiness? The implications of having developmen-
tal coordination disorder (DCD). Neural Plasticity, 10 as the key deficits that characterize the disorder are
(1–2), 59–68. directly linked to skills typically learned during
Gillberg, C., & Kadesjoe, B. (2000). Attention-deficit/ natural developmental cycles. Skills that may be D
hyperactivity disorder and developmental coordina- deficient in early development for individuals with
tion disorder. In T. E. Brown (Ed.), Attention-deficit
disorders and comorbidities in children, adolescents, autism include areas such as basic purposeful
and adults (pp. 393–406). Washington, DC: American communication, initiating social interactions, and
Psychiatric Publishing. imitating functional use of objects or toys. Devel-
Smyth, M. M., & Mason, U. C. (1997). Planning opmental delays may result in gaps in skill acquisi-
and execution of action in children with and without
developmental coordination disorder. Journal of Child tion and/or performance and create widely varying
Psychology and Psychiatry, 38(8), 1023–1037. strengths and weaknesses in some children.
Volkmar, F. R., & Martin, A. (2011). Essentials of child Evaluations used to assess developmental
and adolescent psychiatry. Philadelphia: Lippincott, delays vary among practitioners and typically
Williams, and Wilkins.
Wann, J. (2007). Current approaches to intervention in include a measure of adaptive functioning with
children with developmental coordination disorder. assessments such as the Vineland Adaptive
Developmental Medicine and Child Neurology, Behavior Scales. This rating scale can be used
49(6), 405. to document delays in social and communicative
development in individuals with autism. In addi-
tion, there are a number of motor assessments
Developmental Delay available, tests to measure cognitive levels, and
specific communication assessments.
Michelle Lestrud
The Gengras Center, University of Saint Joseph,
West Hartford, CT, USA See Also
Definition ▶ Intellectual Disability
Developmental delay is a significant lag in

reaching the typical childhood milestones in the References and Readings
areas of language; cognition; social, emotional,
adaptive functioning; and motor development. Anderson, D. K., Lord, C., Risi, S., DiLavore, P. S.,
Shulman, C., Thurm, A., et al. (2007). Patterns of
Each milestone is reached within a certain num-
growth in verbal abilities among children with autism
ber of months based on research of typically spectrum disorder. Journal of Consulting and Clinical
developing children. When a child does not Psychology, 75(4), 594–604.
reach one or more of the milestones during the Gillham, J. E., Carter, A. S., Volkmar, F. R., & Sparrow,
S. S. (2000). Toward a developmental operational
expected time frame, then he or she may be definition of autism. Journal of Autism and Develop-
suspected of having a developmental delay. mental Disorders, 30(4), 269.
In the context of public education, the IDEA Gray, K. M., Tonge, B. J., Sweeney, D. J., & Einfeld, S. L.
definition of developmental delay is only inclusive (2008). Screening for autism in young children
with developmental delay: An evaluation of the devel-
of children aged three to nine and lists physical opmental behaviour checklist–early screen. Journal
development, cognitive development, communica- of Autism and Developmental Disorders, 38(6),
tion development, social or emotional development, 1003–1010.
D 888 Developmental Disabilities
Mayes, S., & Calhoun, S. (2003). Ability profiles in children Major Types
with autism: Influence of age and IQ. Autism: The Inter- 1. Developmental language disorder (specific
national Journal of Research & Practice, 7(1), 65–80.
Openden, D., Whalen, C., Cernich, S., & Vaupel, M. language impairment (SLI), dysphasia) – in
(2009). Generalization and autism spectrum disorders. affected infants, the disorder presents as vari-
In C. Whalen (Ed.), Real life, real progress for chil- ably delayed/impoverished expressive lan-
dren with autism spectrum disorders (pp. 1–18). guage. There are three main clinical types,
Baltimore, MD: Brookes.
Provost, B., Lopez, B. R., & Heimerl, S. (2007). each with subtypes:
A comparison of motor delays in young children: a. Expressive type: impaired speech produc-
Autism spectrum disorder, developmental delay, and tion and articulation (phonology) with ade-
developmental concerns. Journal of Autism and Devel- quate comprehension. Prognosis generally
Weiss, M. J., & LaRue, R. H. (2009). Enhancing general- fairly good, except in the most severe
ization of skills taught through discrete trial instruc- subtype – verbal dyspraxia (not to be con-
tion. In C. Whalen (Ed.), Real life, real progress for fused with oromotor disability, a deficit in
children with autism spectrum disorders (pp. 41–56). motor control of the speech musculature).
Baltimore, MD: Brookes.
b. Mixed receptive/expressive type: compre-
hension equal to or somewhat better
Developmental Disabilities than expression. Phonology, grammar,
and vocabulary affected. Prognosis vari-
Isabelle Rapin able, often the harbinger of dyslexia, and
Neurology and Pediatrics (Neurology), Albert poor when phonologic decoding is severely
Einstein College of Medicine, Bronx, NY, USA defective.
c. Mainly receptive type: impaired compre-
hension of discourse. Often overlooked
Synonyms when speech articulation, grammar, and
vocabulary are spared. Particularly frequent
Academic disability; Specific learning disability but not exclusively so in verbal children on
the autism spectrum.
Note: Language disorders in children on
Definition the autism spectrum (ASD) – Pragmatics,
i.e., the communicative/conversational use
Learning disability is not used here to refer to overall of language, universally, characteristically,
intellectual handicap (i.e., “mental retardation”). and permanently impaired. The prevalence
• Developmental disability refers to unexpected of types of language disorders in ASD
delay or deficiency apparently healthy young children differs from that of dysphasic
children experience in the acquisition of children: some have mixed expressive/recep-
a learned cognitive/intellectual skill (as opposed tive disorders; very few have expressive
to a sensory-motor skill) despite overall intellec- disorders with adequate comprehension;
tual competence, attention and motivation, lack most verbal children have receptive disorders
of auditory or visual handicap, and sufficient with telltale echolalia, use of scripts, inces-
exposure to appropriate models and educational sant questioning, perseveration on self-
opportunity in an adequately supportive and selected topics, answering questions off
nurturing environment. topic, and aberrant prosody.
• Developmental disabilities are extremely preva- 2. Reading disability (dyslexia) – difficulty
lent; they are dimensionally defined with fuzzy learning the alphabetical code of written lan-
borders even though they denote atypical devel- guage at school age. Dyslexia is often the
opment of particular brain circuitries. residual of a developmental language disorder
• They are both genetically and environmen- with difficulty making fine auditory discrimi-
tally influenced. nations between speech sounds. Most dyslexic
Developmental Intervention Model 889 D
individuals eventually learn to read more or
less efficiently, but retain difficulty reading Developmental Disabilities –
pronounceable non-words and, often, poor Children’s Global Assessment Scale
spelling (dysorthographia). Less frequent (DD-CGAS)
causes include visual discrimination difficul-
ties or sequencing problems implicating ▶ Children’s Global Assessment Scale
deficient working memory.
3. Mathematical disability (dyscalculia) – diffi-
culty with mental or written arithmetic, geom- D
etry, word problems, or other mathematical Developmental Disability (Ontario)
operations. Identification of its cause requires
detailed neuropsychologic investigation. Atten- ▶ Mental Retardation
tion deficit disorder contributes to dyscalculia
and complex arithmetical operations. Visuo-
spatial problems impair not only geometry but
also written arithmetic. Developmental Dyscalculia
4. Dysgraphia – poor handwriting, associated or
not with dysorthographia. Either due to an ▶ Dyscalculia
overt or subtle motor deficit or difficulty in
learning complex motor skills (dyspraxia).
A large sloppy handwriting (dyspraxia) with
excellent spelling (superior rote memory)
often characterizes ASD.
Developmental Dysphasia
5. Others – tone deafness, grossly deficient
▶ Childhood Aphasia
ability to draw or classify can be considered
learning disabilities when they interfere with
children’s acquisition of required skills.
Developmental Dyspraxia
▶ Verbal Apraxia
Fletcher, J. M. (2009). Dyslexia: The evolution
of a scientific concept. Journal of the International
Neuropsychology Society, 15, 501–508.
Landerl, K., Fussenegger, B., Moll, K., &
Willburger, E. (2009). Dyslexia and dyscalculia: Developmental Intervention Model
Two learning disorders with different cognitive
profiles. Journal of Experimental Child Psychology, Amanda C. Gulsrud1 and Connie Kasari2
103, 309–324. 1
UCLA Semel Institute for Neuroscience and
Rapin, I., Dunn, M., & Allen, D. A. (2003). Developmen-
tal language disorder. In S. J. Segalowitz & I. Rapin Human Behavior, Los Angeles, CA, USA
2
(Eds.), Part II: Child neuropsychology (2nd ed., Graduate School of Education and Information
Vol. 8, pp. 593–630). Amsterdam, NL: Elsevier. Studies and the Semel Institute, University
Shaywitz, B. A., Lyon, G. R., & Shaywitz, S. E. (2006).
of California, Los Angeles, Los Angeles,
The role of functional magnetic resonance imaging in
understanding reading and dyslexia. Developmental CA, USA
Vernes, S. C., Newbury, D. F., Abrahams, B. S., Definition
Winchester, L., Nicod, J., Groszer, M., et al. (2008).
A functional genetic link between distinct develop-
mental language disorders. The New England Journal The developmental approach to intervention
of Medicine, 359, 2337–2345. draws upon the knowledge of typical
D 890 Developmental Intervention Model
development to design treatment objectives Rationale or Underlying Theory

for children with autism. Child development
research informs the developmental processes The underlining theory behind developmental
that determine goals, measure change, and select treatment approaches is that each child is
treatment practices. The main pillars of this an individual with corresponding strengths
approach include the selection of developmen- and weaknesses. Not every child has the same
tally appropriate targets, individualized instruc- profile of development, especially children
tion by focusing on child preferences and with a heterogenous disorder such as an autism
interests, and the incorporation of family spectrum disorder. The developmental approach
needs, values, and preferences into intervention to intervention strives to tailor curriculum
objectives. A number of developmental models to the needs of each child and provide
exist in the early intervention of children with opportunities for learning skills that are appropri-
autism including the DIR/Floortime (Greenspan ate to the child’s current level of functioning.
& Weider, 1999), RDI (Gutstein & Sheely, A developmental framework for early social-
2002), Hanen Centre programs (Coulter & communication intervention pulls from the
Gallagher, 2001), JASPER (Kasari, Freeman, extensive literature on facilitative teaching. This
& Paparella, 2006), and SCERTS (Prizant, teaching approach is child-centered and child-
Wetherby, Rubin, Laurent, & Rydell, 2006) directed and involves such strategies as following
models, to name a few. Contemporary behav- the child’s motivations and interests, offering
ioral approaches to early intervention for chil- choices within activities, responding to child ini-
dren with autism also emphasize developmental tiations, and expanding on a child’s verbal and
objectives (e.g., PRT, Koegel & Koegel, 2006; nonverbal communicative bids (Prizant et al.,
Incidental teaching, McGee, Moyer, & Daly, 2006). Unlike typical behavioral approaches
1999; the Denver Model, Rogers et al., 2000; that are adult-directed and stick to a strict hierar-
and Early Start Denver Model (ESDM), Rogers chy of program objectives, developmental
& Dawson, 2010). models strive to follow the child’s interests in
a naturalistic learning environment. The hope is
that by embedding learning opportunities within
Historical Background highly motivating and natural contexts, children
will be more apt to participate and the total
This treatment approach has its origins in amount of intervention or dosage each day will
work with typical children. Teaching during increase. An underlining goal of developmental
naturalistic and play-based activities has approaches is to foster a deeper connection
a long history in the typical early childhood between the child and a social partner that results
literature to ensure motivation and cooperation in meaningful teaching opportunities.
with instruction.
In recent years, these principles have also
been applied to children with developmental Goals and Objectives
disorders, such as autism spectrum disorders.
Most developmental interventions for children Several common goals exist across early develop-
with autism focus on the core deficit of social mental interventions for autism. These goals
communication and include specific emphasis include the emphasis on individualizing treatment
on joint attention, social engagement, and early and targeting developmentally appropriate skills
expressive language (e.g., SCERTS, RDI, and deficits consistent with ASD. Many develop-
JASPER, Hanen). Several comprehensive treat- mental interventions emphasize the social and
ment approaches have also adopted a develop- communication deficits in children with autism.
mental framework (e.g., Denver model, All developmental models of early intervention
ESDM, PRT). place importance on children becoming effective
communicators. Expressive language is a priority children. Principles of PRT are used across the
as is improving social interactions and promoting lifespan. Clearly, more needs to be done to assure
engagement between children and their caregivers. that children and adults across the lifespan
Some programs, such as the Walden preschool, can benefit from developmental treatment
also place an emphasis on early interactions with approaches.
peers. There is also an emphasis on the child’s
emotion regulation abilities and providing devel-
opmentally appropriate supports for student learn- Treatment Procedures
ing. The SCERTS model emphasizes the need to D
help the child regulate arousal as a foundation to Developmental interventions use naturalistic
early intervention. Other developmental models teaching strategies in a variety of settings. The
also believe that helping the child reach the opti- goal is for treatment to be embedded within
mal level of arousal is an early developmental skill natural social experiences; thus, many of the
necessary for successful learning (e.g., DIR, developmental intervention models are play-
JASPER, ESDM). Another common theme is to based. Teaching objectives are embedded within
provide learning opportunities within the natural these highly motivating play activities. Research
social context of daily activities. This includes in typical development has shown that children
embedding intervention objectives within play- who are engaged in highly preferred activities are
based activities and providing support and training more likely to initiate social interactions. Thus, it
for parents to generalize treatment objectives to is believed that children with autism will also
the home environment. benefit from having more autonomy in the choice
of activities and more opportunity to lead the
interaction.
Treatment Participants Developmental interventions incorporate the
use of a wide range of treatment settings includ-
The developmental approach is typically applied ing clinics, schools, and the home. Many of these
in the early intervention of children with autism. treatments are adapted for use across multiple
The Early Start Denver Model (ESDM) has been settings. For example, the ESDM can be applied
applied to infants as young as 12 months of age, in center-based preschools, inclusive preschools,
and the Denver Model spans into preschool and and the home environment, although data cur-
elementary ages. Other developmental models, rently exist for home settings only. PRT has
such as DIR, also support the development of been applied and has empirical support for its
infants, toddlers, and preschoolers. Children in use across these settings as well.
the Walden preschool program typically enroll Instruction is also delivered using a variety of
between the ages of 15–30 months and stay for methods. Many developmental models will have
about 1 year. Restrictions are not made based a portion of the instruction delivered in a 1:1
upon child developmental characteristics, such teaching model with a trained therapist and
as cognitive, language, and adaptive functioning. the child (e.g., ESDM, PRT, JASPER, SCERTS)
With the increasing emphasis on early detection and also group settings (e.g., Denver Model,
and intervention, it follows suit that these models Walden). The Walden preschool uses a zone-
would support the development of the youngest based teacher deployment where a lead teacher
children affected by the disorder. “conducts” the classroom and several other
Some attempts have also been made to apply teachers lead simultaneous centers to ensure that
developmental models of intervention to older children have choices and teaching is continuous.
children and adults. The JASPER intervention is The JASPER model implements a parent-
a modular treatment that is currently being tested mediated model where a parent and child are
for efficacy in a wide range of children from interacting together with a trained clinician serv-
toddlers to older nonverbal and school-aged ing as a “coach” for these social interactions.
D 892 Developmental Intervention Model
Efficacy Information SCERTS has almost 30 years of clinical practice,

very little research into its efficacy has been
Several developmental early intervention programs conducted. Similarly, DIR has some interesting
have been tested for efficacy. While all interven- single-subject work showing improvement on a
tions require greater study with more scientifically case-by-case basis. In a review of 200 cases, over
rigorous methods, there is some promising evidence 50% of these cases made “significant progress”
of improvement using these models. Perhaps the evidence by gaining age-appropriate academic
most studied approach is the Denver Model and and social capabilities (Greenspan & Weider,
ESDM by Rogers and colleagues. To date, they 1997). In addition, a pre-/postdesign was used to
have numerous peer-reviewed papers on the effi- evaluate 68 children who received DIR delivered
cacy of this intervention. The early work using this by parents trained in the home (Solomon,
model utilized a within-subject pre-/postdesign, Necheles, Ferch, & Bruckman, 2007). Results
which as a method may not be adequate for deter- were promising in that overall children showed
mining effective treatments. Later work involved improvements in their social and pragmatic
some quasi and true experimental designs including development and 45.5% of children made good
a randomized controlled clinical trial (RCT) of to very good developmental gains.
ESDM, which suggests evidence of improvement Researchers at the Walden preschool used
in the domains of cognition (DQ), language, and a within-subject pre-/postdesign to examine the
adaptive functioning (Dawson, Rogers, Smith, efficacy of its program and found that 82% of
Munson, & Winter, 2010). toddlers with autism were verbalizing upon
Another treatment approach that has exiting the program, a gain from 36% at entry.
gained scientific support is PRT. Utilizing single- In addition, 71% of children showed improve-
subject methodology, PRT has been documented ment in a measure of proximity to peers
to improve social skills, disruptive behaviors, (McGee et al., 1999).
responsivity, language, and other social behaviors These studies and others like them illustrate
(e.g., Koegel & Frea, 1993; Koegel, Koegel, Hurley, the trend toward efficacious treatment in autism
& Frea, 1992; Koegel, Koegel, & Surratt, 1992). research. Currently, researchers are focused on
Studies by Kasari and colleagues have shown identifying the active ingredients of interventions
effectiveness for JASPER, a developmental and the exploration of which treatments work the
social-communication intervention for toddlers best for different populations of children with
and preschoolers with autism. In several RCT autism. There is a clear need for more research
trials, children randomly assigned to interven- into this area to establish stricter guidelines for
tions targeting core deficits of autism including “best practices” in autism intervention. Although
joint attention and symbolic play made signifi- there is promising evidence for the efficacy of
cant gains in joint attention initiations and sym- developmental approaches in early intervention
bolic play, respectively (Kasari et al., 2006), and for autism spectrum disorders, these develop-
also both made significant gains in expressive mental models need to be tested against other
language at a follow-up visit 1 year later com- approaches of early intervention (e.g., DTT) to
pared to participants in a control condition better answer the question of which treatments
(Kasari Paparella, Freeman, & Jahromi, 2008). work best for the wide range of children affected
Similarly, in a wait-list-control design of toddlers with the disorder.
with autism and their caregivers using a parent-
mediated approach, children improved in their
joint attention, play, and joint engagement with Outcome Measurement
their caregivers (Kasari et al., 2010).
Several other developmental approaches, Many of the early developmental interventions
including DIR and SCERTS, have limited target social communication in our youngest chil-
research into their efficacy at this time. While dren affected with autism. It follows suit that
outcome measures for these interventions would References and Readings
tap into domains of social and communicative
functioning. The JASPER intervention has Coulter, L., & Gallagher, C. (2001). Evaluation of the
Hanen early childhood educators programme. Interna-
reported on outcome measures specifically tied to
tional Journal of Language & Communication Disor-
the treatment objectives and includes behavioral ders, 36, 264–269.
recordings of joint attention, symbolic play, Dawson, G., Rogers, S. J., Smith, M., Munson, J., &
expressive language, and joint engagement mea- Winter, J. (2010). Randomized controlled trial of the
early start Denver model: A relationship-based devel-
sured from semi-structured interactions with the
child (Kasari et al., 2006, 2008, 2010). In addition,
opmental and behavioral intervention for toddlers with D
autism spectrum disorders: Effects on IQ, adaptive
standardized measures of expressive and receptive behavior and autism diagnosis. Pediatrics, 125, 1–7.
language measured by early language assessments Fenson, L., Dale, P. S., Reznick, J. S., Thai, D., Bates,
E., Hartung, J. P., et al. (1993). The MacArthur commu-
such as the Reynell Developmental Language
nicative development inventories: User’s guide and tech-
Scales (Reynell, 1977) and parent report of child nical manual. San Diego, CA: Singular Publishing
language collected by a questionnaire measure Group.
such as the MacArthur-Bates Communicative Greenspan, S. I., & Weider, S. (1997). Developmental
patterns and outcomes in infants and children with
Development Inventory (Fenson et al., 1993) are
disorders in relating and communicating: A chart
also utilized. These outcome measures are clearly review of 200 cases of children with autistic spectrum
defined and directly related to the treatment objec- diagnoses. The Journal of Developmental and Learn-
tives. The Denver and ESDM (Rogers et al., 2010) ing Disorders, 1, 87–141.
Greenspan, S. I., & Weider, S. (1999). A functional devel-
also use clearly defined and standardized measures
opmental approach to autism spectrum disorders. The
of outcome. This comprehensive model targets a Journal of the Association for Persons with Severe
wider range of domains and is not limited to the Handicaps, 24(3), 147–161.
area of social-communication. The outcomes Gutstein, S., & Sheely, R. (2002). Relationship develop-
ment intervention with young children: Social and emo-
include cognitive IQ measures (Mullen), language,
tional development activities for Asperger syndrome,
imitation, social initiative, adaptive functioning autism, PDD, and NLD. London: Jessica Kingsley.
(Vineland), and diagnostic severity (ADOS). Kasari, C., Freeman, S., & Paparella, T. (2006). Joint
Other developmental models have less clearly attention and symbolic play in children with autism:
A randomized controlled intervention study. Journal
defined treatment outcomes and may consist of
of Child Psychology and Psychiatry, 47, 611–620.
a case-by-case compilation of clinical evalua- Kasari, C., Gulsrud, A., Wong, C., Kwon, S., & Locke, J.
tions, progress notes, videotaped interactions, (2010). Randomized controlled caregiver mediated
and evaluations by therapists, such as in the DIR joint engagement intervention for toddlers with
autism. Journal of Autism and Developmental Disor-
model (Greenspan & Weider, 1997).
ders, 40, 1045–1056.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. (2008).
Language outcome in autism: Randomized comparison
Qualifications of Treatment Providers of joint attention and play interventions. Journal of
Consulting and Clinical Psychology, 76, 125–137.
Koegel, R. L., & Frea, W. D. (1993). Treatment of social
Most developmental interventions require spe- behavior in autism through the modification of pivotal
cific training to implement. Trained clinicians social skills. Journal of Applied Behavior Analysis, 26,
carry out the models described above with checks 369–377.
Koegel, R. L., & Koegel, L. K. (2006). Pivotal response
for fidelity to instruction standards occurring
treatments for autism: Communication, social, and
at regular intervals for several programs (e.g., academic development. Baltimore: Paul Brooks.
PRT, ESDM, JASPER). Hanen requires speech Koegel, L. K., Koegel, R. L., Hurley, C., & Frea, W. D.
and language therapists to implement the inter- (1992). Improving social skills and disruptive behav-
iors in children with autism through self-management.
vention. Many treatments also involve the train-
ing of parents to generalize program goals to the Koegel, R. L., Koegel, L. K., & Surratt, A. (1992). Lan-
home setting. Some models also conduct train- guage intervention and disruptive behavior in pre-
ings to extend instruction to general education school children with autism. Journal of Autism and
teachers and peers (e.g., Walden, PRT).
D 894 Developmental Language Delay/Disorder
McGee, G. G., Morrier, M. J., & Daly, T. (1999). An by specified ages during infancy and early
incidental teaching approach to early intervention for childhood in typical development. Develop-
toddlers with autism. The Journal of the Association
for Persons with Severe Handicaps, 24, 133–146. mental milestones are often presented in lists
Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., broken down by ages, beginning around
& Rydell, P. J. (2006). The SCERTS Model: 1–3 months of age and progressing through
A comprehensive educational approach for children approximately 5 years of age. The Centers
with autism spectrum disorders. Baltimore: Paul H.
Brooks. for Disease Control and Prevention (CDC)
Reynell, J. K. (1977). Reynell developmental language provides easily accessible information through
scales. Windsor, UK: NFER. their website (2010). Several categories of
Rogers, S. J., & Dawson, G. (2010). Early start Denver skills are often focused on including vision
model for young children with autism: Promoting lan-
guage, learning and engagement. New York: The and hearing, social, cognitive, language,
Guilford Press. motor, and self-help. Parents, day-care pro-
Rogers, S. J., Hall, T., Osaki, D., Reaven, J., & Herbison, viders, teachers, child psychologists, and
J. (2000). The Denver model: A comprehensive, inte- pediatricians often note emerging concerns
grated educational approach to young children with
autism and their families. In J. S. Handleman & S. L. regarding development when infants and chil-
Harris (Eds.), Preschool Education Programs for dren fail to reach developmental milestones
Children with Autism (2nd ed., pp. 95–133). Austin, on time.
TX: Pro-Ed. While some variation is to be expected
Solomon, R., Necheles, J., Ferch, C., & Bruckman, D.
(2007). Pilot study of a parent training program for among individuals, developmental milestones
young children with autism: The PLAY Project Home are used as guidelines to assist in the identifica-
Consultation Program. Autism, 11, 205–224. tion of developmental delays, including autism
Sussman, F. (1999). More than words: Helping parents spectrum disorders. When an infant or child is
promote communication and social skills in children
with autism spectrum disorders. Toronto, ON: The not reaching developmental milestones or is sig-
Hanen Centre. nificantly delayed in meeting them, further
assessment and evaluation should be completed.
Early diagnosis and early intervention for
Developmental Language autism are important for best outcomes. Skills
Delay/Disorder that may be deficient in early development for
individuals with autism spectrum disorders
▶ Expressive Language Disorder include social behavior, joint attention, visual
orientation, orienting to noise, response to
name, imitation of movement or sounds, and
Developmental Language Disorder language acquisition including both receptive
and expressive language (Watson, Baranek, &
▶ Expressive Dysphasia DiLavore, 2003).
Developmental Milestones
See Also
Jennifer S. Beighley and Johnny L. Matson
Department of Psychology, Louisiana State ▶ Developmental Delay
University, Baton Rouge, LA, USA ▶ Early Diagnosis
▶ Early Intervention
▶ Expressive Language
Definition ▶ Imitation
▶ Joint Attention
Developmental milestones are a set of behav- ▶ Milestone
iors, skills, or abilities that are demonstrated ▶ Receptive Language
Developmental, Individual Difference, Relationship-Based (DIR) Model 895 D
Developmental, Individual
Centers for Disease Control and Prevention. (2010). Difference, Relationship-Based (DIR)
Learn the signs. Act early. Retrieved May 6,
2011, from http://www.cdc.gov/ncbddd/actearly/
Model
milestones/
Watson, L. R., Baranek, G. T., & DiLavore, P. C. (2003). Serena Wieder
Toddlers with autism: Developmental perspectives. Profectum Foundation, New York,
Infants and Young Children, 16, 201–214.
NY, USA
D
Definition
Developmental Reading Disorder The Developmental, Individual Difference,

Relationship-Based model of intervention (DIR)
▶ Dyslexia provides a developmental framework for
interdisciplinary assessment and intervention for
autism spectrum and related disorders. It is
a comprehensive foundation model that utilizes
affect-based interactions and experiences tailored
Developmental Right Hemisphere to individual needs to promote development. “D”
Syndrome refers to fundamental capacities for joint atten-
tion and regulation, engagement across a wide
▶ Nonverbal Learning Disabilities (NLD) range of emotions, two-way communication,
and complex social problem solving which
underlie the development of symbol formation,
language, and intelligence. Intervention starts
with pleasurable interactions between children
Developmental Right-Hemisphere and parents that are at the heart of building the
Syndrome relationships that support developmental pro-
gress. “I” refers to individual differences related
▶ Right-Hemisphere Syndrome to sensory reactivity and regulation, visual-
spatial and auditory/language processing, and
purposeful movement. Challenges in these
neurobiological factors make it difficult to partic-
ipate in the emotional interactions that enable
Developmental Test of Visual-Motor mastery of the developmental capacities (“D”).
Integration “R” refers to relationships with caregivers that
are the vehicle for affect-based developmentally
▶ Beery-Buktenica Developmental Test of appropriate interactions. Parents and families are
Visual-Motor Integration central to this model because of their ongoing
opportunities to support their child’s everyday
functioning to carry out emotionally meaningful
goals based on developmental levels. Cultural
and environmental influences are also consid-
Developmental Verbal Apraxia ered. By taking all three areas of DIR into
(or Dyspraxia) account, the foundation for functioning, learning,
and relating to others in meaningful ways is
▶ Verbal Apraxia established.
D 896 Developmental, Individual Difference, Relationship-Based (DIR) Model
DIR is also commonly known as Floortime, A comprehensive model was needed to inte-
which is the central and initially most intensive grate theory with the emerging understanding of
component of DIR’s approach. Floortime is both environmental risks, individual differences, and
a philosophy and a specific technique where parent-infant interactions. The initial formula-
caregivers follow the child’s natural emotional tion, the developmental structuralist theory
interests and create states of heightened pleasure developed during a preventive intervention
in playful interactions tailored to the child’s research study on multirisk families, described
unique motor and sensory-processing profile to the emotional capacities that organize experience
strengthen the connection between sensation, at successively higher levels and provide the
affect, and motor action. Connecting words to structure for development (Greenspan et al.,
underlying affects that give them purpose and 1987; Greenspan & Lourie, 1981). As more
meaning leads to the formation of symbols, imag- children at risk for disorders in relating and
inative play, and reflective conversations. In communicating were identified, the DIR model
addition, semi-structured problem solving and evolved and provided the first relationship-based
social activities; play dates, language, sensory- developmental approach to autism that empha-
motor, and visual-spatial therapies and activities; sized how emotions and emotional interactions
educational programs; family support; and aug- impact cognitive and language abilities, as well
mentative and biomedical interventions make as many complex social and self-regulation skills
DIR a comprehensive model. The child’s (Greenspan & Wieder, 1998, 2006, 2011).
evolving DIR profile determines the individual- Interest in a developmental perspective grew
ized intervention as he progresses. While DIR as others identified autism-specific deficits and
emphasizes early identification and early inter- saw autism as a social-emotional-communicative
vention, it is a foundation model that guides disorder derailed by poor joint attention and
developmental intervention across the life span intentional communication, recognizing the
(Greenspan & Wieder, 1998, 2006, 2011; importance of interactive affective engagement
Wieder, 2011; Wieder & Greenspan, 2001). (Kasari, Sigman, Yirmiya, & Mundy, 1994;
Rogers & Pennington, 1991). Empirical results
also pointed to the importance of natural and
Historical Background spontaneous interests and initiation, and these
were highlighted by other behavioral models
The components of the DIR Model have long (Koegel, Koegel, Harrower, & Carter, 1999;
theoretical, clinical, and research traditions. Rogers & Dawson, 2010). Simultaneously, neuro-
Developmental frameworks go as far back as science research found poor connectivity and neural
Freud; were expanded by Erikson, Piaget, synchronization in different processing areas
Anna Freud, Mahler, Pine, and Bergman; and (Minshew, Goldstein, & Siegel,1997; Mostofsky
enhanced by the clinical reports of Spitz, Bowlby, et al., 2006; Williams & Minshew, 2007). These
Winnicott, Fraiberg, Lourie, Provence, and converging streams of knowledge all relate to
others who described the critical impact disrupted elements of the DIR model.
and impoverished environments had on early
relationships and development. Meanwhile,
Escalona, Murphy, Brazelton, and others were Rationale or Underlying Theory
identifying biological influences in development.
This coincided with the rejection of psychogenic Autism’s deficits relate to the inability to interact
theory which blamed parents for their children’s with emotional signals, gestures and vocalizations,
autism implied by Kanner, Asperger, and Bettel- and difficulty in maintaining these interactions
heim in prior decades and opened the door to with others. DIR hypothesizes these deficits that
understanding individual differences (Green- stem from a compromised capacity to connect
span, DiGangi & Wieder, 2001; Wieder, 2011). emotions or intent to motor planning/sequencing
and to sensations and later to early forms of sym- 1. Regulation and Joint Attention (Between
bolic expression of intent or emotions (Greenspan Infant and Caregiver). From birth to 3 months,
& Shanker, 2004; Greenspan & Wieder 1998, an infant’s capacity grows for calm, focused
2006). Usually, an infant connects the sensory sys- interest in the sights and sounds of the outer
tem to the motor system through affect, e.g., seeing world while she begins to share her interests
the caregiver’s smiling face or hearing her wooing with the caregiver.
voice entices the infant to turn and look and listen 2. Forming Attachments and Engaging in Rela-
and smile back. Through many of these interactions, tionships. During the next first 4 months,
the infant begins to recognize patterns as they share infant and parents become more intimate as D
attention, take pleasure in interactions, read each they interact with warmth, trust, and intimacy.
others’ cues, and respond to each other over and They each use their senses to enjoy each other
over again through gaze, vocalizations, and ges- through looks, hugs, songs, and dancing
tures. By the end of the first year, the infant recog- together. Over time, the infant will need to
nizes variations in his caregiver’s affect as well as remain related and engaged across the full
his own feelings related to love, anger, feeling range of emotions, even when disappointed,
proud, disapproved of, etc. By the second year of scared, angry, or experiencing other stress.
life, these patterns lead to a sense of self as purpose- 3. Intentional Two-Way Affective Communica-
ful and a differentiated sense of others. By the third tion. Between 4 and 10 months, purposeful,
year of life, these affect-based interactions enable continuous flow of interactions with gestures
a child to form and give meaning to symbols leading and reciprocating emotions gets underway.
to higher levels of thinking. The infant begins to act purposefully, now
When sensory-motor processing and chal- that she has matured and is more aware of
lenges in language comprehension and visual- her body and the functions it can perform. As
spatial knowledge derail this process, affect the infant gains motor control over her body
must be brought into intervention as early as and intent, she is better able to communicate
possible strengthening the connection between her desires. With emerging abilities to reach;,
sensation, affect, and motor action, i.e., simulta- sit and turn;, crawl and creep;, and give and
neously looking, listening, and moving while take or drop objects, the infant’s awareness of
engaging in meaningful problem-solving interac- the interpersonal world is growing, as is her
tions through heightened states of pleasure and awareness of her body in space and in relation
other affects. Longer chains of co-regulated to others who may also be moving.
affective gesturing will enable the child to recog- 4. Complex Social Problem Solving. Between 9
nize the variations in the caregiver’s gestures, and 18 months, an infant has learned the back
facial expressions, and tone of voice and become and forth rhythm of interactive emotional
aware of his anxiety and repetitive behavior. The signaling and begins to use this ability to
relationship becomes the vehicle for affect trans- think about and solve problems that are emo-
formations that allow the child to negotiate each tionally meaningful to get what he wants, such
of the above functional emotional developmental as pulling mommy to the door to go outside
levels. It is affect that transforms labels into and play. All of the child’s senses work with
meanings leading to symbolic thinking and his motor system as he interacts with others to
more complex and abstract reasoning (Greenspan solve problems. Difficulties arise when he
& Shanker, 2004; Greenspan & Wieder, 1998; becomes aware that things are not as they
Wieder & Greenspan, 2003). should be based on his memory of prior expe-
DIR theory identifies six fundamental capaci- riences and encounters new difficulties to
ties or levels that emerge in infancy and expand solve as his experience expands.
in duration, range, and stability as the child 5. Emotional Ideas. Between 18 and 36 months,
develops. These foundational capacities are nec- the toddler begins to represent or symbolize
essary for functioning across the life span: intentions, feelings, and ideas in imaginative
play and/or language, using gestures, words, is feeling a certain way and contrast this with
and symbols. The toddler now calls on a toy how she usually feels or she can compare her
phone, sets up a picnic or tea party, takes the current efforts with earlier ones. This kind of
sick baby to the doctor, or repairs his car thinking allows her to make inferences about
before driving somewhere. These first ideas herself and others and create new choices and
come from experiences in real life that can ideas.
now be enacted in pretend dramas as the Various researchers have confirmed chal-
child experiments with different roles and lenges related to these developmental capacities,
feelings. including difficulties with shared attention,
6. Emotional Thinking, Logic, and Sense of Real- social referencing, and problem solving
ity. At about three, the child begins to combine (Mundy, Sigman, & Kasari, 1990); emotional
ideas to tell a story as he develops more logic reciprocity (Dawson & Galpert, 1990); and func-
and understanding of himself and others, and tional (pragmatic) language (Wetherby, Prizant,
of what is real or not real. His stories use & Hutchinson, 1998); empathy (Baron-Cohen,
imaginative characters and animal figures Leslie, & Frith, 1985); and higher-level abstract
that talk and may have magic as he discovers thinking (Minshew et al., 1997).
he needs more power to encounter the fears
and conflicts in life, but reasoning skills click
in to elaborate sequences, and stories become Goals and Objectives
increasingly logical and realistic. Over the
next few years, the child’s emotional and The goal of the DIR model is to enable children
mental abilities move toward abstract think- on the autism spectrum to form a sense of them-
ing, and he develops the ability to distinguish selves as intentional, interactive individuals, who
reality from fantasy, self from nonself, and can develop cognitive, language, and social
one feeling from another, and make distinc- capacities. This calls for the mastery of six func-
tions concerning time and space. tional developmental levels and comprehensive
Level six later expands to: interventions that treat problems related to gaps
7. Multicausal and Comparative Thinking. At in these foundational capacities.
this level, the child “deepens the plot” as he Specific objectives:
can explore multiple motives, get opinions, • To identify the degree to which each develop-
and compare and contrast ideas. The child mental level is mastered fully, partially, or
can express how she would feel “in your unmastered and how stable or consistent. The
shoes” and predicts what you will do based critical principle is to engage the child at his or
on your “affect cues” such as deception, fair- her level and to help the child master that level
ness, and justice. and subsequent levels. When a child has par-
8. Relativistic or Gray-Area Thinking. Here, the tial mastery of a higher level, e.g., using ideas,
child differentiates more of his thoughts, rather but is not fully engaged or interactive, he still
than thinking only in “black and white” terms. needs work at the earlier levels.
The lion may pay a price for killing the zebra or • To identify and treat the bioneurological reg-
the bear devouring all the honey will disappoint ulatory, sensory, and motor-processing chal-
his friend. The child now considers different lenges that effect developmental levels.
possibilities and contingencies and is aware of • To identify gaps in daily adaptation and
different outcomes and of how he would feel expected competencies.
under different circumstances. • To identify family’s needs for counseling,
9. Self-Reflection or Thinking Using an Internal family functioning, and advocacy.
Standard. Now, the child has a sense of her- • To organize comprehensive individualized pro-
self; she can look at and reflect on her perfor- grams that apply principles of affect-based
mance and feelings. She can question why she interactions throughout all interventions.
• To use developmentally appropriate practices have been mastered fully, partially, or not at all
which support child initiation, intent, commu- and how individual differences in sensory modu-
nication, and discovery. lation, processing, and motor planning effect
• To keep intervention dynamic and flexible, each level and underlie particular symptoms,
modifying as needed to support rate of behaviors, and learning challenges. These ses-
progress. sions begin with discussions and observations
that include two or more 45-min clinical obser-
vations of child-caregiver and/or clinician-child
Treatment Participants interactions; developmental history and review D
of current functioning; review of family
This model provides a road map for the treatment and caregiver functioning; review of standard
of autism spectrum disorders as well as other diagnostic assessments, current programs, and
developmental, learning, and emotional chal- patterns of interaction; consultation with speech
lenges and diagnoses across the life span. This pathologists,; occupational, physical, and arts
widespread applicability is possible because it is therapists,; educators,; developmental pediatri-
based on a theory that focuses on capacities cians; and optometrists and mental health
fundamental to the development of all children. colleagues, including the use of structured tests
It is also a comprehensive model with a range of (neuropsychological, educational, speech and
interventions that can be tailored to specific language, OT, PT, etc.) as needed, rather than
underlying sensory processing, motor, and learn- routine bases; and biomedical evaluation. These
ing challenges, as well as family and cultural lead to recommendations for an individualized
factors. Since autism is so heterogeneous, DIR program.
can guide each family to identify the most appro- DIR is unique in its comprehensiveness, its
priate program for the child and family based on developmental focus, the role of the family, its
their individual profiles and helps set priorities. emphasis on emotional and symbolic develop-
This theory of development is especially useful ment, and its long-term developmental perspec-
for early identification in infancy when capacities tive. As a dynamic model, it is flexible and
for regulation and joint attention, engagement, changes as the child progresses moving onto
and communicative intent begin and red flags typical activities. There is no attempt to fit the
become evident. The intervention begins as child into a program, and the specific interven-
soon as challenges are evident or at risk for tions and frequency depend on individual needs;
occurring during infancy, toddlerhood, and pre- for example, some children receive speech or
school years. The model is also brought in at occupational therapy weekly, twice weekly, or
older ages (children, adolescents, and adults) not at all. While these therapies are common to
when gaps in development are identified, rate of other treatments, DIR provides the unifying goals
progress is less than expected, and core develop- and principles for an integrated approach. The
mental capacities need strengthening in order to sessions may be individual and/or group based,
benefit from the various other interventions that in schools or therapy offices, and parents partic-
are in order. ipate (Greenspan & Wieder, 2000, 1998, 2006).
DIR interventions include the following:
Floortime, the center of DIR intervention,
Treatment Procedures starts with 6–8 daily spontaneous unstructured
“play” sessions of 20–30 min provided by parents
Implementation of an appropriate assessment of and other caregivers, including teachers, thera-
all the relevant functional areas requires pists, and Floortime players. Key elements are as
a number of sessions with the child and family. follows: Observe child’s interests, wait for his
A senior DIR clinician and/or multidisciplinary initiation and response, follow his intentions,
team determines which developmental levels and engage in what gives him pleasure using
affect cues to sustain joint attention; expand back typical enjoyable social activities which he
and forth interactions by helping child do what he may first practice with an adult partner or
intends, becoming playfully obstructive, and join peer models. These games may range
increasing problem solving in gestures or words from ritualized songs and movement such
to get the child to further elaborate his intent and as ring-around-the-rosy to less predictable
reciprocity. The parent does not change topics or sequence actions such as red light-green
direct but works within the child’s interests to light, red rover, relay races, treasure hunts, or
deepen engagement and expand ideas at pre- tag. Secondary goals are to help the child learn
symbolic and symbolic levels where imaginative to negotiate, make deals as to what to do first
play focuses on emotions and abstract thinking. or second, play structured turn taking games
These Floortime principles also inform all and understand chance games, and resolve
education and therapies so that children are max- conflicts.
imally interested and engaged in learning • Play dates and social activities with peers to
interactions. form friendships and spontaneous interac-
• Semi-structured Problem-Solving Interven- tions, sharing ideas, and negotiations. Number
tions. The child with autism may not benefit per week depends on age of the child.
just from exposure to experiences and needs • Sensory Motor/Visual-Spatial Activities.
mediation and systematic implementation. Four to six 20–30-min daily sessions a day.
Natural learning from the environment gets Many, if not all, children with autism have
derailed by constricted interests, repetitive motor planning, coordination, or executive
behaviors, poor imitation, poor auditory and function challenges and rely on memory to
visual-spatial comprehension, and motor stay oriented in space. Many have reduced
planning difficulties (praxis), as well as hyper- muscle tone and movement/discriminative
sensitivity or underreactivity. Opportunities movement difficulties. Ocular motor and other
are created daily to get the child to tune into visual-spatial processing challenges contribute
his environment and think when his expecta- to attention and learning difficulties as well as
tions are challenged, and the change poses daily adaptation. Therefore, intensive daily
a problem for him. These situations are always practice to strengthen these areas is beneficial.
meaningful and relevant to his emotions such Activities range from specific fun exercise rou-
as desires for more or less of something; con- tines, involving running, jumping, climbing,
cern something he is missing or broken, or not and pulling to solo sports, such as gymnastic,
finding what he wants in usual places; feeling biking, swimming, or track, and to interactive
challenged when needing to open containers, ball sports. While challenges in this area vary in
or unwrap books or toys; having to pack his degree, these activities support competence,
backpack, serve as a messenger, follow multi- need to be fun, and are opportunities for inter-
ple directions, getting ready independently for action and negotiation.
routines, etc. Reasoning is inserted to compre- • Individual and group language, occupational,
hend the problem and helps the child feels that physical, visual-spatial, and creative arts ther-
the new expectations are not arbitrary, with apies are determined by individual needs of
co-regulated interactions to deal with frustra- the child, and frequency will vary depending
tion or disappointment, as well as excitement on other activities addressing the child’s
and success. The challenge increases as the needs. Therapists working within the DIR
child progresses and involves more elaborate model maintain a developmental perspective,
sequences of actions and thoughts with the include parents in the sessions, and guide
larger goal of helping child develop compe- home activities between sessions.
tencies off of real-life experiences. • Educational programs range from inclusion in
• Social Games and Activities. When meaning- regular education and public and private
ful and fun, the child chooses or is enticed into special education with varying degrees of
inclusion, hybrid programs of school- and accelerated gains when intervention focused on
home-based intervention, specialized tutoring play, language, cognition, and social relations (Rog-
programs, etc. These programs vary in the level ers et al., 1986; Rogers, Lewis, & Reis, 1987).
of structure provided and are selected on the Recently, Rogers and Dawson’s Early Start Denver
basis of which setting will best insure compre- model reported affectively rich engaging social
hension, social interaction, and learning. interactions to teach social and language skills
• Augmentative and assistive technologies as improved IQ, language, social interaction, initia-
indicated. tive, behavior, and adaptive skills and decreased
• Family counseling to help parents implement severity of ASD symptoms (Rogers & Dawson, D
interventions, support family functioning, and 2010). Zwaigenbaum’s et al.’s (2009) summary of
provide advocacy when needed. studies on children at high risk for autism empha-
• Consideration of nutrition and diet, biomedical sized the importance of active social learning and
interventions, and when indicated, medications parent-child relationships. Similarly, Wallace and
addressing regulation and anxiety, possible Rogers (2010) emphasized four factors important
seizures, concentration, and movement. for effective intervention: parental responsivity and
sensitivity, individualization, broad learning tar-
gets, and early intensive intervention. Sensory inte-
Efficacy Information gration studies also report improved social
responsiveness, sensory processing, and functional
For a disorder as complex and as heterogeneous as motor skills and social-emotional factors and
autism, many methods and research from various decreased autistic mannerisms (Pfeiffer, Koenig,
disciplines, including combined developmental Kinnealey, Sheppard, & Henderson, 2011), as
and behavioral approaches, support elements of well as reduced difficulties in sensory modulation
DIR’s complex model. In recent years, research disorders common to autism (Miller, Coll, &
related to these elements has increased signifying Schoen, 2007). Lastly, neuroimaging research
the importance of affect-based interactions. For reports attuned relationships in infancy change
example, responsive parent-child interactions brain structure in ways that later affect social and
have been found to improve social engagement emotional development (Siegel, 2001). Evidence
and communication (Gernsbacher, 2006; Gutstein, of poor neural connectivity between different brain
2005; Mahoney & Perales, 2005; Prizant, regions might account for the poor information
Wetherby, Rubin & Laurent, 2003; Schreibman processing and connectivity contributing to indi-
& Koegel, 2005; Vismara & Rogers, 2009). Stud- vidual differences in sensory-motor processing
ies on joint attention, emotional attunement, and seen in autism (Mostofsky et al., 2007).
play reported gains in language and symbolic DIR research ranges from clinical reports and
thought (Kasari, Paparella, & Freeman, 2006; chart reviews to surveillance and a within-group
Kasari, Freeman, Paparella, & Jahromi, 2008; pre-post study with randomized control interven-
Mundi, Sigman, & Kasari, 1990). Following tion and imaging studies underway or in review.
a child’s lead improved communication as well as The landmark chart review of 200 children revealed
language development over long-term periods patterns in underlying sensory-processing and mod-
(Schreibman & Koegel, 2005; Siller & Sigman, ulation difficulties, and 58% of children who started
2002). The strength of relationships and attachment intervention between 22 months and 4 years
is tied to parent’s sensitive responsiveness just as and treated for a minimum of 2 years between 2
with typical children (Capps, Sigman & Mundy, and 8 years improved to no longer met the
1994; Oppenheim, 2009; Rogers, Ozonoff & criteria for autism (Greenspan & Wieder, 1997).
Maslin-Cole, 1993). Support for co-regulation strat- Findings revealed capacities for joyful relation-
egies during distress episodes decreased children’s ships, empathy, affective reciprocity, reality testing,
negativity (Gulsrud, Jahromi, & Kasari, 2010). And impulse control, creative thinking, and good peer
Rogers and colleagues have long reported on relationships. Some still evidenced auditory or
visual-spatial difficulties, and most had some continuing need for clinical approaches
degree of motor challenges. Contrary to the stereo- based on individual needs, and DIR provides
types of autism, they seemed eager for emotional such a model.
contact;, but had trouble figuring out how to achieve
it and seemed grateful when their parents helped
them express their desire for interaction. The10- Outcome Measurement
to15-year follow-up study of a subset of 16 boys,
between 12 and 17, showed a group of empathetic, DIR studies utilize the standard outcome mea-
creative, abstract, and reflective adolescents sures in autism research, including the following
(Wieder & Greenspan, 2005). instruments and rating scales: Autism Diagnos-
The six functional emotional developmental tic Observation Scale (ADOS), Achenbach
capacities were used in a norm-referenced sur- Child and Adolescent Behavior Checklists,
veillance of 1,500 children from birth to 42 BASC (Behavior Assessment System for Chil-
months using the Greenspan Social-Emotional dren), Greenspan Social-Emotional Growth
Growth Chart and identified infants at risk for Chart, Mahoney Maternal and Child Behavior
autism with a sensitivity of 87% and specificity Rating Scales, Mullen Scales of Early Learning,
of 90%. It has become an important screening MacArthur CDI, Reynell Developmental Lan-
tool for early identification (Greenspan, 2004). guage Scales, Vineland-II, Parenting Stress
A pre-post study of the P.L.A.Y. project that Index, CES-D Depression Scale, the FEAS
trains parents of children with autism aged 2–6 (Functional Emotional Assessment Scale – in
to carry out 15 h of Floortime weekly for 8–12 revision) (Greenspan et al., 2001), and other
months found 45.5% made significant develop- various rating scales for symbolic play and
mental progress (p 0.0001) in the FEAS child joint attention, are developed by autism
subscale scores (Solomon, Necheles, Ferch, & researchers.
Bruckman, 2007). Based on the strength of
this study, a large-scale randomized controlled,
community-based clinical trial is underway. Qualifications of Treatment Providers
A randomized controlled trial of DIR at York
University assessing the efficacy of a 12-month Treatment is provided by multidisciplinary
DIR/Floortime treatment for children ages 30–51 licensed/credentialed professionals who com-
months compared to the community standard found plete a multiyear certificate process at different
significant gains in interaction skills, with initiation levels to develop competencies within their
of joint attention, involvement, and severity of lan- discipline. They coordinate, consult, and/or
guage delay associated with improved language oversee the intervention teams and supervise
skills, and caregiver skills targeted by the interven- paraprofessional Floortime players and various
tion were associated with changes in children’s assistants who implement specified activities in
interaction skills (Casenheiser, Shanker, & Stieben, schools, social activity centers, and homes. Pro-
2011). fessionals include clinical and developmental
While support for developmental models is psychologists, regular and special educators,
growing, including DIR, various reviews indi- and speech and language, occupational, physi-
cate there is still no definitive evidence on cal, movement, and creative arts therapists.
any one method being better than standard Senior professionals coordinate teams. Parents
of care that any method improves all the work side by side with the therapists, are
symptoms of ASD, and there are no compar- coached to provide Floortime, and implement
ative studies between approaches indicating the home programs. Developmental pediatri-
any one method is superior to others (Lord cians, pediatricians, child psychiatrists, neurol-
& McGee, 2001; Seida et al., 2009; Spreckley ogists, nutritionists, and other specialists are
& Boyd, 2009). These reviews suggest the consulted as needed.
See Also 200 cases of children with autistic spectrum diagnoses.
Journal Developmental Learning Disorders, 1, 87–141.
Greenspan, S., & Wieder, S. (1998). The child with special
▶ Developmental Intervention Model needs: Encouraging intellectual and emotional
▶ Developmental-Pragmatic Approaches/ growth. Reading, MA: Perseus Books.
Strategies Greenspan, S., & Wieder, S. (2000). Principles of clinical
▶ Early Start Denver Model practice for assessment and intervention. Develop-
mentally appropriate interactions and practices.
▶ Mutual Regulation Developmentally based approach to the evaluation
▶ RJA/IJA (Initiating/Responding to Joint process. In Interdisciplinary Council on Developmen-
Attention) tal and Learning Disorders Clinical Practice Guide- D
▶ Self and Autism lines (pp. 261–282). Bethesda, MD: Interdisciplinary
Council on Developmental and Learning Disorders.
▶ Sensory Impairment Greenspan, S., & Wieder, S. (2005). Can children with
autism master the core deficits and become empathetic,
creative and reflective? A ten to fifteen year follow-up
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for young children with autism. New York: Guilford. Wieder, S. (1996). Climbing the “symbolic ladder”:
Rogers, S., Herbison, J., Lewis, H., Pantone, J., & Reis, K. Assessing young children’s symbolic and representational
(1986). An approach for enhancing the symbolic, capacities through observation of free play interaction. In
Developmentally Appropriate Practice (DAP) 905 D
S. Meisels & E. Fenichel (Eds.), New visions for the Definition
developmental assessment of infants and young children
(pp. 267–287). Washington, DC: Zero to Three.
Wieder, S. (2011). DIR: Developmental, individual- Developmentally appropriate practice (DAP)
difference, relationship-based model: A dynamic refers to providing intervention in a manner that
model for the 21st century. In D. Zager, M. Wehmeyer, is individually appropriate and culturally relevant
& R. Simpson (Eds.), Research-based principles for the learner. This term was first introduced by
and practices for educating students with autism
(pp. 82–98). New York: Routledge/Taylor & Francis. Sue Bredekamp and the National Association for
Wieder, S., & Greenspan, S. (2001) The DIR (Developmen- the Education of Young Children (NAEYC) in
tal, Individual-difference, Relationship-based) approach 1987 to warn early educators against the trend of D
to assessment and intervention planning. Zero to Three, pushing typically developing or gifted children too
21, 11–19.
Wieder, S., & Greenspan, S. (2003). Climbing the sym- far too fast, or what some developmental psychol-
bolic ladder in the DIR model through floortime/inter- ogists referred to as “robbing children of their
active play. Autism, 7, 425–436. childhood” with deleterious effects that may not
Williams, D. L., & Minshew, N. J. (2007). Understanding show up until adolescence or later. It also has
autism and related disorders: What has imaging taught
us? Neuroimaging Clinics of North America, 17(IV), important implications for working with students
495–509. who have cognitive deficits so that families and
Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., interventionists interact with people in a manner
Carter, A., Carver, L., et al. (2009). Clinical assess- that is age appropriate and provide opportunities to
ment and management of toddlers with suspected
autism spectrum disorder: Insights from studies of people that are both age appropriate and matched
high-risk infants. Pediatrics, 123, 1383–1391. with individual strengths and preferences.
This concept of DAP is important when
planning and implementing interventions for
people with ASD. Developmentally appropriate
Developmentally Appropriate interventions are those that take the student’s
Practice chronological as well as developmental age into
consideration when identifying targets, materials,
▶ Normalization places, and strategies for intervention. Interven-
tions that are developmentally appropriate also
consider issues of cultural relevance and attempt
to insure that the behaviors and skills selected as
Developmentally Appropriate intervention targets are related to improving the
Practice (DAP) quality of life for the person with ASD and his/
her family.
Ilene Sharon Schwartz1 and Bonnie McBride2
1
Haring Center for Applied Research and
Training in Education, University of See Also
2
Intervention Services for Autism, University ▶ Curriculum
of Oklahoma College of Medicine, Oklahoma, ▶ Early Intervention
OK, USA

Synonyms
Boulware, G., Schwartz, I. S., Sandall, S. R., & McBride, B. J.
Chronological age appropriateness; Individual (2006). Project DATA for toddlers: An inclusive
approach to very young children with ASD. Topics in
appropriates; Intervention targets and strategies Early Childhood Special Education, 26, 94–105.
that are related to increased quality of life Carr, E. G. (2007). The expanding vision of positive
outcomes behavior support: Research perspectives on happiness,
D 906 Developmental-Pragmatic Approaches/Strategies
helpfulness, hopefulness. Journal of Positive of language acquisition serve as the foundation

Behavioral Interventions, 9, 3–14. for language intervention which is derived from
Carta, J. J., Schwartz, I. S., Atwater, J. B., & McConnell,
S. R. (1991). Developmentally appropriate practice: this thinking: (1) language develops within
Appraising its usefulness for young children with dis- the context of the caregiver-child relationship,
abilities. Topics in Early Childhood Special Education, with an attuned and loving partner; (2) early
11(1), 1–20. developments in engagement, intentionality, and
Copple, C., & Bredekamp, S. (2009). Developmentally
appropriate practice (in early childhood programs, communication set the stage for the ability to
serving children from birth through age 8). Washington, comprehend and produce language; and (3) the
DC: NAEYC. use of language includes the capacity to know
Schwartz, I. S., & McBride, B. (2008). Getting a good when to say what to whom.
start: Effective practices in early intervention. In K. D.
Burton & P. Wolfberg (Eds.), Educating learners
on the autism spectrum: Translating theory into
meaningful practice. Kansas City, KS: Autism Historical Background
Asperger.
Schwartz, I. S., Sandall, S. R., McBride, B. J., &
Boulware, G. L. (2004). Project DATA (Developmen- The field of speech-language pathology was
tally appropriate treatment for autism): An inclusive, dramatically impacted by the introduction of
school-based approach to educating children with social-pragmatic models of language acquisition
autism. Topics in Early Childhood Special Education, in the 1970s and early 1980s (Bates, 1976;
24, 156–168.
Bates, Camaiono, & Volterra, 1975; Bruner,
1975; Bruner, 1977; Dore, 1975; Halliday, 1975;
Prutting, 1982). With these models, the world of
communication disorders began to reconsider fun-
Developmental-Pragmatic damental questions, such as what defines a language
Approaches/Strategies user and how does a language disorder compromise
these capacities. Interest in constructs such as inten-
Sima Gerber tionality, nonlinguistic communication, functions
Department of Linguistics & Communication of language, social interaction, contexts of language
Disorders, Queens College, Flushing, NY, USA learning and language use, discourse, and conver-
sational skills represented a departure from earlier
thinking in both language acquisition and language
Definition intervention. Taxonomies from the world of typical
social-pragmatic development began to appear in
Developmental-pragmatic approaches to lan- language assessment protocols and intervention
guage intervention have a dual focus: (1) generat- plans for children with autism spectrum disorders.
ing treatment goals and procedures based on the These included taxonomies of prelinguistic devel-
child’s stage of development as determined by opment (communicative intentions), speech acts
what is known about typical trajectories and and functions of language (labels, comments,
(2) generating treatment goals and procedures requests, greetings, etc.), and conversational analy-
based on the tenets of social-pragmatic perspec- sis (initiating and maintaining topics, turn-taking,
tives on language acquisition and use. The child’s and contingency). These paradigms were immedi-
developmental stage, rather than his or her ately of interest to speech-language pathologists
chronological age, is considered not only in ref- (SLPs) working with children with autism spectrum
erence to language but also in reference to those disorders because for the first time, the nature
areas of development thought to be precursors of these children’s language and communication
and cocursors of language, such as symbolic- challenges was more adequately described and
cognitive (e.g., play abilities) and social- understood.
emotional functioning (e.g., interacting with Once the breadth of pragmatic models of
others). Three tenets of social-pragmatic models language acquisition and language use were
Developmental-Pragmatic Approaches/Strategies 907 D
integrated into the world of communication dis- with SLPs who were working with children who
orders, the work of speech-language pathologists were nonverbal (e.g., standing in the corner to
expanded to include new dimensions of typical communicate anxiety) and/or using unconven-
language development and language use and tional means of communication (e.g., repetitively
greater attention to the contexts of language asking questions to deal with transitions).
learning and language use. The earlier “semantic Although the impact of developmental-
revolution” which brought us from “form” pragmatic models of language acquisition had
(i.e., the structure of language) to “content” a lasting effect on language assessment and inter-
(i.e., the meanings of language) led quite quickly vention with both children and adults with a range D
to a “pragmatic revolution” which required proof language disorders, many would agree that
fessionals to once again rethink the nature and the speech and language intervention with children
boundaries of their work as they added a third with autism spectrum disorders was particularly
component to the definition of language, namely, effected by embracing this model. The nature and
“use.” Perhaps as important was the shift in think- breadth of pragmatic views of language spoke
ing about the role of the SLP, from the teacher of directly to the nature and breadth of the children’s
language to the partner in the language acquisi- challenges, providing new directions for SLPs
tion process. Encouraging the child’s initiation working with this group of children.
and intentionality was seen as more important
than obtaining responses from the child. Finally,
the notion of therapy contexts expanded to poten- Rationale or Underlying Theory
tially include all the contexts of the child’s life,
from home to school to play, with a variety of A developmental-pragmatic model (DPM) rests
partners, both in terms of number and age (from on the universals, processes, and facts of typical
one adult to groups of peers). language acquisition. This information clarifies
The focus on the interpersonal functions of what is learned by a typically developing child at
language was particularly attractive to clinicians each point in development, resulting in the
who were working with children who could talk child’s acquisition of a symbolic language system
but did not use language appropriately for the and his or her success as a social communicator.
typical range of communicative intentions The speech-language pathologist who embeds his
(commenting, reporting, requesting answers). In or her thinking in this theory believes that the
fact, the new taxonomies provided ways of language acquisition of children on the autism
understanding the unconventional linguistic pat- spectrum includes both typical and atypical
terns used by some children on the autism spec- parameters, all of which are best understood by
trum. Prizant and Duchan (1981) noted that reference to the universals of speech, language,
children with autism were often expressing and communication development.
typical functions of language with echolalic Developmental-pragmatic models of language
utterances. Obviously, the relationship between intervention pay particular attention to the social
form and function was idiosyncratic (e.g., the underpinnings of language acquisition and use.
child says “Do you want a drink?” to indicate While encompassing the interest in the form of
that he or she wants a drink), but nonetheless, language (phonology, morphology, and syntax)
the utterances were intentional and certainly and the content of language (semantics), pragmatic
could not be simply discounted as inappropriate. thinking leads us to consider the broader interper-
The “discovery” that echolalic language was sonal context of language acquisition and the early
intentional led to shifts in intervention procedures ability of the communicator to use gestures, facial
from those which suggested ignoring or discour- expressions, and words for social interaction pur-
aging echolalia to those that honored it. The pri- poses. Thus, the emphasis on context, both of
macy of function over form, a direct outgrowth of language learning (i.e., caretaker-child interac-
pragmatic models, was a theme that resonated tions) and language use (e.g., how the intent of
our utterances is understood depending on who is relationships, and affective range (Tomasello,
being spoken to, what the setting is, and the knowl- 1988; Greenspan & Wieder, 1998; Mundy &
edge of the participants), is considered develop- Sigman, 2006), speech-language pathologists
mentally from birth to adulthood. The fact that continued to integrate the expanding theory into
some children on the autism spectrum have their work with children with challenges (Prizant,
strengths in form and content with considerable Wetherby, Rubin, & Rydell, 2006). More and
deficits in pragmatics speaks to the components of more intervention programs began to address
language necessary to be a successful and conven- the social engagement issues of children on the
tional language user. autism spectrum, and, in fact, approaches which
Regardless of the specific discipline, develop- differed considerably in the strategies and con-
mental approaches begin with the assumption texts of intervention now share the emphasis on
that all strategies of intervention, regardless of interaction, reciprocity, and shared attention. The
the target group or desired outcome, can be fact that typically developing infants can easily
derived from normative theories of development. participate in attuned, communicative exchanges
That is to say, the general principles of develop- and that children with autism spectrum disorders
ment apply to all children independent of their find this developmental step so challenging is
biological variability or the range of environ- a universal concern in the educational and thera-
ments in which they live (National Research peutic planning for children on the autism
Council and Institute of Medicine, 2000). We spectrum.
might add to this that goals of intervention can Once again, while many of the pragmatic con-
best be derived from normative theories of devel- structs speak to the process of language acquisi-
opment as well and that this is particularly com- tion and, thus, are relevant for intervention
pelling when considering children with deficits in programs for all children with delays and disor-
social-pragmatic aspects of language. ders in speech and language development, the
This overarching understanding of develop- nature of autism spectrum disorders has led to
mental approaches paired with the specifics of a particular interest in this body of work.
pragmatic thinking served as a rich resource for The following list of principles reflect the
recasting the assessment and intervention of chil- underlying theory of a developmental-pragmatic
dren on the autism spectrum. The emphasis in model of language intervention (Gerber, 2003)
pragmatic approaches on the intersect between and are thought to serve as the basis for and
the capacity to interact and the capacity to com- rationale for intervention goals and procedures:
prehend and produce language immediately reso- • Language is learned in the context of sponta-
nated with the challenges and needs of children on neous, natural everyday interactions between
the autism spectrum. The models presented in the the caregiver and the child.
literature by Bates et al. (1975); Dore (1974, • The child’s language acquisition is embedded
1975); Halliday (1975); Bloom, Rocissano, and in his or her cognitive, affective, and social
Hood (1976); Snow (1973, 1978); etc., offered development and life.
the theory and frameworks for reconsidering • The development of communicative intention-
what and how we were teaching children with ality precedes the development of language.
autism spectrum disorders to learn and use • Prelinguistic developments in cognitive,
language. SLPs began to use and adapt the taxon- social, emotional, and communicative
omies which appeared in the research literature on domains precede the comprehension and
topics such as the speech acts expressed by young production of language.
children using single words, the early development • The child’s communicative interactions
of conversational skills, and the nature of adult include many opportunities to play speaker-
input to language-learning youngsters. initiator and listener-responder discourse roles.
As this movement continued and moved more • Both typically and many atypically develop-
deeply into the world of joint attention, early ing children move through the same general
stages of linguistic and communicative notion that nonlinguistic communication con-
development. tinues to be a goal of therapy even for children
• The specifics of language development who are verbal was welcomed by clinicians who
(e.g., rate, style, strengths) are characterized were working with children on the autism spec-
by individual variation. trum who could talk but did not use pointing and
• Imitation may play a role in language learning showing, eye gaze, and intonation to communi-
for some children; its role in the development cate their intentions.
of communication is generally recognized. Further, for children who are at very early
• The child plays an active role in his or her developmental stages, pragmatic goals address D
language development – meaningful and joy- the social-emotional precursors to language.
ful interactions with the world of objects and These include increasing engagement in back
the world of people serve as the context for the and forth adult-child interactions; facilitating
development of language. affective exchanges between the adult and the
child using nonlinguistic communicative forms;
increasing periods of joint attention with care-
Goals and Objectives givers; communicating a range of intentions
using differentiated vocalizations, pointing, eye
Operationalizing developmental-pragmatic goals gaze, and word approximations; and facilitating
and objectives can be thought of in a number of social referencing. Of course, precursory goals
ways, all of which differ from traditional perspec- related to the content of language and the form
tives on how to view the basic components of of language would also be a part of every child’s
language intervention. These components include intervention plan. At these early stages, goals for
what the goals of intervention are, who the partic- the caregivers include increasing their respon-
ipants are during intervention, what procedures siveness to the child’s potentially communicative
should be used, where the therapy takes place, attempts and fostering reciprocal interactions,
and what role the adult plays during the interac- using the child’s current repertoire of behaviors.
tion. A continuous thread from paradigms of Of particular relevance for children with
assessment to paradigms of intervention are char- autism spectrum disorders was the notion of
acteristic of language intervention programs which intentional communication and functions of lan-
are based on developmental social-pragmatic the- guage which moved to center stage in language
ories of language acquisition (Gerber & Prizant, intervention as a result of the understanding of
2000; Prutting & Kirschner, 1987). pragmatic models of language development. The
One of the most significant impacts of prag- fact that this group of children did not
matic models on the world of language disorders use their nonlinguistic or linguistic systems to
was the rethinking of the intervention goals communicate a range of intentions had been
addressed with children who had challenges in documented in the research and confirmed by
the acquisition of speech, language, and commu- clinical experience. Thus, rather than moving on
nication. The fact that nonverbal communication to the development of larger vocabularies and
including gestures, facial expression, body longer sentences, clinicians began to facilitate
language, and vocalizations were now considered the use of the children’s existing systems for
appropriate goals of intervention represented one functions beyond requests, such as greetings,
significant departure from earlier views which comments, and social routines. The idea that
focused on the production of words and children needed to acquire not only the forms of
sentences. For those children who had not yet language but also the interpersonal functions led
developed the capacity to communicate through to an expansion of goals and objectives that has
nonlinguistic forms, the importance of that step in had considerable longevity.
the developmental trajectory on the way to For children whose nonlinguistic and linguistic
language was more fully recognized. In fact, the systems are somewhat unconventional, intervention
goals begin with an attempt to analyze the form- • To facilitate the use of spontaneous, self-
function relationship in that child’s system. One initiated communication, with nonlinguistic
finding from this type of analysis has been that and/or linguistic forms
a child who does not use conventional language • To expand the range of forms used to commu-
may very well be communicating intentions. nicate, including both nonlinguistic forms
Unconventional behaviors, echolalia, delayed (gestures, signs, visual systems) and linguistic
echolalia, and scripts are often attempts to initiate forms (vocalizations, intonation patterns,
conversation and/or to communicate particular words, utterances)
functions and meanings of language. In terms of • To facilitate the use of social referencing, with
a less conventional nonlinguistic system, if a child’s nonlinguistic and/or linguistic forms of
tendency to put his or her face close to that of communication
another person is seen as an attempt to start an • To facilitate the child’s intention to commu-
interaction, the function of the behavior can be nicate in a range of naturalistic contexts (at
acknowledged while more conventional forms are home, on the playground, with adults, with
modeled (“let’s play”). Responding in this way to peers)
a child’s behaviors, with an eye toward the function • To respond to all of the child’s attempts to
they may serve, came from the focus on function in communicate whether they are conventional
the pragmatic analysis of language and communi- or unconventional
cation. Similarly, when working with a child who For children at higher developmental stages of
was using a less conventional linguistic system, language, typical developmental-pragmatic goals
clinicians began to understand the importance of might include:
imbuing the child’s echolalic utterances and • To facilitate participation in conversational
scripting with communicative intent. This response exchanges, playing both the speaker and the
to the child turns a somewhat ambiguous commu- listener roles
nicative moment into a productive one and again • To facilitate the use of contingent responses
illustrates how goals informed by pragmatic think- during conversational exchanges
ing were drastically different from more traditional • To facilitate an understanding of the listener’s
ones. perspective and the need to modify one’s
Developmental-pragmatic goals are deter- nonlinguistic and linguistic communication
mined by assessing the child’s developmental for a range of partners
stage of language acquisition and strengths and • To facilitate the ability to repair communica-
challenges in social-pragmatic domains of tion breakdowns
development. Some examples of typical develop- • To facilitate peer interactions, first in
mental-pragmatic goals for children functioning dyadic interactions and eventually in larger
at earlier stages of development might include the groups
following, written from the perspective of what • To facilitate the coordination of conventional
the SLP will focus on: nonlinguistic and linguistic systems to com-
• To facilitate the child’s interpersonal engage- municate intentions
ment and emotional range (e.g., happy, sad, It should be noted that depending on the
curious, frustrated, angry), with nonlinguistic child’s developmental stage of language, simul-
and/or linguistic forms of communication taneous goals addressing the comprehension
• To facilitate the child’s participation in joint and production of language would be included
attention interactions with an adult, with in an integrated plan of language intervention.
nonlinguistic and/or linguistic forms of Similarly, social-emotional, cognitive-symbolic,
communication and regulation goals will necessarily be consid-
• To facilitate the child’s range of communica- ered in all intervention plans that are addressing
tive intentions, with nonlinguistic and/or lin- the further development of language and
guistic forms of communication communication.
Treatment Participants peers. Remembering that pragmatics refers to the
ability to know what to say when to whom, prag-
One of the most vivid and lasting effects of the matic interventions go beyond the traditional
pragmatic revolution on the field of speech and therapy room and the SLP-child interaction. The
language was the change of thinking about who child’s interactions with typical and atypical
the treatment participants should be during inter- peers must be built into the intervention planning.
vention, Here, again, this notion had particular In fact, quite a few programs have been devel-
resonance for children on the autism spectrum oped where typical peers coach their classmates
because of the nature of their difficulties in inter- who are on the autism spectrum to enhance the D
personal interactions. possibility of more frequent and successful
With the early and continuing interest in prag- exchanges (Kohler, Strain, & Goldstein, 2005).
matic models and social-emotional approaches to Prior to the introduction of developmental-
working with children with developmental chal- pragmatic models, the fact that a successful
lenges, SLPs have been exposed to a deepened language user can communicate effectively with
understanding of the nature of the caregiver-child many different partners was not recognized as
relationship. This relationship sets the stage for a potential language intervention goal. This
the child’s healthy development in all areas of notion led to one of the most significant shifts in
functioning, including the development of the the intervention paradigms of speech-language
comprehension and production of language. pathologists. Improving the child’s ability to
SLPs began to think not only of what was learned communicate with different partners requires
in the prelinguistic period but who was propelling the SLP to consider the child’s interactions with
the development and why this relationship was every person in his or her life and to potentially
key to the process. The notion that more of the use these interactions as the contexts for language
“work” in language intervention should be done therapy.
with the mother or primary caregiver and the
child, rather than the therapist and the child,
continues to be difficult to realize during inter- Treatment Procedures
vention and, yet, is a clear implication of prag-
matic models of language acquisition. Even in The use of developmental-pragmatic models to
settings where it is easier to work with the care- generate treatment procedures requires an under-
giver, such as in early intervention conducted in standing of the way language acquisition pro-
the child’s home, practitioners are not necessarily gresses and language use is realized in authentic
comfortable with the idea of “coaching” a parent communicative contexts. As mentioned in the
during an interaction and, often, prefer to have previous section, implications from a develop-
the parent observe as the therapist interacts with mental-pragmatic model affect decisions about
the child. While understandable, this is not in all the components of therapy, not only what the
sync with the research now spanning more than goals of intervention are and who the participants
30 years, suggesting that the caregiver-child are during intervention but also what procedures
interaction is where the “action” is relative to will be used during treatment. In this discussion,
setting the stage for development. intervention procedures include intervention
Further, because pragmatic models of strategies, intervention contexts, and the role of
language acquisition underscore the fact that lan- the adult during the interaction.
guage use occurs across contexts with different The following list captures the nature of strat-
partners, language intervention which has its egies generated from developmental-pragmatic
roots in this model embraces the notion that the models of language use:
child’s ability to use language must be addressed • Provide many opportunities to facilitate
in a range of real-life situations, including his or sustained engagement and reciprocal interac-
her other interaction with family, teachers, and tions, both nonlinguistically and linguistically.
• Provide many opportunities to expand shared In reference to intervention contexts,

attention and more consistent responsiveness pragmatic views of language suggest that all the
to the communicative partner. contexts of a person’s life are of interest when we
• Interpret all of the child’s behaviors, conven- are studying and supporting language use. Much
tional and unconventional, as intentional and like the idea of different partners, pragmatic
meaningful. models are rooted in the idea of the range of
• Maintain a reciprocal flow by treating all of contexts which make up the person’s life and
the child’s behaviors as communicative as you the variations in both nonlinguistic (setting,
alternate turns in the interaction. activity, participants) and linguistic (prior dis-
• Model the use of nonlinguistic and linguistic course) aspects of each context. As a result,
forms of communication to express the child’s attempts were made to expand the notion of
meanings, messages, and intentions, not yours. “therapy context” to include those activities that
• Engineer the context so that the child has an reflected the child’s typical day (lunch, recess,
opportunity to play both initiator and soccer, classroom, etc.).
responder roles in the “conversation.” Understanding that every moment is
• Engineer “turn-taking,” by expectancy, a potential language intervention moment pushed
waiting, and nonverbal communication. the idea of context in language treatment beyond
• Teach language within the context of natural the previous discrete boundaries. In this view,
interactions and discourse. every interaction offers the child an opportunity
• Embed language training in contexts that are to learn about language use and to practice how to
familiar to the child relative to meaning and be a successful language user. For example,
affectively laden. a 10-year-old child on the autism spectrum, M.,
• Reduce the complexity of your language input who the author sees for language intervention,
while maintaining the “grammar” of language, was interested in interacting with a 2-year-old
the melody, and the interactive flow of boy, J., who he met each week in the waiting
communication. room of the clinic. In his attempt to interact
• Pair language with the child’s actions, interests, with this toddler, M. often hugged J. a bit too
agenda; timing and contextual support are crit- vigorously or spoke to him a bit too loudly.
ical at early stages of language learning. Needless to say, the 2-year-old moved away
• Join in the meaning and affective tone of the from M. and backed into his caregiver’s lap. In
child’s script. order to help M. express his natural interest in
• Teach language when the cognitive, social, interacting with the young child and to have
affective, and pre- and/or corequisites are in a more successful experience, the clinician prac-
place. ticed with him how he might approach the boy
• Teach the child’s parents, teachers, and thera- (i.e., from a distance) and what he might say to
pists how best to facilitate language through- him (e.g., show him a toy). In fact, from
out the child’s daily life. a pragmatic point of view, the SLP welcomes
• Teach language with words and silence. the opportunity to see how the child functions in
• Teach language when the interaction is different contexts in his or her attempt to make
flowing. the therapeutic experience representative of the
• Teach language by matching and meeting the child’s typical interactions and to address those
child and then “up the ante.” missteps that may be interfering with his positive
• Teach pragmatic skills within the context of opportunities for interaction.
natural conversation. Finally, in reference to the role of the adult
• Engineer natural opportunities for promoting during the interaction, pragmatic models of lan-
nonverbal pragmatic abilities such as proxe- guage acquisition and use suggest that the clini-
mics, body language, gestures, and facial cian assume more of a partner and less of
expressions. a teacher role during intervention. The adult is
seen as sharing the communicative interaction in children whose parents became more respon-
with the child, not directing it. Often, the idea of sive (Aldred, Green, & Adams, 2004; Baker,
“following the child’s lead” is used to help par- Messinger, Lyons, & Grantz, 2010; Mahoney &
ents and professionals understand that the child’s Perales, 2003, 2005; Siller & Sigman, 2002).
ideas and intentions should take precedence over The SCERTS (Social Communication, Emo-
the adult’s. With the goals in mind, the adult will tional Regulation, and Transactional Support) pro-
support, scaffold, and facilitate development, gram developed by Prizant et al. (2006) represents
always beginning from where the child is an educational program which embraces the core
and engaging in a dynamic that is more reciprocal components of developmental-pragmatic frame- D
and less adult led. The full impact of works. This program emphasizes functional,
a developmental-pragmatic approach can be developmentally appropriate goals and objectives
seen as therapy sessions which reflect this think- which are addressed in meaningful and purposeful
ing, where adults are watching, waiting, observ- activities throughout the child’s day. The child’s
ing, and then determining based on the child’s individual differences, including learning style
actions, behaviors, vocalizations, body move- and interests, are embraced; the family, educators,
ments, and words how the next steps in develop- and clinicians are seen as a collaborative team.
ment can be encouraged. The description of social communication in
the SCERTS program (Prizant et al., 2006)
as the “development of spontaneous, functional
Efficacy Information communication, emotional expression, and secure
and trusting relationships with children and adults”
Although many language intervention programs speaks to the priorities of all pragmatically ori-
integrate aspects of developmental-pragmatic ented programs. Similar to More Than Words
models of language, two programs in particular (Sussman, 1999), the fact that the family and pro-
reflect the basic tenets of this perspective. The fessionals are taught to respond to the child’s needs
Hanen Program, More Than Words (Sussman, and interests is derived from the focus in develop-
1999), focuses on teaching parents to use respon- mental-pragmatic models on the partner’s roles
sive strategies that promote social interaction and, in the child’s acquisition of language. Prizant,
ultimately, language development. The fact that Wetherby, Rubin, and Laurent (2010) provide
the training is designed to support the primary many references to support the positive outcomes
caregivers in their interactions with their children of training in social communication, with
places this program at the heart of pragmatic approaches that range from those that are more
thinking. Recent studies (McConachie, Randle, behavioral to those that are more representative
& Couteur, 2005; Girolametto, Sussman, & of developmental-pragmatic ones (Kaiser, Han-
Weitzman, 2007) have shown that parents who cock, & Nietfeld, 2000; Wetherby & Woods,
participated in the More Than Words program 2006).
used more responsive interaction strategies than
the control group of parents. Moreover, gains in
vocabulary, frequency of communication, and/or Outcome Measurement
participation in turn-taking routines were noted in
the children. Measuring progress in pragmatic goals and
Other studies have also investigated the objectives has always presented its own set of
effects of responsiveness training on the care- challenges for SLPs. The very nature of pragmat-
givers’ interactive style and the resulting effects ics speaks to the way language use varies relative
on their child’s social interaction and communi- to changing aspects of the context such as the
cation. Specific improvements in joint attention, participants, the setting, nonlinguistic supports,
initiation of communication, periods of engage- ongoing discourse, etc., making measurement for
ment, and expressive language have been noted this area of language more complicated than
others. Perhaps, the best way to think about the outcomes on a daily or weekly basis, and others
emergence of pragmatic behavior is relative to over a longer span of time. When outcome mea-
a continuum of contexts of the child’s life, with surement is being used to determine the success of
outcomes measured within specific contexts a particular step in the program, more frequent
(e.g., the child’s initiation of communication assessment leads to more frequent modification
with one particular peer during toy play). From of the parameters of the treatment plan. Finally,
a pragmatic perspective, intervention progress the SLP who is working from a developmental-
can only be thought of with an understanding of pragmatic framework will want to periodically
the dimensions of natural contexts and real-life measure the child’s progress across the contexts
partners. of his or her life, as a reflection of the ability to use
The outcome measurements of developmental- language in the learning and social interactions
pragmatic interventions span a wide range of that make up his or her day.
behaviors. Unlike most other approaches, these
include both the child’s and the partner’s behav-
iors, as the pragmatic approach is anchored in the Qualifications of Treatment Providers
caregiver’s role in creating interactive exchanges.
In fact, the responsiveness of the caregiver to the The majority of treatment providers for
child’s behaviors is seen as one of the most impor- developmental-pragmatic approaches to lan-
tant aspects of interaction to measure. Given the guage intervention are speech-language patholo-
underlying theory of typical language learning, gists. Those SLPs who are working directly with
clinicians who are working from this framework parents will need additional training in how to
will want to track the parent’s ability to sensitively teach strategies and procedures for affecting
respond to all of the child’s communicative change in the caregivers’ interactive styles
attempts (not just those that involve spoken lan- (e.g., Hanen programs). Other more broadly
guage). Parent responsiveness provides more based developmentally oriented models, such as
opportunities for social interaction and, ultimately, the Developmental, Individual Difference, Rela-
the acquisition of language. tionship-Based (DIR) approach (Greenspan &
All of the goals and objectives indicated in Wieder, 1998), include training components in
the previous section are easily translated into their certificate process for professionals from
outcomes to measure (occasions of intentional a range of disciplines who want to learn how to
communication, use of a range of speech acts, “coach” parents effectively. Once SLPs begin
ability to engage in turn-taking exchanges, etc.). working with parents closely, they are often
Although behavioral principles could be used to aware of the need for further training in counsel-
conceptualize how to measure a new behavior ing in order to deal with the emotional issues
(e.g., 80% criterion), a developmentalist may be typically and understandably raised by the
more comfortable with a continuum of criteria, caregivers.
ranging from “emerging” to “achieved.” Develop- In addition, SLPs working in this model often
mental thinking implies that measures will mirror collaborate with teachers to help them implement
how typical development proceeds gradually over a developmental-pragmatic approach in the class-
time rather than thinking in terms of the use of a room. The SLP will be called on to help other
particular behavior in 8 out of 10 trials. professionals shift their thinking to implement
Developmental-pragmatic models rely heavily the goals and strategies in the contexts of
on checklists of targeted behaviors, question- the child’s academic and social life. Here, again,
naires, naturalistic observation, language sam- the developmental-pragmatic approach requires
pling, and semistructured assessment to measure additional programming and planning on the
the child’s progress in selected goals and objec- part of the SLP as the work moves beyond the
tives. The frequency of assessment will vary with therapy walls and out into the child’s everyday
the program and the system, with some measuring world.
See Also Halliday, M. A. K. (1975). Learning how to mean: Explo-
rations in the development of language. London:
Edward Arnold.
▶ Developmental Intervention Model Kaiser, A., Hancock, T., & Nietfeld, J. (2000). The effects
▶ Pragmatic Language Impairment of parent-implemented enhanced milieu teaching on
▶ Pragmatic Language Skills Inventory the social communication of children who have
▶ Pragmatic Rating Scale autism. Early Education and Development, 11,
423–446.
▶ Social Interventions Kohler, F. W., Strain, P. S., & Goldstein, H. (2005).
Learning experiences. . .. An alternative program for
preschoolers and parents: Peer-mediated interventions D
References and Readings for young children with autism. In E. D. Hibbs & P. S.
Jensen (Eds.), Psychosocial treatments for child and
Aldred, C., Green, J., & Adams, C. (2004). A new social adolescent disorders: Empirically based strategies for
communication intervention for children with autism: clinical practice (2nd ed., pp. 659–687). Washington,
Pilot randomized controlled treatment study suggesting DC: American Psychological Association.
effectiveness. Journal of Child Psychology and Psychi- Mahoney, G., & Perales, F. (2003). Using relationship-
atry, 40, 1–11. focussed intervention to enhance the social-emotional
Baker, J., Messinger, D., Lyons, K., & Grantz, C. (2010). functioning of your children with autism spectrum
A pilot study of maternal sensitivity in the context of disorders. Topics in Early Childhood Special Educa-
emergent autism. Journal of Autism and Developmen- tion, 23, 77–89.
tal Disorders, 40, 988–999. Mahoney, G., & Perales, F. (2005). Relationship-focused
Bates, E. (1976). Language and context: The acquisition intervention with children with pervasive develop-
of pragmatics. New York: Academic Press. mental disorders and other disabilities:
Bates, E. C., Camaiono, L., & Volterra, V. (1975). The A comparative study. Developmental and Behavioral
acquisition of performatives prior to speech. Merrill- Pediatrics, 26, 77–85.
Palmer Quarterly, 21, 205–216. McConachie, H., Randle, V., & Couteur, L. (2005).
Bloom, L., Rocissano, L., & Hood, L. (1976). Adult-child A controlled trial of a training course for parents of
discourse: Developmental intervention between infor- children with suspected autism spectrum disorder.
mation processing and linguistic knowledge. Journal of Pediatrics, 147, 335–340.
Cognitive Psychology, 8, 521–552. Mundy, P., & Sigman, M. (2006). Joint attention, social
Bruner, J. (1975). The ontogenesis of speech acts. Journal competence and developmental psychopathology. In
of Child Language, 2, 1–19. D. Cicchetti & D. Cohen (Eds.), Developmental
Bruner, J. (1977). Early social interaction and language psychopathology, theory and methods (2nd ed.).
acquisition. In R. Schaffer (Ed.), Studies in Hoboken, NJ: Wiley.
mother-infant interaction (pp. 271–289). New York: National Research Council and Institute of Medicine.
Academic Press. (2000). From neurons to neighborhoods: The science
Dore, J. (1974). A pragmatic description of early language of early childhood development. Washington, DC:
development. Journal of Psycholinguistic Research, 4, National Academy Press.
343–350. Prizant, B., & Duchan, J. (1981). The functions of imme-
Dore, J. (1975). Holophrases, speech acts, and language diate echolalia in autistic children. The Journal of
universals. Journal of Child Language, 2, 21–40. Speech and Hearing Disorders, 46, 241–250.
Gerber, S. (2003). A developmental perspective on Prizant, B., Wetherby, A., Rubin, E., & Laurent, A.
language assessment and intervention for children on (2010). The SCERTS model and evidence-based
the autistic spectrum. Topics in Language Disorders, practice. www.scerts.com/docs/SCERTS_EBP%2009
23(2), 74–95. 0810%20v1.pdf.
Gerber, S., & Prizant, B. (2000). Speech, language, Prizant, B., Wetherby, A., Rubin, E., & Rydell, P. (2006).
and communication assessment and intervention for The SCERTS model: A comprehensive approach for
children. In Clinical practice guidelines: Redefining children with autism spectrum disorders. Baltimore:
the standards of care for infants, children, and families Paul H. Brookes.
with special needs. Bethesda, MD: ICDL Press. Prutting, C. (1982). Pragmatics as social competence. The
Girolametto, L., Sussman, F., & Weitzman, E. (2007). Journal of Speech and Hearing Disorders, 47,
Using case study methods to investigate the effects of 123–134.
interactive intervention for children with autism spec- Prutting, C., & Kirschner, D. (1987). A clinical appraisal
trum disorders. Journal of Communication Disorders, of the pragmatic aspects of language. The Journal of
40, 470–492. Speech and Hearing Disorders, 52, 105–119.
Greenspan, S., & Wieder, S. (1998). The child with Siller, M., & Sigman, M. (2002). The behaviours of
special needs. Reading, MA: Addison Wesley parents of children with autism predict the subsequent
Longman. development of their children’s communication.
D 916 Dexedrine
Journal of Autism and Developmental Disorders, See Also

32(2), 77–89.
Snow, C. (1973). Mother’s speech to children learning
language. Child Development, 43, 549–565. ▶ Dextroamphetamine
Snow, C. (1978). The conversational context of language
acquisition. In R. Campbell & P. Smith (Eds.), Recent
advances in the psychology of language (Vol. 4a, References and Readings
pp. 253–269). New York: Plenum Press.
Sussman, F. (1999). More than words: Helping parents
promote communication and social skills in children Handen, B. L., Taylor, J., & Tumuluru, R. (2011).
with autism spectrum disorder. Toronto, ON: The Psychopharmacological treatment of ADHD symp-
Hanen Centre. toms in children with autism spectrum disorder. Inter-
Tomasello, M. (1988). The role of joint attentional pro- national Journal of Adolescent Medicine and Health,
cesses in early language development. Language 23(3), 167–73.
Sciences, 10, 69–88.
Wetherby, A., & Woods, J. (2006). Early social interac-
tion project for children with autism spectrum disor-
ders beginning in the second year of life: A
preliminary study. Topics in Early Childhood Special Dextroamphetamine
Education, 26(2), 67–82.
Evdokia Anagnostou1 and Deepali Mankad2
1
Department of Peadiatrics, University of
Toronto Clinician Scientist, Bloorview Research
Institute, Toronto, ON, Canada
Dexedrine 2
Holland Bloorview Kids Rehabilitation
Hospital, Toronto, ON, Canada
Evdokia Anagnostou1 and Deepali Mankad2
1
Department of Peadiatrics, University of
Toronto Clinician Scientist, Bloorview Research Synonyms
Institute, Toronto, ON, Canada
2
Holland Bloorview Kids Rehabilitation Adderall; Dexedrine
Hospital, Toronto, ON, Canada
Definition
Synonyms
Dextroamphetamine is a stimulant medication
Adderall; Dextroamphetamine useful for the treatment of ADHD symptoms
and narcolepsy. It is available in tablets or
extended release capsules.
Definition Side effects tend to be mild and include insom-
nia, loss of appetite, weight loss, headaches, dry
Dexedrine is a stimulant medication useful mouth, and erectile dysfunction. It can also produce
for the treatment of ADHD symptoms and narco- transient increases in blood pressure and may have
lepsy. It is available in tablets or extended-release an effect on seizure threshold and certain heart
capsules. arrhythmias.
Side effects tend to be mild and include
insomnia, loss of appetite, weight loss, head-
aches, dry mouth, and erectile dysfunction. See Also
It can also produce transient increases in blood
pressure and may have an effect on seizure ▶ Adderall
threshold and certain heart arrhythmias. ▶ Dexedrine
Diagnosis and Classification 917 D
References and Readings USA originally focusing on causes of mortality
but gradually expanding to include a range of
Handen, B. L., Taylor, J., & Tumuluru, R. (2011). diseases and injuries. This effort results in what
Psychopharmacological treatment of ADHD symp-
is now the International Classification of Diseases
toms in children with autism spectrum disorder. Inter-
national Journal of Adolescent Medicine and Health, (ICD-10). In psychiatry, early efforts to assign
23(3), 167–173. diagnoses were limited and classification schemes
highly theoretical in nature; this limited their use
more generally and with clinicians who did not
share similar theoretical orientations. This shifted D
Diagnosis and Classification dramatically with the 3rd edition of the American
Psychiatric Association’s Diagnostic and Statisti-
Fred R. Volkmar cal Manual (DSM-III) (American Psychiatric
Director – Child Study Center, Irving B. Harris Association, 1980) which adopted an atheoretical
Professor of Child Psychiatry, Pediatrics and approach and which quickly came to dominate
Psychology, School of Medicine, Yale psychiatric diagnosis throughout the world.
Current Knowledge
Definition
Diagnosis is intimately related to issues of clas-
As used in medicine (including psychiatry), sification. The tendency to engage in the latter
a diagnosis is determined as part of a diagnostic activity is an intrinsically human activity that has
process in the attempt to identify a specific disor- the potential to facilitate observation and then
der. Diagnoses are used in many ways and for help generate general principles and hypotheses.
different purposes. As both a term and a process, When approaches to classification are shared,
the issue of diagnosis is very much related to communication is enhanced. In medicine in par-
issues of classification. Indeed, the word diagnosis ticular, the assignment of some specific label to
comes through Latin and Greek sources which a condition may itself be a source of relief to the
have to do with understanding/distinguishing patient or family members since it is often
things. In clinical medicine, the assignment of (mistakenly) assumed that having a label implies
a diagnosis often involves various tests, examina- an understanding of etiology and specific treat-
tions, and so forth; the diagnosis typically guides ments. As with any human construction, diagnos-
treatment. In addition, diagnoses have other uses, tic labels can be misused. While official systems
e.g., in public health, in establishing eligibility for like DSM-IV or ICD-10 tend to be organized
services, and so on. Some special issues arise with around categories, other approaches, e.g., using
respect to psychiatric diagnosis and are discussed dimensions of function/dysfunction, could also
subsequently (see also ▶ DSM-IV entry). readily be used. Classification systems vary
depending on their purpose but to be generally
useful that must be amenable to ready and reli-
Historical Background able use by a range of individuals. In the past,
theoretically based approaches to classification
Although diagnoses have been used since antiq- were common but now have given way to more
uity, it was only as the causes of various medical “phenomenologically based” approaches.
illness began to be identified in the 1800s that A number of misconceptions regarding
attempts were made to study the issue more issues of diagnosis and classification should be
systematically, e.g., in relation to causes of death. noted: (1) by itself, deviant behavior does not
This effort took place both in Europe as well as the need to imply a disorder and (2) diagnoses do
D 918 Diagnosis and Classification
not necessarily have to have a biological base noted that disorders not individuals are classified
even when symptoms are expressed somatically (failure to do this results both in problems of
(e.g., maladaptive personality traits can be stigmatization and potential adverse effects of
a disorder and severe psychological stress can labeling).
give rise to a range of persistent physical Having one problem may increase risk for
symptoms). other difficulties (what is termed comorbidity).
Issues for classification arise from numerous It has been noted that for individuals with
sources. One has to do with the primary goal(s) of intellectual disability, there has often been
classification (e.g., to enhance research or to a tendency to overlook other problems (what
facilitate clinical work). Also, there are some is termed “diagnostic overshadowing”). There
special issues for classification in relation to are different approaches to the problem of
difficulties of childhood onset. The two major comorbidity, and the problem is a special
classification systems for psychiatric and devel- challenge for childhood-onset disorders since
opmental disorders (DSM-IV and ICD-10) adopt having one problem may contribute to risk for
approaches that are in some ways similar and in another one.
other ways quite different. Although it is often
assumed that some ideal classification system
must exist in reality, many different factors Future Directions
impact approaches to diagnosis. To complicate
things further, different apparent etiologies might Particularly in the area of psychiatry, DSM-III
result in rather similar clinical pictures, while marked a watershed event in improving diag-
sometimes the same etiological factor is associ- nostic reliability and significantly advanced
ated with a wide range of clinical outcomes; often research in the field. In autism and related
intervention is much more concerned with disorders, similar changes have occurred with
the expression of the clinical problem rather diagnostic systems becoming more and more
than its cause. With a few interesting exceptions data based and, in turn, more likely to advance
(e.g., reactive attachment or post-traumatic stress research in general. New knowledge in the
disorders in DSM-IV), etiologies have typically areas of genetics, biological models, and identi-
not been specified. fication of end phenotypes or intermediate
Difficulties of childhood onset present special endophenotypes may further advance work on
problems for classification and diagnosis. Devel- these disorders.
opmental factors must be considered, e.g., in
relation to the ways they may impact symptom
expression or in the ways the symptoms See Also
may interfere with development. The use of
a multiaxial approach helps in dealing with ▶ Comorbidity
this problem. In the past, theoretically based ▶ DSM-III
approaches to classification were common but ▶ DSM-III-R
now have given way to more “phenomenologi- ▶ DSM-IV
cally based” approaches.
Contextual factors are of great importance in
understanding the clinical expression of condi- References and Readings
tions in children, i.e., family, school, and ethnic
or cultural background may significantly impact American Psychiatric Association. (1980). Diagnostic
the clinical presentation. These issues are often and Statistical Maual (3rd ed.). Washington, DC:
APA Press.
most complicated in very young children where
American Psychiatric Association. (2000). Diagnostic and
disentangling child-maternal difficulties can statistical manual (4th ed., Text Rev.). Washington,
sometimes be quite difficult. It should also be DC: APA Press.
Diagnostic Instruments in Autistic Spectrum Disorders 919 D
First, M. B., & Pincus, H. A. (2002). The DSM-IV text
revision: Rationale and potential impact on clinical Diagnostic Instruments in Autistic
practice. Psychiatric Services, 53(3), 288–292.
Hobbs, N. (Ed.). (1975). Issues in the classification of Spectrum Disorders
children. San Francisco: Jossey-Bass.
Klin, A., Lang, J., Cicchetti, D. V., & Volkmar, F. R. Christina Corsello
(2000). Brief report: Interrater reliability of clinical Department of Psychiatry, Child & Adolescent
diagnosis and DSM-IV criteria for autistic disorder:
Results of the DSM-IV autism field trial. Journal of Services Research Center, University of
Autism and Developmental Disorders, 30(2), 163–167. San Diego, San Diego, CA, USA
Kupfer, D. A., First, M. B., & Regier, D. A. (2002). A D
research agenda for DSM-V. Washington, DC: Amer-
ican Psychiatric Publishing.
Ritvo, E. R., & Freeman, B. J. (1977). National society for Definition
autistic children definition of the syndrome of autism.
Journal of Pediatric Psychology, 2(4), 142–145. Diagnostic measures are designed to capture behav-
Rutter, M. (1978). Diagnosis and definition of childhood iors in the areas of communication, reciprocal social
autism. Journal of Autism and Childhood Schizophre-
nia, 8(2), 139–161. interactions, and restricted and repetitive behaviors
Rutter, M. (1989). Annotation: Child psychiatric disorders that characterize an autism spectrum disorder.
in ICD-10. Journal of Child Psychology and Psychia- These measures attempt to quantify behaviors
try, 30, 499–513. associated with an autism spectrum disorder by
Rutter, M., & Schopler, E. (1993). Diagnosis by
DSM-III–R versus ICD-10 criteria: Response. Journal assigning them numerical scores. These quantita-
of Autism and Developmental Disorders, 23(3), tive behavior scores are then translated into sum-
573–574. mary scores that result in a classification that is
Rutter, M., Shaffer, D., & Shepherd, M. (1975). A multi- typically either consistent with one of the autism
axial classification of child psychiatric disorders: An
evaluation of a proposal. Albany, NY: World Health spectrum disorders or not. Current diagnostic instru-
Organization. ments include parent questionnaires and interviews
Volkmar, F. R., Cicchetti, D. V., Bregman, J., & Cohen, as well as standardized observational measures. The
D. J. (1992a). Three diagnostic systems for autism: time and training required to administer and score
DSM-III, DSM-III–R, and ICD-10. Special issue:
Classification and diagnosis. Journal of Autism and these instruments varies from minimal for parent
Developmental Disorders, 22(4), 483–492. questionnaires to more involved for observational
Volkmar, F. R., Cicchetti, D. V., Bregman, J., & measures and semistructured interviews.
Cohen, D. J. (1992b). Brief report: Developmental
aspects of DSM-III–R criteria for autism. Special
issue: Classification and diagnosis. Journal of Autism
and Developmental Disorders, 22(4), 657–662. Historical Background
Volkmar, F. R., & Klin, A. (2005). Issues in the classifi-
cation of autism and related conditions. In
F. R. Volkmar, A. Klin, R. Paul, & D. J. Cohen One of the first widely used scales for identifying
(Eds.), Handbook of autism and pervasive develop- children with autism was The Rimland Diagnostic
mental disorders (Vol. 1, pp. 5–41). Hoboken, Form for Behavior Disturbed Children (Form E-1;
NJ: Wiley.
Rimland, 1968). This measure was an important
Volkmar, F. R., Schwab-Stone, M., & First, M. (2007).
Classification. In A. Martin & F. Volkmar (Eds.), development in the field, as it focused on identify-
Lewis’s child and adolescent psychiatry: ing carefully selected symptoms of autism.
A comprehensive textbook (4th ed., pp. 302–309). Another early diagnostic measure developed at
Philadelphia: Wolters Kluwer.
around the same time was the Behavior Rating
Wing, L., & Gould, J. (1979). Severe impairments of
social interaction and associated abnormalities. Jour- Scale for Autistic and Atypical Children (BRIAAC;
nal of Autism and Developmental Disorders, 9(1), Ruttenberg, Dratman, Fraknoi, & Wenar, 1966).
11–29. This measure is historically significant because it
World Health Organization. (1992). Mental and behav-
was the first to be based on actual observations
ioral disorders, clinical descriptions and diagnostic
guidelines. In International classification of diseases of behavior from clinician case notes rather than
(10th ed.). Geneva: Author. parent report.
D 920 Diagnostic Instruments in Autistic Spectrum Disorders
The Handicaps, Behaviors and Skills Sched- its current form which includes five modules for
ule (HBS; Wing & Gould, 1978) was also an assessing toddlers through adults with module
early influential measure because it was the first choice dependent on the individual’s age
widely used semistructured parent interview and and language level. The Childhood Autism Rat-
it contributed to the understanding of the “triad of ing Scale (CARS: Schloper, Van Bourgondien,
impairments” that has led to our current under- Wellman, & Love, 2010) is another example of
standing of autism. Not technically considered this evolution, with the addition of a scale for
a diagnostic measure, the HBS was a framework high-functioning autism, as the original version
for gathering information regarding symptoms missed many children with better language and
and behavior that could be utilized in a clinical cognitive skills.
evaluation. This measure has been revised and is
currently known at the Diagnostic Interview for
Social and Communication Disorders (DISCO; Current Knowledge
Wing, Leekam, Libby, Gould, & Larcombe,
2002 – see below). There are currently several measures available
Another scale of importance in the initial for diagnostic purposes, ranging from those that
group of diagnostic measures was the Behavior are very quick to administer and require minimal
Autism Rating Scale (BOS; Freeman, Ritvo, training to those that take more time and train-
Guthrie, Schroth, & Ball, 1978). This measure ing. As with any other psychometric measure,
was the first instrument that emphasized control- diagnostic measures are evaluated based on reli-
ling the environment in which the child was ability and validity data. This section will cover
observed, as well as standardizing the behaviors the most widely used and available diagnostic
that were observed (Lord & Corsello, 2005). protocols. For more detailed information on
Most of these measures have been revised, these measures, please see the respective indi-
with Rimland’s Form E-1 becoming Form E-2, vidual entries included within this encyclopedia
the HBS now the DISCO, and the BOS leading to (Table 1).
the development of the Real Life Rating Scale
(RLRS; Freeman, Ritvo, Yokota, & Ritvo, 1986). Parent Questionnaires
Diagnostic measures have evolved over time, The Autism Behavior Checklist (ABC): This
both because diagnostic criteria have changed questionnaire is one component of the Autism
with each revision of the Diagnostic and Statisti- Screening Instrument for Education Planning
cal Manual, Fourth Edition (DSM-IV), and (ASIEP; Krug, Joel, & Almond, 1980), now in
because empirical studies continue to provide its third revision. It builds on several other mea-
information about how well each measure differ- sures, including Rimland’s Form E-2, the BOS,
entiates children with autism from those without and the BRIAAC. It contains five items across
autism based on current definitions. The diagnos- five areas, and ranges are provided to distinguish
tic measures have changed as we have learned a high probability of autism, a low probability of
more about the disorder, including the expansion autism, or mixed probability. Standard scores are
of age range and developmental levels of children available for children between the ages of 3 and
included within this diagnostic group. 13 years. It was initially intended to be completed
As the current gold standard in autism diag- by teachers or other professionals working with
nostic measures, the Autism Diagnostic Observa- a child. This measure requires no special training.
tion Schedule (ADOS; Lord et al., 2000) It has also been used with parents on a retrospec-
illustrates the change from DSM III to DSM IV tive basis for children with high-functioning
criteria to now include Asperger’s syndrome and autism. One concern regarding this measure,
pervasive developmental disorder, not otherwise however, is its low sensitivity, as many children
specified on the spectrum. This measure evolved on the spectrum appear to be missed using the
from its original form developed in the 1980s to suggested cutoff score.
Diagnostic Instruments in Autistic Spectrum Disorders, Table 1 Summaryof measures
Administration Diagnostic
Measure Format time Age range criteria used Training Suggested use
SRS Parent/teacher/self-report 15 min Preschool DSM-IV None Screening/
questionnaire to response to
adulthood treatment
SCQ Parent/caregiver 15 min Preschool DSM-IV None Screening
questionnaire to
adulthood
GARS-2 Parent/caregiver 15 min Preschool DSM-IV None Screening
D
questionnaire to
adulthood
CARS-2 Clinician rating based on 30 min Preschool DSM-III-R Minimal Diagnostic
observation to
adulthood
BSE-R Rating based on observation, 5 min 1½ to 12 N/A Yes Symptoms for
review of records, and years research
interview
ABC Teacher questionnaire Not specified 3–13 years DSM-IV Minimal Measure
maladaptive
behavior
PDDRS Parent questionnaire Not specified Not DSM-III-R None Screening
specified
GADS Parent questionnaire 10 min 3–22 years DSM-IV Yes Assess Asperger’s
disorder behavior
ASAS Parent or teacher 10 min 3–19 years Not specified None Screening
questionnaire
ADI-R Semistructured interview 1.5–3 h Toddler to DSM-IV Yes Research and
adulthood clinical diagnosis
DISCO Semistructured interview 2–3 h Any age ICD-10 Yes Assess individual
needs, treatment
goals
ASDI Semistructured interview Not specified Not Gillberg’s None Screening
specified criteria
AOSI Semistructured observation 20 min 6–18 DSM-IV Yes Early
months identification
ADOS Observation 30–60 min Toddler to DSM-IV Yes Research and
adulthood clinical diagnosis
PEP-III Caregiver report and clinical 45–90 min 1–7 years DSM-IV Minimal Assess
observation development,
create treatment
goals
The Australian Scale for Asperger’s Syndrome measure, and the original study had several meth-
(ASAS): This questionnaire includes 19 items odological issues, including raters who were not
covering five areas and is scored on a seven blind to diagnosis. Though the measure does not
point Likert-type scale. It is designed to be com- result in a classification of Asperger’s disorder, as
pleted by a teacher or parent and covers ages a screener, it provides information on whether
3–19 years. The authors recommend that the a child should receive a diagnostic evaluation.
measure be used as a screener rather than Behavior Summarized Evaluation – Revised
a diagnostic measure because of low specificity. (BSE-R): This rating form is comprised of items
There are little published data available on this from two overlapping instruments, the Behavioral
Summarized Evaluation Scale (BSE) and the Infant probability of an Asperger’s disorder. As with
Behavioral Summarized Evaluation Scale (IBSE; the GARS, the standardization sample diagnosis
Barthelemy et al., 1997). It is primarily designed to was reported by parent or professional and not
document behavioral symptoms associated with confirmed.
autism as they relate to neurophysiological mea- The Gilliam Autism Rating Scale – Second
sures. These scales consist of 20 items scored on Edition (GARS-2): This questionnaire has
a five-point Likert scale by trained raters on the recently been revised and is now known as the
basis of direct or videotaped observation, discus- GARS- 2. It consists of 56 items across four sub-
sion of the child’s history, and access to informa- scales, covers the ages between 3 and 22 years,
tion from multiple sources. It covers the ages of 18 and takes approximately 5–10 min to administer.
months through 12 years and takes approximately The measure is based on DSM-IV and Autism
five minutes to administer. Interrater reliability and Society of America criteria and results in an
convergent validity is reported to be strong. autism quotient that indicates whether a child
The Childhood Autism Rating Scale – Second has a “low probability” or a “high probability”
Edition (CARS-2): This rating form has been one of having autism. No training is required. The
of the strongest, best documented, and most measure is intended for screening; however,
widely used rating scales for behaviors associated several studies using the original version of the
with autism. It consists of 15 items on which GARS found that it missed up to 52% of
children and adults are rated, generally after the children who met diagnostic criteria for
observation, on a four-point Likert scale and autism clinically and received scores within
results in classifications of not autistic or mild to the autism range on other standardized diagnostic
severe autism. This measure, most commonly measures (South et al., 2002). The initial norma-
completed by a clinician based on observation, tive sample was large, but the diagnoses were
requires minimal training and approximately reported by the parent and not confirmed. Revi-
15 min to complete. The revision of this measure sions to the GARS-2 have attempted to address
includes a form to better capture children with these concerns by lowering the cutoff score and
high-functioning autism and is recommended for providing a new normative sample. As with the
use with individuals whose IQs are above 70 and initial normative sample, not much information is
who are over the age of 6 years. The original available on the group. While the measure is
CARS form has not changed and is included in considered to be appropriate for use with adults,
the CARS-2 for use with children under the age scores should be interpreted cautiously because
of 6 years or who have lower IQ scores. The only 9% of normative sample was over 16 years
CARS-2 was recently adapted, and there are (Montgomery, Newton, & Smith, 2008).
not yet many research studies evaluating the The Pervasive Developmental Disorders
effectiveness of the rating scale for children Rating Scale (PDDRS): This measure is a revi-
with high-functioning autism. sion of an earlier scale (Eaves, 2003). It includes
The Gilliam Asperger’s Disorder Scale 51 items across three subscales and is based on
(GADS): This parent questionnaire consists of the DSM-III-R. Each behavior is based on a five-
32 items and is based on DSM-IV and ICD-10 point Likert scale. A child is considered to fall
criteria of Asperger’s disorder. It takes approxi- within the range of an autism spectrum disorder if
mately 5–10 min to score and also includes both the total score and arousal score fall one
a parent interview section that is not scored but standard deviation below the mean. No standard
provides information on language and cognitive diagnostic procedure was used to define the
and adaptive behavior which is important in sample, and therefore the suggested use of
differentiating Asperger’s disorder from other the PDDRS is for screening only.
autism spectrum diagnoses. Like the Gilliam Social Communication Questionnaire (SCQ):
Autism Rating Scale (GARS), this measure This questionnaire, formerly known as the
results in an Asperger’s quotient of low or high Autism Screening Questionnaire, is based on
a well-validated standardized parent interview, the 18 years of age. More recently, two additional
Autism Diagnostic Interview – Revised (ADI-R). It versions have been developed and are available
was initially designed as a screening measure and for research use and are soon to be available for
consists of 40 items that cover the areas of com- use clinically: an adult version in a self-report and
munication, reciprocal social interactions, and other report form, and a preschool version.
restricted and repetitive behaviors and interests. It Suggested uses include screening and response to
is designed to be filled out by a parent and takes treatment.
approximately 15 min to complete. No training is
required, and scoring instructions are available in Semistructured Interviews D
the manual. The Autism Diagnostic Interview – Revised (ADI-
There are two versions of the measure, R): The ADI-R is one of the most widely validated
a “current” version that is designed for children diagnostic measures available. Based on DSM-IV
under the age of 5 years and covers current criteria, it is administered as a semistructured inter-
behavior, and a “lifetime” version that is view by a clinician to a parent or caregiver, and
designed for children over 5 years of age to adult- covers current behavior for all children and histor-
hood and covers early behavior, focusing on the ical information for older children and adults. The
ages between 4 and 5 years. For children under measure consists of 89 items that are coded on a 0–
the age of 5 years, several studies have found that 3 point scale, several of which are transferred to
a lower cut off score of greater than or equal to 12 a diagnostic algorithm that results in a diagnostic
results in the greatest diagnostic differentiation. classification. One of the biggest weaknesses of
For those older than 5 years of age, scores of this measure is administration time, which is
greater than or equal to 15 are considered to be between 1.5 and 3 h. The extensive reliability and
significant and suggestive of a possible autism validity data available for the ADI and the clini-
spectrum disorder. cally rich information it provides make this mea-
Little information is available on its use with sure the gold standard in research despite its
children under the age of 3 years. It works fairly lengthy administration time.
well as a screener for children over the age of The Asperger’s Syndrome (and High-
3 years, with the modified cutoff for children Functioning Autism) Diagnostic Interview
under the age of 5 years. It has higher specificity (ASDI): This measure was designed as a diagnostic
than many screening measures, and its perfor- tool for verbally fluent individuals with autism and
mance has been found to be similar to a standard- Asperger’s disorder. It is a semistructured inter-
ized diagnostic interview in at least one study view based on Gillberg’s criteria and includes 20
(Corsello et al., 2007). items that operationalize six criteria. The inter-
Social Responsiveness Scale (SRS): This ques- viewer is instructed to obtain descriptions of actual
tionnaire was initially developed to measure social behaviors to accurately code each item. This inter-
and communication difficulties along a continuum. view does well in distinguishing Asperger’s disor-
It consists of 65 items covering the areas of com- der from psychiatric disorders and normality, but
munication, reciprocal social interactions, and has yet to develop a means of distinguishing
restricted and repetitive behaviors and interests. Asperger’s from autism (Gillberg, Gillberg,
Gender norms are available, and the measure Rastam, & Wentz, 2001).
results in a T-score and a social severity impair- The Diagnostic Interview for Social and Com-
ment score ranging from typical to severe. Both munication Behaviors (DISCO): This measure is
a teacher version and a caregiver version are a standardized semistructured interview based on
currently available, and each takes approximately the HBS, and it is now in its ninth revision. It
15–20 min to complete. The SRS does not require was designed to obtain behaviors relevant to the
training to administer, and instructions for scoring diagnosis of autism for the purpose of assessing
are included in the manual. The first version of individual needs and development across several
the SRS was designed for children between 4 and areas. The DISCO includes items that cover the
areas associated with autism spectrum disorders, on a small sample were fair to good. Reliability
as well as developmental items and atypical was calculated using kappas, and a skewed distri-
behaviors. This measure was not originally bution may affect results. Scores at the ages of 12
designed for diagnostic purposes, but rather to and 18 months were considered to be predictive of
assist clinicians in generating recommendations a later diagnosis of autism. Available data has been
for older individuals with an autism spectrum on high-risk infant groups, primarily high-risk sib-
disorder. Diagnostic algorithms have been devel- lings, and on relatively small samples. The
oped for research purposes intended use of this measure is to identify children
who may be likely to later meet criteria for
Observational Measures a diagnosis of autism in a high-risk sample, and
The Autism Diagnostic Observation Schedule it is available for use in research protocols
(ADOS): The ADOS is one of the most widely (Bryson, Zwaigenbaum, McDermott, Rombough,
studied and used diagnostic instruments, and, & Brian, 2008).
along with the ADI-R, is considered the gold stan- The Psychoeducational Profile Revised
dard in research studies. It is a semistructured (PEP-3): This measure was designed to assess
observational measure that consists of several development and diagnostic characteristics of
tasks that are administered to a child or adult for children with an autism spectrum disorder. This
diagnostic purposes. The measure includes a num- measure was designed for children between 12
ber of coded behaviors that allow for assessment in months and 7 years of age. The PEP-3 consists of
the areas of communication, reciprocal social inter- a pathology section that is designed to measure
actions, and restricted and repetitive behaviors and the severity of behaviors associated with autism
interests. Scores are transferred to an algorithm and spectrum disorders. There is little information
result in a classification of autism, autism spectrum available on the reliability or validity of the
disorder, or non-spectrum. pathology section. The PEP-R was primarily
The ADOS is based on DSM-IV criteria and designed to assess development and create treat-
takes approximately 30–60 min to administer. It ment goals. This measure requires approximately
is organized into five modules covering children 45–90 min to administer and requires experience
of toddler age who use little or no phrase speech with children with autism spectrum disorders.
to older children and adults with fluent language. The suggested uses are primarily to create treat-
A toddler module has recently been added. Now ment goals and to assess development.
there are also revised algorithms designed to
improve specificity without sacrificing sensitiv-
ity, as well as newly developed severity scores for Future Directions
the purpose of measuring change over time. The
ADOS requires training and experience with Diagnostic measures continue to be modified and
autism spectrum disorders. refined as more is learned about their effectiveness,
The Autism Observation Scale of Infancy as the diagnostic criteria for autism spectrum dis-
(AOSI): The AOSI is a semistructured, standard- orders changes with new revisions of the diagnostic
ized observational measure designed for infants manual, and as health-care funding changes. There
between 6 and 18 months of age. It consists of continues to be a need for measures that can be
18 items covering specific behaviors that have used for research and clinical purposes. Standard-
been considered to be early indicators of a later ized observational measures are generally brief
autism spectrum disorder diagnosis based on enough to be used as part of a clinical evaluation
empirical studies and clinical experience. Training or research protocol. Several studies suggest that
on administration and scoring is required. Interrater using both a standardized parent interview in con-
reliability on a small sample of infants was good to junction with a standardized diagnostic observa-
excellent with the exception of a subset of items at tional measure and clinical judgment results in
the 6 month assessment. Interrater reliability scores the most accurate diagnosis. However, the most
well-validated diagnostic interview, the ADI-R, is Corsello, C., Hus, V., Pickles, A., Risi, S., Cook, E. H., Jr.,
long and takes time to administer. As funding Leventhal, B. L., et al. (2007). Between a ROC and
a hard place: Decision making and making decisions
changes, there is an increasing need for more effi- about using the SCQ. Journal of Child Psychology and
cient diagnostic measures, and consequently, Psychiatry, 48(9), 932–940.
attempts have been made to use more question- Eaves, R. C. (2003). The Pervasive Developmental Disor-
naires and to decrease the length of time required ders Rating Scale. Opelika, AL: Small World.
Freeman, B. J., Ritvo, E. R., Guthrie, D., Schroth, P., &
to conduct standardized interviews. Screening Ball, J. (1978). The behavior observation scale for
measures and questionnaires are also being refined autism: Initial methodology, data analysis, and prelim-
to make them more suitable for diagnostic use in inary finding on 89 children. Journal of the American D
research protocols. Academy of Child Psychiatry, 17, 576–588.
Freeman, B. J., Ritvo, E. R., Yokota, A., & Ritvo, A.
As a field, we have begun to recognize youn- (1986). A scale for rating symptoms of patients with
ger children as at risk for autism spectrum the syndrome of autism in real life settings. Journal
disorders, requiring measures that can identify of the American Academy of Child Psychiatry, 25,
toddlers that may later develop the disorder. 130–136.
Gillberg, C., Gillberg, C., Rastam, M., & Wentz, E.
Interviews and questionnaires are also being (2001). The Asperger syndrome (and high-functioning
extended, downward to identify the youngest autism) diagnostic interview (ASDI): A preliminary
children and upward to better capture older and study of a new structure clinical interview. Autism,
higher functioning children with autism spectrum 5(1), 57–66.
Krug, D. A., Joel, A., & Almond, P. (1980). Behavior
disorders. As treatment attempts to address the checklist for identifying severely handicapped individ-
core deficits of autism spectrum disorders, there uals with high levels of autistic behavior. Journal of
have also been requests to develop measures that Child Psychology and Psychiatry, 21(3), 221–229.
can capture response to treatment. This has, in Lord, C., & Corsello, C. (2005). Diagnostic instruments in
autism spectrum disorders. In F. R. Volkmar, R.
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The fifth revision of the DSM is expected (3rd ed., pp. 730–771). New York: Wiley.
within the next few years and will lead to mod- Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Jr.,
Leventhal, B. L., DiLavore, P. C., et al. (2000). The
ifications in current measures to match the new autism diagnostic observation schedule-generic:
diagnostic criteria. Currently there are several A standard measure of social and communication
very strong diagnostic measures available for deficits associated with the spectrum of autism.
use for screening or diagnosis of autism spec- Journal of Autism and Developmental Disorders,
30(3), 205–223.
trum disorders. The diagnostic measures in Montgomery, J. M., Newton, B., & Smith, C. (2008).
the field of autism are dynamic and evolving, Review of GARS-2: Gilliam autism rating scale-
with their widespread use in both clinical second edition. Journal of Psychoeducational Assess-
and research settings leading to modifications ment, 26(4), 395–401.
Rimland, B. (1968). On the objective diagnosis of infantile
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Bryson, S. E., Zwaigenbaum, L., McDermott, C., South, M., Williams, B. J., McMahon, W. M., Owley, T.,
Rombough, V., & Brian, J. (2008). The autism Filipek, P. A., Shernoff, E., et al. (2002). Utility of the
observation scale for infants: Scale development and Gilliam Autism Rating Scale in research and clinical
reliability data. Journal of Autism and Developmental populations. Journal of Autism and Developmental
Disorders, 38, 731–738. Disorders, 32(6), 593–599.
D 926 Diagnostic Interview for Social and Communication Disorders
Wing, L., & Gould, J. (1978). Systematic recording of symptoms (e.g., sensory symptoms, emotion
behaviours and skills of retarded and psychotic chil- symptoms, gross and fine motor skills, psychiat-
dren. Journal of Autism and Childhood Schizophrenia,
8, 79–97. ric and forensic problems, maladaptive behavior,
Wing, L., Leekam, L., Libby, S., Gould, J., & sleep difficulties, etc.), and (c) that it has a strong
Larcombe, M. (2002). The diagnostic interview for developmental focus, including the detailed
social and communication disorders: Background, assessment of current developmental level and
inter-rater reliability and clinical use. Journal of
Child Psychology and Psychiatry, 43, 307–325. developmental delay.
The Diagnostic Interview for Social and Com-
munication Disorders (DISCO) is based on
a concept of a spectrum of autistic disorders that
predated the earliest ICD and DSM criteria for
Diagnostic Interview for Social and autism and pervasive developmental disorders
Communication Disorders (Wing, 1988, 1996; Wing & Gould, 1979). This
concept is similar to, but wider than, the concept
Susan Leekam of pervasive developmental disorders (PDD)
School of Psychology Cardiff University, described in DSM-IV and ICD-10. Therefore,
Cardiff, UK the use of the DISCO enables diagnosis of spe-
cific autism conditions according to DSM-IV and
ICD-10, but the DISCO goes beyond this. Infor-
Synonyms mation collected is placed in a broad develop-
mental and behavioral context that reflects
DISCO a dimensional view of a spectrum of autistic
disorder and emphasizes its broad-ranging
nature. Therefore, an individual’s difficulties
Abbreviations with reciprocal social interaction, communica-
tion, and repetitive behavior can be understood
ADI-R Autism diagnostic interview-revised against the pattern of their developmental skills
PDD Pervasive developmental disorders and associated abilities and difficulties. In
addition, symptoms of other related disorders
(e.g., language, attention, or motor impairments)
Description can be elicited for further investigation. Further-
more, as the DISCO is concerned with the assess-
The Diagnostic Interview for Social and Commu- ment of needs as well as with the diagnosis of
nication Disorders (DISCO) is a semistructured ASD, the information it collects is relevant for
interview schedule used with the parent or carer guiding recommendations relating to manage-
of an individual to elicit a broad picture of the ment and interventions.
individual’s behaviors and needs. Its primary The DISCO interview schedule comprises
purpose is to elicit information relevant to the more than 300 questions that are organized into
autistic spectrum in order to assist clinicians in eight parts. Part 1 provides a factual record of
their judgment of an individual’s level of devel- family, medical, and identifying information.
opment, disabilities, and specific needs. It con- Part 2 deals with the first 2 years of life. This
tains sets of algorithms for diagnosis of autism infancy section consists of medical questions rel-
according to the international classification evant to the diagnostic criteria for Rett’s syn-
criteria (ICD and DSM) and other sets of diag- drome and a further set of questions relating to
nostic criteria. Key features of the DISCO are behaviors. Part 3 “Developmental Skills” forms
(a) that it can be used at any age, (b) that it the largest part of the DISCO. This section
collects extensive information not only on the comprises subsections related to the following
core symptoms of autism but also beyond these domains: (a) gross motor skills, (b) self-care,
Diagnostic Interview for Social and Communication Disorders 927 D
(c) domestic skills, (d) independence, (e) verbal “pervasive developmental disorders” (World
and nonverbal communication, (f) social interac- Health Organization [WHO], 1993). Selected
tion with adults and peers, (g) social play and items throughout the interview provide the diag-
leisure, (h) imagination, (i) pictures, reading, nostic criteria not only for these diagnostic sys-
and writing, (j) visuo-manual skills, and (k) cog- tems but also for other diagnostic systems. These
nitive skills. All the items are rated by the inter- diagnostic systems include (a) Kanner’s early
viewer in terms of three aspects: (a) current level, infantile autism (Kanner & Eisenberg, 1956),
(b) delay in acquiring relevant skills, and (c) (b) Asperger’s syndrome based on Gillberg and
untypical (or unusual) behavior associated with Gillberg (1989) (Ehlers & Gillberg, 1993; Wing, D
the relevant skills. The untypical behaviors cover 1981), (c) autistic spectrum disorder (Wing &
both the past and present behaviors. Gould, 1979), and (d) Wing and Gould’s defini-
Other parts of the DISCO also record both tion of social impairment.
the past and present behavior patterns of the indi- Completion of the entire interview takes
vidual. Part 4 on repetitive activities includes approximately 2–3 h, and this provides a compre-
subsections on stereotypies, atypical sensory hensive picture of the individual’s skills and
responses, and repetitive routines. Part 5 on emo- abilities. This is particularly useful for complex
tions includes questions on anxiety and mood cases. However, it is possible to adapt the DISCO
changes. Part 6 on maladaptive behavior is for specific purposes. For example, in some cases,
concerned with behavior that impinges adversely some sections may not be needed such as the
on other people such as aggression and temper section on medical/family information, where
tantrums and disturbances of sleep. Part 8 on information may already be recorded, or the sec-
psychiatric conditions and forensic problems tion on psychiatric conditions and forensic prob-
includes considerations of a range of psychiatric lems which applies to adolescents and adults.
conditions relevant for adolescents and adults There may also be cases where the clinician
that may need further investigations such as needs only to obtain information on the current
symptoms of schizophrenia, personality disor- clinical picture, and therefore questions about
ders, and eating disorders, and this part also delays in development and past behavior can be
includes specific subsections on catatonic fea- omitted. It is also possible to complete the inter-
tures and sexual problems. view using only items relevant for the diagnostic
Finally, there is a separate section (Part 7) to algorithms.
help guide clinicians to arrive at a clinical judg- The DISCO is distinctively different from
ment independent of quantitative results. This other interview schedules, such as the Autism
part includes the interviewer’s judgment on the Diagnostic Interview-Revised (ADI-R) (Lord,
quality of social interaction, social communica- Rutter, & Le Couteur, 1994), that were designed
tion, social imagination, and overall pattern of to be closely related to the ICD-10 research
activities. Whereas elsewhere during the inter- criteria for childhood autism (WHO, 1993) and
view, the aim is for the interviewer to establish for DSM-IV autistic disorder (APA, 1994). The
the facts related to specific skills or behavior, in DISCO is more detailed in the information it
Part 7, the ratings are made on an overview of all collects and is broader and more developmental
the available information. This part of the sched- in focus. For example, the interviewer collects
ule usually does not involve direct questioning of information on a very large number of separate
the informant and elicits judgments by the items each covering specific examples of types of
interviewer. behavior, from the most common to the rare, in
As mentioned above, the DISCO enables diag- order to facilitate the final clinical judgments.
nosis of specific autism conditions according to The interviewer also records the individual’s cur-
DSM-IV category “pervasive developmental rent developmental level and their developmental
disorders” (American Psychiatric Association delays for all domains of functioning. Finally,
[APA], 1994) and the ICD-10 category the interviewer can then apply a number of
algorithms for different diagnostic systems using assessment of needs, and the specialist psycho-
the DISCO. logical assessment. Stage 1 is for 3 days preceded
The DISCO can be used both clinically by pre-course work and followed by evaluated
(see section “Clinical Uses” below) and for interim coursework. Stage 2 is for 2 days leading
research. A number of research studies have to accreditation. A computer program is available
been published using different data sets to exam- for accredited users. Training is available for
ine its psychometric properties (see section “Psy- clinicians involved in diagnosis and assessment
chometric Data” below). Research using the of needs and for professionals who use DISCO
DISCO includes examination of its algorithms for research. Information about training is avail-
for Asperger’s syndrome, for Wing and Gould’s able from the following email address: elliot.
autistic spectrum disorder, and for ICD-10 child- house@nas.org.uk.
hood autism (Leekam et al., 2002; Leekam,
Libby, Wing, Gould, & Gillberg, 2000). Research
has also used the DISCO to investigate the role of Historical Background
associated sensory symptoms (Leekam et al.,
2007), the adult outcomes of autism (Billstedt, The origins of the DISCO are to be found in
Gillberg., & Gillberg, 2007; Cederlund et al., a study comparing children with autism with
2008), ASD symptoms and behavioral profiles children with other disabilities (Down’s syn-
in Rett’s syndrome (Wulffaert et al., 2009a), Cor- drome, developmental receptive language disor-
nelia de Lange syndrome (Wulffaert et al., 2009), ders, developmental expressive language
mild intellectual disability (Soenen et al., 2009), disorders, partial sight and partial hearing) and
gender dysphoria (de Vries, Noens, Cohen- a group of children with typical development
Kettenis, van Berckelaer-Onnes, & Doreleijers, (Wing, 1969). The “Childhood Behavior Sched-
2010), fetal alcohol syndrome (Mukherjee, Lay- ule,” a questionnaire sent to parents by post, was
ton, Yacoub, & Turk, 2011), and the link between designed for this study. It elicited information
epilepsy and autism symptoms (Danielsson, concerning the social, language, imagination,
Gillberg, Billstedt, Gillberg, & Olsson, 2005; and motor impairments and the odd responses to
Turk et al., 2008). Epidemiological studies have sensory input and stereotyped behavior found in
also used the DISCO to study autism in adulthood autism. These behaviors are now covered in
(Brugha et al., 2011) and in the population of the much more detail in the DISCO.
Faroe Islands (Ellefsen et al., 2006). In addition, The original questionnaire schedule was
items within the DISCO have extracted to reorganized and expanded to include items on
form research questionnaires and checklists for developmental skills and was named the “Handi-
research purposes. These research measures have caps, Behavior, and Skills (HBS)” schedule.
been used in studies of autism and typical A variety of sources were used when constructing
populations. For example, a checklist has been the developmental items, including Cooper,
used to investigate the empirical clustering of Moodley, and Reynell (1978), Doll (1965), Egan,
symptoms and cognitive abilities (Prior et al., Illingworth, and MacKeith (1969), Griffiths
1998) and the relation between language delay (1967), Sheridan (1973, 1977), and Williams and
and diagnosis (Eisenmajer et al., 1996) and Kushlick (1970). The HBS was used for research
a questionnaire used in the study of the develop- in an epidemiological study of autism spectrum
ment of repetitive behaviors (Leekam et al., disorders in children in the former London
2007). Borough of Camberwell (Wing & Gould, 1979)
Training for the DISCO has been developed and in a follow-up of the children into adult life
by Dr. Judith Gould and Dr. Lorna Wing and (Wing, 1988). The original epidemiological study
consists of a 5-day training course in two stages. was designed to identify children with any of the
Training covers the Lorna Wing Centre’s method features of autism in order to see if any clinical
of diagnosis, the complexities of diagnosis and patterns could be discovered. This distinguished it
Diagnostic Interview for Social and Communication Disorders 929 D
from previous studies (e.g., Lotter, 1966, 1967) 3–11 years. Thirty-six had autistic spectrum dis-
which looked specifically for children showing order, 17 had learning disability, and 14 had
the narrow criteria originally suggested by Kanner language impairments. Inter-rater reliability was
and Eisenberg (1956). analyzed for over 400 items in the interview.
The DISCO interview schedule was devel- Inter-rater reliability was high with kappa coeffi-
oped from the HBS schedules for use in diagnos- cient or intra-class correlation at.75 or higher for
tic work for both clinical work and research over 80% of the interview items. Analyses with
purposes. It was designed to include referrals the same sample examined two algorithms based
with associated physical or psychiatric conditions on the ninth revision of the schedule (DISCO 9). D
or other developmental disorders such as dyslexia Algorithm diagnoses were applied to interview
and dyspraxia. The schedule was developed to be items in order to analyze the relationship between
relevant for all these variations in the clinical clinical and algorithm diagnoses and the inter-
pictures. It has been expanded to include past rater reliability between interviewers for each
behavior from infancy onward as well as for algorithm output. Results showed that clinical
current state. It is also suitable for use with adults diagnosis was significantly related to the diagnos-
(see section on “Clinical Uses” below). tic outputs for both algorithms and inter-rater
Reliability and validity studies of the DISCO reliability was high for both algorithms. The
items were published in 2002 (see section on ICD childhood disorder algorithm produced
“Psychometric Data” below), when the ninth ver- more discrepant diagnoses than the Wing and
sion was current (Leekam, Libby, Wing, Gould, Gould’s autistic spectrum algorithm. Analysis of
& Taylor, 2002; Wing, Leekam, Libby, Gould, & the ICD-10 algorithm items and combination of
Larcombe, 2002). The schedule has had two sub- items helped to explain the reason for these
sequent minor revisions and the current version is discrepancies.
the eleventh revision and research has been The Swedish study (Nygren et al., 2009) used
published on both these versions (see “Psycho- a translation of the tenth version of the DISCO
metric Data” section). To date, research has been (DISCO-10). Validity analysis compared DISCO-
published using the algorithms of ICD-10 child- 10-algorithm diagnoses with clinical diagnoses
hood autism, ICD-10 Asperger’s syndrome, and and with Autism Diagnostic Interview-Revised
ICD-10 atypical autism, Gillberg’s Asperger’s (ADI-R) algorithm diagnoses in 57 cases of chil-
syndrome, and Wing and Gould’s autism spec- dren and adults. Results showed good to excellent
trum disorder (see Leekam et al., 2000 and inter-rater reliability in 40 cases. The criterion
Leekam et al., 2002). Research using the other validity was excellent when compared with clinical
algorithms – DSM-IIIR pervasive developmental diagnoses and the ADI-R. The report concluded
disorders (American Psychiatric Association, that although the DISCO-10 is not as widely used
1987), Kanner’s and Eisenberg’s criteria (Kanner as the ADI-R, the evidence shows that it has the
& Eisenberg, 1956), and Wing and Gould’s def- same level of psychometric credibility.
inition of social impairment – has not yet been The most recent psychometric research has
published. been carried out by Maljaars, Noens, Scholte, and
Berckelaur-Onnes (2011) using the Dutch transla-
tion of the DISCO-11. Their study included young
Psychometric Data children with different levels of intellectual disabil-
ity (ID) including no ID, borderline, mild, moder-
The psychometric properties of the DISCO have ate, and severe ID. DISCO algorithms for ICD-10
been examined in studies carried out in UK, in childhood autism and atypical autism were used in
Sweden, and in Holland. The UK studies comparison with clinical classification and the
(Leekam et al., 2002; Wing et al., 2002) used Autism Diagnostic Observation Schedule (ADOS;
DISCO-9 to carry out inter-rater reliability and Lord et al., 1999) and Social Communication
validity analyses with data from 82 cases aged Questionnaire (SCQ: Rutter et al., 2003) to
examine its criterion and convergent validity. the information gathered from the DISCO allows
Sensitivity and specificity of the DISCO were.96 the experienced clinician to use their clinical
and.79, respectively. Strong agreement was found judgment to make a working diagnosis in order
between DISCO-11 and ADOS classification to plan a management program. Finally, another
(k ¼.69, p <.001), although lower agreement was important purpose of the DISCO is to provide
found with the SCQ (k ¼.49, p <.001). Compari- information that will guide a clinician’s recom-
sons with clinical diagnosis showed correct classi- mendations concerning programs of education,
fication for the majority of cases with mismatches adult support, and management of behavior.
mainly explained by cases in the moderate and
severe ID range. These results confirm that the
DISCO has good criterion and convergent validity. See Also
This was especially the case for those with average
intelligence or mild intellectual disability. How- ▶ Asperger, Hans
ever, the specificity was lower for those with ▶ Autism Diagnostic Observation Schedule
moderate and severe levels of intellectual disability ▶ Diagnostic Instruments in Autistic Spectrum
(IQ < 50), in line with previous findings. Disorders
▶ Epilepsy
▶ Fetal Alcohol Syndrome
Clinical Uses ▶ ICD 10 Research Diagnostic Guidelines
The DISCO schedule can be used in clinical ▶ Kanner, Leo
practice to fulfill three main purposes – to provide ▶ Rett’s Syndrome
a clinical description, to make a clinical diagno- ▶ Wing, Lorna
sis, and to provide recommendations. First, it can
be used to provide a clinical description by
assisting the clinician in collecting information References and Readings
needed to compile a developmental history and
a description of the present clinical picture. This Billstedt, E., Gillberg, C., & Gillberg, C. (2007). Autism in
information, including current level of develop- adults, symptom patterns and early childhood predic-
tors: Use of the DISCO in a community sample
ment in everyday skills and the pattern of behav-
followed from childhood. Journal of Child Psychology
ior, can be used as the basis of a narrative clinical and Psychiatry, 48(11), 1102–1110.
report. Usually, the informant is someone who Brugha, T. S., McManus, S., Bankart, J., Scott, F.,
has known the person concerned from birth. Purdon, S., Smith, J., et al. (2011). Epidemiology of
autism spectrum disorders in adults in the community
However, when the DISCO is used with an
in England. Archives of General Psychiatry, 68(5),
adult and no informant is available to give an 459–465.
early history, the items of the DISCO schedule Danielsson, S., Gillberg, C., Billstedt, E., Gillberg, C., &
can be completed for current skills, deficits, and Olsson, I. (2005). Epilepsy in young adults with
autism: A prospective population-based follow-up
untypical behavior. Second, the DISCO can be
study of 120 individuals diagnosed in childhood.
used to assist in making a clinical diagnosis of Epilepsia, 46, 918–923.
autism spectrum disorders as well as of other de Vries, A. L. C., Noens, I. L. G., Cohen-Kettenis,
disorders of development affecting social inter- P. T., van Berckelaer-Onnes, I. A., & Doreleijers,
T. A. (2010). Autism spectrum disorders in gender
action and communication. Related to this pur- dysphoric children and adolescents. Journal of
pose, the schedule can be used to run a number of Autism and Developmental Disorders, 40(8),
different diagnostic algorithms according to dif- 930–936.
ferent classification systems (see “Description” Eisenmajer, R., Prior, M., Leekam, S., Wing, L., Ong, B.,
Gould, J., et al. (1998). Delayed language onset as
section earlier). In the case of an adult, where no
a predictor of clinical symptoms in pervasive develop-
developmental history is available, a diagnosis mental disorders. Journal of Autism and Developmental
according to DSM and ICD is not possible, but Disorders, 28(6), 527–533.
Diagnostic Interviews 931 D
Ellefsen, A., Kampmann, H., Billstedt, E., Gillberg, C., & Wing, L., & Gould, J. (1979). Severe impairments of
Gillberg, C. (2007). Autism in the Faroe Islands: An social interaction and associated abnormalities in
epidemiological study. Journal of Autism and Devel- children: Epidemiology and classification. Journal of
opmental Disorders, 37, 437–444. Autism and Developmental Disorders, 9, 11–29.
Leekam, S., Libby, S., Wing, L., Gould, J., & Wing, L., Leekam, S., Libby, S., Gould, J., &
Gillberg, C. (2000). Comparison of ICD-10 and Larcombe, M. (2002). Diagnostic interview for social
Gillberg’s criteria for Asperger syndrome. Autism, and communication disorders: Background, inter-rater
4(1), 11–28. reliability and clinical use. Journal of Child Psychol-
Leekam, S., Libby, S., Wing, L., Gould, J., & Taylor, C. ogy and Psychiatry, 43, 307–325.
(2002). Diagnostic interview for social and communi-
cation disorders: Algorithms for ICD-10 childhood D
autism and wing and Gould autistic spectrum disorder.
Journal of Child Psychology and Psychiatry, 43,
327–342.
Leekam, S. R., Nieto, C., Libby, S., Wing, L., & Gould, J. Diagnostic Interviews
(2007). Describing the sensory abnormalities of
individuals with autism. Journal of Autism and Devel- Ann S. LeCouteur1 and Thomas P. Berney2
opmental Disorders, 37(5), 894–910. 1
Leekam, S., Tandos, J., McConachie, H., Meins, E., Institute of Health & Society, Newcastle
Parkinson, K., Wright, C., et al. (2007). Repetitive University, Sir James Spence Institute, Royal
behaviours in typically developing 2-year-olds. Victoria Infirmary, Newcastle upon Tyne, UK
Journal of Child Psychology and Psychiatry, 48(11), 2
Newcastle University, Sir James Spence
1131–1138.
Maljaars, J., Noens, I, Scholte, E. & Berckelaur-Onnes, I. Institute, Royal Victoria Infirmary, Newcastle
(2011). Evaluation of the criterion and convergent upon Tyne, UK
validity of the diagnostic interview for social and com-
munication disorders in young and low-functioning
children. Autism: International Journal of Research
and Practice. Online June 2011. Definition
Mukherjee, R. A. S., Layton, M., Yacoub, R., & Turk, J.
(2011). Autism and autistic traits in people exposed to The diagnostic interview (DI) is a central
heavy prenatal alcohol. Advances in Mental Health component of the process (diagnostic process) in
and Intellectual Disabilities, 5(1), 42–49.
Nygren, G., Hagberg, B., Billstedt, E., Skoglund, A., which, for a variety of reasons ranging from
Gillberg, C., & Johannson, M. (2009). The Swedish research to the development of an intervention
version of the diagnostic interview for social and plan, a decision is made as to whether there is
communication disorders (DISCO-10) psychometric sufficient evidence in an individual’s symptoms
properties. Journal of Autism and Developmental
Disorders, 39(5), 730–741. and signs for a diagnosis of one or more of
Prior, M., Eisenmajer, R., Leekam, S., Wing, L., Gould, J., the “disorder(s)” defined by the criteria of the
Ong, B., et al. (1998). Are there subgroups within the internationally agreed diagnostic classification sys-
autistic spectrum? A cluster analysis of a group tems (▶ ICD 10 Research Diagnostic Guidelines).
of children with autistic spectrum disorders. Journal
of Child Psychology and Psychiatry, and Allied
Disciplines, 39(6), 893–902.
Turk, J., Bax, M., Williams, C., Amin, P., Eriksson, M., &
Gillberg, C. (2008). Autism spectrum disorder in chil-
dren with and without epilepsy: Impact on social
functioning and communication. Acta Paediatrica, Following the initial descriptions of autism and
98(4), 675–681. Asperger syndrome in the 1940s, agreed criteria
Wing, L. (1969). The handicaps of autistic children:
A comparative study. Journal of Child Psychology
emerged slowly and a number of checklists were
and Psychiatry, 10, 1–40. developed which matched a list of symptomatol-
Wing, L. (1988). The continuum of autistic characteris- ogy against the criteria evolving at the time
tics. In E. Schopler & G. Mesibov (Eds.), Diagnosis in ICD 9 (1975) and DSM-II (1980) (DSM-III)
and assessment in autism (pp. 91–110). New York:
Plenum.
focusing on accounts of observable behavior,
Wing, L. (1996). The autistic spectrum. London: particularly in childhood, notably the E-2 (Rim-
Constable. land diagnostic form for behavior disturbed
D 932 Diagnostic Interviews
children (E-2)) and the Autism Behavior of interviews to identify these behavioral and per-
Checklist (ABC). sonality characteristics.
In the 1960s, in both America and the UK, In many of these, the emphasis was on
the search for greater consistency and precision obtaining material from informants (usually par-
in psychiatric diagnosis led to the development ents) about behavior. At the end of the 1990s, the
of standardized diagnostic interviews; initially Autism Diagnostic Observation Schedule (ADOS)
schedules of standard questions, these became was developed as play and activities based assess-
elaborated into a more clinical interview that ment with the individual; this assessment is
encouraged the interviewer to cross-examine the described as a series of tightly defined, detailed
patient until the nature of the symptom was clear observations which systematically elicits autistic
(Wing, Birley, Cooper, Graham, & Isaacs, 1967). symtomatology.
A decade later, the same model led to the devel- In the last decade, the number of instruments,
opment of more systematic interviews in making their use varying from screening to diagnosis, has
the diagnosis of autism (as the prototypical dis- reflected the mounting interest in ASD while
order of the pervasive developmental disorders). increased public awareness and the Internet
Wing and Gould produced the Handicaps, Behav- have fostered the growth of self-rating scales
ior, and Skills Schedule (HBSS) which they later and the demand for confirmatory diagnostic
refined into the DISCO (Diagnostic Interview for interviews.
Social and Communication Disorder), Schopler
and Reichler developed the Childhood Autism
Rating Scale (CARS), and Le Couteur, Rutter, Current Knowledge
and Lord produced the Autism Diagnostic
Interview (later revised to become the ADI-R) The Content of the Interview
(Autism Diagnostic Interview-Revised). These There are a variety of models for conducting
standardized diagnostic instruments consist of a diagnostic interview. The structure or framework
a semi-structured interview (based on the agreed for the DI is important, but there is no compelling
symptom criteria) with an adult informant and evidence to recommend any particular interview
became recognized as the “gold standard” in format for any specific situation. For all DIs
terms of their comprehensiveness and reliability (irrespective of the interview format), the underly-
in obtaining a clinical history. ing context is the social engagement and interaction
The identification of a broader spectrum of between the interviewer and the interviewee. The
autism disorders (ASD), going beyond the original interviewing skills and attitudes of the interviewer
narrow definition for autism, led to an extension (clinician or researcher) affect the quality of the
of the content and form of diagnostic instruments interaction which in turn influences the success of
(diagnostic instruments in autistic spectrum the information-gathering process. The responses of
disorders). Examples of these are the Asperger Syn- the interviewee (also affected by many factors
drome Diagnostic Interview (ASDI) and the Autism including whether they already know the inter-
Questionnaire (AQ) (Baron-Cohen, Wheelwright, viewer; the interviewee is in fact the subject of the
Skinner, Martin, & Clubley, 2001) for Asperger interview; his or her intellectual and communicative
syndrome, the Pervasive Developmental Disorder ability, motivation, emotional state, and so on) and
in Mental Retardation Scale (PDD-MRS) for peo- the setting can also influence the outcome and “suc-
ple with intellectual disability (Kraijer & de Bildt, cess” of the diagnostic interview (DI).
2005), and the Diagnostic Interview Guide for use For an ASD DI to be successful, it should
in general adult psychiatry (Royal College of include:
Psychiatrists, 2011). The recognition of autistic 1. An account of the individual’s current
traits (broader autism phenotype – broader concerns – the symptoms that have brought
spectrum prevalence) in the relatives of people to interview at this particular time, and their
with ASD has led to the development of a variety development.
2. A systematic survey of the symptomatology How the DI progresses is at least in part depen-
associated with ASD, especially that which is dent on the skills of the interviewer, their training
directly related to the diagnostic criteria. This and expertise, as well as the setting of the inter-
review should also include consideration of view and the expectations of the interviewees. All
other behavioral features known to be com- these different aspects can foster a “dialogue”
monly associated with ASD such as motor between clinician and individual. Instruments
coordination, sensory and perceptual symp- may be combined for history-taking and observa-
toms, and feeding and bowel problems. It tion although, in the end, the distinction between
should include any other behavioral problems them is one of emphasis rather than clear-cut. For D
recognizing that these can occur in response to example, while the framework of observational
a variety of potentially modifiable influences ratings is central to the ADOS, it is also a semi-
from toothache to a change in school timetable structured interview, fostering a “dialogue”
or work colleagues. between clinician/researcher and individual.
3. The wider setting – the individual’s
everyday life and activities, relationships, The Format of the Diagnostic Interview
and accomplishments. The interview may take a range of formats
4. The structure of their family and any history of depending on its purpose:
developmental or psychiatric disorder. (a) Unstructured. The structure is not immediately
5. An account of the individual’s development apparent, but the interviewer’s clinical impres-
and their acquisition of skills, not just in sion (or equivalent) determines the content,
infancy and early childhood but subsequently, purpose, and conclusions of the interview. Its
through school and after, to give a detailed primary purpose may be a different one with
“developmental history.” diagnosis as a secondary consideration. Such an
6. An account of any other anomaly, past or pre- assessment depends greatly on the individual
sent, including developmental, psychiatric, or clinician’s experience and for this reason it is
medical disorder as well as of any other adver- likely to be difficult to understand or replicate.
sity including deprivation or substance abuse. (b) Semi-structured/interviewer based. The
The diagnostic interview will usually be interview, usually based on a predetermined
complimented by a direct examination of the diagnostic framework, has well-defined symp-
individual together with the collation of back- toms to be explored. Usually conducted in
ground reports (including direct observation in a conversational style, it takes the form of
other settings). All these sources of information required questions supplemented by additional,
will contribute to the accuracy and value of the optional, open-ended prompts as necessary
final, “best estimate,” diagnostic conclusions until there is sufficient information for the
which, in turn, will inform the multiagency trained interviewer to make the coding judg-
needs and skills-based management plan. ment for each item and section of the interview.
While the DI and examination are conceptu- The precision and clarity with which symptoms
ally distinct, in practice, there is likely to be and their codings are defined contribute to the
a substantial overlap. For example, when an quality of the instrument.
individual is being interviewed and asked to (c) Structured/respondent based. The trained
provide their own account, the clinician will be interviewer closely follows a defined format
considering the way the account is being given, without deviation; the interview may be
the quality and content of the social interaction, restricted further by giving the interviewee
and other individual characteristics (such as a limited number of choices. The interviewer
their appearance, behavior, and communication). is not called upon to make any clinical judg-
These factors will inevitably affect the interac- ment (and, indeed, may not know very much
tion between the clinician and the interviewee, about ASD and other diagnoses to complete
thus shaping the course of the DI. the interview).
The result is a relatively high inter-rater summary algorithms to identify ASD using
reliability and an interview that lends itself prespecified thresholds. However, the protean pre-
to being turned into a self-completion sentations of ASD and the demands of clinical work
questionnaire. This can be administered as mean that, in the end, even the best of these instru-
a preinterview contribution or completed in ments does not remove the need for knowledge and
a computerized format (e.g., the E-2) or Autism experience of ASD in coming to a clinical diagnosis
Spectrum Quotient (AQ) questionnaires). which will inform the diagnostic formulation and
Increasingly for some individuals, access to intervention planning. There are cases, notably in
this type of questionnaire has been a staging adulthood, of individuals with less clear-cut presen-
post in their journey to diagnosis. tations where it is difficult to discern the pattern of
(d) A composite. The interview incorporates the symptoms. It is here that the experience of working
material from a preinterview questionnaire. with a wide variety of people across the variations
Not only is this a more effective use of time, of age, ability, gender, ethnicity, and comorbidity
substantially shortening the DI, but many makes it possible to appreciate the characteristic
individuals are more comfortable (and there- impairments of ASD. In addition, within the assess-
fore more open) with the impersonality of ment team, there needs to be sufficient knowledge
a self-completion questionnaire. Examples and experience to recognize the developmental and
of DIs that use information-collected psychiatric disorders that are associated with ASD
preinterview include the Developmental, (notably attention deficit hyperactivity disorder
Dimensional and Diagnostic Interview (3Di) (ADHD) (▶ Attention Deficit/Hyperactivity Disor-
(Skuse et al., 2004) and the Adult Asperger der) and developmental coordination disorder
Assessment (AAA) (Baron-Cohen, Wheel- (▶ Developmental Coordination Disorder)).
wright, Robinson, & Woodbury-Smith, 2005). The choice to use a particular diagnostic
It is difficult to define the point at which the instrument will be informed by both the
self-completion or screening checklist becomes purpose of the interview and the features of the
a more formal diagnostic instrument as this will instrument. For example, the ADI-R (▶ Autism
depend on the skill, experience, and intent of Diagnostic Interview-Revised) provides a sum-
those employing it. mary lifetime diagnosis, using information about
The more standardized the format for gather- early childhood and the current state for key
ing and organizing the information, the greater aspects of behavior and development and
the consistency in the data collected and the diag- a record of the particular unusual behaviors
noses arrived at by clinicians and researchers of (such as restricted, repetitive mannerisms and
varied experience and views and from different stereotyped behaviors) relevant to the decision
centers. However, validity is lost with increasing as to whether a pervasive developmental disorder
rigidity that limits the clinician’s skills. Using is present or not. The frequency and intensity of
agreed diagnostic systems permits prospective each symptom is carefully graded to give
research as well as making clinical material a detailed quantified picture of key components.
available for retrospective review for service The DISCO (▶ Diagnostic Interview for Social
and academic analysis. The whole process is and Communication Disorders) takes a rather
more transparent and can be taught to trainees. broader approach to arrive at a systematic
The style of interview has to be appropriate to description that allows the identification of other
the task in hand: a structured interview, with its very developmental disorders. The 3Di is a computer-
narrow, specific remit, will be used for screening or based interview designed to focus on current
surveys and as such can be administered by functioning to assess autistic traits, social impair-
a technician. The semi-structured interview pro- ments, and comorbidities in children of normal
vides the framework for a more in-depth assessment ability. The content of the interview generates
when a definitive research or clinical diagnosis a structured report with summary algorithms
is required, and usually includes one or more of symptom profiles for autism and common
non-autistic comorbidities. By contrast, the with colleagues can help to maintain best practice
CARS (▶ Childhood Autism Rating Scale) in administration of the procedure as well as
draws on observation as well as interview. The reliability between colleagues and different cen-
format is much less structured, guiding the inter- ters. However, because this is time consuming
viewer through the relevant domains rather than and may be seen as additional pressure on scarce
individual symptoms, requiring the researcher/ resources, it is all too easily overlooked.
clinician to reach the coding decisions through
the integration of information from subject and Implementing the Interview
informants A DI may take place as a single event in one D
Most structured instruments (▶ Diagnostic setting or be spread across several sessions and
Instruments in Autistic Spectrum Disorders) settings. The venue (clinic, specialist center,
have been designed for a specific group, often home, school, or other setting) will depend on
defined by age (e.g., childhood) or ability. This the needs of individual, their family/carers, clini-
means that the phrasing or materials might not cians, and services. For example, a very anxious
be suitable for a different “client” group when individual or a disabled relative may only be
adaptation of materials and further reliability and accessible in the home; a clinic may be the only
validity studies would be required. place to get the opinion of a busy clinician or be
As adults come forward for diagnosis, includ- the best place to provide the structured, calm
ing, for example, those with a severe intellectual setting needed to see someone at their best. It
disability, women of normal ability, and individ- may be necessary to go to a school, nursery, or
uals with preexisting psychiatric and personality workplace to see the context and thereby under-
disorder diagnoses, the challenge will be how stand what is happening there. Observation in
best to tailor the format and content of the DI different settings may allow some distinction to
appropriately. A particular issue is the necessity be made between what behavior is pervasive and
of a developmental history to confirm that the what is situational and in response to a particular
evidence of delayed or deviant development environment or set of circumstances.
dates back to early childhood. This becomes par- The DI must provide sufficient information for
ticularly important in adulthood should there be the interviewer to decide whether the symptoms
a need to differentiate ASD from other disorders and signs are:
(such as schizophrenia (▶ Schizophrenia) or (a) Sufficiently pronounced in their intensity or
dissocial or obsessive-compulsive personality disor- frequency to cross the threshold that separates
ders (▶ Obsessive-Compulsive Disorder (OCD))). so-called normal variation for developmental
However, it is this client group who may experience progress and personal characteristics from dis-
real difficulty finding an informant with accurate order: threshold that may well vary according to
knowledge about their early development. the problems experienced by the individual, the
Whatever the format of the DI, training in its context and situation, and the “demands” and
use is required. This applies especially to stan- expectations placed upon them. For example,
dardized instruments where the more structured a young child who has managed well in their
the interview, the more straightforward the train- home with a supportive family may find it much
ing. While it may be obtained by attending more difficult to settle into an educational set-
a specific training course, receiving in-house ting such as preschool if they do not have suf-
individual tuition or by using a self-taught pro- ficiently flexible communication, social, and
gram, it should include a check that the clinician/ play skills to join in with other young children
researcher has reached an acceptable standard of or cope with new and unexpected changes in
accuracy and reliability. This should be followed routine in an otherwise familiar environment.
by regular opportunities to maintain consistency Similarly, an adult who may have learnt to
and reliability over time. Undertaking the rating manage effectively in a particular workplace
of standardized videos or attending joint sessions may still find that he/she is less able to succeed
in social and more personal relationships. For if repeated, whether by the same clinician or
the diagnostic interview to be successful, the others). The process needs to be acceptable to
interviewer needs to understand the importance all, sufficiently transparent to be understood,
of gathering information about the develop- and sufficiently valued for the results to be useful.
ment of the individual’s behavior in different Most instruments require the interviewer to
settings and contexts over time. This may well make judgments and ascribe a numerical score to
require (especially for children and young peo- each item in the assessment. These scores may be
ple but often also for adults) information from collated to symptom and/or domain scores which
other informants who know the subject well in can be summarized within one or more instrument-
different settings. specific diagnostic algorithms. For a number of
(b) Sufficiently close to the currently agreed instruments, usually those that have been developed
criteria (▶ ICD 10 Research Diagnostic for research, the reliability and validity of the algo-
Guidelines) for a diagnosis of ASD or might rithm scores and instrument-specific diagnostic
be explained better by some other disorder. thresholds have been tested and refined in different
ASD is a neurodevelopmental disorder defined populations. However, it is important to recognize
by its onset in early childhood, something that that a diagnostic algorithm score derived from
may be difficult to confirm in later adulthood. a particular instrument may contribute to, but is
The interview therefore has to enable the not equivalent to, a clinical diagnosis. This is some-
clinician to distinguish the signals of ASD thing broader, using an internationally agreed diag-
against the background noise of other compli- nostic classification system, based on information
cating disorders, particularly other develop- gathered from several sources, and often involving
mental and psychiatric disorders such as professionals working in different agencies to pro-
intellectual disability, specific speech and lan- vide a multidisciplinary assessment. This informa-
guage disorders, attention deficit hyperactivity tion, in turn, will contribute to, but is not sufficient
disorder (ADHD), epilepsy, and/or mental for, the development of a (needs and skills based)
health problems such as anxiety or obsessive- management plan. The DI, which may include the
compulsive disorder. use of a structured instrument, is an opportunity for
The interview must also be appropriate to its the development of a dialogue between the inter-
immediate purpose: for example, the require- viewer, the individual, and the family/carer and, as
ments for inclusion in a research study might be such, can also provide the context for sharing the
more stringent than those needed as the basis for outcome of the multiagency assessment.
clinical or administrative planning. One of the great values of using an agreed
A diagnosis may be sought for many reasons, diagnostic classification system is that it facili-
ranging from inclusion in a research study, tates the possibility of successful research collab-
accessing specific treatments and interventions, orations between clinical academic centers as
eligibility for particular education provision, well as making clinical material available for
achieving financial benefits, and gaining family service review and analysis. With greater trans-
understanding, through to assisting a court to under- parency between services and centers, there is an
stand the needs of the individual. Most importantly, increase in research capacity, the ability to share
it can give the individual a more complete under- new knowledge and significant developments,
standing of their profile of strengths and impair- and opportunities for trainees to learn from the
ments. The diagnostic interview also provides experiences of their colleagues.
a benchmark against which subsequent progress
can be measured. It has to be tuned accordingly to
meet these specific requirements. Future Directions
The results of the interview should be valid
(i.e., that others would agree with the diagnostic A number of standardized instruments are now in
conclusions) and reliable (they would be the same routine use for the DI providing both a valuable
framework for the history as well as being the sensitivity and motor coordination), this informa-
basis for the start of a therapeutic relationship tion will always need to collated alongside the find-
with individuals and families. Many are time ings of a DI to achieve a diagnostic formulation. At
consuming and resource intense, and this has to least for the foreseeable future, classification sys-
be balanced against the benefits of the therapeutic tems used in clinical and research practice, together
alliance and detailed descriptions of behavior. with other social and resource pressures, will con-
While the use of a detailed DI may well be appro- tinue to require a categorical diagnosis of ASD.
priate for a behavioral syndrome that has such
a variety of presentations and underlying disor- D
ders, there is great pressure to develop briefer See Also
processes and ever greater consistency while
maintaining validity. ▶ Anecdotal Observation
The value of increasingly sophisticated online ▶ Asperger Syndrome Diagnostic Interview
questionnaires as an adjunct to the DI needs to be ▶ Autism Behavior Checklist
investigated. New measures will also be required as ▶ Autism Diagnostic Interview-Revised
further understanding of the complexity of the ▶ Autism Diagnostic Observation Schedule
autism spectrum across the lifespan become avail- ▶ Broader Autism Phenotype
able. However, the development of new instruments ▶ Childhood Autism Rating Scale
is a complex and expensive task. An equally impor- ▶ Developmental Coordination Disorder
tant challenge is to investigate the best ways of ▶ Diagnostic Interview for Social and
getting reliable information from different sources Communication Disorders
to complement the DI and enable the clinician/ ▶ Diagnostic Process
researcher, referred individual, and family achieve ▶ Dimensional Versus Categorical Classification
a valid diagnostic formulation that in turn leads to an ▶ DISCO
accurate needs- and skills-based management plan. ▶ DSM-III
The recognition of autistic traits in the families ▶ Dyspraxia
of people with autism has led to the development ▶ Evaluation of Sensory Processing
of instruments to identify these which, once ▶ ICD 10 Research Diagnostic Guidelines
sufficiently validated and standardized, will be ▶ Informal Assessment
published. ▶ Obsessive-Compulsive Disorder (OCD)
In spite of many claims and much research, ▶ Psychotic Disorder
there is still no reliable laboratory test for ASD. ▶ Schizophrenia
However, even if such a test were ever developed, ▶ Sensory Impairment in Autism
its results would complement the diagnostic ▶ Theory of Mind
interview rather than replace it, a model seen in
other medical conditions as, for example, the use
of genetic testing in the clinical diagnosis of
Down or Rett syndrome.
With increasing awareness and understanding of Baron-Cohen, S., Wheelwright, S., Robinson, J., &
ASD, there is likely to be greater emphasis on the Woodbury-Smith, M. (2005). The Adult Asperger
identification of the strengths, skills, needs, and Assessment (AAA). A Diagnostic Method. Journal of
Autism and Development Disorders, 35(6), 807–819.
impairments of the individual and their family, as Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J.,
well as on diagnosis, to inform a dimensional & Clubley, E. (2001). The autism-spectrum quotient
diagnosis and profile across different domains of (AQ): Evidence from asperger syndrome/high-
functioning. Although separate assessments may functioning autism, males and females, scientists and
mathematicians. Journal of Autism and Developmen-
be needed to measure different aspects of an indi-
tal Disorders, 31(1), 5–17.
vidual’s functioning (e.g., social responsiveness, Kraijer, D., & de Bildt, A. (2005). The PDD-MRS: An
language and flexibility, anomalies in sensory instrument for identification of autism spectrum
D 938 Diagnostic Overshadowing
disorders in persons with mental retardation. Journal the ability of clinicians to make accurate judgments
of Autism and Developmental Disorders, 35(4), with regard to other co-occurring disorders (c.f.,
499–513.
Royal College of Psychiatrists. (2011). Diagnostic Jopp & Keys, 2001; White et al., 1995).
interview guide for adults with autism spectrum disorder Jopp and Keys provide a review of the concept
(ASD). http://www.rcpsych.ac.uk/training/aboutthecetc/ of diagnostic overshadowing in addition to possible
cetcwhatsnew/diagnosticinterviewresource.aspx moderators (Jopp & Keys, 2001). Their review
Skuse, D., Warrington, R., Bishop, D., Chowdhury, U.,
Lau, J., & Mandy, W. (2004) The developmental, indicated that most clinician based variables, such
dimensional and diagnostic interview (3Di): A novel as nature of clinical position (e.g., school, clinical
computerized assessment for autism spectrum and counseling psychologists, social workers), edu-
disorders. http://www.ixdx.org/ cational level (e.g., graduate student vs. Ph.D.), and
Wing, J. K., Birley, J. L. T., Cooper, J. E., Graham, P., &
Isaacs, A. D. (1967). Reliability of a procedure for years of experience, were not associated with the
measuring and classifying “Present Psychiatric strength of the bias. Moreover, though the presence
State.”. The British Journal of Psychiatry, 113, of multiple disabilities would presumably be more
499–515. inherently difficult to disentangle for a diagnosing
clinician, the research clearly indicated that the
clinician’s perception of the cognitive deficits pre-
sent in the individual being assessed was the most
Diagnostic Overshadowing salient feature reducing diagnostic accuracy.
Diagnostic overshadowing causes clinicians to
Steve Kanne overlook a range of comorbid mental illness in
Department of Health Psychology, individuals with intellectual disability, including
School of Health Professions Thompson Center phobias, schizophrenia, avoidant personality disor-
for Autism and Neurodevelopmental Disorders, der, and depression (Jopp & Keys, 2001). As
University of Missouri, Columbia, MO, USA Jopp and Keys note, the bias potentially serves to
reduce both sensitivity and specificity – two impor-
tant components of accurate diagnosis. Sensitivity
Definition refers to the ability to accurately diagnose individ-
uals who have a disorder, while specificity refers
Diagnostic overshadowing refers to the negative to the ability to accurately rule out individuals who
bias impacting a clinician’s judgment regarding do not have a particular disorder. Diagnostic
co-occurring disorders in individuals who have overshadowing may reduce sensitivity by creating
intellectual disabilities or other mental illness. more false negatives, such as when a child with
Symptoms or behaviors that may be due to a a cognitive deficit is not diagnosed with an anxiety
specific mental illness are attributed to another disorder that they truly have. It may also reduce
disorder, historically Mental Retardation, with- specificity by increasing the number of false posi-
out considering alternative etiology. tives, such as when a child is diagnosed with an
intellectual disability when they really have another
disorder that has caused the cognitive deficit.
Historical Background Only one factor has been found to moderate the
impact of diagnostic overshadowing, which is how
Reiss, Levtan, and Szyszko first coined the clinicians process information, termed cognitive
term “diagnostic overshadowing” to describe the complexity (Jopp & Keys, 2001). That is, when
tendency to assess individuals with intellectual dis- a clinician is able to view a patient’s behaviors in
ability less accurately (Reiss, Levitan, & McNally, a multidimensional fashion, incorporating a wide
1982; Reiss, Levitan, & Szyszko, 1982; Reiss & range of thoughts, feelings, and behaviors, which in
Szyszko, 1983). Subsequent research has consis- turn leads to generating multiple hypotheses, the
tently demonstrated that the cognitive deficits impact of the patient’s cognitive deficits and the
displayed by an individual negatively impacted resulting diagnostic overshadowing can be reduced.
Diagnostic Overshadowing 939 D
The concept of diagnostic overshadowing has range of cognitive abilities in addition to the
direct epidemiological implications. If diagnostic other symptoms of autism, such as communica-
accuracy is impacted and individuals are missed tion problems and other challenging behaviors,
with regard to a diagnosis, or misdiagnosed, then clinicians may be underdiagnosing comorbid
prevalence data may be misleading or incorrect. disorders in individuals with autism, despite
Moreover, epidemiological studies not only inform the accumulation of evidence that demonstrates
prevalence and incidence of a disorder and its asso- a high prevalence of co-occurring disorders
ciated characteristics, but can also help guide etio- in autism such as mood disorders, attentional
logical understanding. For example, this was disorders, and behavioral disorders (Simonoff, D
especially the case in autism wherein the initial Pickles, Charman, Chandler, & Baird, 2008).
report of the prevalence of co-occurring epilepsy Others have demonstrated how diagnostic
in autism led to scientists to examine biological overshadowing has impacted epidemiological
mechanisms in contrast to the nonbiological theo- research results. For example, Charman and col-
ries promulgated at the time (Bryson & Smith, leagues, using the Special Needs and Autism Pro-
1998; Lotter, 1974). If diagnostic overshadowing ject sample (i.e., total population cohort of 56, 946
causes clinicians to overlook important co- children in the UK ages 9–10), compared the con-
occurring disorders, advancements in etiological cordance of their research-based diagnosis to the
understanding may also be impacted. diagnoses derived from local services in children
with IQs above and below 70. They found that the
amount of children diagnosed with an autism spec-
Current Knowledge trum disorder from local services who had cognitive
impairment was less than those in that group that
More recently, clinicians and researchers have had been diagnosed through their epidemiological
extended the notion of diagnostic overshadowing research design, 25% compared to 45% (Charman
beyond individuals with cognitive deficits to et al., 2009). These results demonstrate the potential
those with other disorders such as autism. In diagnostic overshadowing bias and its impact on
addition, diagnostic overshadowing has been prevalence rates of autism depending on method
extended beyond the diagnostic process to dis- of ascertainment.
cussions regarding how it may impact treatment.
For example, some researchers have found that
diagnostic overshadowing has direct treatment Future Directions
implications. How an individual is diagnosed
affects what treatments are recommended by In their 2001 review, Jopp and Keys noted four
their treating providers. If the treating provider areas in need of research with regard to diagnostic
is affected by diagnostic overshadowing and thus overshadowing which remain relevant despite the
does not recognize other disorders, those other broadening of diagnostic overshadowing beyond
difficulties will not be appropriately treated. intellectual disability: (1) improve specification
Minnes and Steiner found that parents of children of clinical decisions that make up diagnostic
with Down syndrome, for example, reported overshadowing, (2) note the processes whereby
more problems receiving treatment for the diagnostic overshadowing occurs, (3) increase the
co-occurring illnesses, such as cataracts, thyroid appreciation of other variables such as the environ-
problems, and possible dementia (Minnes & ment as they impact overshadowing, and (4) explore
Steiner, 2009). overshadowing more fully using qualitative and
Researchers have proposed that the same other methodologies (Jopp & Keys, 2001). How
mechanism biasing clinicians who work with much overshadowing actually takes place in local
individuals with cognitive deficits may also and “real world” clinics, as opposed to the vignettes
apply to clinicians who work with individuals used in the research that explore its presence, needs
with autism. More specifically, given the wide to be more fully explored, as well as a better
D 940 Diagnostic Process
delineation of how diagnostic overshadowing is

impacting other diagnoses, such as autism, in addi- Diagnostic Process
tion to cognitive deficits alone.
Johnny Matson and Julie Worley
Department of Psychology, Louisiana State
See Also University, Baton Rouge, LA, USA
▶ Autism
▶ Epidemiology Definition
Autism spectrum disorders (ASDs) are a group of

References and Readings heterogeneous disorders that share overlapping
diagnostic criteria. These include deficits in
Bryson, S. E., & Smith, I. (1998). Epidemiology of autism:
communication and socialization, and restricted
Prevalence, associated characteristics, and implications
for research and service delivery. Mental Retardation interests and repetitive behaviors. Deficits in social-
and Developmental Disabilities Research Reviews, 4, ization are the hallmark of all ASDs, and deficits in
9–103. this area are diagnostically required to meet criteria
Charman, T., Pickles, A., Chandler, S., Wing, L.,
for all of the ASDs. Important to note is that even
Bryson, S., Simonoff, E., et al. (2009). Commentary:
Effects of diagnostic thresholds and research vs with these three core domains of impairment, het-
service and administrative diagnosis on autism preva- erogeneity across these symptoms exists on an indi-
lence. International Journal of Epidemiology, 38(5), vidual basis. As such, the classification systems
1234–1238. author reply 1243–1234.
Jopp, D. A., & Keys, C. B. (2001). Diagnostic
used to categorize the core impairments in ASD
overshadowing reviewed and reconsidered. American have been amended over time. Even still, the diag-
Journal on Mental Retardation, 106(5), 416–433. nostic process of ASD is complicated by numerous
Lotter, V. (1974). Factors related to outcome in autistic factors including the differential diagnosis within
children. Journal of Autism and Childhood Schizophre-
ASDs, a push to identify symptoms of ASD at very
nia, 4(3), 263–277.
Minnes, P., & Steiner, K. (2009). Parent views on enhanc- young ages, and the stability of ASD diagnoses over
ing the quality of health care for their children with time. Thus, this entry will review these factors in
fragile X syndrome, autism or Down syndrome. Child: regard to the diagnostic process of ASD.
Care, Health and Development, 35(2), 250–256.
Reiss, S., Levitan, G. W., & McNally, R. J. (1982).
Emotionally disturbed mentally retarded people: An
underserved population. American Psychologist, Historical Background
37(4), 361–367.
Reiss, S., Levitan, G. W., & Szyszko, J. (1982). Emotional
Autism spectrum disorders were first introduced
disturbance and mental retardation: Diagnostic
overshadowing. American Journal of Mental into the diagnostic nomenclature in 1980 (i.e., Diag-
Deficiency, 86(6), 567–574. nostic and Statistical Manual of Mental Disorders,
Reiss, S., & Szyszko, J. (1983). Diagnostic Third Edition [DSM-III]; American Psychiatric
overshadowing and professional experience with men-
Association [APA], 1980) under the category of
tally retarded persons. American Journal of Mental
Deficiency, 87(4), 396–402. pervasive developmental disorders. However, two
Simonoff, E., Pickles, A., Charman, T., Chandler, T. L., & of the currently recognized diagnoses, pervasive
Baird, G. (2008). Psychiatric disorders in children with developmental disorder not otherwise specified
autism spectrum disorders: Prevalence, comorbidity,
and Asperger’s disorder, were not introduced as
and associated factors in a population-derived sample.
Journal of the American Academy of Child and diagnostic disorders until 1987 and 1994, respec-
Adolescent Psychiatry, 47(8), 921–929. tively. Although the diagnostic categories have
White, M. J., Nichols, C. N., Cook, R. S., Spengler, P. M., changed throughout the different editions of the
Walker, B. S., & Look, K. K. (1995). Diagnostic
DSM, the main areas of impairment (i.e., symptom
overshadowing and mental retardation: A meta-analysis.
American Journal on Mental Retardation, 100(3), domains) have remained largely consistent. For
293–298. example, deficits in interpersonal relationships,
Diagnostic Process 941 D
impairment in communication, and bizarre psychopathology and challenging behaviors,
responses to the environment were the three main and should use ASD measures that also address
symptom domains in the DSM-III. Currently, the these issues.
three main symptom domains include impairment More recently, there has been a move to
in social interaction, impairment in communication, diagnose ASD at very young ages. Fortunately,
and restricted interests and repetitive behaviors assessments designed to screen for symptoms of
(APA, 2000). ASD in young populations have been developed.
The measures with the best research to support them
for this purpose are the Modified Checklist for D
Current Knowledge Autism in Toddlers (M-CHAT; Robins, Fein, Bar-
ton, & Green, 2001) and the Baby and Infant Screen
ASD is an umbrella term used to encompass five for Children with aUtIstic Traits-Part1 (BISCUIT-
disorders: autistic disorder (AD), Asperger’s dis- Part1; Matson, Boisjoli, Wilkins, 2007). Both mea-
order (AS), pervasive developmental disorder not sures are rating scales that can be administered in
otherwise specified (PDD-NOS), Rett’s disorder, 30 min or less, have determined cutoff scores, and
and childhood disintegrative disorder. Given the present with sound psychometric properties. Given
very low incidence of these latter two conditions, the push to identify symptomatology indicative of
the focus of this overview is related to AD, AS, ASD at younger ages, researchers have explored the
and PDD-NOS. A child is referred for an assess- diagnostic stability of symptoms using samples of
ment of ASD if developmental milestones are not toddlers. Outcomes of such investigations have pro-
met or after observations of behaviors related to vided support for the diagnostic stability for ASD
diagnoses on the autism spectrum. Initial obser- for children under age three (Worley, Matson,
vations of symptoms or concerns regarding Mahan, Kozlowski, & Neal, 2011). If diagnostic
developmental milestones are most often made status changes, it is often from one ASD to another
by teachers, day-care providers, pediatricians, (e.g., PDD-NOS to AD; Cox et al., 1999; Eaves &
and parents. As with other psychiatric disorders, Ho, 2004; Kleinman et al., 2008). Thus, at this time,
best practices in regard to the assessment of ASD research supports the need and the ability to reliably
is to incorporate multiple informants and multi- diagnose ASD during the toddler years. Diagnosing
ple methods. Informants come in the form of ASD at very young ages is important, as early
teachers, day-care providers, parents, grandpar- intervention is key for long-term success.
ents, guardians, and other therapists familiar with Another factor to consider when choosing an
the child (e.g., physical therapist, speech thera- assessment tool is the ability of the measure to
pist). The assessment for a diagnosis of ASD differentiate between the various ASDs, given the
should include an interview, an observation, and blurred boundaries of the various disorders com-
the administration of at least one assessment prising the spectrum. The reader will note that with
measure that has been psychometrically investi- the appearance of the DSM-V, all ASDs will be
gated to screen/diagnose ASD. It is also common collapsed together into one diagnostic category.
practice to utilize measures of cognitive function- However, for the purpose of service planning,
ing and adaptive function to assess for a comorbid evaluating the severity and symptom profiles will
diagnosis of intellectual disability. During the remain very important.
entirety of the assessment sessions, clinicians Although ASD can be reliably differentiated
assess for the triad of impairments indicative of from other developmental disorders, differential
an ASD diagnosis: deficits in communication, diagnosis between AD, AS, and PDD-NOS remains
impairments in socialization, and the presence difficult. This phenomenon is largely due to the
of repetitive motor movements (e.g., hand flap- overlapping diagnostic criteria used to define these
ping) or intense and restricted interests (e.g., will disorders in the diagnostic nomenclature. More
only play with cars). Clinicians should also specifically, the diagnostic criteria for PDD-NOS
be mindful of the high rates of comorbid are ill defined with no specific number of criteria
D 942 Diagnostic Process
established to obtain this diagnosis. In addition, the and AD. For instance, individuals diagnosed with
diagnostic symptoms for AD and AS overlap AS typically fall within the average range of
exactly in the area of socialization and repetitive cognitive functioning whereas those diagnosed
behavior and restricted interests. As a result, many with AD often have a comorbid diagnosis of ID.
researchers have examined differences between dis- However, these boundaries become blurred when
orders comprising the spectrum. However, findings examining those with AS and “high-functioning
are largely inconsistent. Nonetheless, it is still autism” (HFA), most of whom have intelligence
important to assess for the different ASDs as quotients (IQ) in the average range. Conversely,
a means of conforming with the current diagnostic individuals diagnosed with AS tend to have higher
classification system. Two measures that assist in verbal than performance IQs, and those diagnosed
the differential diagnosis between the various ASDs with HFA tend to have higher performance than
are Autism Spectrum Disorders Diagnostic for verbal IQs.
Child (ASD-DC; Matson & González, 2007) and In sum, the assessment process is conducted
the Pervasive Developmental Disorders Behavior to arrive at a diagnosis of either AD, AS, or
Inventory (PDDBI; Cohen & Sudhalter, 1999). PDD-NOS or to rule out these diagnoses. First,
Both tests are rating scales that can be completed AD is characterized by impairments in all three
in 20 min or less. core domain areas. Children with AD are often
In addition to the need to differentially diagnose referred for an assessment at very young ages
between different psychiatric disorders, medical since parents’ first concerns typically arise during
conditions also need to be ruled out as symptoms the first year of life. In contrast, individuals meet-
of certain medical conditions may simulate symp- ing diagnostic criteria for AS are often not iden-
toms of certain psychiatric disorders. As such, tified until later in childhood. Likely, this is due to
a medical assessment should be conducted prior to deficits in socialization which are the most
making an ASD diagnosis. The most important impairing symptom associated with a diagnosis
factors to assess during the medical evaluation of AS. As social demands increase with age, these
would be the child’s hearing, vision, and oral func- deficits become more pronounced and more obvi-
tioning. Ruling out any problems with the afore- ous. Thus, deficits in this area become more
mentioned is vital to ensure that symptoms of ASD apparent to the outside observer as the child
are not better accounted for by medical conditions. develops and has more social interactions with
For example, individuals with ASD present with others. In addition, unlike children diagnosed
delays in communication and socialization. If with AD, language development is not delayed
a child is having trouble hearing or having oral for children meeting diagnostic criteria for AS.
motor problems, these challenges would affect Instead, individuals diagnosed with AS tend to
their ability to speak and, subsequently, their ability have exceptional vocabularies. Therefore, as tod-
to socialize with others. In addition, visual impair- dlers, there is no obvious cause for concern for
ments could account for other symptoms such as children eventually meeting criteria for an AS
failure to initiate and sustain eye contact and diagnosis. Lastly, a diagnosis of PDD-NOS is
joint attention. given when symptoms of ASD are present, but
Lastly, intellectual disability (ID) is a highly the individual does not meet the criteria for
comorbid condition with ASD. As such, the assess- another disorder on the spectrum. Therefore, the
ment process should incorporate evaluations of both diagnostic category of PDD-NOS is a subthresh-
adaptive skills and intellectual functioning to assess old category. Children comprising this diagnostic
for deficits specific to these areas. Deficits in cogni- category have less severe deficits in socialization
tion and adaptive behavior are required to meet and may have minimal deficits in communication
criteria for a diagnosis of ID. The assessment of or less presentation of restricted interests or repet-
intellectual functioning also assists with the differ- itive behaviors when compared to a child meeting
ential diagnosis of ASDs, specifically between AS criteria for AD. In addition, it may be that these
Diagnostic Process 943 D
children present with the same symptoms of the ASD diagnostic category, being able to iden-
a child meeting criteria for AD, but the age of tify symptom severity will still be critical. Even
onset occurs after 36 months of age. more important, existing measures that assess for
symptoms of ASD would need to be renormed to
follow the new diagnostic criteria and continuing
Future Directions emerging research.
The current classification system for ASD is

categorical. However, this approach is problematic See Also D
due to the poorly defined boundaries of the
disorders comprising the autism spectrum. Due to ▶ Asperger Syndrome
these poorly defined boundaries, there has been ▶ Autistic Disorder
a failure to find consistent differences between ▶ Diagnostic Interviews
AD, AS, and PDD-NOS in regard to diagnostic ▶ Pervasive Developmental Disorder Not
criteria. As such, a dimensional approach to diag- Otherwise Specified
nosing has been proposed. This approach to diag-
nosing ASD is supported in the literature by
researchers who have examined the underlying References and Readings
latent structure of symptoms of ASDs utilizing
cluster analytic techniques or taxometric analyses. American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders – text
Although results often contradict each other, it has
revision (4th ed.). Washington, DC: Author.
been suggested that the underlying taxon of ASD is American Psychiatric Association. (2010). DSM-V.
dimensional (Boisjoli, 2010; Verté et al., 2006). Retrieved October 20, 2010, from www.dsm5.org
As a result of the overlap in the behavioral American Psychiatric Association. (1980). Diagnostic
phenotype of ASDs, the APA (2010) has pro-
posed revisions for ASD to be included in the Boisjoli, J. (2010). A taxometric analysis of autism
DSM-V, set to be published in 2013. The revi- spectrum disorders in toddlers. Unpublished doctoral
sions include utilizing a dimensional approach to dissertation, Louisiana State University.
Cohen, I. L., & Sudhalter, V. (1999). PDD behavior inven-
diagnosing ASD. As such, there will be no sub-
tory: Professional manual. Lutz, FL: Psychological
categories of ASD, but instead one diagnostic Assessment Resources.
entity referred to as autism spectrum disorder. In Cox, A., Klein, K., Charman, T., Baird, G., Baron-Cohen,
regard to diagnostic criteria, impairment related S., Swettenham, J., . . .Wheelwright, S. (1999). Autism
spectrum disorders at 20 and 42 months age: Stability of
to socialization and communication would be
clinical ADI-R diagnosis. Journal of Child Psychology
amalgamated into one domain. The second and Psychiatry, 40, 719–732.
domain refers to symptoms of restricted interests Eaves, L. C., & Ho, H. H. (2004). The very early identi-
and repetitive behaviors. The third domain would fication of autism: Outcome to age 4 ½ - 5. Journal of
indicate that symptoms need to be present in early
Kleinman, J. M., Ventola, P. E., Pandey, J., Verbalis, A.
childhood; however, early childhood is not further D., Barton, M, Hodgson, S., . . .Fein, D. (2008). Diag-
defined. Lastly, the symptoms must cause impair- nostic stability in very young children with autism
ment in everyday functioning (APA, 2010). spectrum disorders. Journal of Autism and Develop-
These changes will bring about further modi-
Matson, J. L., Boisjoli, J., & Wilkins, J. (2007). The baby
fications to the diagnostic process. For instance, and infant screen for children with autism traits
parceling out differences between the various (BISCUIT). Baton Rouge, LA: Disability Consultants,
ASDs would no longer be necessary, since LLC.
Matson, J. L., & González, M. L. (2007). Autism spectrum
PDD-NOS, AS, and AD would no longer repre- disorders – diagnosis – child version. Baton Rouge,
sent discrete diagnostic entities. However, given LA: Disability Consultants, LLC. Translated into
what will be even greater heterogeneity within Italian, Chinese, Hebrew, and Japanese.
D 944 Diagnostic Substitution
Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. developmental disabilities from 1987 to 1994
(2001). The modified checklist for autism in toddlers: found little change in the administrative preva-
An initial study investigating the early detection of
autism and pervasive developmental disorders. Journal lence of intellectual disability, whereas autism
of Autism and Developmental Disorders, 31, 131–144. rates increased nearly fivefold (Croen, Grether,
Verté, S., Geurts, H. M., Roeyers, H., Rosseel, Y., Hoogstrate, & Selvin, 2002, 2003). Another
Oosterlaan, J., & Sergeant, J. A. (2006). Can the chil- study examined special education enrollment
dren’s communication checklist differentiate autism
spectrum subtypes? Autism, 10, 266–287. data from Minnesota for the years 1991–2001
Worley, J. A., Matson, J. L., Mahan, S., Kozlowski, A. M., and found no substantial decrease in administra-
& Neal, D. (2011). Stability of symptoms of tive prevalence for other disabilities while autism
autism spectrum disorders in toddlers: An examination enrollment counts were increasing (Gurney et al.,
using the Baby and Infant Screen for Children with
aUtIsm – Part1. Developmental Neurorehabilitation, 2003).
14, 36–40. A study using state-level special education
data for the whole United States found that the
growing administrative prevalence of autism
from 1994 to 2003 was strongly associated with
Diagnostic Substitution decreasing prevalence in other disability catego-
ries, though not in every state (Shattuck, 2006).
Paul Shattuck A study of special education enrollment in
George Warren Brown School of Social Work, British Columbia from 1996 to 2004 found that
Washington University, St. Louis, MO, USA nearly one third of growing autism prevalence
was explained by children who had initially
been classified with some other type of disability
Definition being relabeled with autism (Coo, 2007).
Diagnostic substitution has been hypothesized as

one possible explanation for why growing num- See Also
bers of children have been classified with a label
of autism in publicly funded service systems such ▶ Intellectual Disability
as special education and state systems of care for
people with developmental disabilities. The term
has been used in two related ways. One refers to
a historical shift in the probability of being References and Readings
labeled with autism, whereby some proportion
Blaxill, M. F., Baskin, D. S., & Spitzer, W. O. (2003).
of children labeled with autism in recent years Commentary: Blaxill, Baskin, and Spitzer on Croen
would have been classified with a different label et al. (2002), The changing prevalence of autism in
had they been served by the same organization California. Journal of Autism and Developmental
at a previous point in time. The other refers Disorders, 33(2), 223–226.
Coo, H., Ouellette-Kuntz, H., Lloyd, J., Kasmara, L.,
to individual children initially being labeled
Holden, J., & Lewis, M. (2008). Trends in autism
with one diagnosis and then being reclassified prevalence: Diagnostic substitution revisited. Journal
with autism at a later age. In each case, the hypoth- of Autism and Developmental Disorders, 38,
esis predicts that as enrollment tallies in the 1036–1047.
Croen, L. A., & Grether, J. K. (2003). Response:
autism category increased, there would be some A response to Blaxill, Baskin, and Spitzer on Croen
corresponding decrease in the number of children et al. (2002), “The changing prevalence of autism in
being enrolled and labeled in other administrative California”. Journal of Autism and Developmental
categories (e.g., ▶ Intellectual Disability). Disorders, 33(2), 227–229.
Croen, L. A., Grether, J. K., Hoogstrate, J., & Selvin, S.
Evidence testing the diagnostic substitution (2002). The changing prevalence of autism in
hypothesis has been mixed. One study of data California. Journal of Autism and Developmental
from California’s service system for people with Disorders, 32(3), 207–215.
Dichotic Listening 945 D
Gurney, J. G., Fritz, M. S., Ness, K. K., Sievers, P., References and Readings
Newschaffer, C. J., & Shapiro, E. G. (2003). Analysis
of prevalence trends of autism spectrum disorder in Stahl, S. (2009). The prescriber’s guide: Stahl’s essential
Minnesota. Archives of Pediatrics and Adolescent psychopharmacology (pp. 139–143). Cambridge:
Medicine, 157, 622–627. Cambridge University Press.
Shattuck, P. (2006). The contribution of diagnostic substi-
tution to the growing administrative prevalence of
autism in U.S. Special education. Pediatrics, 117(4),
1028–1037.
Dichotic Listening D
Jennifer McCullagh
Diastat Department of Communication Disorders,
▶ Diazepam New Haven, CT, USA
Description
Diazepam Dichotic listening is the auditory process that

involves listening with both ears. Dichotic listen-
Rizwan Parvez ing can be broken into two different processes:
Yale Child Study Center, New Haven, binaural integration and binaural separation. Bin-
CT, USA aural integration is the ability to perceive different
acoustic messages presented to the left and right
ears at the same time. Binaural separation is the
Synonyms ability to perceive an acoustic message in one ear
while ignoring a different acoustic message in the
Diastat; Valium other ear. In order to perceive the acoustic mes-
sages in both ears, the outer, middle, and inner ears
must be working properly, but more importantly,
Definition the auditory brainstem nuclei, auditory cortical
neurons, as well as neurons in the corpus callosum
A long-acting anxiolytic medication in the must be functioning properly. Individuals with
benzodiazepine class. Diazepam is commonly dichotic listening deficits often have difficulty
used in the treatment of anxiety disorders, agitation, hearing in the presence of background noise.
and spasticity. Diazepam and other medicines of
this class bind to benzodiazepine receptors, enhanc-
ing the inhibitory effects of g-aminobutyric acid Historical Background
(GABA). Side effects of benzodiazepines can
include sedation, dizziness, fatigue, and confusion. Dichotic speech testing was first introduced by
Additionally, prolonged use of diazepam or other Broadbent in 1954. It requires the simultaneous
benzodiazepines may lead to tolerance and physical presentation of different speech stimuli to each of
dependence. the ears; the listener must repeat back everything
that is heard (binaural integration) or what is heard
in one ear only (binaural separation). In 1961,
See Also Kimura first used these tests to demonstrate
hemispheric asymmetry and cortical dysfunction.
▶ Anxiety She demonstrated contralateral auditory deficits
D 946 Dichotic Listening
following temporal lobe lesions. These findings Clinical Uses

indicate that if a lesion is located in the left temporal
lobe, the auditory signal presented to the right ear Dichotic listening tests are used in clinical audiol-
will not be perceived. In typical individuals (those ogy to evaluate the central auditory processes of
with normal hearing and no known lesions in the binaural integration and separation. These tests
central auditory nervous system), a right ear advan- may be used in the assessment of children or adults
tage has consistently been reported (Berlin, Lowe- with possible central auditory nervous system dys-
Bell, Cullen, Thompson, & Loovis, 1973; Dirks, function. Since dichotic listening tests (tests of bin-
1964; Kimura, 1961a, b). Right ear advantage refers aural integration and separation) evaluate two
to the ability to better perceive the auditory signal critical auditory processes, it is important for these
presented to the right ear than the speech signal tests to be included in a central auditory processing
in the left ear. The right ear advantage exists test battery. Clinically, the person administering
because the hemisphere in the brain responsible dichotic listening tests should take into consider-
for processing the speech signal is in the left ation the cognitive, hearing, speech, and language
hemisphere. Since the contralateral pathways are abilities of the individual being tested as these fac-
stronger, the speech signal presented to the right tors may affect performance. Thus, dichotic listen-
ear travels directly to the left hemisphere for ing tests are not typically administered to children
processing; however, the speech signal presented with autism, and performance on these tests should
to the left ear must travel to the right hemisphere be interpreted with caution in this population.
and across the corpus callosum to the left hemi-
sphere to be processed (creating a slight time delay).
Currently, a variety of dichotic listening tests See also
are available for clinical use. Common dichotic
speech tests, specifically binaural integration ▶ Central Auditory Processing Disorder
tests, are the Dichotic Digits Test (Musiek, 1983; ▶ Corpus Callosum
Musiek & Wilson, 1979; Musiek, Wilson, & ▶ Temporal Lobes
Pinheiro, 1979); the Staggered Spondaic Word
Test (SSW; Katz, 1962), and Dichotic Consonant-
Vowels (Dichotic CVs; Berlin et al., 1973). Some References and Readings
common binaural separation tests are Competing
Sentences (Willeford, 1977) and the Synthetic Sen- Berlin, C., Lowe-Bell, S., Cullen, J., Thompson, S., &
tence Identification with Contralateral Competing Loovis, C. (1973). Dichotic speech perception: An
interpretation of right-ear advantage and temporal
Message (SSI-CCM; Jerger, 1970).
offset effects. Journal of the Acoustical Society of
America, 53, 699–709.
Broadbent, D. (1954). The role of auditory localization in
Psychometric Data attention and memory span. Journal of Experimental
Chermak, G., & Musiek, F. (1997). Central auditory
Dichotic listening tests, such as the Dichotic processing disorders: New perspectives. San Diego:
Digits, Dichotic CVs, SSW, Competing Singular Publishing Group.
Sentences, and SSI-CCM, have been shown to Dirks, D. (1964). Perception of dichotic and monaural
verbal material and cerebral dominance for speech.
be sensitive and specific to central auditory ner-
Acta Otolaryngologica, 58, 73–80.
vous system lesions, including interhemispheric Efron, R. (1985). The central auditory system and issues
lesions (for review, see Musiek & Pinheiro, related to hemispheric specialization. In M. Pinheiro &
1985). Peripheral hearing sensitivity should be F. Musiek (Eds.), Assessment of central auditory
dysfunction: Foundations and clinical correlates
symmetrical and normal when using dichotic lis-
(pp. 143–155). Baltimore: Williams & Wilkins.
tening tests since any hearing differences Jerger, J. (1970). Development of the synthetic sentence
between ears can influence test results. identification (SSI) as a tool for speech audiometry.
Didactic Approaches 947 D
In C. Rojskjaer (Ed.), Speech audiometry. Odense, instructional stimuli, obligates a response from the
Denmark: Danavox. child, evaluates child responses, and provides
Katz, J. (1962). The use of staggered spondaic words for
assessing the integrity of the central auditory system. reinforcement for correct responses and feedback
Journal of Auditory Research, 2, 327–337. for incorrect ones. Intervention methods for early
Kimura, D. (1961a). Some effects of temporal lobe communication in children with autism spectrum
damage on auditory perception. Canadian Journal of disorders (ASD) are often divided into three
Kimura, D. (1961b). Cerebral dominance and the categories: didactic, naturalistic, and pragmatic or
perception of verbal stimuli. Canadian Journal of developmental.
Psychology, 15, 166–171. Didactic approaches utilize a variety of concepts D
Musiek, F. (1983). Assessment of central auditory from behavioral theory, including massed trials,
dysfunction: The Dichotic Digit test revisited. Ear
and Hearing, 4, 79–83. operant conditioning, shaping, prompting, chaining,
Musiek, F., & Pinheiro, M. (1985). Dichotic speech tests and reinforcement. Difficulty with the generaliza-
in the detection of central auditory dysfunction. In M. tion and maintenance of behaviors learned through
Pinheiro & F. Musiek (Eds.), Assessment of central this method along with the passive communication
auditory dysfunction: Foundations and clinical corre-
lates (pp. 201–219). Baltimore: Williams & Wilkins. acquired by many children (i.e., waiting on adults’
Musiek, F., & Wilson, D. (1979). SSW and Dichotic lead during interactions) are some of the drawbacks
Digits results pre- and post-commissurotomy: A case associated with this approach. Still, the effective-
report. Journal of Speech and Hearing Disorders, 44, ness of this approach in initiating and expanding
528–533.
Musiek, F., Wilson, D., & Pinheiro, M. (1979). Audiolog- expressive language and developing attention to
ical manifestations in split-brain patients. Journal of language and comprehension in preverbal children
the American Auditory Society, 5, 25–29. with ASD is supported by research from numerous
Willeford, J. (1977). Assessing central auditory behaviour case studies and several group studies.
in children: A test battery approach. In R. Keith (Ed.),
Central auditory dysfunction (pp. 43–73). New York: As this approach requires a notable amount of
Grune & Stratton. adult direction, a passive role as responder by the
child, repetitive drills and practice, and specific
events that should occur before and after a child’s
response, this method is ideally effective if the
Didactic Approaches instructor consistently monitors the student’s inter-
est level, readiness for the information being con-
Sarita Austin veyed, and the motivational value of reinforcers.
Laboratory of Developmental Communication The passivity and prompt-dependence that can
Disorders, Yale Child Study Center, New Haven, result from these methods led to the development
CT, USA of more naturalistic instructional techniques (e.g.,
contemporary applied behaviors analysis).
Synonyms
See Also
ABA; Adult/clinician/teacher-directed approaches;
Behavioral approaches; Direct instruction ▶ Applied Behavior Analysis
▶ Teach Me Language
Definition
A didactic approach to teaching refers to a manner
Goldstein, H. (2002). Communication intervention for
of instruction in which information is presented children with Autism: A review of treatment efficacy.
directly from the teacher to the pupil, in which the Journal of Autism and Developmental Disorders, 32,
teacher selects the topic of instruction, controls 373–396.
D 948 Differential Ability Scales
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., learning processes. A General Conceptual Ability
& Stanislaw, H. (2005). A comparison of intensive (GCA) composite score is generated that reflects
behavior analytic and eclectic treatments for young
children with Autism. Research in Developmental conceptual and reasoning abilities. Three cluster
Disabilities, 26(4), 359–383. scores of the DAS-II measure more specific learn-
Paul, R. (2008). Interventions to improve communication ing processes: verbal, nonverbal reasoning, and
in Autism. Child and Adolescent Psychiatric Clinics of spatial abilities. There is also a Special Nonverbal
Remington, B., Hastings, R., Kovshoff, H., Degli Composite that can be derived for an individual of
Espinosa, F., Jahr, E., Brown, T., et al. (2007). Early any age where the verbal demands are too taxing to
intensive behavioral intervention: Outcomes for obtain standardized results. The core subtests of the
children with Autism and their parents after two DAS-II tap into specific cognitive processes that are
years. American Journal of Mental Retardation, 112,
418–438. used to estimate the cluster and GCA scores, and the
Rogers, S. (2006). Evidence-based intervention for lan- abilities they assess are directly related to educa-
guage development in young children with Autism. In tional needs at each age range. There are also Diag-
T. Charman & W. Stone (Eds.), Social and communi- nostic subtests that measure memory, processing
cation development in autism spectrum disorders:
Early identification, diagnosis, and intervention speed, and early school learning abilities. These
(pp. 143–179). New York: Guilford Press. scores do not contribute to the overall cluster or
GCA scores; however, they are still important
foundational skills that address a child’s profile of
cognitive strengths and weaknesses, as well as
Differential Ability Scales educational needs.
▶ Differential Ability Scales (DAS and DAS-II) Core Batteries of the DAS-II
There are two batteries of the DAS-II: Early Years
and School Age. Within Early Years, there are two
levels. The first level is for children ages 2 years,
Differential Ability Scales 6 months through 3 years, 5 months. This lower
(DAS and DAS-II) level consists of 4 core subtests (Verbal Compre-
hension [VCom], Naming Vocabulary [NVoc], Pic-
Celine A. Saulnier ture Similarities [PSim], and Pattern Construction
Department of Pediatrics, Emory University [PCon]) and yields a Verbal Ability (VCom +
School of Medicine, Atlanta, GA, USA NVoc) and Nonverbal Ability (PSim + PCon)
cluster score, as well as the GCA. The upper level
is for children ages 3 years, 6 months to 6 years,
Synonyms 11 months and has 6 core subtests (VCom, NVoc,
PSim, Matrices [Mat], PCon, and Copying [Copy])
Cognitive measures; DAS; DAS-II; Differential that yield three cluster scores: Verbal Ability
ability scales (VCom + NVoc), Nonverbal Ability (PSim +
Mat), and Spatial Ability (PCon + Copy), as well
as the GCA.
Description The School-Age battery of the DAS-II can be
administered on children ages 7 years, 0 months
The Differential Ability Scales, Second Edition to 17 years, 11 months, and it is comprised of six
(DAS-II; Elliott, 2007) is an individually adminis- core subtests (Word Definitions [WDef], Verbal
tered test designed to measure distinct cognitive Similarities [VSim], Mat, Sequential and Quan-
abilities for children and adolescents ages 2 years, titative Reasoning [SQR], Recall of Designs
6 months to 17 years, 11 months. The DAS-II is [RDes], and PCon) that yield three cluster scores:
comprised of individual subtests that evaluate Verbal Ability, Nonverbal Reasoning Ability,
strengths and weaknesses of a broad range of and Spatial Ability, as well as the GCA.
Differential Ability Scales (DAS and DAS-II) 949 D
Both the Early Years and School-Age batte- Fourth Edition (WISC-IV; Wechsler, 2003) or
ries of the DAS-II are normed on children Stanford-Binet Intelligence Scales, Fifth Edition
between the ages of 5 years, 0 months and (SB5; Roid, 2003), where the theoretical models
8 years, 11 months. This allows the School-Age tend to focus more on generalized intelligence
subtests to be administered for brighter young than on distinct cognitive abilities. Nevertheless,
children and, in contrast, the Early Years subtests the DAS and DAS-II have an overall composite
to be administered for older, less cognitively able score that reflects general cognitive functioning
children. (i.e., General Conceptual Ability score) and that
is derived from those subtests which load highest D
Diagnostic Subtests of the DAS-II on the factor of general intelligence, or g. This
The Early Years battery of the DAS-II consists of results in the GCA being a more refined score
the following ten Diagnostic subtests: Early Num- than other measures of global intelligence that are
ber Concepts [ENS], Matching Letter-like Forms derived from a broader collection of subtests.
[MLLF], Phonological Processing [PhP], Recall of However, examiners are cautioned against
Sequential Order [SeqO], Recall of Digits Forward interpreting the GCA as a global measure of
[DigF], Recall of Digits, Backward [DigB], Speed functioning, as many children have a variable
of Information Processing [SIP], Rapid Naming cognitive profile that one general score cannot
[RNam], Recall of Objects – Immediate and appropriately encapsulate. This is particularly
Delayed [RObI, RObD], and Recognition of the case for children with autism spectrum disor-
Pictures [RPic]. Seven of these subtests contribute ders (ASD), where scatter within a cognitive pro-
to three cluster scores: School Readiness (ENC + file is the norm rather than the exception (e.g.,
MLLF + PhP), Working Memory (SeqO + DigB), Klin, Saulnier, Tsatsanis, & Volkmar, 2005).
and Processing Speed (SIP + RNam). Although the theoretical development of the
The School-Age battery of the DAS-II only BAS, DAS, BAS-II (Elliott, 1996), and DAS-II
consists of seven Diagnostic subtests that yield predated theoretical work on the Cattell-Horn-
two cluster scores: Working Memory (SeqO + Carroll theory of intelligence (CHC; McGrew,
DigB) and Processing Speed (SIP + RNam). 2005), the structure of the DAS-II fits well into the
The School Readiness subtests from the Early seven-factor CHC model. For instance, the DAS-II
Years battery are not included in the School- Verbal Ability cluster measures crystallized intelli-
Age norms, with the exception of PhP, which gence (Gc), the Nonverbal Reasoning cluster mea-
has norms up to age 12 years, 11 months. sures fluid intelligence (Gf), the Spatial Ability
cluster measures visual-spatial processing (Gv),
the Working Memory diagnostic cluster measures
Historical Background short-term memory (Gsm), the Recall of Objects
subtest measures long-term storage and retrieval
The original Differential Ability Scales (DAS; (Glr), the Processing Speed cluster measures cog-
Elliott, 1990) was modeled after the British Abil- nitive processing speed (Gs), and the Phonological
ity Scales (BAS; Elliott, Murray, & Pearson, Processing subtest measures auditory processing
1979). Both instruments were unique in the field (Ga).
of intelligence tests in that their focus was on
distinct subtest scores that could be used to flush
out cognitive profiles of strengths and weak- Psychometric Data
nesses rather than on an overall intelligence quo-
tient or estimation of IQ. This conceptualization The DAS-II has been standardized on
of cognitive assessment sets the DAS and subse- a normative sample of 3,480 children ages
quent second edition (DAS-II; Elliott, 2007) 2 years, 6 months to 17 years, 11 months that is
aside from other commonly used measures, such representative of the general population. Data are
as the Wechsler Intelligence Scale for Children, also available for a range of clinical samples,
D 950 Differential Ability Scales (DAS and DAS-II)
including developmental risk, learning disabil- Wechsler Preschool and Primary Scale of Intelli-
ities, attention deficit/hyperactivity disorder, gence, Third Edition (WPPSI-III; Wechsler, 2002)
mild to moderate intellectual disability, and the Full Scale IQ is .87; however, WPPSI-III Index and
gifted and talented. FSIQ scores range from 1.7 to 5.1 points higher than
On the DAS and DAS-II, Verbal, Nonverbal, DAS-II cluster scores. WISC-IV Index and FSIQ
Spatial, and Special Nonverbal cluster scores, as scores also range from 1.2 to 6.6 points higher than
well as the GCA score, are reported in standard DAS-II cluster scores, with a correlation coefficient
scores that have a mean of 100 and standard of .84 between the two measures.
deviation of 15 and that range from 30 to 170. In nonclinical samples, the correlation
Individual subtest scores are reported as T scores between the DAS-II GCA and measures of aca-
that have a mean of 50 and a standard deviation of demic achievement is as follows: .82 with the
10 and that range from 10 to 90. T scores are total score of the Wechsler Individual Achieve-
derived from ability scores, which are based on ment Test, Second Edition (WIAT-II; Harcourt
the number of correct responses (i.e., the raw Assessment, 2005); .81 with the Comprehensive
scores) and on the difficulty of administered Achievement Composite of the Kaufman Test
items, following the Rasch Model of item of Educational Achievement, Second Edition
response theory. The administration and scoring (KTEA-II; Kaufman & Kaufman, 2004); and .80
system of the DAS and DAS-II is also different with the Total Achievement score of the Wood-
from other common measures in that raw scores cock-Johnson III Tests of Cognitive Abilities
are computed based on the number of items (WJ-III; Woodcock, McGrew, & Mather, 2001).
administered within a response set, rather than
calculating this number in addition to items
below the basal. In this way, children are admin- Clinical Uses
istered only those set of items that are appropriate
in difficulty to their ability level. Subtest scores There are several clinical benefits to using the
can be presented as age equivalents that represent DAS-II when assessing individuals with autism
the median ability score for each child’s perfor- spectrum disorders (ASD; Klin et al., 2005;
mance, and descriptive categories are provided Saulnier, Quirmbach, & Klin, 2011). These
for standard scores that range from “Very High” advantages include the following:
(70 and above) to “Very Low” (69 and below). 1. The teaching items that are provided within
The DAS-II has strong internal reliability, each DAS-II domain are extraordinarily useful
with average reliability coefficients for the Early when complex instructions impede a child’s
Years subtests ranging from .79 to .94 and for the ability to comprehend a given verbal request.
School-Age subtests ranging from .74 to .96. When the examiner is allowed to model or
The average reliability for the DAS-II GCA is demonstrate the correct response, the child is
.95 for Early Years and .96 for School Age. better able to comprehend the nature of the
Confirmatory factor analyses were conducted to task and successfully complete a subtest on
assess the internal validity of the DAS-II, and which they otherwise might have failed to
general results confirmed the existing clusters; obtain a basal level of performance.
for instance, the structure of cognitive abilities 2. The extended norms on the DAS-II Early
varies with age, with fewer models emerging for Years battery allow for obtaining standard
the youngest children (e.g., Verbal and Nonver- scores for older, more impaired individuals
bal clusters) and additional models emerging through age 8 years, 11 months – an option
with age (e.g., Spatial, Short-term Memory, and not available in other measures (Elliott, 2007).
Cognitive Speed clusters). 3. The extended norms of the School-Age
Correlations between the DAS and DAS-II are battery down to age 5 allow for adequately
strong, with .88 for the GCA and .85 for the SNC. testing younger children with ASD with
The correlation between the DAS-II GCA and the more advanced cognitive skills.
Differential Ability Scales (DAS and DAS-II) 951 D
4. The Special Nonverbal Composite makes it par- and nonverbal skills had greater social impair-
ticularly appealing for individuals on the autism ments, and impaired social functioning was inde-
spectrum with significant language vulnerabil- pendent of their verbal skills.
ities for whom the language demands on the
verbal tasks are too taxing. The SNC is also
useful for other unique samples, such as children See Also
with speech, language, and/or hearing impair-
ments or children who are not fluent in English. ▶ Achievement Testing
5. The results can generate recommendations for ▶ Cognitive Skills D
educational and treatment programming that ▶ Educational Testing
are clinically relevant to each child. ▶ Intelligence Quotient
The DAS-II is also extremely useful for ▶ Psychological Assessment
clinical research in ASD. First, the extensive ▶ Standardization
age range makes it possible to conduct scientific ▶ Standardized Tests
studies on both cohort and longitudinal studies of ▶ Wechsler Intelligence Scale for Children
children between the ages of 2 and 17. Second, ▶ Wechsler Preschool and Primary Scale of
the extended norms allow for utilizing the same Intelligence
battery for varying levels of functioning. Finally, ▶ Wechsler Scales of Intelligence
the core subtests can be administered quickly ▶ Woodcock-Johnson Cognitive and
while generating a more comprehensive measure Achievement Batteries
of cognitive functioning than an abbreviated
measure of intelligence.
There have been several studies using the References and Readings
DAS that highlight its utility in detecting learning
disabilities and cognitive delays. For instance, in Dumont, R., Cruse, C., Price, L., & Whelley, P. (1996).
The relationship between the Differential Ability
one study comparing composite scores between
Scales (DAS) and the Wechsler Intelligence Scale for
the DAS and WISC-III, children with learning Children, Third Edition (WISC-III) for students with
disabilities evidenced a specific weakness in the learning disabilities. Psychology in the Schools, 33,
Nonverbal Reasoning cluster of the DAS that was 203–209.
Elliott, C. D. (1990). Differential ability scales.
not demonstrated on the Perceptual Reasoning
San Antonio, TX: The Psychological Corporation.
Index of the WISC-III (Dumont et al., 1996). Elliott, C. D. (1996). British ability scales (2nd ed.).
The majority of research on cognitive profiles Windsor: NFER-Nelson.
in autism spectrum disorders (ASD) has been Elliott, C. D. (2007). Differential ability scales (2nd ed.).
New York: The psychological corporation.
conducted using the Wechsler Scales. Less Elliott, C. D., Murray, D. J., & Pearson, L. S. (1979).
research has investigated DAS and DAS-II British ability scales. Windsor: National Foundation
profiles in ASD, despite the fact that many for Educational Research.
researchers have used both measures as part Harcourt Assessment. (2005). Wechsler individual
achievement test (2nd ed.). San Antonio, TX: Author.
of the characterization process for research para-
Joseph, R., Tager-Flusberg, H., & Lord, C. (2002). Cog-
digms. A study conducted by Joseph, Tager- nitive profiles and social-communicative functioning
Flusberg, and Lord (2002) used the DAS on in children with autism spectrum disorder. Journal of
a longitudinal sample of children with and with- Child Psychology and Psychiatry, 43(6), 807–821.
Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman
out ASD. They found that the majority of pre- Assessment Battery for Children, Second Edition
school-aged children exhibited lower verbal than (KABC-II). Circle Pines, MN: American Guidance
nonverbal cluster scores and that greater discrep- Service.
ancies between verbal and nonverbal abilities Klin, A., Saulnier, C. A., Tsatsanis, K., & Volkmar, F. R.
(2005). Clinical evaluation in autism spectrum disorders:
were detected in ASD vs. the normative sample, Psychological assessment within a transdisciplinary
with this gap widening with age. Furthermore, framework. In F. R. Volkmar, R. Paul, A. Klin, &
children with larger gaps between their verbal D. Cohen (Eds.), Handbook of autism and pervasive
D 952 Differential Reinforcement
developmental disorders (Vol. 2, pp. 772–798). Hobo- a child raising her hand before being called upon to
ken, NJ: Wiley. answer a question and ignoring that child if she
McGrew, K. S. (2005). The Catell-Horn-Carroll theory
of cognitive abilities: past, present, and future. In were to shout out the answer without raising her
D. P. Flanagan & P. L. Harrison (Eds.), Contemporary hand. The goal of differential reinforcement is to
intellectual assessment: theories, testing, and issues. increase the strength of the response being
New York, NY: Guilford Press. reinforced, while weakening the strength of the
Roid, G. H. (2003). Stanford-Binet intelligence scales
(5th ed.). Itasca, IL: Riverside. other responses not being reinforced.
Saulnier, C. A., Quirmbach, L., & Klin, A. (2011).
Clinical diagnosis of autism. In E. Hollander,
A. Kolevzon, & J. T. Coyle (Eds.), Textbook of autism Current Knowledge
spectrum disorders (pp. 25–37). Washington, DC:
Wechsler, D. (2002). The Wechsler preschool and primary A basic principle in understanding differential
scale of intelligence (3rd ed.). San Antonio, TX: reinforcement and how people learn in most
Harcourt Assessment. situations is the concept of discrimination. Basi-
Wechsler, D. (2003). The Wechsler intelligence scale for
children (4th ed.). San Antonio, TX: The Psychologi- cally, discrimination is a process for behaving
cal Corporation. one way in one situation or context, and behaving
Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). in a completely different way in a different situ-
Woodcock-Johnson III tests of cognitive abilities. ation or context. Thus, discrimination is the abil-
Itasca, IL: Riverside.
ity to tell the difference between environmental
events (or contexts or cues) and behaving accord-
ingly. Discrimination typically develops as
Differential Reinforcement a result of differential reinforcement.
Almost all learning occurs due to the concept
Thomas Zane of discrimination and differential reinforcement.
The Institute for Behavioral Studies, Endicott For example, consider learning the letters of the
College, Beverly, MA, USA alphabet. When the letter “B” is shown and
the learner asked to identify the letter, indicating
“B” will be reinforced and naming any other
Definition letter will not be. This process of differentially
reinforcing the learner’s responses (as correct and
Differential reinforcement is the process of incorrect) results in learning of the alphabet.
reinforcing a specific response in a particular con- Consider learning to speak. When an infant says
text and not reinforcing (i.e., extinguishing) other “mama” in the presence of the mother, that
responses. More specifically, differential rein- response will be reinforced with smiles, hugs,
forcement involves providing either positive and positive attention. If the infant says “mama”
or negative reinforcement for a targeted response in the presence of the father, there will be
(or targeted member of a response class) and with- no reinforcement. Differentially reinforcing a
holding reinforcement from all other responses (or response in one context (i.e., in presence of the
members of a response class). The withholding of mother) and not in another (i.e., in the presence of
reinforcement is defined as “extinction.” Thus, the father) results in the baby learning what to say
differential reinforcement is a two-part process – in the presence of each parent. Consider the
reinforcing the desired response(s) and acquisition of social behaviors. Some young chil-
extinguishing all other responses. For example, dren refuse to share their toys. When this occurs,
a parent might reinforce with praise a young the adult rarely reinforces such selfishness. How-
child calling out the mother’s name and ignoring ever, when a child does in fact share her toys,
(and thus not reinforcing) the child’s behavior of adults provide positive attention and reinforce-
hitting the parent. Another example would be ment. In this case, the adult responds differently
a teacher reinforcing (with praise and attention) to two different behaviors – sharing and not
Differential Reinforcement 953 D
sharing. Through this process, the child learns individual continues to tantrum and does not ask
that sharing is preferred and hoarding toys is appropriately for a break, the caregiver would
not. Thus, virtually all learning is accomplished continue to keep the person in the demand situa-
through the process of learning discriminations tion by requiring work. The use of formal rein-
via differential reinforcement. forcement preference assessments is considered
The procedure of differential reinforcement best practice to determine the most motivating
has been used to both increase and decrease the reward items available.
strength (future rate) of specific behaviors. How- The last step in the procedure is to determine if
ever, even though the goals are different (when and how reinforcement can be withheld from the D
considering increasing or decreasing future rates individual when she/he displays a behavior other
of behaviors), the procedure of differential than the targeted one. In the case of using differ-
reinforcement is the same. The basic procedural ential reinforcement to increase the strength of an
components of all differential reinforcement pro- appropriate behavior, the interventionist must
grams are these. First, the interventionist must only reinforce the targeted appropriate behavior.
operationally define the target behavior to be In the example of a child shouting out answers
changed. That could be an appropriate behavior instead of raising a hand, the teacher will rein-
that must be increased in rate, a behavior deemed force hand raising but will have to decide exactly
inappropriate that must be decreased in rate, or how to respond to the shouting out of answers.
both. The behavior must be operationally defined The interventionist will need to ensure that no
to allow for both correct recording of its occur- positive reinforcement follows any behavior
rence (so the interventionist can objectively other than the targeted one. An important ques-
determine if the differential reinforcement proce- tion is whether the inappropriate behavior can be
dure is having the desired effect) as well as for ignored. In the case of shouting out an answer, it
accurate implementation of the procedure (i.e., so is probably the case that planned ignoring can be
that the interventionist(s) reinforce (or not rein- used effectively. However, in other situations,
force) the correct response). with other behaviors such as self-injury or
The second step in using differential rein- aggression, planned ignoring may be difficult.
forcement is to determine the actual reinforce- There are many variations of differential rein-
ment that will be made contingent upon the forcement procedures that have been used. The
required response. This, by necessity, will vary most common ones are differential reinforcement
across the individual due to the fact that what of alternative behaviors (DRA), differential rein-
constitutes a motivating reinforcer is so person- forcement of incompatible behaviors (DRI),
alized across individuals. However, most of the differential reinforcement of other behaviors
time, the interventionist will use some form of (DRO), and differential reinforcement of low
positive reinforcement, such as praise, smiles, rate behaviors (DRL; see “See Also” section,
good grades, tokens, or other forms of tangible below).
reinforcement found desirable by the individual. Differential reinforcement is one of the most
On occasion, the interventionist might use a form widely used procedures to change behavior. The
of negative reinforcement, such as allowing the treatment of problem behaviors has evolved to
individual to escape a work demand contingent the point that there is a common assumption that
upon displaying the targeted response. For exam- reinforcement-based procedures are considered
ple, in the case where an individual tantrums in to be best practice and the most ethical strategies
order to escape or avoid work, the caregiver to implement. The procedure is a natural one
might allow that person to take a break from to most interventionists, in which desired behav-
work if the individual asks for a break instead of iors are rewarded and all other behaviors not
tantruming. Allowing the individual to briefly rewarded. The research has shown that differen-
escape an unpleasant work demand negatively tial reinforcement procedures can be very effec-
reinforces asking for a break. However, if the tive in changing behaviors, and – since they are
D 954 Differential Reinforcement Procedures
based on the use of reinforcement (most of the Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M.,
time, positive, as opposed to negative) – many & Santana, C. M. (2002). An evaluation of two differ-
ential reinforcement procedures with escape extinction
caregivers are comfortable with using such to treat food refusal. Journal of Applied Behavior
interventions. An advantage of differential rein- Analysis, 35, 363–374.
forcement procedures is that caregivers have Ringdahl, J., Kitsukawa, K., Andelman, M., Call, N.,
a systematic way to implement a technique that Winborn, L., Barretto, A., et al. (2002). Differential
reinforcement with and without instructional fading.
focuses on appropriate (positive) behaviors. Journal of Applied Behavior Analysis, 35, 291–294.
Another advantage is that such procedures main- Tiger, J. H., Bouxsein, K. J., & Fisher, W. W. (2007).
tain a positive learning atmosphere and allow the Treating excessively slow responding by a young man
instructional (or work activities) to continue in with Asperger syndrome using differential reinforce-
ment of short response latencies. Journal of Applied
the context in which these procedures are used. Behavior Analysis, 40, 559–563.
A third advantage is that differential reinforce- Vollmer, T. R., & Iwata, B. (1992). Differential reinforce-
ment can be effective without the addition of ment as treatment for behavior disorders – procedural
aversive or unpleasant procedures, such as pun- and functional variations. Journal of Applied Behavior
Analysis, 13, 393–417.
ishment. Differential reinforcement is also a good Vollmer, T. R., Iwata, B., Smith, R., & Rodgers, T. (1992).
procedure to implement when targeting problem Reduction of multiple aberrant behaviors and concur-
behaviors due to the fact that this procedure can rent development of self-care skills with differential
be used before and after the administration of reinforcement. Research in Developmental Disabil-
ities, 13, 287–299.
functional assessment strategies to determine
the function of that behavior. In these cases, dif-
ferential reinforcement can possibly establish
appropriate replacement behaviors, by orienting Differential Reinforcement
staff to notice and reinforce desired behaviors. Procedures of Alternative Behavior
This is important because differential reinforce- (DRA/DRAlt) of Incompatible
ment procedures do not address the function of Behavior (DRI)
challenging behaviors. That is, these procedures
are used in an attempt to “override” the Thomas Zane
reinforcing function of problem behaviors. The Institute for Behavioral Studies, Endicott
College, Beverly, MA, USA

Definition
River, NJ: Pearson.
Differential reinforcement of alternative behav-
Karsten, A. M., & Carr, J. E. (2009). The effects of iors (DRA) and differential reinforcement of
differential reinforcement of unprompted responding incompatible behaviors (DRI) are both proce-
on the skill acquisition of children with autism. dures designed to decrease the rate of targeted
unwanted behaviors. Targeted behaviors
Lennox, D. B., Miltenberger, R. G., Spengler, P., &
Erfanian, N. (1988). Decelerative treatment practices decrease due to two mechanisms – reinforcement
with persons who have mental retardation: A review of of appropriate behaviors that will replace the
five years of the literature. American Journal on unwanted behavior and the withholding of rein-
Lerman, D., Kelley, M., Vorndran, C., Kuhn, S., &
forcement that historically followed the
LaRue, R. (2002). Reinforcement magnitude and unwanted behavior. DRI is often considered
responding during treatment with differential rein- a type of DRA procedure.
forcement. Journal of Applied Behavior Analysis, 35, With both of these procedures, reinforcement
29–48.
Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012).
is contingent upon specific behaviors that will
Behavior analysis for lasting change (2nd ed.). replace the unwanted behavior. The nature of
Cornwall-on-Hudson, NY: Sloan Publishing. the replacement behaviors marks the difference
Differential Reinforcement Procedures 955 D
between DRA and DRI. In DRI, the replacement stimulation, or self-injury and that greatly interfere
behaviors are physically incompatible with the with the person learning positive adaptive skills and
unwanted behavior. They both cannot be done increasing their independence in life. Psychologists
at the same time. For example, if the unwanted and educators have long investigated the best treat-
behavior were out of seat, a physically incompat- ment for these types of concerns. One approach that
ible behavior would be staying in seat. If has been studied extensively has been the use of
the unwanted behavior were putting fingers in restrictive or punitive procedures. These involve
the mouth, a physically incompatible behavior either presenting a stimulus that is aversive or
would be putting hands in pants pockets. Thus, unpleasant to the individual following the occur- D
with a DRI procedure, the replacement behavior rence of the unwanted behavior or by removing
is both an appropriate one, as well as physically a desirable stimulus following the display of the
incompatible with the unwanted behavior. In unwanted behavior. Although these procedures
DRA, there is no concern about the replacement have been shown to be effective in eliminating
behaviors being physically incompatible; it is a wide variety of unwanted behaviors, they have
simply an appropriate behavior that could fulfill been associated with a number of negative side
the same function as the unwanted behavior. For effects, as well as potential ethical problems, includ-
example, if the unwanted behavior were screaming misuse and abuse.
ing (to indicate a need to escape a work demand), Alternatives to punishment have been pursued
an interventionist might use a DRA procedure vigorously in the research over the past few decades.
and select an appropriate replacement behavior One development has been that of functional assess-
such as pointing to a card to signal a need to break ment procedures, which allow the practitioner to
from work. Another example would be that if the determine the reinforcement maintaining the
unwanted behavior were a child inappropriately unwanted behaviors. Research has shown that if the
calling out answers in class (without waiting for reinforcement maintaining an unwanted behavior
the teacher to call on her), an appropriate replace- can be prevented from occurring, then the unwanted
ment behavior would be to raise her hand to behavior will reduce in strength. Similarly, if an
be called on. Note that in both of these examples, appropriate behavior that will earn the same rein-
the appropriate replacement behavior is not forcement (function) as the unwanted behavior can
physically incompatible with the targeted unwanted be taught, then the individual will likely shift to the
behavior; both the unwanted behavior and appropriate replacement behavior and reduce the
the replacement behavior could be displayed simul- occurrence of the unwanted behavior.
taneously. In both procedures, reinforcement is Along with functional assessment, researchers
delivered for the alternative or incompatible behav- have developed a set of procedures that emphasize
ior, and reinforcement is withheld (extinguished) the use of positive reinforcement to reduce
from the targeted unwanted behavior. Both proce- unwanted behaviors. Among these are the DRA
dures result in a decrease in rate of the unwanted and DRI procedures that focus on simultaneously
behavior. The strength of these procedures lies in reinforcing behaviors that can replace the unwanted
the discrimination between the two – the alternative behavior and removing the reinforcement that has
or incompatible behaviors are reinforced, while the maintained the targeted unwanted behavior. Find-
unwanted behaviors are not. ings of dozens of studies show that using reinforce-
ment in particular ways can have the same results as
punishment in stopping targeted behaviors.
The three general areas of concern for persons with Current Knowledge
autism are social, behavior, and language. Many
persons with this diagnosis display behaviors that Differential reinforcement procedures have been
are deemed inappropriate, such as aggression, self- found to be some of the most frequently used
D 956 Differential Reinforcement Procedures
procedures to reduce and eliminate unwanted The fourth step in using DRA or DRI is to
behaviors, across educational, social, and voca- determine the actual reinforcement that will be
tional contexts. DRA is useful for behaviors that made contingent upon the required alternative or
may occur at high or low rates, as this procedure incompatible response. The implementer will be
involves teaching the individual to engage in guided by two considerations here – the function
a more appropriate behavior than the behavior of the unwanted behavior (determined through
targeted for reduction. Often, DRA is combined a functional assessment) and the preferences of the
with DRI. DRI is preferable, as the student cannot individual. Reinforcement needs to be determined
engage in the targeted behavior for reduction based upon the particular individual with whom the
since the reinforced response is physically implementer is working, since reinforcement is so
incompatible with the unwanted behavior. individualized. Most of the time, the implementer
The procedural steps for both DRA and DRI will use some form of positive reinforcement, such
are similar. First, the implementer must opera- as praise, smiles, good grades, tokens, or other forms
tionally define the targeted unwanted behavior to of tangible reinforcement desired by the person. On
be reduced or eliminated so that the implementer occasion, the implementer might use a form of
(s) will not deliver reinforcement after its occur- negative reinforcement, such as allowing the indi-
rence and that there will be increased accuracy in vidual to escape a work demand contingent upon
data collection, to confirm (or not) if the differ- displaying the targeted response. These procedures
ential reinforcement procedure is having the are referred to as differential negative reinforcement
desired effect. With both of these procedures, of alternative behaviors (DNRA) and differential
the implementer must track the occurrence of negative reinforcement of incompatible behaviors
both the targeted unwanted behaviors, as well as (DNRI). For example, in the case where a person
the alternative and incompatible ones. tantrums in order to escape or avoid work, the care-
Second, the interventionist should determine giver might allow the individual to take a break from
the function of the unwanted behavior. This work if she/he asks for a break instead of tantruming.
information is helpful when deciding the proce- Thus, in this procedure, asking for a break is nega-
dures to use to prevent the reinforcement of the tively reinforced by allowing the person to briefly
unwanted behavior (see below), as well as in escape an unpleasant work demand. However, if the
guiding the selection of the appropriate replace- individual continues to tantrum and does not ask
ment behaviors, which is the third step. The appropriately for a break, the caregiver would keep
implementer must operationally define one or the individual in the demand situation and continue
more behaviors that will be (a) desirable alterna- to present work demands. The use of formal rein-
tives to the unwanted behaviors, (b) fulfill the forcement preference assessments is considered best
same function as the unwanted behaviors, and practice to determine the most motivating reward
(c) preferably be physically incompatible or com- items available.
pete with the unwanted behaviors. For example, The last step in the procedure is to identify the
if the unwanted behavior is swearing when frus- extinction procedures to implement contingent
trated, then an alternative behavior to strengthen upon the occurrence of the targeted unwanted
could be having the individual write down what is behavior. The results of the functional assess-
frustrating. When planning on using a DRI pro- ment are critically important here. Once the rein-
cedure, the implementer must define an appropri- forcement for the unwanted behavior has been
ate behavior that is physically incompatible with determined, the interventionist must plan on
the targeted inappropriate one. In the example of how to prevent that reinforcement from occurring
an individual swearing, an incompatible behavior when the unwanted behavior is emitted. In the
to reinforce could be saying, “oh, I am so frus- case of using DRA and DRI, the implementer will
trated, I need help!” instead of swearing. Note need to ensure that no reinforcement follows the
that expressing frustrating using that phrase is unwanted behavior. For example, when an indi-
physically incompatible with swearing. vidual swears, how will the implementer react?
Differential Reinforcement Procedures 957 D
In DRA and DRI, the implementer must ignore the effort involved. As with most behaviors that
the swearing and not comment or react to it and are targeted for increase, it would be important to
focus on reinforcing the occurrence of the alter- select these appropriate behaviors that will likely
native or incompatible behavior. be naturally reinforced in the individual’s daily
There are several advantages to DRA proce- environment. It is also good practice to select
dures. Of particular importance is the focus on these alternative and incompatible behaviors
appropriate behavior. These procedures require that will be less effort to emit than the targeted
specification of appropriate and positive behaviors unwanted one. As noted earlier, of equal impor-
to strengthen in the individual, which will contrib- tance is to select replacement behaviors that are D
ute to the individuals’ overall level of reinforce- incompatible with the unwanted behavior.
ment. They learn what to do, not just what not to In addition, there is a potential danger of a DRA
do. A second advantage of this group of procedures procedure that focuses on a limited group of
is that they are associated with few or no negative replacement behaviors of reducing the strength of
side effects, unlike more restrictive procedures, other, equally appropriate replacement behaviors.
such as time-out, overcorrection, and other forms For example, consider an unwanted behavior of
of punishment. Since DRA/DRI is associated screaming to escape or avoid a work situation. If
with reinforcement for appropriate responding, the interventionist selected one appropriate replace-
the individual receiving the reinforcement will ment behavior, that of pointing to a break card, the
likely show positive affect, demonstrate generalized individual may learn to use that card when a break is
responding, and develop a positive relationship with desired but at the same time, no longer asks for
the interventionist. a break using words or a communication device.
A third and equally important advantage is To avoid this potential result, the interventionist
that practitioners view these procedures quite should select all replacement behaviors that could
positively, much more so than punitive or restric- serve the same function as the targeted unwanted
tive ones. Caregivers, thus, are more likely to behavior.
carry out these procedures with greater willing- Lastly, the implementer must consistently rein-
ness and fidelity. A final advantage is that DRA force the alternative and incompatible behaviors
procedures are associated with long-term positive and consistently extinguish the unwanted behavior.
change. As the unwanted behavior decreases in The procedures are less effective when some
strength, and the appropriate behaviors increase, instances of the alternative or incompatible behav-
there should be continued suppression and elim- iors are not reinforced and some instances of the
ination of the unwanted behavior. unwanted behavior continue to achieve reinforce-
When considering the use of this group of ment. Extinction of the unwanted behavior seems to
procedures, it has been shown that the effect on be important in the success of DRA/DRI. Research
the targeted replacement behavior may take some has shown that these procedures will be less effec-
time. Reinforcement does result in behavior tive if the unwanted behavior continues to result in
change, but the change may not be that rapid. reinforcement.
To increase the speed of behavior change, it is
recommended selecting powerful reinforcers.
Another way to further increase the speed of Future Directions
further progress, one should select alternative or
incompatible behaviors that already exist in the Differential reinforcement of alternative/incom-
individual’s repertoire. These appropriate behav- patible behaviors should be seriously considered
iors should already be occurring at some level so when planning on addressing unwanted behav-
that the implementer has opportunities to rein- iors. To use these procedures effectively, the
force them when they occur. Although interven- practitioner must carefully determine the rein-
tionists could teach a new skill or behavior as the forcement for the unwanted behavior, plan pow-
replacement behavior, this simply complicates erful reinforcement to strengthen the appropriate
D 958 Differential Reinforcement Procedures of Low Rates of Responding (DRL)
behavior, and develop procedures for preventing Tiger, J. H., Bouxsein, K. J., & Fisher, W. W. (2007).
the unwanted behavior from being rewarded. Treating excessively slow responding of a young man
with Asperger syndrome using differential reinforce-
When working with individuals who display ment of short response latencies. Journal of Applied
unwanted behaviors in which it may be difficult Behavior Analysis, 40, 559–563.
to prevent the reinforcement for those behaviors, Vollmer, T. R., Roane, H. S., Ringdahl, J. E., &
caregivers will need to determine how to manip- Marcus, B. A. (1999). Evaluating treatment challenges
with differential reinforcement of alternative behavior.
ulate the reinforcement for the replacement Journal of Applied Behavior Analysis, 32, 9–23.
behaviors in a way to promote their increase,
regardless of the reinforcement for the unwanted
behaviors. For example, the use of intermittent
reinforcement, increased duration of reinforce-
ment, or a greater magnitude of reinforcement Differential Reinforcement
for the appropriate replacement behaviors could Procedures of Low Rates of
be considered. Responding (DRL)
Thomas Zane1 and Cheryl Davis2

See Also 1
The Institute for Behavioral Studies,
Endicott College, Beverly, MA, USA
▶ Differential Reinforcement 2
7 Dimensions Consulting, Southborough,
▶ Functional Assessment MA, USA
Athens, E. S., & Vollmer, T. R. (2010). An investigation Differential Reinforcement of Low Rates of
of differential reinforcement of alternative behavior
responding (DRL) is a procedure in which the
without extinction. Journal of Applied Behavior
Analysis, 43, 569–589. implementer can lower the rate of a response by
Beare, P. L., Severson, S., & Brandt, P. (2004). The use of reinforcing fewer incidents of that response or by
a positive procedure to increase engagement on-task reinforcing longer time intervals between inci-
and decrease challenging behavior. Behavior Modifi-
dents of the response. For example, if an individ-
cation, 28, 28–44.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). ual rocks back and forth an average of 10 times
Applied behavior analysis (2nd ed.). Upper Saddle per half hour, an interventionist could provide
River, NJ: Pearson. a positive reinforcer contingent upon that indi-
Heinicke, M. R., Carr, J. E., & Mozzoni, M. P. (2009). Using
vidual rocking 8 or fewer times per half hour.
differential reinforcement to decrease academic response
latencies of an adolescent with acquired brain injury. Alternatively, the interventionist could provide
Journal of Applied Behavior Analysis, 42, 861–865. a reinforcer following a rocking incident if there
Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012). had been a minimum amount of time (e.g., 5 min)
Behavior analysis for lasting change (2nd ed.).
since the previous rocking episode.
Petscher, E. S., & Bailey, J. (2008). Comparing main A related term is Differential Reinforcement of
and collateral effects of extinction and differential Diminishing rates (DRD). The technical differ-
reinforcement of alternative behavior. Behavior ence between DRL and DRD is that in DRD,
Modification, 32(4), 468–488.
reinforcement follows a response that has been
Petscher, E. S., Rey, C., & Bailey, J. S. (2009).
A review of empirical support for differential reinforce- preceded by a minimum amount of time since the
ment of alternative behavior. Research in Developmental last response. DRL technically refers to providing
Disabilities, 30, 409–425. reinforcement for fewer and fewer responses
Pipkin, C. S. P., Vollmer, T. R., & Sloman, K. N. (2010).
exhibited by the individual. However, DRL is the
Effects of treatment integrity failures during differential
reinforcement of alternative behavior: A translational most common term and often refers to both of
model. Journal of Applied Behavior Analysis, 43, 47–70. these procedures.
Differential Reinforcement Procedures of Low Rates of Responding (DRL) 959 D
Historical Background Current Knowledge
The three general areas of concern for persons with Even though the DRL procedure is used to reduce
autism are social, behavior and language. Many per- rates of a problem behavior, the reinforcement
sons with this diagnosis display behaviors that are is delivered after the occurrence of that behavior,
deemed inappropriate, such as aggression, self- which may seem counterintuitive. This is in con-
stimulation, or self-injury that, if left untreated, can trast to the Differential Reinforcement Alternative
greatly interfere with the individual acquiring posi- behavior (DRA), which reinforces appropriate
tive adaptive skills and becoming more independent. replacement behaviors; Differential Reinforce- D
Psychologists and educators have long investigated ment of Incompatible behavior (DRI), which pro-
the best treatment for these types of concerns. One vides reinforcement for appropriate replacement
approach that has been studied extensively has been behaviors that are physically incompatible with
the use of restrictive or punitive procedures. These the targeted unwanted behaviors; or Differential
involve either presenting a stimulus that is aversive or Reinforcement of Other behavior (DRO) proce-
unpleasant to the individual following the occurrence dure, in which the reinforcement is delivered
of the unwanted behavior or by removing a desirable in the absence of the target behavior. When
stimulus following the display of the unwanted using DRL, reinforcement occurs following an
behavior. Although these procedures have been unwanted response that remains below a certain
shown to be effective in eliminating a wide variety criterion or following an unwanted response that
of unwanted behaviors, they have been associated was preceded by progressively longer intervals of
with a number of negative side effects, as well as time from the previous response.
potential ethical problems, including misuse and It is important to point out that the goal of
abuse. a DRL procedure is to simply reduce the rate of
Alternatives to punishment have been pursued the targeted behavior but not to eliminate it
vigorously in the research over the past few entirely. Some behaviors that might be consid-
decades. One development has been that of ered undesirable at higher rates may be accept-
functional assessment procedures, which allow ably tolerated at lower rates, without needing to
the practitioner to determine the reinforcement reduce them to zero. For example, perhaps one
maintaining the unwanted behaviors. Research could find as acceptable a child who gets out of
has shown that if the reinforcement maintaining seat in school a few times a week, but the exact
an unwanted behavior can be prevented from same behavior considered intolerable if it were to
occurring, then the unwanted behavior will occur several times an hour. A child with autism
reduce in strength. Similarly, if an appropriate who spontaneously verbalizes movie scripts only
behavior that will earn the same reinforcement a few times per week could be considered more
(function) as the unwanted behavior can be tolerable than engaging in this behavior several
taught, then the individual will likely shift to the times per half-hour period. Thus, the DRL proce-
appropriate replacement behavior and reduce the dure is typically used when considering reducing
occurrence of the unwanted behavior. a behavior that is considered acceptable at lower
Along with functional assessment, researchers rates but not higher levels.
have developed a set of procedures that emphasize There are several variations of the basic DRL
the use of positive reinforcement to reduce procedure. In “full session DRL,” the implemen-
unwanted behaviors. Among these is the DRL pro- ter provides reinforcement at the end of a session
cedure that focuses on reinforcing less occurrences or a predetermined amount of time if the number
of the unwanted behavior and not reinforcing higher of incidents of the undesired behavior falls at or
occurrences of the unwanted behavior. Findings of below a predetermined criterion level. For exam-
dozens of studies show that using reinforcement in ple, a teacher divides the school day into 12-, 30-
particular ways can have the same results as pun- min sessions or time periods. Each half hour
ishment in stopping targeted behaviors. consists of one “session.” A child engages in
D 960 Differential Reinforcement Procedures of Low Rates of Responding (DRL)
tantrums on an average of 6 per half-hour period. Thus, the rule for reinforcement is that only
The initial rule for delivering reinforcement in responses that have been preceded by a minimum
this “full session DRL” program would be that of 3 min from the previous response will receive
the child engages in five or fewer tantrums in reinforcement.
a session. As the rate drops to consistently at The basic procedural components of all DRL
five or fewer, a new rule would be implemented, procedures are these. First, the interventionist
whereby reinforcement would be made contin- must operationally define the targeted unwanted
gent upon four or fewer occurrences in the ses- behavior to be changed. This must be done to
sion. Over time, by gradually reducing the allow for both correct recording of its occurrence
criterion level, the DRL program will eventually (so the interventionist can objectively determine
bring the rate of behavior to an acceptable level. if the differential reinforcement procedure is hav-
Note also that in full session DRL, the individual ing the desired weakening effect) as well as for
has an opportunity to earn reinforcement numer- accurate implementation of the procedure (i.e., so
ous times, across the multiple sessions, since each that the interventionist(s) implement the DRL
new session signals a new opportunity. plan consistently).
Another type of DRL is the “interval DRL,” The second step in using DRL is to determine
which is a procedure for implementing DRL in the current “operant level” of the response. That
which the total session is divided into equal inter- is, the interventionist must have data showing the
vals and reinforcement is provided at the end of current rate of the behavior before implementing
each interval in which number of responses dur- DRL. Depending upon the type of DRL proce-
ing the interval is equal to or below a criterion dure to use, data might be needed showing the
limit. Similar to the full session DRL, this would total number of responses during a day, the total
involve taking the full session and breaking it number of responses (on average) during individ-
down into smaller intervals and reinforcement ual sessions, and/or the average amount of time
could be delivered during each of those intervals. between occurrences of the targeted undesired
For example, a teacher divides a 30-min lunch behavior.
period into 3, 10-min intervals. A child, on aver- The third step in using DRL procedures is to
age, 21 times during the lunch period. The rule determine the actual reinforcement that will be
for delivering reinforcement in this “interval made contingent upon the response meeting the
DRL” would be that if the child swore seven or rule for earning reinforcement. This, by necessity,
fewer times in each 10-min period, reinforcement will vary across individuals due to the fact that what
would be provided. A potential advantage of an constitutes a motivating reinforcer is personalized.
interval DRL program is that the individual has However, most of the time, the interventionist will
multiple opportunities within a session to earn use some form of positive reinforcement, such as
reinforcement, as opposed to just one opportunity praise, smiles, good grades, tokens, or other forms
(at the end of the session). of tangible reinforcement desired by the learner. On
A third variation of the basic DRL procedure is occasion, the interventionist might use a form of
the “space-responding DRL” (sometimes called negative reinforcement, such as allowing the indi-
DRD). This is a procedure for implementing DRL vidual to escape a work demand contingent upon
in which reinforcement follows each occurrence of displaying the targeted response. For example, in
the target behavior that is separated from the previ- the case where a person tantrums in order to escape
ous response by a minimum inter-response time or avoid work, the caregiver might allow the indi-
(IRT). For example, a child correctly answers ques- vidual to take a break from work if s/he asks for
tions asked by the teacher but answers so quickly a break instead of tantruming. In this procedure,
that other students have no opportunity to be called asking for a break is negatively reinforced by
on. The teacher makes a rule with this student that to allowing the individual to briefly escape an unpleas-
be called on to answer a question, 3 min have ant work demand. However, if the person continues
elapsed since the child last answered of a question. to tantrum and does not ask appropriately for
Differential Reinforcement Procedures of Low Rates of Responding (DRL) 961 D
a break, the caregiver would continue to keep the An excellent example of DRL that has been
individual in the demand situation and constantly shown to be effective is called the “Good Behav-
require work. The use of formal reinforcement ior Game.” This procedure involves dividing
preference assessments is considered best practice a group of individuals (such as students in
to determine the most motivating reward items a classroom) into two or more teams. The goal
available. is to be the team with fewest occurrences of
The last step in the procedure is to determine undesired behaviors. Generally, the intervention-
the actual rule for providing reinforcement. Three ist would periodically observe each team and
rules or criteria must be planned. First, the rule note whether or not undesired behaviors are D
for what level of behavior will be required as the occurring. After a set period of time (e.g., end
initial new criterion must be established. To of the day, before lunch, etc.), the team with the
determine this, the interventionist would set the fewest occurrences of the targeted undesired
initial criterion at or a little below the operant behavior will earn some type of positive
level. For example, if the operant level was 10 reinforcer.
occurrences per session or interval, the initial DRL is a positive procedure in that it utilizes
DRL criterion could be anywhere from eight to only reinforcement to reduce undesired behav-
ten. The second rule that must be determined is iors. It is also advantageous in that it is more
the criterion for changing from the current crite- easily tolerated than a behavior-reduction proce-
rion to a new, lower one. This criterion would dure that only provides reinforcement for the
specify the number of sessions that must be at the absence of the targeted behavior (i.e., DRO).
criterion level before changing to new one. The The goal of that procedure is the cessation of
final rule that must be established is the ultimate, the unwanted behavior. A complete elimination
terminal criterion at which point the intervention- would generally be considered more difficult to
ist would consider an acceptable level of the achieve than allowing some (but lower) level of
behavior and at which point the DRL plan the target behavior. The individual exhibiting the
would be discontinued. target behavior may more easily tolerate being
For example, for the full session DRL, the allowed some amount of the unwanted behavior,
interventionist must determine the size of the than attempting to eliminate it altogether. That is
reduction (from the pre-DRL level) within the why DRL is often successful; it results in
session that will result in reinforcement. For exam- a targeted behavior that is inappropriate at higher
ple, if the pre-DRL level of the response was an levels becoming appropriate and tolerated at
average of 25 responses within each session, the lower levels. Lastly, DRL procedures have been
interventionist will need to determine what lower shown in the literature to be effective procedures
number of responses will result in reinforcement. with a wide variety of individuals and target
Generally speaking, a gradual reduction from problems; thus, it has good generalization
baseline levels will likely lead to more success evidence.
than a large reduction. Thus, if the baseline level There are several considerations for using
was an average of 25 responses per session, one DRL most effectively. Firstly, the practioner
should select as the criterion for reinforcement 23 must recognize that the DRL procedure does not
or 24 responses per session. Although there is no produce rapid behavior change; rather, it pro-
definitive rule for how to select the lower criterion duces slow and gradual changes. So, one must
for reinforcement, one should plan on a gradual use DRL to change behaviors that are amenable
reduction, with that level of reduction occurring to gradual change. Secondly, practitioners should
over a set number of sessions. For example, if the not use DRL when targeting behaviors that could
baseline level average was 25 per session, the be physically harmful to the individual or others
interventionist could set 23 responses per session, (such as self-injury, aggression, etc.). For those
over 3 consecutive sessions, as the first lower categories of behaviors, the interventionist
criterion for reinforcement. should use procedures that have more of an
D 962 Differential Reinforcement Procedures of Other Behavior (DRO)
immediate impact or combine DRL with such Hagopian, L. P., & Kuhn, D. E. (2009). Targeting social
strategies. Lastly, DRL does, by its nature, focus skills deficits in an adolescent with pervasive develop-
mental disorder. Journal of Applied Behavior Analysis,
on the undesired behavior, rather than reinforcing 42(4), 909–911.
appropriate replacement behaviors. This suggests Lennox, D. B., Miltenberger, R. G., Spengler, P., &
that the implementer combines DRL with pro- Erfanian, N. (1988). Decelerative treatment practices
cedures that target and reinforce appropriate with persons who have mental retardation: A review of
five years of the literature. American Journal on
replacement behaviors. Mental Retardation, 92, 492–501.
Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012).
Future Directions Cornwall-on-Hudson, NY: Sloan Publishing.
Rolider, A., & van Houten, R. (1990). The role of rein-
forcement in reducing inappropriate behavior: Some
When developing programs for children with myths and misconceptions. In A. C. Repp & N. N.
autism, often part of that programming focuses Singh (Eds.), Perspectives on the use of nonaversive
on attempting to reduce problem behaviors. The and aversive interventions for persons with develop-
mental disabilities (pp. 119–127). Sycamore, IL:
set of DRL programs could be useful in that Sycamore.
regard, depending upon the characteristics of the Shaw, R., & Simms, T. (2009). Reducing attention-
undesired behavior. Future directions could maintained behavior through the use of positive pun-
include clarifying the specific behavioral or con- ishment, differential reinforcement of low rates, and
response marking. Behavioral Interventions, 24,
textual variables that would suggest a particular 249–263.
DRL program be used over another type of pro- Wright, C. S., & Vollmer, T. R. (2002). Evaluation of
gram, such as DRA, DRI, DRO, or more restric- a treatment package to reduce rapid eating. Journal
tive techniques. In addition, rules for determining of Applied Behavior Analysis, 35, 89–93.
the combination of DRL with other programs to
specifically teach, model, and reinforce appropri-
ate incompatible behaviors (to the undesired
ones) would be useful for practitioners.
Differential Reinforcement
Procedures of Other Behavior (DRO)
See Also
Thomas Zane1 and Cheryl Davis2
▶ Differential Reinforcement 1
The Institute for Behavioral Studies, Endicott
College, Beverly, MA, USA
2
7 Dimensions Consulting, Southborough,
References and Readings MA, USA
Anglesea, M. M., Hoch, H., & Taylor, B. A. (2008).

Reducing rapid eating in teenagers with autism: Definition
Use of a page prompt. Journal of Applied Behavior
Analysis, 41(1), 107–111.
Barrish, H. H., Saunders, M., & Wolf, M. M. (1969). Good Differential reinforcement of other behaviors
behavior game: Effects of individual contingencies (DRO) is a reinforcement procedure in which
for group consequences on disruptive behavior in reinforcement is delivered for any response
a classroom. Journal of Applied Behavior Analysis, 2,
119–124.
other than a specific target behavior. This proce-
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). dure results in a decrease in that specific target
Applied behavior analysis (2nd ed.). Upper Saddle behavior because that behavior is never followed
River, NJ: Pearson. by reinforcement; thus, it weakens in future rate.
Deitz, S. M., & Repp, A. C. (1973). Decreasing classroom
misbehavior through the use of DRL schedules of
For example, if a child with autism displays self-
reinforcement. Journal of Applied Behavior Analysis, stimulatory behavior in the form of waving both
6, 457–463. hands in front of his face, a DRO procedure
Differential Reinforcement Procedures of Other Behavior (DRO) 963 D
would be to provide a positive reinforcement for specific appropriate responses. In DRO, reinforce-
a 10-s period during which his hands were not ment is provided contingent upon a passage of time
waving in front of his face. Other names for this in which the targeted undesired behavior does not
procedure include differential reinforcement of occur. Note that reinforcement does not follow any
zero occurrences or omission training. specific response; it can follow any response as long
as that response is not the targeted undesirable
behavior. Because the “other” behaviors are not
Historical Background defined, no one behavior is reinforced so much
that it is likely to increase in strength. But what D
When considering interventions for undesirable does happen is that the targeted undesirable behav-
behaviors, interventionists initially found punish- ior is never reinforced, so over time, it reduces
ment procedures to be effective. Although in rate.
such procedures as overcorrection, time-out, and There are basically two types of DRO,
response cost do indeed reduce unwanted behav- whole-interval and momentary-interval. The
ior, there are often negative side effects for the whole-interval DRO is a procedure in which
individual being exposed to those procedures, reinforcement is available at the end of a fixed
and historically, there have been abuses using interval of duration if the targeted unwanted
aversive techniques. behavior did not occur at any time throughout
As more research was conducted on dealing that interval. For example, a child with autism is
with unwanted behaviors, professionals learned often out of her seat during independent work
that using positive procedures could be effective time. A whole-interval DRO procedure could
tools in obtaining reductions in these behaviors. involve dividing the independent work time
Generally speaking, differential reinforcement period into 6, 5-min periods. During each 5-min
has been shown to both increase appropriate period, the teacher observes the child, and if the
behaviors as well as reducing the strength of child does not get out of seat at all during a 5-min
unwanted responses. One form of differential period, the teacher delivers reinforcement. How-
reinforcement that has been shown in the research ever, if the child did get out of seat during a 5-min
to be quite effective in weakening problem period, no reinforcement will be provided; the
behaviors is DRO. This technique has been child will have another opportunity at the begin-
shown to be effectively across a wide variety of ning of the next 5-min interval. Because the out
unwanted behaviors exhibited by a variety of of seat behavior is not reinforced by the teacher,
individuals. and other behaviors are, the out of seat behavior
should begin to diminish in rate.
This procedure requires constant vigilance and
Current Knowledge observation on the part of the interventionist
throughout the interval, so as to observe any occur-
Differential reinforcement of other behaviors rence of the target behavior. This DRO is appropri-
(DRO) is a procedure for decreasing problem ate for high or low rates of challenging behaviors, as
behavior in which reinforcement is contingent on the interval can be set according to the rates of
the absence of the problem behavior during or at challenging behaviors. Typically, one sets the inter-
specific times. DRO is perhaps the simplest of all val just below the pre-intervention IRT duration of
behavior reduction procedures as it involves the the problem behavior (see below).
simple rule of providing reinforcement whenever The momentary DRO is a DRO procedure
the specific undesirable behavior is not displayed. whereby reinforcement is available at specific
DRO differs from differential reinforcement of moments of time and delivered contingent on
alternative behaviors (DRA) and differential rein- the problem behavior not occurring at that those
forcement of incompatible behaviors (DRI) in that precise moments. For example, a child with
with those two procedures, reinforcement follows autism often whines while playing at home.
D 964 Differential Reinforcement Procedures of Other Behavior (DRO)
A caregiver could make a rule that every 2 min differential reinforcement procedure is having
(and exactly at the 2-min mark), the child will be the desired weakening effect) as well as for accu-
provided a reinforcer if at that very moment of rate implementation of the procedure (i.e., so that
observation, there is no whining being emitted. the interventionist(s) know exactly when rein-
Thus, reinforcement is delivered at the moment of forcement should or should not be provided).
observation if the individual is doing anything other The second step in using DRO is to determine
than whining. Note that this DRO procedure does the actual reinforcement that will be made
not demand constant vigilance and attention on the contingent upon the absence of the unwanted
part of the interventionist as does the whole-interval response and how it will be delivered. This, by
DRO. Using a momentary DRO allows the inter- necessity, will vary across individuals due to the
ventionist to be attentive to the individual only at the fact that what constitutes a motivating reinforcer
precise moment specified by the DRO schedule. is so personalized. However, most of the time, the
Whether reinforcement is delivered is not depen- interventionist will use some form of positive
dent upon whether the targeted behavior was pre- reinforcement, such as praise, smiles, good
sent or absent before or after the moment of grades, tokens, or other forms of tangible rein-
observation; reinforcement is entirely dependent forcement desired by the learner. On occasion,
upon whether it is occurring at the precise observa- the interventionist might use a form of negative
tional moment. reinforcement, (termed differential negative rein-
There are two variations of the whole- and forcement of other behavior, or DNRO) such as
momentary-interval DRO procedures. The inter- allowing the learner to escape a work demand
vals can be a fixed or variable duration. Thus, contingent upon displaying the targeted response.
a fixed-whole-interval DRO consists of the For example, in the case where an individual
interval size be standard across all intervals. tantrums in order to escape or avoid work, the
However, a variable-whole-interval DRO con- caregiver might allow the person to take a break
sists of the interval duration varying per interval. from work if she/he asks for a break instead of
For example, the intervals could range from 5, 10, tantruming. In this procedure, asking for a break
35, 3, and so forth but varying around a set is negatively reinforced by allowing the person to
mean. Momentary-interval DRO programs can briefly escape an unpleasant work demand. How-
be either fixed or variable, too. A fixed-momen- ever, if the individual continues to tantrum and
tary-interval DRO consists of the interval size does not ask appropriately for a break, the care-
being standard across all intervals; a variable- giver would continue to keep the person in the
momentary-interval DRO plan allows each inter- demand situation and constantly requiring work.
val to vary around some average duration. The The use of formal reinforcement preference
advantage of the variable DRO is that individuals assessments is considered best practice to deter-
cannot predict when the interval will end and mine the most motivating reward items available.
reinforcement is available. The third step in implementing a DRO proce-
All DRO procedures target the reduction of dure is to determine which type of DRO will be
targeted inappropriate behavior. The research in used, interval or momentary, and the criteria for
which DRO procedure to use shows mixed establishing the initial interval size and increas-
results; both types of DRO plans can be effective ing the interval size as the behavior begins to
in reducing the targeted undesired behavior. weaken. Once the type of DRO program is
The basic procedural components of all DRO decided, the interventionist must determine the
procedures are these. First, the interventionist interval size to use to begin the procedure.
must operationally define the target behavior to Research has shown the most success is seen
be changed. That requires carefully specifying when the initial interval size is set small and
the targeted unwanted behavior to allow for gradually lengthened over time, as the targeted
both correct recording of its occurrence (so the behavior reduces in rate. This should be based
interventionist can objectively determine if the upon pre-intervention levels of the problem
Differential Reinforcement Procedures of Other Behavior (DRO) 965 D
behavior and the average “inter-response time” are more willing to use positive procedures as
(IRT) duration historically observed. IRT refers opposed to more aversive or unpleasant interven-
to the duration between two occurrences of the tions. Since these procedures are generally effective
target behavior. The formula for calculating IRT and positive, they are more ethically appropriate as
is to divide the total number of responses a treatment choice. DRO is easy for teachers to use
observed during a certain time interval by the in most classrooms and school settings and have
total amount of time of that interval. For example, been shown to work across a wide variety of
if during pre-intervention conditions, the individ- populations and contexts. The effect of such pro-
ual exhibits the target behavior, on average, cedures is more rapid than simply extinguishing the D
10 times every hour, the mean interval between targeted undesired behavior; although extinction
occurrences is 6 min (10 occurrences of the can work, the application of DRO produces quicker
behavior divided by 60 min). That information change. Additionally, the effects of DRO have been
can then be used to establish the initial interval shown to be long lasting, producing durable
size for the DRO procedure. Next, the interven- response suppression. A particular advantage of
tionist must develop a criterion for increasing the a momentary DRO is that it does not require such
interval duration as the DRO program demon- continuous attention, and for a busy teacher or
strates success. For example, if the practitioner parent, that can be a useful feature. With this pro-
begins with an interval size of 6 min, and over cedure, at the moment of observation, the interven-
90% of the intervals show no targeted problem tionist can interrupt what she/he is doing, observe
behavior over 3 consecutive days, then the inter- whether or not the targeted undesirable behavior is
val size could be increased to 7 min. Such a mas- occurring, and deliver (or not deliver) the reinforce-
tery criterion if developed, in advance, will result ment based upon that immediate observation.
in both increased progress in decreasing the prob- However, there are several potential disadvan-
lem behavior and a procedure gradually easier to tages to DRO procedures. One is that such pro-
implement. cedures are not designed to teach and/or increase
The last step in the procedure is to determine any particular appropriate behavior. Its inherent
exactly how to respond to the display of the characteristic is to focus on the absence of the
targeted undesired behavior. The rule in DRO is targeted behavior, and there is no attempt to
to not provide any reinforcement for its occur- operationally define and strengthen an appropri-
rence. So, the interventionist must be careful not ate replacement behavior. Another potential lim-
to react in any way that could possibly provide itation of this procedure is that it focuses the
any source of reinforcement for its occurrence. attention of the interventionist on the negative
An important question is whether the inappropri- or undesired behavior. Since its occurrence trig-
ate behavior can be ignored or if it is such gers whether or not reinforcement is delivered,
a serious behavior that some sort of intervention the interventionist is paying attention primarily to
must apply. In the case of shouting out an answer, whether or not the problem behavior occurs.
it is probably the case that ignoring it can be done This may result in the individual inadvertently
effectively. However, in other situations, with getting attention for the problem behavior.
other behaviors such as self-injury or aggression, Thus, caregivers need to be aware of any poten-
not reacting may be difficult, due to potential tial reaction being given to the individual follow-
safety issues. In those cases, DRO may not be ing the occurrence of the targeted unwanted
the method of choice. behavior. Another potential disadvantage of the
There are several advantages of DRO. The pro- DRO procedures is that since reinforcement is
cedure is positive, easy to implement, and focuses delivered for any response other than the targeted
solely on the use of reinforcement to decrease undesired behavior, there is a risk that other
undesired behaviors. Reinforcers are not removed behaviors equally undesirable may inadvertently
from the individual, and few to no negative side be reinforced and thus strengthened. For exam-
effects are reported. Interventionists appreciate and ple, consider a DRO procedure used to reduce
D 966 Diffusion Tensor Magnetic Resonance Imaging
a self-stimulatory behavior of jumping up and Cowdery, G., Iwata, B., & Pace, G. (1990). Effects and
down repeatedly. With DRO, reinforcement is side effects of DRO as treatment for self-injurious
behavior. Journal of Applied Behavior Analysis,
given whenever jumping is not occurring. 23(4), 497–506.
However, if the individual is not jumping but Daddario, R., Anhalt, K., & Barton, L. (2007). Differential
instead waving fingers in front of the face, rein- reinforcement of other behavior applied classwide
forcement would be allowed (since the rule is to in a child care setting. International Journal of Behav-
ioral Consultation and Therapy, 3(3), 342–348.
provide reinforcement for any response other Hegel, M. T., & Ferguson, R. J. (2000). Differential
than jumping). This potential disadvantage is reinforcement of other behavior (DRO) to reduce
possible when working with an individual who aggressive behavior following traumatic brain injury.
displays a large number of undesired behaviors. Behavior Modification, 24(1), 94–101.
Homer, A. L., & Peterson, L. (1980). Differential
If this potential exists, a recommendation would reinforcement of other behavior: A preferred response
be to provide the reinforcement only when none elimination procedure. Behavior Therapy, 11,
of the undesired behaviors are occurring or to 449–471.
use a procedure other than DRO (such as DRA Kodak, T., Miltennberger, R. G., & Romaniuk, C. (2003).
The effects of differential negative reinforcement of
or DRI). other behavior and noncontingent escape on compli-
ance. Journal of Applied Behavior Analysis, 36,
379–382.
Future Directions Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012).
DRO procedures are effective, show long-lasting Miltenberger, R. G. (2001). Behavior modification:
results, are relatively easy to implement, and Principles and procedures (2nd ed.). Belmont, CA:
preferred by interventionists due to their positive Wadsworth/Thomson Learning.
nature. Further clarification of the behavioral
characteristics of when to use which type of
DRO would enhance its use and effectiveness.
Guidelines for establishing initial interval size Diffusion Tensor Magnetic
and criterion for increasing the interval duration Resonance Imaging
would be helpful as well.
Roger J. Jou1 and Lawrence H. Staib2
1
Child Study Center, Yale University School of
See Also Medicine, New Haven, CT, USA
2
Department of Diagnostic Radiology, Yale
▶ Differential Reinforcement University School of Medicine, New Haven,
CT, USA

Conyers, C., Miltenberger, R., Maki, A., Barenz, R.,
Jurgens, M., Sailer, A., et al. (2004). A comparison Diffusion tensor imaging (DTI) is a magnetic
of response cost and differential reinforcement of other resonance imaging (MRI) modality used in brain
behavior to reduce disruptive behavior in a preschool imaging which measures characteristics of water
classroom. Journal of Applied Behavior Analysis, 37,
411–415.
diffusion in vivo to make inferences on the under-
Conyers, C., Miltenberger, R., Romaniuk, C., Kopp, B., & lying neuroanatomy, such as the structural integrity
Himle, M. (2003). Evaluation of DRO schedules to of white matter. White matter structures probed
reduce disruptive behavior in a preschool classroom. include major neuronal fiber tracts such as associa-
Child and Family Behavior Therapy, 25(3), 1–6.
tion (e.g., superior longitudinal fasciculus), com-
Applied behavior analysis (2nd ed.). Upper Saddle missure (e.g., corpus callosum), and projection
River, NJ: Pearson. (e.g., corticospinal tract) fibers. Water diffusion
Diffusion Tensor Magnetic Resonance Imaging 967 D
can be characterized at each anatomical location by matter integrity. Regardless of the specific mea-
the diffusion tensor, a second-order model which sure, however, each of these parameters provides
provides the direction and the degree of anisotropy different information about the underlying white
(i.e., directionality). The diffusion tensor can be matter architecture. Because of this, considering
visualized as an ellipsoid and generally aligns multiple measures has become a common
with the underlying white matter fibers. Diffusion approach in DTI studies.
properties in tissue can then be captured using Moreover, DTI can also be used to reconstruct
various numeric metrics computed from the tensor the 3D structure of white matter fiber tracts using
and commonly include fractional anisotropy (FA), a technique called tractography or “fiber tracking.” D
radial diffusivity (RD), axial diffusivity (AD), mean Algorithms are used to determine 3D curves which
diffusivity (MD), and apparent diffusion coefficient trace fibers by following the orientation of maxi-
(ADC), with FA being the most widely utilized in mum water diffusion. These fibers can then be
neuropsychiatric research. visualized resulting in spectacular images of multi-
There are some general relationships between ple fiber pathways. Tractography is now being used
the aforementioned metrics and biological fea- regularly in the study of neuropsychiatric disorders
tures of tissue. Thus, knowledge of these infer- such as autism. Previously, such white matter anat-
ences can guide the interpretation of research omy could only be studied by postmortem dissec-
findings using DTI. Each of these measures tion or invasive tracing studies in nonhuman
aims to characterize the restriction of water dif- animals. Because of this, tractography has been
fusion due to physical barriers such as mem- referred to as “virtual dissection.”
branes and myelin; therefore, they are used as DTI has revolutionized the study of structural
surrogates for white matter structural integrity brain connectivity in humans and is extensively
in DTI studies. RD is a measure of the inhibited used in the field of autism research to study alter-
water diffusion occurring across or perpendicular ations in neural connectivity. In the past 5 years,
to nerve fibers. Causes of increased restriction there has been a surge in the number of DTI
perpendicular to the fiber (a low RD) include studies published in autism research with the
thicker myelin, a more water-impermeable mye- overall consensus being that some level of
lin, denser packing of fibers, and/or smaller fiber impairment exists in structural brain connectivity
diameters. Less restriction (a high RD) could be likely in the direction of underconnectivity. The
due to delayed myelination, loss of myelin, more focus of this chapter is the application of DTI in
water-permeable myelin, loss of axonal mem- the study of the neurobiology of autism spectrum
brane integrity, looser fiber packing, disorga- disorders (ASD). While a brief description of the
nized fiber packing, and/or larger-diameter technical aspects of DTI has been provided, the
fibers. On the other hand, AD is a measure of reader is referred to other reading which covers
water diffusion occurring along or parallel to the technical details of DTI in much greater detail
nerve fibers. A higher AD value indicates less (Mori, 2007; Mori & Zhang, 2006).
hindrance to water movement along axons and
could be due to axonal loss and/or less-dense fiber
packing. MD and ADC measure average water Historical Background
diffusion in all directions. Finally, FA ranges
from zero to one and describes the degree to Interestingly, diffusion MRI had been known for
which water diffusion is directionally dependent. many decades as a source of obtaining tissue
A value of zero means that water diffusion is contrast. Early work in the 1950s by Hahn
isotropic; it is equally restricted in all directions (Hahn, 1950), Carr and Purcell (Carr & Purcell,
such that the pattern of diffusion resembles 1954), and Torrey (Torrey, 1956) laid the ground-
a sphere. A value of one means that water diffu- work for diffusion measurements from magnetic
sion is completely restricted to a single direction. resonance, providing an understanding of the
FA is most frequently used to characterize white change in the magnetic resonance signal in the
presence of water diffusion. Stejskal and Tanner false positives which can result from the large
(Stejskal & Tanner, 1965) advanced this formu- numbers of comparisons made (each brain con-
lation and incorporated the diffusion tensor. tains thousands of voxels). At the time of this
Finally, Basser and colleagues (Basser, Mattiello, writing, there are 10 DTI studies which utilize
& LeBihan, 1994) developed the acquisition a voxel-wise approach in the study of ASD. Over-
strategy that allowed computation of the diffu- all, these studies demonstrate diffuse abnormali-
sion tensor. Using multiple acquisitions, each ties in white matter using the previously
sensitive to diffusion in a specified direction, the mentioned metrics, though the most commonly
diffusion tensor can be reconstructed at each reported abnormality is a reduction in FA.
location in the brain image. There are four studies which implement
a voxel-wise analysis studying children with
ASD. Cheung and colleagues (Cheung et al.,
Current Knowledge 2009) reported on a comparison of 13 children
with autism (9.3 2.6 years) and 14 controls (9.9
At the time of this writing, there are over 30 2.5 years) where FA in the autism group was
studies using diffusion imaging, investigating significantly lower than controls in bilateral
the neurobiology of ASD since the first study prefrontal and temporal regions, particularly in
was published in 2004 (Barnea-Goraly et al., the right ventral temporal lobe adjacent to the
2004). In recent years, the number of studies has fusiform gyrus. Additionally, FA was greater in
increased sharply: one study in 2004, five studies in the right inferior frontal gyrus and left occipital
2007, eight studies in 2009, and 13 studies in 2010 lobe. Barnea-Goraly and colleagues (Barnea-
(all reviewed below). The methods implemented in Goraly, Lotspeich, & Reiss, 2010) reported on
these studies are diverse, ranging from voxel-wise a comparison of 13 children with autism (10.5
comparisons to tractography-based studies. Some 2.0 years), 13 of their unaffected siblings (8.9
studies use a combination of methods or other 1.9 years), and 11 controls (9.6 2.1 years).
MRI modalities such as structural and/or functional Both the autism and unaffected sibling groups
MRI. The DTI studies reviewed in this chapter are had widespread FA reductions in the frontal,
presented according to their methodology which parietal, and temporal lobes, including regions
will include voxel-wise, region of interest (ROI), known to be important for social cognition.
tractography, combination DTI, and multimodal Within regions of reduced FA, reductions in AD
MRI studies. White matter properties vary with with preserved RD were observed. There were no
age through development. Thus, in order to better differences in white matter structure between
appreciate the developmental aspects of ASD, these autism and unaffected sibling groups. Sahyoun
DTI studies are further subdivided into child (age and colleagues (Sahyoun, Belliveau, & Mody,
<13 years), adolescent (13–20 years), and adult 2010) reported on a comparison of nine children
(age 21 years) categories based mainly on the with autism (12.8 1.5 years) and 12 controls
average age of ASD participants. (13.3 2.45 years). Controls showed increased
FA within frontal white matter and the superior
Voxel-Wise longitudinal fasciculus. The autism group
The first DTI study published in the autism showed increased FA within peripheral white
research literature was a voxel-wise study. matter, including the ventral temporal lobe.
Thus, it comes as no surprise that voxel-wise Shukla and colleagues (Shukla, Keehn, & Muller,
studies are the most common of the DTI studies 2011) reported on a comparison of 26 children
in ASD. In general, image volumes are warped to with ASD (12.8 0.6 years) and 24 controls
a common space, and then, groups are compared (13.0 0.6 years). The ASD group demonstrated
on a voxel-by-voxel basis within the white mat- decreased FA and increased MD and RD in numer-
ter. A variety of statistical procedures are used to ous white matter structures: corpus callosum, ante-
identify significant differences and control for rior and posterior limbs of the internal capsule,
inferior longitudinal fasciculus, inferior fronto- (15.5 1.8 years). Participants with autism had
occipital fasciculus, superior longitudinal fascicu- lower FA in the left and right superior and infe-
lus, cingulum, anterior thalamic radiation, and rior longitudinal fasciculi which lost significance
corticospinal tract. There were no areas of increased after controlling for age and IQ. MD levels were
FA, reduced MD, or RD in the ASD group. markedly increased in the autism group through-
There are four studies which implement out the brain.
a voxel-wise analysis studying adolescents with In the two remaining voxel-wise studies, one
ASD. In the first published DTI study in ASD, examined adults only, and the other included
Barnea-Goraly and colleagues (Barnea-Goraly, subjects from the entire age range from children D
et al., 2004) reported on a comparison of seven to adults. Bloemen and colleagues (Bloemen
adolescents with autism (14.6 3.4 years) and et al., 2010) reported on a comparison of 13 adults
nine controls (13.4 2.8 years). The autism with Asperger syndrome (39.0 9.8 years) and
group demonstrated reduced FA in white matter 13 controls (37.0 9.6 years). Adults with
adjacent to the ventromedial prefrontal cortices, Asperger syndrome had lower FA than controls
anterior cingulate gyri, and temporoparietal junc- in 13 clusters which were largely bilateral and
tions. FA reductions were also seen adjacent to included white matter in the internal capsule;
the superior temporal sulcus bilaterally, temporal frontal, temporal, parietal, and occipital lobes;
lobes approaching the amygdala bilaterally, cingulum; and corpus callosum. Keller and
occipitotemporal tracts, and corpus callosum. colleagues (Keller, Kana, & Just, 2007) reported
Cheng and colleagues (Cheng et al., 2010) com- on a comparison of 34 children, adolescents, and
pared 25 adolescents with ASD (13.71 adults with ASD (18.9 7.3 years) and 31 con-
2.54 years) and 25 controls (13.51 trols (18.9 6.2 years). Participants with ASD
2.20 years), reporting reduced FA in the right had lower FA in areas within and near the corpus
posterior limb of internal capsule with increased callosum and in the right retrolenticular portion
RD distally and reduced AD centrally. ASD ado- of the internal capsule.
lescents also demonstrated greater FA with
reduced RD in the frontal lobe, greater FA with Region of Interest (ROI)
reduced RD in the right cingulate gyrus, greater In using the ROI method, anatomical area(s)
FA with reduced RA with increased AD in the which are to be studied are traced for each indi-
bilateral insula, greater FA with reduced RD in vidual participant, usually by hand and without
the right superior temporal gyrus, and greater FA knowledge of group membership, in order to
with reduced RD in the bilateral middle cerebel- obtain averaged measures (e.g., FA, RD) within
lar peduncle. Noriuchi and colleagues (Noriuchi the ROI that characterize the selected region for
et al., 2010) reported on a comparison of seven a particular participant. Comparisons can then be
adolescents with ASD (13.96 2.68 years) and made testing for significant group differences.
seven controls (13.36 2.74 years). For the ASD ROI studies are particularly useful when particu-
group, FA and AD were lower in the white matter lar brain structures, which can be readily defined,
around left dorsolateral prefrontal cortex, poste- are suspected to be abnormal. By focusing on
rior superior temporal sulcus/temporoparietal hypothesized regions, the problem of multiple
junction, right temporal pole, amygdala, superior comparisons is greatly reduced. At the time of
longitudinal fasciculus, occipitofrontal fascicu- this writing, there are seven DTI studies which
lus, mid- and left anterior corpus callosum, and use an ROI approach in the study of ASD. Over-
mid- and right anterior cingulate cortex. Higher all, these studies demonstrate various diffusion
AD values were observed in the cerebellar vermis abnormalities in most areas studied with the most
lobules in the ASD group. Groen and colleagues common abnormality being a reduction in FA.
(Groen, Buitelaar, van der Gaag, & Zwiers, 2011) There are four studies which implement an
reported on a comparison of 17 adolescents ROI approach studying children with ASD. Ben
with autism (14.4 1.6 years) and 25 controls Bashat and colleagues (Ben Bashat et al., 2007)
reported on a comparison of seven toddlers 30 individuals with autism (15.78 5.6 years)
with autism with ages ranging from 1.8 to and 30 controls (15.79 5.5 years) with ROIs
3.3 years. ROI measurements in different ana- including superior temporal gyrus and temporal
tomical regions revealed an increase in FA with stem. Tensor skew, a measure of tensor shape,
dominance in the left hemisphere and frontal was used in addition to the more common met-
lobe. Sivaswamy and colleagues (Sivaswamy rics. In the superior temporal gyrus, reversed
et al., 2010) reported on a comparison of hemispheric asymmetry was reported for the
27 children with ASD (mean age 5.0 years) and autism group: tensor skew was greater on the
16 controls (mean age 5.9 years) where ROIs right, and FA was decreased on the left. More-
were placed in the cerebellar peduncles. In the over, there was also increased AD bilaterally. In
ASD group, there was an increase in the MD of the right temporal stem (but not the left),
bilateral superior cerebellar peduncles and rever- increases in MD, AD, and RD were exhibited in
sal of asymmetry in FA of the middle cerebellar the autism group. Alexander and colleagues
peduncle and inferior cerebellar peduncle. Brito (Alexander et al., 2007) reported on
and colleagues (Brito et al., 2009) compared a comparison of 43 individuals with ASD (16.23
eight children with ASD (9.53 1.83 years) 6.70 years) and 34 controls (16.44
and eight controls (9.57 1.36 years). In the 5.97 years) using a corpus callosum ROI. There
ASD group, they reported reduced FA in ROIs were significant group differences in white matter
corresponding to the anterior corpus callosum, volume, FA, MD, and RD which appeared to be
right corticospinal tract, posterior limb of right driven by an autism subgroup with small corpus
and left internal capsules, left superior cerebellar callosum volumes, high MD, low FA, and
peduncle, and right and left middle cerebellar increased RD. Compared to other individuals
peduncles. Shukla and colleagues (Shukla, with autism or the controls, this subgroup had
Keehn, Lincoln, & Muller, 2010) reported on lower performance IQ measures.
a comparison of 26 children with ASD (12.7
0.6 years) and 24 controls (13.0 0.6 years). Tractography
ASD children demonstrated reduced FA and Tractography studies have similarities to ROI stud-
increased RD for whole-brain white matter ies, except the area of interest is defined using
and ROIs corresponding to the corpus callosum tractography. The results of tractography are very
and internal capsule. Additionally, there was sensitive to the method and parameters used in
increased MD for whole-brain white matter and creating these tract volumes; thus, great care must
ROIs corresponding to the anterior and posterior be taken to ensure reliability and blindness. In
limbs of the internal capsule. Finally, reduced AD a manner analogous to ROI studies, diffusion met-
was reported for the ROI of the body of the rics captured within the tract volume are analyzed.
corpus callosum, and reduced FA was also In addition, geometric properties of the tracts can
found for the ROI of the middle cerebellar also be obtained (e.g., lengths, volumes). Compar-
peduncle. isons can be made by averaging these measures
In the three remaining studies, analyses and comparing means between groups. At the time
included subjects across the entire age range of this writing, there are six DTI studies which
including children, adolescents, and adults. Lee utilize a tractography approach in the study of
and colleagues (Lee et al., 2007) reported on the neurobiology of ASD. Overall, studies using
a comparison of 43 individuals with ASD (16.2 tractography demonstrate diffusion abnormalities
6.7 years) and 34 controls (16.4 6.0 years) in many fiber tracts, again with the most common
with ROIs capturing the superior temporal gyrus abnormality being a reduction in FA.
and temporal stem. In all examined regions, the There are two studies which implement the
ASD group demonstrated decreased FA and tractography approach studying children and
increased MD and RD. Lange and colleagues adolescents with ASD. Sundaram and colleagues
(Lange et al., 2010) reported on a comparison of (Sundaram et al., 2008) reported on a comparison
of 50 children with ASD (4.79 2.43 years) and & Behrmann, 2011) reported on a comparison of 12
16 controls (6.84 3.45 years). Tractography adults with autism (28.5 9.7 years) and 18 con-
was performed on frontal lobe long- and short- trols (22.4 4.1 years), performing tractography on
range pathways. The ADC was significantly callosal and visual-association pathways. Com-
higher for whole frontal lobe, long- and short- pared with the control group, the autism group
range association fibers in the ASD group. FA demonstrated an increase in the volume of the
was significantly lower in the ASD group for intra-hemispheric fibers, particularly in the left
short-range fibers but not for long-range fibers. hemisphere, and a reduction in the volume of
There was no between-group difference in the the forceps minor and the body of the corpus D
number of frontal lobe fibers (short and long); callosum. Finally, Pugliese and colleagues
however, the long-range association fibers of (Pugliese et al., 2009) compared 24 children,
frontal lobe were significantly longer in ASD adolescents, and adults with Asperger syndrome
group. Fletcher and colleagues (Fletcher et al., (23.3 12.4 years) and 42 controls (25.3
2010) reported on a comparison of 10 adolescents 10.3 years), performing tractography on the follow-
with autism (14.25 1.92 years) and 10 controls ing limbic pathways: inferior longitudinal fascicu-
(13.36 1.34 years), performing tractography of lus, inferior frontal occipital fasciculus, uncinate,
the arcuate fasciculus (superior longitudinal fas- cingulum, and fornix. There were no significant
ciculus). The results showed an increase in MD in between-group differences in FA and MD. How-
the autism group, due mostly to an increase in the ever, the Asperger group had a significantly higher
RD. Both MD and FA were less lateralized in the number of streamlines in the right and left cingulum
autism group. and in the right and left inferior longitudinal fascic-
The remaining four tractography studies include ulus. In contrast, the group with Asperger syndrome
adults with one study including participants across had a significantly lower number of streamlines in
the entire age range. Catani and colleagues the right uncinate.
(Catani et al., 2008) reported on a comparison of
15 adults with Asperger syndrome (31 9 years) Combination DTI
and 16 controls (35 11 years). Tractography was While each of the DTI methods described above has
performed on short intracerebellar connections, limitations when used alone, these can be overcome
long-range afferent (i.e., corticopontocerebellar by using the methods in combination with one
and spinocerebellar tracts) and efferent (i.e., supe- another, ideally in a synergistic manner. Kumar
rior cerebellar tracts) connections. The Asperger and colleagues (Kumar et al., 2010) reported on
group had significantly lower FA in the short a comparison of 32 children with ASD (mean age
intracerebellar fibers and right superior cerebellar 5.0 years), 12 developmentally impaired children
peduncles, but no difference in the afferent tracts. without ASD (mean age 4.6 years), and 16 controls
Conturo and colleagues (Conturo et al., 2008) (mean age 5.5 years). They essentially performed
reported on a comparison of 17 adults with autism two separate analyses on the same group of partic-
(26.46 2.73 years) and 17 controls (26.08 ipants: voxel-wise and tractography study. In the
2.69 years), performing tractography of voxel-wise portion of the study, when the ASD and
hippocampo-fusiform and amygdalo-fusiform path- developmentally impaired children were compared
ways. While these pathways had normal size and with controls, FA was lower in the right uncinate
shape, the right hippocampo-fusiform had reduced fasciculus, right cingulum, and corpus callosum in
RD compared with controls, opposite to the whole- both affected groups. There was also reduced FA in
brain effect of increased RD. In contrast, left right arcuate fasciculus when ASD children were
hippocampo-fusiform, right arcuate fasciculus, compared with controls and reduced FA in the
and left arcuate fasciculus had increased RD and bilateral inferior fronto-occipital fasciculus when
increased AD in autism. There was a general loss of developmentally impaired children were compared
lateralization compared with controls. Thomas and with controls. ADC was increased in right arcuate
colleagues (Thomas, Humphreys, Jung, Minshew, fasciculus in both ASD and developmentally
impaired children. In the tractography portion of the there are a total of five published studies taking
study, the ASD group showed shorter length of the a multimodal MRI approach: two combining with
left uncinate fasciculus and increased length, vol- structural MRI, two combining with functional
ume, and density of the right uncinate fasciculus; MRI, and one combining with both structural and
increased length and density of the corpus callosum; functional MRI.
and higher density of the left cingulum compared Ke and colleagues (Ke et al., 2009) reported
with the control group. Compared with the devel- on a comparison of 12 children with autism (8.75
opmentally impaired group, the ASD group 2.26 years) and 10 controls (9.40 2.07 years)
had increased length, volume, and density of the using voxel-wise comparison of both white mat-
right uncinate fasciculus; higher volume of the left ter density (structural MRI) and FA (DTI). In the
uncinate fasciculus; and increased length of the autism group, there was a decrease of the white
right arcuate fasciculus and corpus callosum. Jou matter density in the right frontal lobe, left pari-
and colleagues (Jou et al., 2011) reported on etal lobe, and right anterior cingulate. Moreover,
a comparison of 10 ASD adolescents (13.06 there was an increase of the white matter density
3.85 years) and 10 controls (13.94 4.23 years). in the right frontal lobe, left parietal lobe, and
DTI data was analyzed in a synergistic manner left cingulate gyrus. The autism group also
by performing a voxel-wise comparison with exhibited reductions of FA in the frontal lobe
follow-up tractography to identify underlying and left temporal lobe. Mengotti and colleagues
affected white matter structures. The regions of (Mengotti et al., 2011) reported on a comparison
lower FA, as confirmed by tractography, involved of 20 children with autism (7.00 2.75 years)
the inferior longitudinal fasciculus/inferior fronto- and 22 controls (7.68 2.03 years) using a com-
occipital fasciculus, superior longitudinal fascicu- bination of voxel-wise comparison in gray/
lus, and corpus callosum/cingulum. Notably, some white matter and ROIs (corpus callosum, frontal,
volumes of interest were adjacent to the fusiform temporal, parietal, and occipital lobes) comparing
face area, bilaterally, corresponding to involvement ADC. Compared to controls, the autism group
of the inferior longitudinal fasciculus. The largest exhibited increased white matter volumes in the
effect sizes were noted for volumes of interest in right inferior frontal gyrus, right fusiform gyrus,
the right anterior radiation of the corpus callosum/ left precentral and supplementary motor areas, and
cingulum and the right fusiform face area (inferior left hippocampus. Moreover, there were increased
longitudinal fasciculus). Finally, Pardini and gray matter volumes in the inferior temporal gyri
colleagues (Pardini et al., 2009) reported on a com- bilaterally, right inferior parietal cortex, right supe-
parison of 10 adults with autism (19.7 2.83 years) rior occipital lobe, and left superior parietal lobule.
and 10 controls (19.9 2.64 years). They compared Additionally, there were decreased gray matter
FA within orbitofrontal cortex volumes defined by volumes in the right inferior frontal gyrus and left
tractography in addition to voxel-wise comparison supplementary motor area. Finally, the autism
of FA. The low-functioning group with autism group exhibited abnormally increased ADC in the
demonstrated reduced tract volume and lower bilateral frontal cortex and left genu of the corpus
mean FA values in the left orbitofrontal cortex callosum.
network compared with controls. Using a combination of DTI and functional
MRI, Sahyoun and colleagues (Sahyoun, Belliveau,
Multimodal MRI Soulieres, Schwartz, & Mody, 2010) reported
While an extremely powerful technology, DTI on a comparison of 12 adolescents with autism
remains an indirect probe of white matter integ- (13.3 2.1 years) and 12 controls (13.3
rity based on measuring properties of restricted 2.5 years). DTI analysis included a tractography
water diffusion. One strategy to augment this data approach in which fiber tracking was aided by func-
is to use multiple modalities in search for con- tional MRI. FA was captured within these tracts,
verging evidence supporting a particular neuro- and mean FA was compared between groups. The
biological hypothesis. At the time of this writing, functional MRI included response time on pictorial
problem-solving task. Autism and control groups participants into typical (leftward) and atypical
showed similar networks: linguistic processing acti- (rightward) language laterality groups. Participants
vated inferior frontal, superior and middle temporal, with typical left-lateralized language activation had
ventral visual, and temporoparietal areas, whereas smaller frontal language region volume and higher
visuospatial processing activated occipital and infe- FA of the arcuate fasciculus compared to the group
rior parietal areas. However, the autism group acti- with atypical language laterality, across both ASD
vated occipitoparietal and ventral temporal areas, and controls. The group with typical language
whereas controls activated frontal and temporal asymmetry included the most right-handed con-
language regions. The autism group relied more trols and fewest left-handers with ASD. Atypical D
heavily on visuospatial abilities as evidenced by language laterality was more prevalent in the ASD
intact connections between the inferior parietal than in controls.
and ventral temporal ROIs. There was impaired
activation of frontal language areas in the autism
group as evidenced by reduced connectivity of Future Directions
the inferior frontal region to the ventral temporal/
middle temporal regions. Future directions include further refinement
In another combination DTI and functional of DTI techniques, sophistication in the integra-
MRI study, Thakkar and colleagues (Thakkar tion of multiple imaging modalities, and
et al., 2008) reported on a comparison of multidimensional longitudinal designs. Improve-
12 ASD adults (30 11 years) and 14 controls ments in technology include higher scan resolu-
(27 8 years). DTI analysis included a compari- tion, improving signal-to-noise ratio while
son of FA performed 2 mm below the white/ maintaining tolerability, and developing novel
gray matter boundary. Functional MRI included metrics with higher pathological specificity.
a saccadic paradigm where activation was com- Other improvements go beyond the tensor
pared in error versus correct antisaccades, and in model to examine the directional variation of
both correct and error antisaccades versus fixa- diffusion in more detail (Lo et al., 2011).
tion, both within and between groups using Tractography faces challenges in its ability to
a random effects model. Relative to controls, resolve multiple fiber populations in a single
the ASD group made more antisaccade errors voxel (e.g., crossing and kissing fibers), growing
and responded more quickly on correct trials. usage as a more quantitative measure, and lack
The ASD group also showed reduced discrimina- of standardized technique supported by gold-
tion between error and correct responses in rostral standard postmortem studies. While several mul-
anterior cingulate cortex and reduced FA in white timodal studies have been published, there could
matter underlying anterior cingulate cortex. be tighter integration of more modalities (MRI
Finally, in the ASD group, there was increased and beyond) to create novel study designs with
activation on correct trials and reduced FA in higher synergy. The studies reviewed in this
rostral anterior cingulate, both of which were chapter are all cross-sectional; thus, longitudinal
related to repetitive behavior. studies would be optimal to fill in the gaps in
Using a combination of DTI and structural current knowledge. In addition to longitudinal
and functional MRI, Knaus and colleagues imaging across the life span, there should be
(Knaus et al., 2010) reported on a comparison longitudinal clinical assessments designed to
of 14 ASD adolescents (age range 11–19 years) give further meaning to imaging data.
and 20 controls (age range 11–19 years). Struc-
tural MRI analysis included volumetric measure-
ments of language areas. DTI analysis included See Also
tractography to delineate a pathway between tem-
poral and frontal language areas to compare ▶ Functional Connectivity
mean FA. Functional MRI was used to divide ▶ Magnetic Resonance Imaging
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Bloemen, O. J., Deeley, Q., Sundram, F., Daly, E. M., laterality in autism spectrum disorder and typical
Barker, G. J., Jones, D. K., et al. (2010). White matter controls: A functional, volumetric, and diffusion ten-
integrity in Asperger syndrome: A preliminary diffu- sor MRI study. Brain and Language, 112(2), 113–120.
sion tensor magnetic resonance imaging study in Kumar, A., Sundaram, S. K., Sivaswamy, L., Behen,
adults. Autism Research, 3(5), 203–213. M. E., Makki, M. I., Ager, J., et al. (2010). Alterations
Brito, A. R., Vasconcelos, M. M., Domingues, R. C., in frontal lobe tracts and corpus callosum in young
Hygino da Cruz, L. C., Jr., Rodrigues Lde, S., children with autism spectrum disorder. Cerebral
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experiments. Physical Review, 94(3), 630–638. Lee, J. E., Bigler, E. D., Alexander, A. L., Lazar, M.,
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NeuroImage, 41(4), 1184–1191. ters, 424(2), 127–132.
Cheng, Y., Chou, K. H., Chen, I. Y., Fan, Y. T., Decety, J., Lo, Y. C., Soong, W. T., Gau, S. S., Wu, Y. Y., Lai, M. C.,
& Lin, C. P. (2010). Atypical development of white Yeh, F. C., et al. (2011). The loss of asymmetry and
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Cheung, C., Chua, S. E., Cheung, V., Khong, P. L., tractography. Psychiatry Research, 192(1), 60–66.
Tai, K. S., Wong, T. K., et al. (2009). White matter Mengotti, P., D’Agostini, S., Terlevic, R., De Colle, C.,
fractional anisotropy differences and correlates of Biasizzo, E., Londero, D., et al. (2011). Altered white
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Conturo, T. E., Williams, D. L., Smith, C. D., Gultepe, E., diffusion imaging study. Brain Research Bulletin,
Akbudak, E., & Minshew, N. J. (2008). Neuronal fiber 84(2), 189–195.
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Fletcher, P. T., Whitaker, R. T., Tao, R., DuBray, M. B., Noriuchi, M., Kikuchi, Y., Yoshiura, T., Kira, R.,
Froehlich, A., Ravichandran, C., et al. (2010). Shigeto, H., Hara, T., et al. (2010). Altered white
Dimensional Versus Categorical Classification 975 D
matter fractional anisotropy and social impairment in
children with autism spectrum disorder. Brain DiGeorge Syndrome
Research, 1362, 141–149.
Pardini, M., Garaci, F. G., Bonzano, L., Roccatagliata, L.,
Palmieri, M. G., Pompili, E., et al. (2009). White ▶ CATCH 22 (Chromosome 22q11 Deletion
matter reduced streamline coherence in young men Syndrome)
with autism and mental retardation. European Journal
of Neurology, 16(11), 1185–1190.
Pugliese, L., Catani, M., Ameis, S., Dell’Acqua, F.,
Thiebaut de Schotten, M., Murphy, C., et al.
(2009). The anatomy of extended limbic pathways Digitigrade Gait D
in Asperger syndrome: A preliminary diffusion ten-
sor imaging tractography study. NeuroImage, 47(2), ▶ Toe Walking
427–434.
Sahyoun, C. P., Belliveau, J. W., & Mody, M. (2010).
White matter integrity and pictorial reasoning in
high-functioning children with autism. Brain and
Cognition, 73(3), 180–188. Dimensional Versus Categorical
Sahyoun, C. P., Belliveau, J. W., Soulieres, I., Schwartz, S., Classification
& Mody, M. (2010). Neuroimaging of the functional and
structural networks underlying visuospatial vs. linguistic
Andrew Pickles
reasoning in high-functioning autism. Neuropsychologia,
48(1), 86–95. School of Epidemiology and Health Science,
Shukla, D. K., Keehn, B., Lincoln, A. J., & Muller, R. A. University of Manchester, Manchester, UK
(2010). White matter compromise of callosal and sub-
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Shukla, D. K., Keehn, B., & Muller, R. A. (2011). Class versus variable; Discrete versus continuous
Tract-specific analyses of diffusion tensor imaging
show widespread white matter compromise in autism
spectrum disorder. Journal of Child Psychology and
Psychiatry, 52(3), 286–295. Definition
Sivaswamy, L., Kumar, A., Rajan, D., Behen, M., Muzik,
O., Chugani, D., et al. (2010). A diffusion tensor imag-
Is autism a distinct and discrete abnormality or is
ing study of the cerebellar pathways in children with
autism spectrum disorder. Journal of Child Neurology, it simply the upper end of some dimension of
25(10), 1223–1231. normal human variability? Such a contrast of
Stejskal, E. O., & Tanner, J. E. (1965). Spin diffusion categorical and dimensional conceptualizations
measurements: Spin echoes in the presence of a time-
of mental health has a long history, especially
dependent field gradient. Journal of Chemical Physics,
42(1), 288–292. relevant to the discussion about an autism spec-
Sundaram, S. K., Kumar, A., Makki, M. I., Behen, M. E., trum and “the autisms.” It should be noted that
Chugani, H. T., & Chugani, D. C. (2008). Diffusion the question conflates at least two issues: one is
tensor imaging of frontal lobe in autism spectrum
the contrast between discrete and continuous but
disorder. Cerebral Cortex, 18(11), 2659–2665.
Thakkar, K. N., Polli, F. E., Joseph, R. M., Tuch, D. S., the other is the implicit value judgment that is
Hadjikhani, N., Barton, J. J., et al. (2008). Response associated with abnormal and normal. The choice
monitoring, repetitive behaviour and anterior cingulate has broad consequences for almost all aspects of
abnormalities in autism spectrum disorders (ASD).
measurement, explanation, and much of treat-
Brain, 131(9), 2464–2478.
Thomas, C., Humphreys, K., Jung, K. J., Minshew, N., & ment and policy formulation. It is also the basis
Behrmann, M. (2011). The anatomy of the callosal and of much unproductive and confused debate.
visual-association pathways in high-functioning Essentially, all our clinical measurement of
autism: A DTI tractography study. Cortex, 47(7),
autism starts with sets of categorical symptoms or
863–873.
Torrey, H. C. (1956). Bloch equations with diffusion items, though implicit judgments about dimensional
terms. Physical Review, 104(3), 563–565. severity may be implicit in the scoring of each item.
D 976 Dimethylglycine
From these, the international diagnostic systems such See Also

as DSM (American Psychiatric Association [APA],
1994) spent decades refining rules for combining ▶ Atypical Autism
these items into categorical diagnostic categories. ▶ Autism
Screening questionnaires (e.g., Charman et al., ▶ Autism Diagnostic Observation Schedule
2007) commonly start with a similar item set and ▶ Broader Autism Phenotype
form total scores that might be considered ▶ DSM-IV
a dimension. However, the items chosen commonly ▶ Factor Analysis
identify clear abnormality (high threshold or difficult ▶ Latent Variable Modeling
items in the terminology of psychometrics), generate ▶ Screening Measures
strongly nonnormal item-total distributions when
applied to a general population, and, through use of
cut points, are intended to increase the proportion or References and Readings
probability of caseness rather than to provide
a metric. They are not intended to differentiate American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.).
among the majority who fall within the normal
range. By contrast, questionnaires such as the Autism Charman, T., Baird, G., Simonoff, E., Loucas, T.,
Quotient (e.g., Wheelright, Auyeung, Allison, & Chandler, S., Meldrum, D., et al. (2007). Efficacy of
Baron-Cohen, 2010) have items with a range of three screening instruments in the identification of
autism spectrum disorder. The British Journal of
difficulties and are quite explicitly orientated toward
measurement of an autism-related dimension. Gotham, K., Pickles, A., & Lord, C. (2009). Standardizing
Questions then arise as to whether the variation ADOS scores for a measure of severity in autism
that is being differentiated among the normal and spectrum disorders. Journal of Autism and Develop-
supernormal is the same dimension as the variation
Meehl, P. (1995). Bootstraps taxonometrics: Solving the
being differentiated among the abnormal or whether classification problem in psychopathology. American
instead we have a mixture of normal and abnormal Psychologist, 50, 266–275.
populations. Some formal tests have been proposed Pickles, A., & Angold, A. (2003). Natural categories or
fundamental dimensions: On carving nature at the
(e.g., Meehl, 1995).
joints and the re-articulation of psychopathology.
The use of a categorical diagnostic tool and Development and Psychopathology, 15, 529–551.
a separate dimensional severity has the potential Wheelright, S., Auyeung, B., Allison, C., &
to lead to inconsistencies, a problem that can Baron-Cohen, S. (2010). Defining the broader,
medium and narrow autism phenotype among
be resolved if both are derived from the same instru-
parents using the autism spectrum quotient (AQ).
ment, for example, the Autism Diagnostic Observa- Molecular Autism, 1, 1–9.
tion Schedule (Gotham, Pickles, & Lord, 2009). It is
however crucial to distinguish a dimensional severity
measure that relates to symptom abnormality from
one that relates to level of impairment. While these
are correlated, they are not the same. Dimethylglycine
So should autism be treated as a category or as
a high score on a dimension? The arguments of Robert LaRue
Pickles and Angold (2003) imply that while Douglass Developmental Disabilities Center,
a dimensional perspective may be more appropriate Rutgers, The State University of New Jersey,
when considering some aspects of autism, such New Brunswick, NJ, USA
as when assessing treatment outcome effects,
a categorical perspective may be better, even neces-
sary, when considering another, notably treatment Synonyms
eligibility. Whether that dimension should be sever-
ity or impairment will depend on the circumstance. DMG
Diminished Responsibility 977 D
Definition Definition
Dimethylglycine (DMG) is a natural substance In criminal law, the defense of diminished respon-
thought to inhibit the buildup of certain amino sibility reduces a person’s liability in connection
acids in the body and enhance the immune with the killing of another if it can be argued that
response in children with ASD. It is a derivative they were suffering from an “abnormality of mind
of the amino acid, glycine. It is found in foods, (whether arising from a condition of arrested or
such as beans, grains, and liver. retarded development of mind or any inherent
DMG supplementation has been proposed causes or induced by disease or injury) as substan- D
as a treatment for autism. Anecdotal reports tially impaired his mental responsibility for his
have suggested that use of DMG improved social acts and omissions in doing or being a party to
behavior, frustration tolerance, speech, and the killing” (Homicide Act (England & Wales)
reduced aggressive behavior in individuals with 1957). As this definition from English law indi-
autism. However, two randomized clinical trials cates, this defense can only be used in connection
revealed no significant differences in behavior in with charges of murder and, if successful, reduces
individuals with autism after taking DMG a person’s culpability such that they are found
(Bolman & Richmond, 1999; Kern, Miller, guilty of the lesser charge of manslaughter rather
Cauller, Kendall, Mehta, & Dodd, 2001). than murder. It is particularly useful in this context
as there are many “disposal” options available to
the court for a charge of manslaughter, whereas
References and Readings murder carries the mandatory life sentence.
Bolman, W. M., & Richmond, J. A. (1999). A double-blind,
The defense itself was first recognized under
placebo controlled pilot trial of low dose dimethylglycine the common law in Scotland and is recognized in
in patients with autistic disorder. Journal of Autism and several jurisdictions across the globe, including
Developmental Disorders, 29(3), 191–194. several states in the USA; certain territories
Kern, J. K., Miller, V. S., Cauller, P. L., Kendall, P. R.,
in Australia, Hong Kong, and Singapore; and
Mehta, P. J., & Dodd, M. (2001). Effectiveness of
N, N-dimethylglycine in autism and pervasive several Caribbean countries. Moreover, in certain
developmental disorder. Journal of Child Neurology, jurisdictions without this defense, there have
16(3), 169–173. been a number of cases described where a defense
of “lack of intent” has been advanced on the
grounds of a mental disorder not amounting to
insanity, essentially amounting to the same thing
Diminished Capacity
as a diminished defense.
▶ Diminished Responsibility It is important to contrast diminished respon-
sibility with defense of insanity, which states that
if a person, at the time of the act or omission, was,
due to a severe mental disease or defect, unable to
Diminished Responsibility appreciate the nature or quality of their act,
then they cannot be held criminally responsible
Marc Woodbury-Smith for their behavior. As a result, and in contrast
Department of Psychiatry and Behavioural to the defense of criminal responsibility, they
Neuroscience, McMaster University, Hamilton, are deemed to be “not guilty.” Both diminished
ON, Canada responsibility and insanity are therefore
interpreted at the level of a person’s mens rea
(i.e., their ability to form a “guilty mind”).
Synonyms The relevance of this defense to individuals
with ASDs will therefore only really arise in
Diminished capacity connection with allegations of murder. Such an
D 978 Diphen [OTC]
occurrence will be extremely uncommon, and at [OTC]; Benadryl® children’s allergy [OTC];
the time of writing, no case law on the use of this Benadryl® Children’s Allergy Fastmelt®
®
defense for an individual with ASDs is available. [OTC]; Benadryl Children’s Allergy Perfect
Measure™; Benadryl® children’s allergy quick
dissolve [OTC] [DSC]; Benadryl® children’s
See Also dye-free allergy [OTC]; Benadryl® dye-free
allergy [OTC]; Benadryl® itch relief extra strength
▶ Violent/Criminal Behavior in Autism [OTC]; Benadryl® itch stopping [OTC]; Benadryl®
itch stopping extra strength [OTC]; Compoz®
nighttime sleep aid [OTC]; Dermamycin® [OTC];
References and Readings Diphen [OTC]; Diphenhist® [OTC]; Dytan™;
Genahist™ [OTC]; Histaprin [OTC]; Hydramine
Bowden, P. (1995). Psychiatry in criminal proceedings. In [OTC] [DSC]; Nytol® quick caps [OTC]; Nytol®
D. Chiswick & R. Cope (Eds.), Seminars in practical
quick gels [OTC]; PediaCare® children’s
forensic psychiatry. London: Royal College of
Psychiatrists. allergy [OTC]; PediaCare® children’s NightTime
Samuels, A., O’Driscoll, C., & Allnutt, S. (2007). When cough [OTC]; Siladryl allergy [OTC]; Silphen
killing isn’t murder: Psychiatric and psychological cough [OTC]; Simply Sleep™ [OTC]; Sleep-ettes
defenses to murder when the insanity defense is not
D [OTC]; Sleepinal® [OTC]; Sleep-tabs
applicable. Australasian Psychiatry, 15(6), 474–479.
[OTC]; Sominex® [OTC]; Sominex® maximum
strength [OTC]; Theraflu® Thin Strips® multi
symptom [OTC]; Triaminic Thin Strips®
Diphen [OTC] children’s cough and runny nose [OTC]; Twilite®
[OTC]; Unisom® SleepGels® maximum strength
▶ Diphenhydramine [OTC]; Unisom® SleepMelts™ [OTC]
Definition
Diphenhist ® [OTC]
Diphenhydramine (generic name) is also known
▶ Diphenhydramine as Benadryl ®. Diphenhydramine acts by blocking
the effect of histamine on the H1 receptor site.
Diphenhydramine inhibits most responses of
smooth muscle to histamine. It acts as a vasocon-
Diphenhydramine strictor by inhibiting the vasodilator effects of
histamine.
Alvi Azad Diphenhydramine is used to provide relief to
Yale Child Study Center, The Edward Zigler allergic symptoms caused by histamine release,
Center in Child Development and Social Policy, for sedation, as prevention of motion sickness, as
Yale University, New Haven, CT, USA an antitussive, as treatment of phenothiazine-
induced dystonic reactions, as adjunct to epi-
nephrine in the treatment of anaphylaxis, and
Synonyms topically for relief of pain and itching.
Diphenhydramine is often used to control agi-
Aler-Cap [OTC]; Aler-Dryl [OTC]; Aler-Tab tation or aggression in children; however, it does
[OTC]; AllerMax® [OTC]; Altaryl [OTC]; not have an FDA indication for this use.
Anti-Hist [OTC]; Banophen™ [OTC]; Pharmacodynamics/Kinetics:
Banophen™ anti-itch [OTC]; Benadryl® allergy Onset of action: Maximum sedative effect: 1–3 h
[OTC]; Benadryl® allergy quick dissolve Duration: 4–7 h
Direct Instruction 979 D
Distribution: Vd: 3–22 L/kg Its chemical name is 2-(Diphenylmethoxy)-N,
Protein binding: 78% N-dimethylethylamine hydrochloride, and it has
Metabolism: Extensively hepatic n-demethylation a molecular weight of 291.82. The molecular
via CYP2D6; minor demethylation via formula is C17H21NO • HCl.
CYP1A2, 2C9, and 2C19; smaller degrees
in pulmonary and renal systems; significant
first-pass effect See Also
Bioavailability: Oral: 40–70%
Half-life elimination: 2–10 h; elderly: 13.5 h ▶ Anxiolytics D
Time to peak, serum: 2–4 h ▶ Benzodiazepines
Excretion: Urine (as unchanged drug) ▶ Diazepam
▶ Gabapentin
Side Effects ▶ Oxazepam
Since diphenhydramine acts by blocking the effect
of histamine on the H1 receptor site, it can cause
significant anticholinergic side effects such as References and Readings
ataxia; loss of coordination; decreased mucus pro-
duction; consequent dry, sore throat; xerostomia or Akutsu, T., Kobayashi, K., Sakurada, K., Ikegaya, H.,
Furihata, T., & Chiba, K. (2007). Identification of
dry mouth with possible acceleration of dental car- human cytochrome P450 isozymes involved in
ies; cessation of perspiration; consequent decreased diphenhydramine N-demethylation. Drug Metabolism
epidermal thermal dissipation leading to warm, and Disposition, 35(1), 72–78.
blotchy, or red skin; increased body temperature; Blyden, G. T., Greenblatt, D. J., Scavone, J. M., &
RI, Shader. (1986). Pharmacokinetics of diphenhy-
pupil dilation (mydriasis); consequent sensitivity
dramine and a demethylated metabolite following
to bright light (photophobia); loss of accommoda- intravenous and oral administration. Journal of
tion (loss of focusing ability, blurred vision Clinical Pharmacology, 26(7), 529–533.
(cycloplegia)); double vision (diplopia); increased Deshmukh, P., Kulkarni, G., & Barzman, D. (2010).
Recommendations for pharmacological management
heart rate (tachycardia); tendency to be easily
of inpatient aggression in children and adolescents.
startled; urinary retention; diminished bowel move- Psychiatry (Edgmont), 7(2), 32–40.
ment, sometimes ileus; increased intraocular pres- Garnett, W. R. (1986). Diphenhydramine. American
sure; and shaking. Pharmacy, NS26(2), 35–40.
http://www.pfizer.com/files/products/uspi_benadryl.pdf
In high enough doses, diphenhydramine
can cause a cholinergic delirium (children and
elderly are more prone), and may include
confusion, disorientation, agitation, euphoria,
or dysphoria; respiratory depression; memory Direct Instruction
problems; inability to concentrate; wandering
thoughts; inability to sustain a train of thought; Rebecca DeAquair
incoherent speech; wakeful myoclonic jerking; The Center for Children with Special Needs,
unusual sensitivity to sudden sounds; illogical Glastonbury, CT, USA
thinking; visual disturbances (periodic flashes of
light, periodic changes in visual field, restricted
vision); visual, auditory, or other sensory hallu- Definition
cinations (warping or waving of surfaces and
edges, textured surfaces, “dancing” lines, Direct instruction is a general term used to
“spiders,” insects); and, rarely, seizures, coma, describe the explicit teaching of a skill set and
and death. was developed by Siegfried Engelmann, Wesley
Diphenhydramine may cause paradoxical Becker, and colleagues. It is a teaching model
excitation in young children. that focuses on systematically planned lessons
D 980 Direct Observation
and clearly defined teaching procedures. It ongoing behavior process, event, or situation;
often involves breaking down instructional or when there are physical outcomes that can
targets into smaller components and using be readily seen.
a scaffolding approach to teach material. Direct Direct observation can be overt, when the
instruction emphasizes the explicit teaching of subject and individuals in the environment
skills and requires that students consistently know the purpose of the observation, or covert,
demonstrate mastery before moving on to new when the subject and individuals in the environ-
material. Direct instruction requires that stu- ment are unaware of the purpose of the
dents actively participate in learning and neces- observation.
sarily involves meaningful teacher-student Structured direct observations are most appro-
interaction. priate when standardized information needs to be
gathered, and result in quantitative data. Unstruc-
tured direct observation looks at natural occur-
See Also rence and provides qualitative data, such as that
used when administering the Childhood Autism
▶ Didactic Approaches Rating Scale (CARS), the Checklist for Autism in
Toddlers (CHAT), and the American Psychiatric
Association’s Diagnostic and Statistical Manual,
References and Readings 4th Edition (DSM-IV).
Data recording for direct observation
Goeke, J. (2008). Explicit instruction: Strategies for includes narrative notes, video or photographs,
meaningful direct teaching. Boston, MA: Allyn and
recording checklist (yes/no), observation guide-
Bacon.
Marchand-Martella, N. E., Slocum, T. A., & lines (printed forms with space to write notes),
Martella, R. C. (2003). Introduction to direct instruc- and combinations of the above. Direct observa-
tion. Boston, MA: Allyn and Bacon. tion provides the highest degree of ecological
Przychodzin, A. M., Marchand-Martella, N. E.,
validity but lowest degree of experimental con-
Martella, R. C., & Azim, D. (2004). Direct Instruc-
tion mathematics programs: An overview and trol. The value of direct observation is directly
research summary. Journal of Direct Instruction, related to the evaluator’s ability to capture
4, 53–84. detail, determine what is important, and inter-
pret what has been observed. Because autism is
a disorder that is diagnosed and individuals are
evaluated through behavioral observation, direct
Direct Observation observation is a critical evaluative tool that
affords an objective perspective of the individ-
Anne Holmes ual’s profile.
Eden Autism Services, Princeton, NJ, USA
Definition References and Readings
Direct observation, also known as observational Barnhill, G. P. (2002). Behavioral, social and emotional
assessment of students with asd. Assessment for
study, is a method of collecting evaluative infor- Effective Intervention, 27(n1–2), 47–55.
mation in which the evaluator watches the sub- Carr, E. G., Ladd, M. V., & Schulte, C. F. (2008).
ject in his or her usual environment without Validation of the contextual assessment inventory
altering that environment. Direct observation is for problem behavior. Journal of Positive Behavior
Interventions, 10, 91–104.
used when other data collection procedures,
Drury, C. G. (1995). Methods for direct observation of
such as surveys, questionnaires, etc., are not performance. In J. R. Wilson & E. N. Corlett (Eds.),
effective; when the goal is to evaluate an Evolution of human work; a practical ergonomics
Directive Play Therapy 981 D
methodology (2nd ed., pp. 45–68). Philadelphia: provide a set of semi-structured activities and
Taylor and Francis. record and code observed target behavior within
Matson, J. L., & Wilkins, J. (2007). A critical review of
assessment targets and methods for social skill those activities, while others provide a structured
excesses and deficits for children with autism spectrum means to record and code direct observations in
disorders. Research in Autism Spectrum Disorders, 1, the natural environment. A number of direct
28–37. observation scales have been developed for diag-
Noterdaeme, M., Mildenberger, K., Sitter, S., &
Amorosa, H. (2002). Parent information and direct nostic purposes including those that provide
observation in the diagnosis of pervasive and specific semi-structured activities in which to record
developmental disorders. Autism, 6(2), 159–168. and code observations, such as the widely D
Abstract retrieved from http://www.online.sagepub. used Autism Diagnostic Observational Schedule
com
(ADOS; Lord, Rutter, DiLavore, & Risi, 2001)
and the Autism Observation Scale for Infants
(AOSI; Bryson, McDermott, Rombough, Brian,
& Zwaigenbaum, 2000). For assessment of inter-
Direct Observation Scales fering behaviors for the purpose of treatment
planning, direct observation scales are often
Tina Newman used during a functional behavioral assessment
The Center for Children with Special Needs, (FBA). These direct observations are most often
Glastonbury, CT, USA conducted in the natural environment and data is
collected with a very systematic methodology.
Different types of data can be collected during
Definition an FBA including interval, frequency, duration,
latency, and antecedent-behavior-consequence
Direct observation scales are structured instru- (ABC) data.
ments used to collect first-hand information
regarding observable behaviors. They contrast
to scales that provide indirect accounts, such See Also
as rating scales, report forms, or interviews
with parents, caregivers, or teachers regarding ▶ Autism Diagnostic Observation Schedule
behaviors of an individual, although both ▶ Direct Observation
provide important information. Direct observa- ▶ Functional Behavior Assessment
tion scales are critical in both diagnosis and inter-
vention with children with autism spectrum
disorders. While these scales can vary in format, References and Readings
they share common characteristics, including
having a structure as to what is attended to in Bryson, S. E., McDermott, C., Rombough, V.,
Brian, J., & Zwaigenbaum, L. (2000). The autism
the observation and what is coded. Thus, they observation scale for infants. Toronto, ON:
are not simply a description of what an individual Unpublished Scale.
is doing. For autism spectrum disorders, the Lord, C., Rutter, M., DiLavore, P., & Risi, S. (2001).
behaviors central to the diagnosis are most Autism Diagnostic Observation Schedule (ADOS)
manual. Los Angeles: Western Psychological
often the target of direct observation scales
Services.
(e.g., eye contact, social initiations, conversa-
tional turn-taking) and behaviors that interfere
with functioning and are the targets of interven-
tion (e.g., aggression or bolting). Direct observa-
tion scales can be more or less structured in how Directive Play Therapy
the observation situation is set up and how the
data is collected. Some direct observation scales ▶ Play Therapy
D 982 Disability
See Also
Disability
▶ Exceptionality
Michael Miklos ▶ Psychotic Disorder
Pennsylvania Training and Technical Assistance
Network, Harrisburg, PA, USA
Synonyms Assistance to States for the Education of Children

with Disabilities and Preschool Grants for Children
with Disabilities; Final Rule, 2004, 4000-01-U
Affliction; Detriment in skill; Exceptionality; Department of Education 34 CFR Parts 300 and
Incapacity; Relative weakness in an area of 301, Part II.
functioning Individuals with Disabilities Education Act of 2004, 20 U.
S.C., et. seq.
Definition
In common terms, it is the condition of DISCO

being unable to perform a skill as a consequence
of physical or mental incapacity. It may ▶ Diagnostic Interview for Social and
suggest impairments, limitations, or restrictions Communication Disorders
on performing certain activities. Autism is one
category of disability under special education
regulations (IDEA, 2004). Other categories of
disability include mental retardation, a hearing
impairment (including deafness), a speech or lan- Discourse Management
guage impairment, a visual impairment (includ-
ing blindness), a serious emotional disturbance Sarita Austin
(referred to in this part as emotional disturbance), Laboratory of Developmental Communication
an orthopedic impairment, traumatic brain injury, Disorders, Yale Child Study Center, New Haven,
other health impairments, a specific learning CT, USA
disability, deaf-blindness, or multiple disabilities.
A child with a disability under IDEA (2004)
needs special education and related services. Synonyms
Additionally the law provides for services for
children with a disability aged 3 through 9, Conversational discourse; Pragmatic language;
to include a child experiencing developmental Topic management; Turn-taking
delays as measured by appropriate diagnostic
instruments and procedures, in one or more
of the following areas: physical development; Definition
cognitive development; communication develop-
ment; social or emotional development; or adap- Discourse management refers to the ability to
tive development; and by reason thereof, needs organize topics and turns and to repair any com-
special education and related services. In some munication breakdowns during conversation.
situations, children with a disability may be said Carrying on a conversation involves the appro-
to present a developmental delay if members of priate use and coordination of a variety of skills
the IEP team are not certain that the individual including, initiating and maintaining topics,
meets the criteria for autism. using eye contact, taking turns, being polite,
Discretionary Trust 983 D
and observing and responding appropriately to
nonverbal behaviors. During discourse, individ- Discretionary Trust
uals must monitor their own contributions while
taking into account the explicit and implicit Tobi Gilbert
responses, intentions, and knowledge of their Quinnipiac University School of Law, Hamden,
conversational partner(s). The existing literature CT, USA
on language use and conversational skills in indi-
viduals with ASD indicates that the ability to
contribute new information to topics introduced Discretionary Trust D
by others, shift topics appropriately, provide
turns for others within conversation, take turns A discretionary trust is a common method of
appropriately, and provide repairs for conversa- estate planning whereby the creator of the trust
tional breakdowns frequently present challenges (the settlor) transfers the assets to another (the
to this group. trustee), who then has a duty to hold and manage
the assets for the benefit of a third party (the
beneficiary). If the trust is established by
See Also a living settlor, rather than through a will, the
trust acts as a will substitute and the transferred
▶ Conversational Manner estate avoids probate and some estate taxes.
▶ Pragmatics The terms of a discretionary trust delegate
power to the trustee to decide the “time, pur-
pose and amount of all distributions” to one or
References and Readings more beneficiaries (POMS SI }01120.200.
B.10). The trustee may be given complete
Adams, C., Green, J., Gilchrist, A., & Cox, A. (2002). authority over distributions that the trustee
Conversational behaviour of children with Asperger
considers advisable. For example, a settlor
syndrome and conduct disorder. Journal of Child
Psychology and Psychiatry, 43, 679–690. might delegate absolute discretion upon
Colle, L., Baron-Cohen, S., Wheelwright, S., & a trustee in order to protect the long-term inter-
van der Lely, H. K. J. (2008). Narrative discourse ests of a financially irresponsible beneficiary,
in adults with high-functioning autism and Asperger
or to establish a supplemental needs trust for
syndrome. Journal of Autism and Developmental
Disorders, 38(1), 28–40. doi:10.1007/s10803-007- lifetime support of an orphaned or disabled
0357-5. child. The purpose of such trusts may be to
Fine, J., Bartolucci, G., Szatmari, P., & Ginsberg, G. protect a spendthrift beneficiary from poor
(1994). Cohesive discourse in pervasive developmen-
financial decisions; provide funds that “supple-
tal disorders. Journal of Autism and Developmental
Disorders, 24(3), 315–329. ment, but not supplant, sources of income
Paul, R. (2007). Language disorders from infancy to including SSI or other government benefits”
adolescence (3rd ed.). St. Louis, MO: Elsevier. (POMS SI }01120.200B.13); and shield
Theimann, K. S., & Goldstein, H. (2001). Social
the trust against invasion by the beneficiary,
stories, written text cues, and video feedback: Effect
on social communication of children with autism. or the beneficiary’s general creditors. The
Journal of Applied Behavior Analysis, 34(4), trustee may only be compelled to distribute
425–446. money from the trust under very restricted
circumstances.
Alternatively, the settlor may limit the
trustee’s discretion by directing that distributions
be used for specific purposes. Often, such an
Discrete Versus Continuous arrangement is made to provide for the long-
term care and support of an incompetent benefi-
▶ Dimensional Versus Categorical Classification ciary. For instance, a trustee’s discretion is
D 984 Disfluency
limited to distributing money for the “comfort-

able support, education, health and maintenance” Disfluency
of the beneficiary (Leslie & Sterk, 2006).
Support trusts are often used to provide care for ▶ Fluency and Fluency Disorders
a surviving spouse, or an incompetent or elderly ▶ Stuttering
adult.
Depending on the intent and objectives of the
trust, creating a discretionary trust is an effective
estate planning tool that may extend the life and
Disinhibited Attachment Disorder
availability of estate assets, while offering flexi-
bility for the trustee to deal with unanticipated
▶ Attachment Disorder
events. However, problems may arise such as
a trustee’s breach of duty to manage the trust in
“good faith,” or “in accordance with its terms and
purposes,” or in the “interests of the beneficia-
ries” (Uniform Trust Code }801 et. seq., 2005). Disinhibited Social Engagement
This may be demonstrated when the trustee Disorder
abuses the assigned discretionary power, and the
beneficiary is not competent to address the ▶ Attachment Disorder
breach. Therefore, one must carefully evaluate
the goals of the settlor, the competence and trust-
worthiness of the trustee, and the long-term needs
of the beneficiary in order to determine if Disintegrative Disorder
a discretionary trust is the best estate planning
option. ▶ Acquired Autism
▶ Childhood Disintegrative Disorder (Heller’s
Syndrome)
See Also
▶ Beneficiary
▶ Trust
Disintegrative Psychosis
References and Readings ▶ Childhood Disintegrative Disorder (Heller’s

Syndrome)
Sources
Andersen, R. (2003). Understanding trusts and estates.
Newark, NJ: Matthew Bender & Company.
Averill, L. (2005). Wills, trusts, and future interests.
St. Paul, MN: Thomson/West. Disorder of Executive Dysfunction
Leslie, M., & Sterk, S. (2006). Trusts and estates.
New York: Foundation Press.
Programs Operations Manual System (POMS): Trusts }SI
▶ Frontal Lobe Syndrome
01120.200A et. seq. Retrieved March 8, 2011, from
https://secure.ssa.gov/apps10/poms.nsf/lnx/0501120200
Rios v. Astrue, 159 Soc. Sec. Rep. Service 604 (N.D. Ill.
2010). Retrieved March 7, 2011, from Lexis-Nexis
Database: 2010 U.S. Dist. LEXIS 121256
Disordered Attachment
Social Security Act (SSA), }42 U.S.C. }1396p
Uniform Trust Code }801 (2005) et. seq. ▶ Reactive Attachment Disorder
Dispute Resolution Procedures 985 D
Arbitration
Dispute Resolution Procedures
Arbitration is a dispute resolution process in which
Jonathan Sliva the disputing parties present their cases to a third
Quinnipiac University School of Law, party intermediary who makes what is usually
Hamden, CT, USA a binding decision for the parties. Arbitration is
generally not as formal as in-court adjudication,
and the procedural rules can be structured to meet
Definition the necessities of the particular situation. As in D
court-based adjudication, the outcome of an arbitra-
A dispute resolution procedure is a method of tion proceeding will typically result in a clear winner
resolving a conflict between parties. Historically, and loser. Although the arbitrator may recommend
dispute resolution was judicial in nature; how- a solution that clearly benefits both parties, arbitra-
ever, in recent years the number of disputes tors are not expected to develop ideas for meeting
resulting in trial has decreased significantly the interests of both sides or to help the parties see
due in part to the advent of alternative dispute areas of agreement and reconciliation.
resolution (ADR) procedures such as arbitration,
mediation, and negotiation. Today, most refer-
ences to a dispute resolution procedure are Mediation
to these alternatives to litigation (Yarn, 1999,
p. 154). These methods of dispute resolution Mediation is a process in which the parties attempt
along with other types of ADR may be utilized to resolve a conflict with the assistance of a neutral
by parties trying to minimize costs and avoid the third party (mediator) (Yarn, 1999, p. 272). Media-
adversarial nature of litigation. tion is similar to negotiation in that the parties to the
dispute are in control. However, to assist the process
of negotiation, the mediator is present to help reach
Types of Alternative Dispute Resolution a mutually agreeable solution to their differences.
Procedures Although ultimate control and decision-making
authority remain with the parties, the mediator has
Modern alternative dispute resolution procedures significant power throughout the process to direct
were developed primarily as a response to the the negotiations, identify areas of agreement, and
rising levels of litigation in the United States encourage the parties to accept concessions (Gold-
throughout the twentieth century. In the berg, Sander, Rogers, & Cole, 2007, p. 107).
mid-1970s, Harvard Professor Frank Sander
articulated his vision of a system where, instead
of leading directly to litigation, disputes could Negotiation
be directed to various alternative methods to
resolve the dispute without resorting to a trial. Negotiation is a process where the parties, with the
He described this multifaceted system of the aid of a mediator, attempt to come to a mutually
judiciary working alongside other forms of con- acceptable agreement about issues on which they
flict resolution as the “multidoor” courthouse. disagree (Nieuwmeijer, 1988, p. 9). The parties
(Menkel-Meadow, 2005, p. 19). The implemen- use bargaining and open communication to reach
tation of such alternatives to litigation has a consensus over their outstanding issues. Negotiation
greatly reduced the number of cases going to works best in situations where all parties involved in
trial even as the number of complaints filed in the process have a mutual interest in resolving their
courthouses has greatly increased (Stipnowich, dispute and are willing to each make concessions in
2004, p. 844). order to reach an acceptable resolution.
D 986 Disruptive Behavior
See Also studying for a test. It involves the student creating

a schedule of study sessions that are short in
▶ Eligibility (for Services Under IDEA/ADA, duration. Distributed practice can be contrasted
etc.) to massed practice or cramming, where the
student spends fewer studying sessions but for
longer periods of time. This technique has proven
References and Readings to be beneficial for maintaining newly learned
skills. Distributed practice aids students in
Garner, B. A. (Eds.). (2004). Black’s law dictionary. prioritizing learning material.
Tampa, FL: West Group Publishing.
Goldberg, S. B., Sander, F. E. A., Rogers, N. H., & Cole, S. R.
(2007). Dispute resolution: Negotiation, mediation, and
other processes (5th ed.). New York: Aspen. References and Readings
Menkel-Meadow. (2005). Roots and inspirations: A brief
history of the foundations of dispute resolution. In http://web.ics.purdue.edu/rallrich/learn/dist.html
M. Moffitt & R. Bordone (Eds.), The handbook of http://psychology.wikia.com/wiki/distributed_practice
dispute resolution (pp. 13–33). San Francisco, CA: Murray, S. R., & Udermann, B. E. (2003). Massed versus
Jossey-Bass. distributed practice: Which is better? CAHPERD
Nieuwmeijer, L. (1988). Negotiation: Methodology and Journal, 28, 19–22.
training. Preoria: HSRC.
Stipnowich, T. J. (2004). ADR and the “Vanishing Trial”:
The growth and impact of “alternative dispute resolu-
tion”. Journal of Empirical Legal Studies, 1(3),
843–912. Distribution-Free Statistics
Yarn, D. H. (1999). Dictionary of conflict resolution.
San Francisco, CA: Jossey-Bass.
▶ Nonparametric Statistics
Disruptive Behavior
Divalproex
▶ Depakene
Dissocial Behavior
Dizygotic (DZ) Twins
Paul El-Fishawy
State Laboratory, Child Study Center, Yale
Distributed Practice
Rebecca Munday Synonyms

The Center for Children with Special Needs,
Glastonbury, CT, USA Fraternal twins
Definition Definition
Distributed practice is a technique commonly Twins are two individuals who are the result of
used with students who are learning material or the same pregnancy. Dizygotic twins are
Dizygotic (DZ) Twins 987 D
nonidentical or fraternal twins. This is in contrast twins comprise one third. While the rate of mono-
to identical or monozygotic twins. Unlike the zygotic twinning in pregnancies that are unassisted
case in monozygotic twins, the genetic informa- by fertility treatments is relatively stable across
tion or deoxyribonucleic acid (DNA) carried by world populations at a rate of approximately 4 in
each of the individual twins in a pair of dizygotic every 1,000 live births, there is evidence that the
twins is different. This genetic information in the rate of dizygotic twinning in the absence of fertility
form of DNA is the material inherited from each treatments varies from population to population.
of the parents that contains all the instructions for Studies estimate that dizygotic twinning rates are
the creation and subsequent operation of an indi- the lowest in East Asian countries fewer than 8 per D
vidual. Errors in this genetic information can lead 1,000 live births. Dizygotic twinning rates are inter-
directly to disease or make individuals more sus- mediate in Europe, the United States, and India
ceptible to disease. with a rate of approximately 9–16 per 1,000 births.
In singleton pregnancies, a sperm from the They are highest in some African countries where
father fuses with an egg from the mother, and they can be 18 or greater per 1,000 births.
together, they form a single cell called a zygote, The rate of both monozygotic and dizygotic
the earliest stage of an embryo. In the case of twins has increased worldwide since the 1970s.
dizygotic twins, two separate eggs in the mother It is thought that the majority of the increase has
are released at one time. Each of these is then resulted from the increase in dizygotic
fertilized by a separate sperm from the father and twins born as a result of fertility treatments.
forms a distinct zygote and embryo. Since each Twin pregnancies of either type increase preg-
sperm and egg carry distinct genetic material, nancy risk and especially the risk of preterm
each of the two embryos will, thus, carry distinct delivery and low birth weight. Approximately
genetic material. On average, dizygotic twins’ 51% of twins are born preterm compared to
genetic material is only about 50% identical, as 9.4% of singletons.
compared to 100% for monozygotic twins. Since
each dizygotic twin carries distinct genetic mate-
rial, his or her physical appearance will be dis- See Also
tinct. Dizygotic twins may be of the same sex.
However, they might also be of different sexes. ▶ Genetics
Monozygotic twins, in contrast, form as follows. ▶ Twin Studies in Autism
A sperm from the father fuses with an egg from the
mother and initially forms a single zygote. Further
cell divisions occur during embryonic develop-
ment. At an early point in this development, the
embryo in the case of monozygotic twins splits into Alexander, G. R., Kogan, M., et al. (1998). What are the
two separate embryos, the cells of each having fetal growth patterns of singletons, twins, and triplets
originated from the initial zygote. Each of these in the United States? Clinical Obstetrics and Gynecol-
ogy, 41(1), 115.
embryos goes on to develop into a separate and
Bortolus, R., Parazzini, F., et al. (1999). The epidemiology of
complete individual. Since each originated from multiple births. Human Reproduction Update, 5(2), 179.
the same initial cell, each individual is identical in Gilbert, S. F. (1994). Developmental biology. Sunderland,
his or her genetic composition. Barring rare occur- MA: Sinauer Associates.
Hall, J. G. (2003). Twinning. The Lancet, 362(9385),
rences (see Monozygotic Twins), since monozy- 735–743.
gotic twins share the same genetic material, their Machin, G. A. (1996). Some causes of genotypic and
physical appearance will be identical, and they will phenotypic discordance in monozygotic twin pairs.
be of the same sex. American Journal of Medical Genetics, 61(3), 216–228.
Reeve, E. C. R., & Black, I. (2001). Encyclopedia of
Dizygotic twinning is more common than
genetics. London: Routledge.
monozygotic twinning. Dizygotic twins comprise Smits, J., & Monden, C. (2011). Twinning across the
approximately two thirds of all twins. Monozygotic developing world. PLoS One, 6(9), e25239.
D 988 DMG
Strachan, T., & Read, A. P. (2004). Human molecular 95% of right-handers and 65% of left-handers, the
genetics. New York: Garland Press. left side of the brain is dominant for language.
Vitthala, S., Gelbaya, T. A., et al. (2009). The risk of
monozygotic twins after assisted reproductive technol-
ogy: A systematic review and meta-analysis. Human
Reproduction Update, 15(1), 45. See Also
▶ Cerebral Cortex
▶ Neuroscience
DMG
▶ Dimethylglycine References and Readings
Toga, A. W., & Thompson, P. M. (2003). Mapping brain

asymmetry. Nature Reviews Neuroscience, 4(1),
37–48.
DNA
▶ Deoxyribonucleic Acid
Dopamine
Carolyn A. Doyle1 and Christopher J. McDougle2

Dominance, Cerebral 1
Indiana University School of Medicine,
Indianapolis, IN, USA
2
Kevin A. Pelphrey Lurie Center for Autism/Harvard Medical
Child Study Center, Yale University School of School, Lexington, MA, USA
Synonyms Definition
Hemispheric dominance; Hemispheric lateraliza- Dopamine is a neurotransmitter that is implicated

tion; Hemispheric specialization in the pathophysiology of many psychiatric and
neurologic disorders. Its most notable psychiatric
role is in the pathophysiology of psychosis and
Definition schizophrenia, particularly the presence of halluci-
nations and delusions. However, among a compli-
Cerebral dominance refers to the dominance of cated network of neural pathways, dopamine is also
one cerebral hemisphere (commonly referred to believed to influence mood states, anxiety, cogni-
as the left or right side of the brain) over the other tion, and the presence of repetitive symptoms
in the control of particular cerebral functions. experienced in conditions like autism spectrum dis-
After decades of study in the fields of behavioral orders (ASD), Tourette’s disorder, and obsessive-
neurology, systems neuroscience, neuroimaging, compulsive disorder. For these reasons, dopamine
and neuropsychology, it is clear that each hemi- is the target of research attempting to uncover eti-
sphere of the brain is dominant for specific behav- ologies and treatments for such diseases. Under-
ioral and cognitive functions. For example, in standing dopamine’s relationship to ASD may
most right-handed individuals, portions of the offer much insight into the pathophysiology of its
right hemisphere temporal lobe are specialized symptoms.
for processing faces, and similar regions of Dopamine is synthesized in specialized neurons
the left hemisphere temporal lobe are specialized using the amino acid precursor tyrosine (Stahl,
for processing letters. Similarly, in approximately 2008). Tyrosine is first pumped from the
Dopamine 989 D
extracellular space into dopaminergic neurons by mesolimbic pathway is also known to regulate emo-
a tyrosine transporter. Within the neuron, tyrosine tions, motivation, pleasure, and reward. Dysfunction
then passes through the rate-limiting enzyme tyro- in this area may result in symptoms such as avolition
sine hydroxylase, followed by the enzyme dopa and anhedonia, accounting for some of the “negative
decarboxylase, to become dopamine. (Dopamine symptoms” of schizophrenia. The second pathway
can also be converted to the neurotransmitter nor- is the mesocortical pathway, which projects from the
epinephrine via the enzyme dopamine beta-hydrox- dopaminergic cell bodies of the ventral tegmental
ylase.) Dopamine is packaged into vesicles by area to the prefrontal cortex. Branches from this
a vesicular monoamine transporter (VMAT2) for pathway are believed to regulate cognition and exec- D
storage until later use. When a neuron receives the utive function, as well as emotion and affect. Unlike
appropriate signal, dopamine is released from syn- the mesolimbic pathway, where an excess of dopa-
aptic vesicles to travel across the cleft between the mine is hypothesized to produce symptoms of psy-
presynaptic and postsynaptic axon terminals. Once chosis, a deficit of dopamine in the mesocortical
in the cleft, dopamine is free to attach to dopamine pathway is thought to cause more negative symp-
receptors on the postsynaptic axon terminal. It can toms observed in schizophrenia, such as flat affect,
also be taken up by dopamine transporters in the reduced cognition, and impaired executive function.
presynaptic axon terminal to be repackaged for later The model of increased or decreased dopaminergic
use or degraded. One of the most notable receptors activity in different pathways is hypothetical and is
is the dopamine-2 (D2) receptor, which is located on likely an oversimplification of a more complex sys-
postsynaptic axon terminals, presynaptic axon ter- tem yet to be understood. The third pathway is the
minals, and somatodendritic areas. When dopamine nigrostriatal pathway, which projects from the dopa-
attaches to D2 receptors on the presynaptic axon minergic cell bodies in the brainstem substantia
terminal or somatodendritic areas, D2 receptors nigra to the basal ganglia or striatum. This area
provide negative feedback that slows or further pre- regulates motor movements and is part of the extra-
vents the release of dopamine from the presynaptic pyramidal nervous system. Hypoactivity of dopa-
terminal. Excess dopamine is degraded within mine in this pathway produces parkinsonian
the neuron by the enzymes monoamine oxidase symptoms of rigidity, akinesia or bradykinesia, and
(MAO)-A or MAO-B and outside the neuron tremor. Hypoactivity in the basal ganglia specifi-
by the enzyme catechol-O-methyltransferase cally can result in dystonia or akathisia. Hyperactiv-
(COMT). In some areas in the brain, such as ity of dopamine in this pathway results in
the frontal cortex, there are fewer dopamine trans- hyperkinetic movements, such as tics, chorea, and
porters to take up excess dopamine remaining in dyskinesia. Longer term blockade of the D2 recep-
the cleft, so these alternative routes of degradation tors via antipsychotics can produce a hyperkinetic
function to regulate dopamine concentration. disorder known as tardive dyskinesia. The fourth
There are five key dopamine pathways in the pathway is the tuberoinfundibular pathway, which
brain. The first is the mesolimbic pathway, which projects from the hypothalamus to the anterior pitu-
projects from the dopaminergic cell bodies of itary. Dopamine typically inhibits prolactin,
the ventral tegmental area of the brainstem to the a hormone that results in lactation. When dopami-
nucleus accumbens in the ventral striatum. Increased nergic activity is blocked in this pathway, prolactin
dopamine activity in this pathway is thought to levels rise as it is no longer inhibited. Elevated
generate psychosis, also known as the “positive prolactin can cause galactorrhea (breast secretions),
symptoms” of schizophrenia, which include halluci- amenorrhea (loss of ovulation and menstruation),
nations and delusions. Stimulant drugs, like amphet- and possibly sexual side effects. This can occur
amine and cocaine, produce increased dopaminergic with the use of antipsychotic medication, which
activity and subsequent psychotic symptoms, blocks D2 receptors. The fifth pathway is the
whereas first- and second-generation antipsychotic lesser-known thalamic dopamine pathway, which
medications, which antagonize dopamine in this innervates the thalamus. It is thought to originate in
pathway, cause reduced psychotic symptoms. The multiple sites, including the periaqueductal gray
D 990 Dopamine
matter, ventral mesencephalon, hypothalamic emphasis on chemical transmission. Slowly,

nuclei, and lateral parabrachial nucleus. The func- others began uncovering similar results, publish-
tion of this pathway may involve regulation of sleep ing studies showing an absence of dopamine in
and arousal. the basal ganglia in patients with Parkinson’s
disease (Ehringer & Hornykiewicz, 1960) and
that healthy basal ganglia neurons contain high
Historical Background levels of dopamine (Birkmayer & Hornykiewicz,
1961; Dahlstrom & Fuxe, 1964). The drug is not
In the late 1950s, a Swedish pharmacologist named without imperfection, and unwanted side effects
Arvid Carlsson was the first person to discover such as nausea and emesis can occur. At times,
dopamine as a distinct neurotransmitter, and in the the drug can lose its therapeutic effect in some
year 2000, he won the shared Nobel Prize in patients. Nonetheless, L-dopa continues to be the
Physiology and Medicine for this very significant first-line treatment for Parkinson’s disease. It also
contribution. As outlined in Abbott’s article in likely garnered increased public awareness after
Nature (2007), this monumental discovery occurred being featured in the 1973 book Awakenings by
while experimenting with reserpine, the first anti- British neurologist Oliver Sacks. This memoir
psychotic to be used in the treatment of schizophre- recounts Dr. Sacks’ use of L-dopa in 1969 to
nia. Treatment with reserpine was observed to cause treat patients with catatonia who survived the
a catatonic state in experimental rabbits, but the 1917–1928 outbreak of encephalitis lethargica,
mechanism by which this happened was unknown. otherwise known as sleeping sickness. The book
Using a spectrophotofluorimeter, a machine used was transformed into a 1990 film with the same
to measure the amount of neurotransmitter name starring American actors Robin Williams
synthesized from fluorescently tagged precursors, and Robert De Niro. In 1961, L-dopa was injected
Dr. Carlsson determined that reserpine somehow into the first Parkinson’s patients with dramatic
drained stores of brain neurotransmitters. Because effect, providing relief for their rigidity and
the known neurotransmitters serotonin and norepi- immobility.
nephrine were not able to cross the blood-brain Not long after the discovery of dopamine’s
barrier, Dr. Carlsson hypothesized that their pre- relationship to Parkinson’s disease, neurologists
cursors could be injected and cross over the blood- observed that treatment with L-dopa resulted in
brain barrier to be converted to the needed neuro- psychosis, leading to the discovery that the path-
transmitters, hopefully restoring movement. He ophysiology of schizophrenia may be related to
extracted serotonin and norepinephrine precursors, dopamine. The observation that antipsychotic
one of which was L-dopa (levodopa), and injected drugs caused movement disorders similar to
them into the catatonic rabbits. L-dopa restored that observed in Parkinson’s disease leads
movement in the animals, and Dr. Carlsson deter- Dr. Carlsson to reason that antipsychotics
mined dopamine to be a separate neurotransmitter blocked dopamine receptors, resulting in a feed-
while examining the rabbits’ postmortem brains. back mechanism by which neurons released more
With the help of his graduate students, compensatory dopamine. These conclusions have
Dr. Carlsson went on to discover dopamine con- led Dr. Carlsson to become a pivotal figure in the
centrated in areas of the brain associated with discovery of dopamine as a distinct neurotrans-
movement, like the basal ganglia. Given the sim- mitter, as well as someone who uncovered fun-
ilarities between reserpine’s side effects and damental mechanisms in neurotransmission that
Parkinson’s disease, he hypothesized that the discontinue to be employed today.
ease must be caused by a deficiency of dopamine. With time, neural pathways controlling dopa-
He brought these ideas to various symposia but mine were thought to influence motivation and
received a mixed reception; the favored thinking reward, exemplified by the tendency of patients
at that time was that nerve conduction in the brain treated with L-dopa to gamble excessively.
occurred via electrical impulses, with little Research into addiction and drugs of abuse has
Dopamine 991 D
also implicated brain regions and neural path- et al. (2010) used positron emission tomography
ways primarily governed by dopamine. Dopa- (PET) to study the binding of dopamine and sero-
mine’s widespread effect in the brain has led tonin transporters in the brains of autistic male
autism researchers to investigate it in the patho- adults compared to age- and IQ-matched controls.
physiology of ASD. The relationship between They found that dopamine transporter binding was
dopamine and ASD is explored in the “Current significantly higher in the orbitofrontal cortex of the
Knowledge” section. autistic individuals and that this was inversely cor-
related with serotonin binding, which was lower
throughout the brain of autistic individuals. They D
Current Knowledge concluded that dysfunction in dopamine and sero-
tonin systems likely contributes to the pathophysi-
Due to its extensive innervation of the brain, dopa- ology of autism.
mine has been hypothesized to be involved in the Research has attempted to link symptoms of
pathophysiology of ASD. According to Baskerville ASD to specific genetic polymorphisms and neuro-
and Douglas (2010), neurologic behavioral disor- anatomical regions of the brain. For example, the
ders caused by profound disruption of the key dopa- presence of repetitive, stereotyped behaviors in
minergic pathways in the brain are known to ASD has been associated with the basal ganglia
adversely affect prosocial behavior. These path- and frontal lobe circuitry (Langen et al., 2011),
ways likely involve complex interactions with mul- which is believed to be regulated by the dopamine
tiple other neurotransmitters and neuropeptides, and system. Housed in the basal ganglia is the caudate
it is hypothesized that dysfunctional interactions nucleus, a brain region associated with behavioral
result in the aberrant social behavior observed in rigidity. The caudate nucleus has been found to be
ASD. One of the proposed interactions is between enlarged in ASD, representing one of the best rep-
dopamine and oxytocin, a neuropeptide with phys- licated neuroimaging findings in ASD research
iologic and behavioral influences. Oxytocin is an (Langen et al., 2009). The basal ganglia, particu-
endocrine hormone that regulates parturition and larly the caudate nucleus, exhibit high expression of
milk ejection, but is also involved in regulating the dopamine-3 receptor gene (DRD3), a gene that
social behaviors such as social bonding, parental appears to be associated with ASD. Genetic studies
behavior, and sexual behavior (Lee et al., 2009). It have revealed an association between the SNP (sin-
is also thought to regulate nonsocial behaviors such gle nucleotide polymorphism) rs16777 on DRD3
as stress, anxiety, and aggression, which all appear and ASD (de Krom et al., 2009). This polymor-
in ASD, and has been thought to be influenced by phism is also related to risperidone-induced extra-
dopamine pathways. Given their shared roles, dopa- pyramidal symptoms (Gasso et al., 2009), which is
mine and oxytocin are hypothesized to jointly con- significant because risperidone and aripiprazole (a
tribute to aberrant social behaviors, anxiety, and partial agonist at the D2 receptor) are the only FDA-
aggression in ASD. The results of studies linking approved drugs for the treatment of symptoms asso-
oxytocin to the pathophysiology of ASD have been ciated with ASD (Staal, de Krom, & de Jonge,
mixed, however, but treatments involving intrana- 2011). The DRD3 receptor site is also an action
sal oxytocin have resulted in improvements in com- site for atypical antipsychotic drugs, and another
munication and secure relationship attachment of its polymorphisms is a predictor for improvement
(Heinrichs et al., 2009; Kosfeld et al., 2005). Unfor- with risperidone therapy (Correia et al., 2010). All
tunately, revealing a definitive, symbiotic relation- of this data supports a positive association between
ship between oxytocin and dopamine has yet to the presence of the DRD3 gene and ASD; however,
occur, but research in this area continues. There a small study performed by Staal et al. (2011)
has been stronger evidence linking dopamine dys- revealed that the presence of SNP rs16777 on
function with autism-like disorders, particularly DRD3 paradoxically decreased the risk for “insis-
involving the dopamine transporter and D4 receptor tence on sameness,” a form of stereotyped behavior
genes (Baskerville & Douglas, 2010). Nakamura observed in ASD. Given the breadth of findings,
D 992 Dopamine
some which are conflicting, there is a need for only two atypical antipsychotics that are FDA-
continued research into DRD3 and its relationship approved for the treatment of irritability in autistic
to symptoms of ASD. disorder: risperidone (Risperdal) and aripiprazole
Other genetic biomarkers of interest (Abilify). Risperidone is FDA-approved for the
include dopamine transporter gene (DAT1) treatment of irritability in patients with autistic dis-
and dopamine D4 receptor gene (DRD4). In order aged 5–16 years, whereas aripiprazole is
a study by Gadow et al. (2010), the DAT1 and approved for the treatment of patients with autistic
DRD4 genotypes approached significance for disorder aged 6–17 years. Risperidone is a potent D2
teachers’ ratings of oppositional behavior and antagonist, whereas aripiprazole has partial
mothers’ ratings of tics. The researchers proposed D2 receptor agonists, meaning it detaches from the
that variation in the alleles for DRD4 may serve D2 receptor more readily than risperidone and typ-
as biomarkers predicting challenging behaviors ical antipsychotics. These traits may contribute to
in children with ASD, but the study was small these drugs’ relative success in managing symp-
and would require replication with larger toms observed in ASD. Other antipsychotics that
samples. have been studied include the “typicals,” such as
Despite these attempts at localizing specific haloperidol, pimozide, chlorpromazine, trifluopera-
genes implicated in the pathophysiology of zine, thiothixene, trifluperidol, fluphenazine, and
autism, some research indicates that it may not molindone. Other atypical antipsychotics include
be so simple. A study genotyping 28 SNPs of clozapine, olanzapine, quetiapine, and ziprasidone.
14 prominent dopamine pathway candidate In addition to irritability, some studies have
genes concluded that the evidence was not noted reductions in other symptom domains such
strong in favor of linkage or association to any as repetitive behavior and inattention, hyperactivity,
specific gene or combination of genes within the and impulsivity. However, the direct relationship
pathway (Anderson et al., 2008). The role of between dopamine and these symptom outcomes
genes within the dopamine pathway, if any, was is not always apparent, so future research is needed
considered mild to moderate in the pathogenesis to explicate this.
of autism.
Inattention and hyperactivity, symptoms that
commonly occur in autism, also appear to result Future Directions
from dysfunction of the dopamine system.
Gadow et al. (2008) found that a variable number Future directions for research into the relationship
tandem repeat (VNTR) in a region of the dopa- between dopamine and autism will likely involve
mine transporter gene (DAT1, SLC6A3) was genetic studies, neuroendocrine research, neuroim-
associated with the severity of ADHD, anxiety, aging, and pharmacologic treatment development.
and tics in children with ASD. Genetic research has focused on identifying poly-
The association between dopamine and autism is morphisms that may or may not be associated with
also evident via the observed effects of antipsy- symptoms of ASD. This type of research has yielded
chotics medication on the treatment of irritability mixed results but will likely continue to examine the
in ASD. Approximately 30% of children and ado- association between ASD and dopamine receptor
lescents with ASD suffer from moderate-to-severe genes like DRD3 and DRD4. Attempting to link
irritability (Lecavalier, 2006). Irritability can dopamine and oxytocin has also not yielded strong
include aggressive acts towards the self (self- results, but their shared roles with regard to social
injurious behavior) or others and severe tantrums. behavior, stress, anxiety, and aggression will likely
Currently, the most effective drugs used to treat spur continued research attempting to find an asso-
symptoms of irritability are the antipsychotics, ciation. Given the consistent finding of an enlarged
which are believed to antagonize postsynaptic D2 caudate nucleus in patients with ASD, a dopamine-
receptors in the brain, although some may also have rich area of the brain, neuroimaging may continue to
serotonin receptor antagonism. At present, there are yield useful information about other brain regions
Dopamine 993 D
that utilize dopamine and how they relate to symp- Dahlstrom, A., & Fuxe, K. (1964). Localization of mono-
toms of ASD. It may also reveal more about dopa- amines in the lower brain stem. Experientia, 20(7),
398–399.
mine binding in such areas. Lastly, new de Krom, M., Staal, W. G., et al. (2009). A common variant
pharmacological treatments for symptoms of ASD in DRD3 receptor is associated with autism spectrum
should be investigated via randomized, double- disorder. Biological Psychiatry, 65(7), 625–630.
blind, placebo-controlled studies to ensure Ehringer, H., & Hornykiewicz, O. (1960). Distribution of
noradrenaline and dopamine (3-hydroxytyramine) in
a variety of safe and efficacious treatments are the human brain and their behavior in diseases of the
available to patients. The atypical antipsychotic extrapyramidal system. Klinische Wochenschrift, 38,
paliperidone, which is the active metabolite of ris- 1236–1239. D
peridone, is an evident choice since risperidone has Emanuele, E., Boso, M., et al. (2010). Increased dopamine
DRD4 receptor mRNA expression in lymphocytes
shown efficacy in treating children and adolescents of musicians and autistic individuals: Bridging the
with autistic disorder (Stigler et al., 2010). music-autism connection. Neuro Endocrinology
Letters, 31(1), 122–125.
Gadow, K. D., Devincent, C. J., et al. (2010). Association
of DRD4 polymorphism with severity of oppositional
See Also defiant disorder, separation anxiety disorder and
repetitive behaviors in children with autism spectrum
▶ Antipsychotics: Drugs disorder. European Journal of Neuroscience, 32(6),
▶ Aripiprazole 1058–1065.
Gadow, K. D., Roohi, J., et al. (2008). Association of
▶ Atypical Antipsychotics ADHD, tics, and anxiety with dopamine transporter
▶ Caudate Nucleus (DAT1) genotype in autism spectrum disorder.
▶ Clozapine Journal of Child Psychology and Psychiatry, 49(12),
▶ Obsessive-Compulsive Disorder (OCD) 1331–1338.
Gasso, P., Mas, S., et al. (2009). A common variant in
▶ Olanzapine DRD3 gene is associated with risperidone-induced
▶ Pimozide extrapyramidal symptoms. The Pharmacogenomics
▶ Psychosis Journal, 9(6), 404–410.
▶ Quetiapine Heinrichs, M., von Dawans, B., et al. (2009). Oxytocin,
vasopressin, and human social behavior. Frontiers in
▶ Risperidone Neuroendocrinology, 30(4), 548–557.
▶ Tourette Syndrome Kosfeld, M., Heinrichs, M., et al. (2005). Oxytocin increases
▶ Ziprasidone trust in humans. Nature, 435(7042), 673–676.
Langen, M., Leemans, A., Johnston, P., Ecker, C.,
Daly, E., Murphy, C. M., et al. (2011). Fronto-striatal
circuitry and inhibitory control in autism: Findings
References and Readings from diffusion tensor imaging tractography. Cortex,
48, 183–193.
Abbott, A. (2007). Neuroscience: The molecular wake-up Langen, M., Schnack, H. G., et al. (2009). Changes in
call. Nature, 447(7143), 368–370. the developmental trajectories of striatum in autism.
Anderson, B. M., Schnetz-Boutaud, N., et al. (2008). Biological Psychiatry, 66(4), 327–333.
Examination of association to autism of common Lecavalier, L. (2006). Behavioral and emotional problems
genetic variation in genes related to dopamine. Autism in young people with pervasive developmental disor-
Research, 1(6), 364–369. ders: Relative prevalence, effects of subject character-
Baskerville, T. A., & Douglas, A. J. (2010). Dopamine and istics, and empirical classification. Journal of Autism
oxytocin interactions underlying behaviors: Potential and Developmental Disorders, 36(8), 1101–1114.
contributions to behavioral disorders. CNS Neurosci- Lee, H. J., Macbeth, A. H., et al. (2009). Oxytocin: The
ence and Therapeutics, 16(3), e92–e123. great facilitator of life. Progress in Neurobiology,
Birkmayer, W., & Hornykiewicz, O. (1961). The L-3,4- 88(2), 127–151.
dioxyphenylalanine (DOPA)-effect in Parkinson- Nakamura, K., Sekine, Y., et al. (2010). Brain serotonin
akinesia. Wiener Klinische Wochenschrift, 73, 787–788. and dopamine transporter bindings in adults with high-
Correia, C. T., Almeida, J. P., et al. (2010). Pharmaco- functioning autism. Archives of General Psychiatry,
genetics of risperidone therapy in autism: Association 67(1), 59–68.
analysis of eight candidate genes with drug efficacy Neuhaus, E., Beauchaine, T. P., et al. (2010). Neurobio-
and adverse drug reactions. The Pharmacogenomics logical correlates of social functioning in autism.
Journal, 10(5), 418–430. Clinical Psychology Review, 30(6), 733–748.
D 994 Double-Blind Study
Sacks, O. Awakenings (E.P. Dutton, 1973). citalopram study (▶ Citalopram), 34% of the sub-
Staal, W. G., de Krom, M., & de Jonge, M. V. (2011). jects randomly assigned to placebo showed
Brief report: The dopamine-3-receptor gene (DRD3) is
associated with specific repetitive behavior in autism a positive response rated by clinician who was
spectrum disorder (ASD). The Journal of Autism and blind to treatment assignment.
Developmental Disorders, 42(5), 885–888. Several elements are essential in the conduct
Stahl, S. M. (2008). Stahl’s essential psychopharmacol- of a double-blind, placebo-controlled trial. First
ogy: Neuroscientific basis and practical applications
(3rd ed., pp. 102–105). New York: Cambridge Univer- and perhaps most important is random assign-
sity Press. 266–279. ment. Random assignment is essential to ensure
Stigler, K. A., Erickson, C. A., et al. (2010). Paliperidone that the two treatment groups are similar. Second,
for irritability in autistic disorder. Journal of Child and there should be a match between the entry criteria
Adolescent Psychopharmacology, 20(1), 75–78.
and the study treatment. For example, in the
risperidone trial conducted by the RUPP Autism
Network (▶ Citalopram), subjects were required
to have serious behavioral problems. This ensures
Double-Blind Study that there is room for improvement on the target
clinical symptoms. This is important for ethical
Lawrence David Scahill and statistical reasons. It is fair to compare a new
Nursing & Child Psychiatry, Yale University medication to placebo when it is unknown
School of Nursing, Yale Child Study Center, whether the new treatment is effective. In most
New Haven, CT, USA situations, however, it seems unfair to enroll sub-
jects into a medication study if it was known that
the active treatment has a low chance of confer-
Definition ring benefit. In statistics, investigators are inter-
ested in finding out if the new treatment is
DOUBLE-BLIND TRIAL. The double-blind superior to placebo. Subjects who have low
trial is a research method that attempts to severity on the clinical target have little room
reduce the bias in research studies. In the classic for improvement, which will make it difficult to
double-blind trial, subjects are randomly detect change. Finally, there is the issue of sam-
assigned to receive an active medication or ple size. A trial that is too small cannot answer the
a placebo. The placebo is formulated to look question whether the new medication is superior
and perhaps even taste like the active medication to placebo. This could be unfortunate if
– but the placebo contains no active ingredients. a beneficial treatment is abandoned too soon
We use the term “double-blind” to indicate that because it failed to show efficacy in a small
investigators and patients (and parents) do not trial. On the other hand, treatment trials are
know whether the patient is getting the active expensive.
medication or the placebo. The treatment mask Moreover, we are asking subjects and families to
is intended to reduce bias and expectation. consider randomization to placebo. A trial should
When a new medication is being introduced, only be as large as needed to test whether the new
there may be a lot of interest and hope for the new treatment is superior to placebo. Investigators have
medication. In the absence of placebo control, to determine the minimum magnitude of benefit
this interest and hope could lead to false impres- that would be considered clinically meaningful
sions about the benefits of the medication. and then calculate the sample size needed. The
Indeed, high expectations can also contribute to “minimum clinically meaningful benefit” depends
the so-called “placebo effect.” In several recent on the treatment target. For example, self-injurious
studies in children with autism spectrum disor- behavior is a serious problem. Even a modest level
ders, as many as one third of the subjects on of benefit might be considered meaningful. Repet-
placebo were classified as much improved or itive behavior such as rocking or watching the same
very much improved. For example, in the video over and over can be problematic – but not
Douglass Development Disabilities Center 995 D
a severe as self-injury. For a less severe behavior, undergraduate and doctoral students in the latest
a higher level of benefit might be demanded of methods of treating people with autism spectrum
a new treatment. In general, the smaller the differ- disorders (ASD), and (3) do research on questions
ence between medication and placebo, the larger of importance in the treatment of people with
the trial has to be. autism and on meeting the needs of their families.
From its inception, the DDDC has relied on the
principles of applied behavior analysis (ABA) to
References and Readings guide services. As the teaching strategies derived
from ABA have grown more elegant and precise, D
Vitiello, B., & Scahill, L. (2011). Clinical trials so too have the teaching methods at the Center.
methdology and design. In A. Martin, L. Scahill, &
Methods that were once at the heart of practice in
C. Kratochvil (Eds.), Pediatric psychopharmacology:
Principles and practice (pp. 711–724). New York: the 1970s have evolved steady into the more
Oxford University Press. effective and extensively studied techniques in
use in the twenty-first century.
Douglass Development Disabilities Major Activities

Center
Direct Service to People with Autism
Lara Delmolino and Sandra Harris Two units at the DDDC are devoted to center-
Douglass Developmental Disabilities Center, based direct instruction of people with autism.
Rutgers, The State University of New Jersey, These are the Douglass School and Adult
New Brunswick, NJ, USA Services.
The Douglass School is approved by the New
Jersey Department of Education as a “college-
Major Areas or Mission Statement operated program” to serve children and adoles-
cents from 3 to 21 years of age with autism
The Douglass Developmental Disabilities Center spectrum disorders (ASD) who need a special-
(DDDC) is a unit of the Graduate School of ized setting to address their educational needs
Applied and Professional Psychology at Rutgers, and behavior intervention services to address
the State University of New Jersey, and is located inappropriate behaviors. Because of a very
in New Brunswick, New Jersey, on the Rutgers intense staff to student ratio, the Douglass School
campus. The DDDC opened in 1972 to serve has sufficient staff members to address the unique
children with autism. Because of the university needs of each learner. Both skill acquisition and
affiliation, the Rutgers Board of Governors had to behavior reduction programs for all learners
officially approve its establishment. In the begin- regardless of age are based on the science of
ning, there were nine children, two teachers, and applied behavior analysis. Specific strategies
several graduate students as well as a small vary based on the needs of the learner and the
cohort of undergraduates from the university. most current empirically validated and least
intrusive strategies that meet the needs of each
individual. Families are urged to be active in the
Landmark Contributions education of their children and are provided with
training in ABA teaching methods as well as
In the decades since its modest start, the DDDC being invited to do regular observations at the
has steadily expanded its services and refined its Center. In addition to work in the classroom and
mission. The current tripart functions of the at home, every effort is made to bring students
DDDC are to (1) serve people on the autism into the community so they can use their skills in
spectrum and their families, (2) educate the settings where they will be most appropriate.
D 996 Douglass Development Disabilities Center
The DDDC’s Small Wonders Preschool is an provide in-class consultation to teachers who
integrated classroom that has both children on the have children with ASD in their classrooms or
autism spectrum and typically developing peers for support in establishing an in-district applied
who serve as role models for age appropriate behavior analysis program. These consultations
behavior. This classroom model, which was vary from once or twice a month to several days
opened in the early 1980s, has been adopted by a week depending on the needs and request of
other programs in the public and private sector. the school district. Some districts contract for a
Over the years, approximately half of the target brief period and others draw on these consultation
children served in this classroom have left the services for many years to ensure that their
Center for a regular education classroom in teachers continue using state-of-the-art ABA
a public or private school. techniques as those methods evolve.
The adult services program serves adults with Outreach Services also provide two kinds of
autistic disorder and intellectual disability who home-based services. One of these is early inter-
are 21 years of age or older. These adults either vention for children under the age of 3 years and
continue to need a very intense adult to client the other is home-based services on a full-day
ratio and/or have other significant challenges basis or after the child’s school day has ended.
that make it difficult for them to be in a less The early intervention program (EI) serves
specialized adult program. The Center’s objec- infants and toddlers younger than 3 years of age
tive for every person in the adult program is to in their own homes. In addition to direct services
integrate them as fully as possible into the com- to the child by the home consultant, parents are
munity. As of 2011, a little under a quarter of the also taught the ABA intervention techniques
adults spend 5 days a week in community voca- so they can use them in their daily interactions
tional settings, the majority of the other adults with their child. Among the older children who
spend 3–4 days a week in a community voca- receive home-based services about 30% have
tional setting, and it is a rare for an adult client full day/4 or 5 days a week intervention. The
to have no vocational activities outside of the rest of the families receive services after school
Center. These vocational placements include jan- or on a part-time basis during the day. Again,
itorial work at local restaurants, yard work both these services are based on the principles of
on and off of campus, house cleaning, and doing ABA and typically involve direct instruction to
basic clerical work in offices including filing, the child as well as helping parents master the
copying, and other support tasks. In addition, techniques so they can apply the ABA methods
among those adults who are not engaged in on their own.
vocational tasks 5 days a week, all of them take
part in community-based recreational activities. Other Services to Families
The parent of one adult at the center created In addition to educational/treatment services
a private entity called “Men with Mops” that through Douglass Outreach, the DDDC provides
bills private individuals and companies for the assessment and diagnostic services for families
services the adults provide and issues paychecks and schools. This includes diagnostic assess-
to the workers. ments, intelligence testing, speech and language
assessments, and learning evaluations. The
Consultation to Schools and Families Center has a group of full-time staff and part-
In addition to direct service to people with time consultants who do these evaluations and
autism, the Center also provides extensive con- make treatment recommendations. Douglass
sultation services to public and private schools in Outreach Services have an NJ Department of
the New Jersey, New York, and Pennsylvania Education–approved child study team for provid-
area. These services are provided by staff mem- ing second opinions at the request of families
bers working for the DDDC’s Outreach Services. and/or schools. Outreach Services staff members
Schools sign contracts with Outreach Services to also do functional assessments of problematic
Douglass Development Disabilities Center 997 D
behaviors for schools and families and make supporting case management and behavior ana-
detailed treatment recommendations based on lytic research. Advanced doctoral students also
these assessments. support the DDDC’s research mission while
conducting independent theses and dissertations.
Educating Undergraduate and Graduate Graduate students gain experience in teaching
Students by coordinating the undergraduate courses in
Educating undergraduate students about autism and fieldwork and research.
behavioral intervention strategies has been at the Other graduate training at the DDDC takes
core of the DDDC’s mission since its inception. place through the University’s Center for Applied D
Junior and senior undergraduate students at Rutgers Psychology and Continuing Education program.
University can enroll in fieldwork in psychology. Graduate students from other university depart-
Through the field work course, 40–50 undergradu- ments and professionals from the general com-
ates per semester participate in one day per week of munity can enroll in a series of graduate courses
clinical work in a classroom for students or adults taught by DDDC faculty. These courses are
with autism. Their hands-on clinical training is designed to fulfill the academic requirements for
supplemented by didactic training and lectures by becoming board-certified behavior analysts.
the DDDC’s teachers, graduate teaching assistants,
and faculty. Fieldwork training covers topics such The Research Mission of the DDDC
as behavioral intervention, applied behavior analy- The research mission of the DDDC is to explore
sis teaching strategies, assessment, curriculum, and best practice behavior analytic treatments for
characteristics of autism. Undergraduates are able autism and contribute to the dissemination of
to take a second semester of fieldwork and partici- research to support their use. Research activity
pate in an advanced seminar while continuing their at the DDDC is driven by the clinical needs of
clinical experience. clients at the Center and the needs of the general
Undergraduates are also able to enroll in and scientific communities to which we belong.
a research methods class focusing on single- As such, the focus of the DDDC’s clinical
case design and applied behavior analysis research shifts according to the presenting needs
research methodology. A small number of stu- of the students and the status of the science in the
dents enrolled in the research course each semes- field of behavioral autism treatment.
ter spend 10 h per week participating in ongoing The DDDC also works collaboratively with
DDDC research projects and activities such as researchers across different disciplines at the
running experimental sessions, integrity and reli- University and at other University settings, by
ability data collection, literature review and supporting recruitment, methodology consulta-
critique, and data coding and compilation. tion, and providing autism expertise to projects
Students are also active in a weekly seminar led by multidisciplinary research teams.
by a senior graduate student. Current and ongoing research themes in
Graduate training at the DDDC takes place in the DDDC research plan are the evaluation of
one of three ways. Primary graduate training behavior analytic teaching strategies, methods
experiences are available to the full-time doctoral for assessing and intervening with challenging
program in clinical psychology through the Grad- behavior, impact of autism on families, and
uate School in New Brunswick and the Graduate methods for assessing and predicting treatment
School of Applied and Professional Psychology outcome and progress in behavioral treatment.
at Rutgers, the State University of New Jersey.
Graduate students are offered practicum posi-
tions or graduate assistantships at the DDDC. See Also
Graduate students serve as behavioral consulta-
tion staff and support in the assessment and ▶ Applied Behavior Analysis
treatment of challenging behavior, while also ▶ Early Intensive Behavioral Intervention (EIBI)
D 998 Down Syndrome
impression that Down syndrome individuals

Down Syndrome are typically more social than might otherwise
be expected given their cognitive level although
Fred R. Volkmar several case reports suggest that Down syndrome
Director – Child Study Center, Irving B. Harris and autism co-occur. Howlin, Wing, and
Professor of Child Psychiatry, Pediatrics and Gould (1995) described four such cases and
Psychology, School of Medicine, Yale emphasized the importance of correct diagnosis
University, New Haven, CT, USA of both condition to be able to provide appropri-
ate services.
Synonyms
See Also
Down’s syndrome; Trisomy 21
Definition
This condition, first described by Langdon Down

in the 1860s, is caused by the presence of three Dykens, E. M., Shah, B., Sagun, J., Beck, T., &
copies of chromosome 21 (trisomy 21). The King, B. H. (2002). Maladaptive behaviour in children
trisomy can reflect an entire extra copy of and adolescents with Down’s syndrome. Journal of
chromosome 21 or a partial one (the latter due Intellectual Disability Research, 46(Pt. 6), 484–492.
Ghaziuddin, M., Tsai, L. Y., & Ghaziuddin, N. (1992).
to translocation). At one time, a very common
Autism in Down’s syndrome: Presentation and
genetically caused form of intellectual disability, diagnosis. Journal of Intellectual Disability Research,
the frequency has decreased given the potential 36(Pt. 5), 449–456.
for diagnosis early in the pregnancy. Both cogni- Howlin, P., Wing, L., & Gould, J. (1995). The recognition
of autism in children with Down syndrome: Implica-
tive difficulties and characteristic features and
tions for intervention and some speculations about
medical problems are present. pathology. Developmental Medicine and Child
Overall, cognitive level is typically in the mild Neurology, 37(5), 406–414.
to moderate range of impairment (average IQ 50). Kasari, C., Freeman, S. F., Bauminger, N., & Alkin, M. C.
(1999). Parental perspectives on inclusion: Effects of
Individuals with mosaic Downs (where only some
autism and Down. Journal of Autism and Developmen-
cell lines exhibit the trisomy 21) may have higher tal Disorders, 29(4), 297–305.
IQs. Physical problems include slow physical Yirmiya, N., Pilowsky, T., Solomonica-Levi, D., &
growth and characteristic features such as unusual Shulman, C. (1999). Brief report: Gaze behavior and
theory of mind abilities in with autism, down syndrome,
facial appearance (due to a round face, epicanthal
and mental retardation of unknown. Journal of Autism
folds, and small chin, and large tongue). Cardiac and Developmental Disorders, 29(4), 333–341.
defects are frequent. Other medical problems can
include seizures, ear infections, thyroid problems,
as well as leukemia and higher rates of
Alzheimer’s disorder. Educational interventions
Down’s Syndrome
focus on fostering overall development and adap-
tive skills to achieve the highest possible func-
▶ Down Syndrome
tional outcomes in adults.
Interest in Down syndrome relative to autism
arises for several reasons. It has frequently been
the case that individuals with Down syndrome Doxepin
have been used as control or comparison groups
in studies of autism. There has also been an ▶ Sinequan
DSM-III 999 D
a specific theoretical (e.g., psychodynamic) frame-
Draw-a-Person Intellectual Ability work. Developments more broadly in the field (par-
Test for Children, Adolescents, and ticularly at Washington University in St. Louis and
Adults subsequently at Columbia University) led to a focus
on less theoretical and more descriptive definitions
▶ Human Figure Drawing Tests useful for research. This research diagnostic criteria
approach (Spitzer, Endicott, & Robins, 1978)
proved particularly helpful, and the decision was
made for the 3rd edition of DSM to move toward D
DSM-III such an approach as well as greater convergence
with the ICD (Spitzer, Endicott, & Robins, 1978).
Fred R. Volkmar
Professor of Child Psychiatry, Pediatrics and Current Knowledge
University, New Haven, CT, USA Changes were made in DSM-III based on a series
of consideration including issues of reliability and
results of “field trials.” By the time it was
Definition published in 1980, DSM-III included over 260
categories and quickly proved invaluable in
The 3rd edition of the American Psychiatric Asso- transforming research in psychiatry. Although
ciation’s Diagnostic and Statistical Manual (DSM- not without controversy (e.g., around use of
III) appeared in 1980 and proved to be a landmark terms like neurosis and the approach to diagnosis
in the development of psychiatric taxonomy. of sexual orientation problems) for childhood-
onset disorders, DSM-III had several important
advantages. It recognized disorders like autism
Historical Background for the first time (previously the term childhood
schizophrenia was the only “official” diagnosis
Beginning in the 1800s, attempts had begun to be available) based on a series of papers in the
made in categorizing and studying rates of various 1970s demonstrating the unique diagnostic fea-
disorders (including psychiatric disorders) in the tures and course of children with autism (Kolvin,
USA and other countries. For psychiatry, an 1971; Rutter, 1972). Autism was included along
attempt was made to codify a specific approach in with several other disorders in a newly class of
the early 1900s and was subsequently revised. conditions – the pervasive developmental disor-
These early attempts included only a small of cat- ders (PDD). Disorders recognized within this class
egories. However, following World War II, included infantile autism, residual infantile autism
a concern for providing mental health services in (for individuals who once met full criteria for the
a more systematic fashion (and including to the infantile form of the disorder), childhood-onset
many returning veterans) provided a stimulus for pervasive developmental disorder (COPDD) (to
the first edition of DSM. This effort reflected both encompass the rare individuals who developed
a growing awareness of the mental health issues in autism or something very like it after several
the military in the USA as well as the stimulus years of normal development), and a residual
provided by a revision (the 6th edition) of the COPDD category along with a new subthreshold
International Statistical Classification of Diseases condition atypical PDD. The class name pervasive
(ICD) which recognized mental disorders for the developmental disorder was used to refer to what
first time. A second edition was undertaken in the today might more usually be termed autism spec-
1960s, and DSM-II recognized over 180 disorders. trum disorders. The PDD term was meant to con-
Both the first and second editions of DSM adopted vey that a range of functions were impacted,
D 1000 DSM-III
although the term itself was widely debated (e.g., (Rank, 1949; Rank & MacNaughton, 1949).
see Gillberg, 1991; Volkmar & Cohen, 1991b). Another problem arose because of the recognition
Apart from the explicit recognition of autism as that autism was NOT a kind of schizophrenia and
a specific and valid diagnostic category, the DSM- the adoption of an exclusionary rule for autism and
III had several important advantages for childhood schizophrenia; on the other hand, one might rea-
disorders in general including the use of multiple sonably argue that adolescents and adults with
axes of diagnosis (psychiatric, developmental, autism are not necessarily protected from this con-
medical, and psychosocial stressors and overall dition in later life – at rates presumably at least
adaptive functioning). This multiple axial comparable to those of the general population
approach proved especially helpful for child psy- (Volkmar & Cohen, 1991b). Finally the multiaxial
chiatry (Rutter, Shaffer, & Shepherd, 1975). The placement of autism and related disorders was
use of more detailed and specific definitions with- somewhat controversial. Autism and mental retar-
out a specific theoretical bias also enhanced reli- dation (intellectual disabilities) were by conven-
ability. The DSM-III system also had some tion made axis I diagnosis, while the specific
disadvantages for autism. The proposed was developmental disorders were placed on axis II
based largely on Rutter’s modification (Rutter, of the multiaxial system. The problems with
1978) of Kanner’s (1943) original description, but DSM-III were widely recognized, and a major
in the attempt to make this more operational, the revision was undertaken for DSM-III-R (American
monothetic definition adopted focused on what Psychiatric Association, 1980, 1987).
might now be thought of as more prototypical
(“classical”) autism, i.e., more “infantile” autism
(consistent with the name chosen). For example, See Also
the social criterion emphasized a pervasive lack of
social responsiveness. This effectively meant that ▶ DSM-III-R
for many children who developed (to varying ▶ DSM-IV
degrees) greater social skills, the clinician was ▶ DSM-IV Field Trial
technically forced to use the “residual” autism ▶ ICD 10 Research Diagnostic Guidelines
category. A problem with this lack of developmen-
tal orientation was the implicit implication that
somehow their problems were less severe. Simi-
larly, the rationale for COPDD as a category was to References and Readings
account for the small number of children who had
American Psychiatic Association. (1980). Diagnostic and
developed an autistic-like disorder at a somewhat
statistical manual. Washington, DC: APA Press.
later point in early childhood (Kolvin, 1971); American Psychiatric Association. (1987). Diagnostic
COPDD was not, however, meant to be simply and statistical manual. Washington, DC: APA Press.
with Heller’s syndrome (disintegrative psychosis) Gillberg, C. (1991). Debate and argument: Is
autism a pervasive developmental disorder? Journal of
(Heller, 1908, 1930) as it was assumed, probably
incorrectly, that the latter was invariably a result of Heller, T. (1908). Dementia infantilis. Zeitschrift fur die
a general medical/neurological process (see Erforschung und Behandlung des Jugenlichen
Volkmar & Rutter, 1995). Similarly, the term atyp- Schwachsinns, 2, 141–165.
Heller, T. (1930). Uber dementia infantalis. Zeitschrift fur
ical PDD was used as a placeholder for the sub-
Kinderforschung, 37, 661–667.
threshold condition (“autistic like” or now “autism Kanner, L. (1943). Autistic disturbances of affective contact.
spectrum disorder”) for difficulties that appeared to The Nervous Child, 2, 217–250.
be best thought of as occurring within the over- Kolvin, I. (1971). Studies in the childhood psychoses. I.
Diagnostic criteria and classification. The British Journal
arching PDD class but meeting criteria for infantile of Psychiatry, 118(545), 381–384.
autism or COPDD. Unfortunately, this term had its Rank, B. (1949). Adaptation of the psychoanalytic technique
own prior history in that it was suggestive of for the treatment of young children with atypical devel-
Rank’s earlier concept of atypical personality opment. The American Journal of Orthopsychiatry, 19,
DSM-III-R 1001 D
130–139. American Psychological Assn/Educational and her colleagues (e.g., see Wing, 1981) who
Publishing Foundation, US. adopted a somewhat broader diagnostic view of
Rank, B., & MacNaughton, D. (1949). A clinical contri-
bution to early ego development. In A. Freud, H. the concept. This revision also put much greater
Hartmann, et al. (Eds.), The psychoanalytic study of weight on developmental changes discarding the
the child (Vol. 3/4, pp. 53–65). Oxford: International earlier concept of “residual” infantile autism and
Universities Press. replacing it with a single category with criteria
Journal of Autism and Childhood Schizophrenia, 2(4), applicable to the entire range of functioning over
315–337. age and developmental level. Consistent with the
Rutter, M. (1978). Diagnosis and definition of childhood previous definition, the three major domains of D
autism. Journal of Autism and Childhood Schizophrenia, dysfunction (social, communicative, and restricted
8(2), 139–161.
Rutter, M., Shaffer, D., & Shepherd, M. (1975). A multi- interests/behaviors) were included, although early
axial classification of child psychiatric disorders: An age of onset was no longer required. Final scoring
evaluation of a proposal. Albany, NY: World Health rules were developed based on a field trial (Spitzer
Organization. & Siegel, 1990) with 16 criteria; a diagnosis of
Spitzer, R. L., Endicott, J. E., & Robins, E. (1978). Research
diagnostic criteria. Archives of General Psychiatry, 35, autism required that an individual exhibited at
773–782. least 8 of these features (with a specified distribu-
Volkmar, F. R., & Cohen, D. J. (1991a). Comorbid asso- tion over the three areas). The problematic earlier
ciation of autism and schizophrenia. The American concept of childhood-onset pervasive develop-
Journal of Psychiatry, 148(12), 1705–1707.
Volkmar, F. R., & Cohen, D. J. (1991b). Debate and mental disorder (COPDD) was dropped, and
argument: The utility of the term pervasive develop- throughout the manual, the earlier term “atypical”
mental disorder. Journal of Child Psychology and was replaced with “not otherwise specified” (in
Psychiatry, 32(7), 1171–1172. large part because of the potential confusion with
Volkmar, F. R., & Rutter, M. (1995). Childhood disinte-
grative disorder: Results of the DSM-IV autism field an earlier diagnostic concept – atypical personality
trial. Journal of the American Academy of Child and development; see (Volkmar & Klin, 2005)).
Adolescent Psychiatry, 34(8), 1092–1095. The greater developmental orientation of the
approach was welcomed but also appeared to
come at a price. Several reports suggested high
rates of false positives – particularly relative to
DSM-III-R more intellectually disabled individuals; this led
to an apparent overdiagnosis of autism in more
Fred R. Volkmar intellectually handicapped individuals while
Director – Child Study Center, Irving B. Harris also diverting attention from more cognitively
Professor of Child Psychiatry, Pediatrics and able persons. Additional problems included
Psychology, School of Medicine, Yale a complex and detailed criteria set with inclusion
University, New Haven, CT, USA of examples within criteria (thus tending to
“reify” the examples as features that should be
present). The changes introduced complicated
Definition interpretation of previous research and were par-
ticularly acute relative to pending changes in the
The successor to DSM-III (appearing in 1987) ICD (see Volkmar & Klin, 2005; Volkmar,
work on this edition began shortly after DSM-III Cicchetti, Bregman, & Cohen, 1992).
(1980) had appeared. Originally viewed as
a small-scale revision, major changes were made
in several categories including autism and related See Also
conditions (see Waterhouse, Wing, Spitzer, &
Siegel, 1993). The definition of autistic disorder ▶ DSM-III
(name changed from infantile autism in DSM-III) ▶ False Positive
was more consistent with the views of Lorna Wing ▶ ICD 10 Research Diagnostic Guidelines
D 1002 DSM-IV
References and Readings Historical Background
American Psychiatric Association. (1987). Diagnostic Preparations for the fourth edition of DSM began
and statistical manual (3rd revised ed.). Washington,
shortly after DSM-III-R (APA, 1987) due, in part, to
DC: APA Press.
Spitzer, R. L., & Siegel, B. (1990). The DSM-III-R field the pending revision of ICD-10, and this edition
trial of pervasive developmental disorders. J Am Acad appeared partly due to the pending changes in the
Child Adolesc Psychiatry, 29(6), 855–862. ICD-10. The intention was to base the revision on
Volkmar, F. R., Cicchetti, D. V., Bregman, J., & Cohen,
research and with consideration of relevant issues
D. J. (1992). Three diagnostic systems for autism:
DSM-III, DSM-III-R, and ICD-10. Journal of Autism such as clinical utility, reliability, and descriptive
& Developmental Disorders, 22(4), 483–492. validity of categories and the issue of coordination
Volkmar, F. R., & Klin, A. (2005). Issues in the with ICD-10 (WHO, 1994). As part of this process,
classification of autism and related conditions. In
a series of literature reviews were conducted with
F. R. Volkmar, A. Klin, R. Paul, & D. J. Cohen
(Eds.), Handbook of autism and pervasive develop- emphasis on categories “new” to DSM. On balance,
mental disorders (Vol. 1, pp. 5–41). Hoboken, NJ: these reviews suggested the potential usefulness of
Wiley. including categories in addition to autism within the
Waterhouse, L., Wing, L., Spitzer, R., & Siegel, B. (1993).
overarching pervasive developmental disorder
Diagnosis by DSM-III–R versus ICD-10 criteria. Jour-
nal of Autism & Developmental Disorders, 23(3), (PDD) group (see Volkmar and Klin (2005)) and
572–573. also supported the desire for compatibility with
Wing, L. (1981). Language, social, and cognitive impair- ICD-10. As part of this process, a series of data
ments in autism and severe mental retardation. Jour-
reanalyses that were undertaken focused on autism,
nal of Autism & Developmental Disorders, 11(1),
31–44. and these suggested the DSM-III-R definition to be
overly broad (Volkmar, Cicchetti, Cohen, &
Bregman, 1992). Other issues identified included
the inclusion (or not) of early age of onset as an
essential feature and the variability of sensitivity/
DSM-IV specificity in relation to IQ and other variables, and
to address these concerns, a large, international field
Fred R. Volkmar trial was undertaken in conjunction with ICD-10.
Psychology, School of Medicine, Yale Current Knowledge
The DSM-IV Field Trial
The final DSM-IV definition was based on the
Definition results of the DSM-IV field trial which included
21 sites from around the world, over 100 raters, and
The fourth edition of the American Psychiatric nearly 1,000 cases (Volkmar et al., 1994). Cases
Association’s Diagnostic and Statistical Manual were sometimes rated more than once (for reliabil-
was published in 1994 with a subsequent text ity) and other issues (e.g., rater experience) were
revision published in 2000. The publication of addressed. In general, cases were rated as seen over
DSM-IV followed several years of preparation. the course of a year but with some supplementation
For autism and related disorders, the definitions of previously seen cases for certain issues (e.g.,
proposed were, for the first time, convergent with children with “late-onset” autism). Cases could be
the International Classification of Diseases 10th included if the clinician believed autism to reason-
edition (CD-10). The fourth edition marked some ably be part of the differential diagnosis. Multiple
important changes from its predecessors while sources of information (assessment, history) were
maintaining much in the way of historical available to the raters who judged the quality of
continuity. data available to them good or excellent about 75%
DSM-IV 1003 D
DSM-IV, Table 1 ICD-10 criteria for autism and related pervasive developmental disorders
Childhood autism (F84.0)
A. Abnormal or impaired development is evident before (1) Receptive or expressive language as used in social
the age of 3 years in at least one of the following areas: communication
(2) The development of selective social attachments or of
reciprocal social interaction
(3) Functional or symbolic play
B. A total of at least six symptoms from (1), (2), and (1) Qualitative impairments in social interaction are
(3) must be present, with at least two from (1) and at least manifest in at least two of the following areas: D
one from each of (2) and (3) (a) Failure adequately to use eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social
interaction
(b) Failure to develop (in a manner appropriate to mental
age, and despite ample opportunities) peer relationships that
involve a mutual sharing of interests, activities, and emotions
(c) Lack of socio-emotional reciprocity as shown by an
impaired or deviant response to other people’s emotions; or
lack of modulation of behavior according to social context;
or a weak integration of social, emotional, and
communicative behaviors
(d) Lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people (e.g., a lack of
showing, bringing, or pointing out to other people objects
of interest to the individual)
(2) Qualitative abnormalities communication as manifest
in at least one of the following areas:
(a) Delay in or total lack of development of spoken
language that is not accompanied by an attempt to
compensate through the use of gestures or mime as an
alternative mode of communication (often preceded by
a lack of communicative babbling)
(b) Relative failure to initiate or sustain conversational
interchange (at whatever level of language skill is present),
in which there is reciprocal responsiveness to the
communications of the other person
(c) Stereotyped and repetitive use of language or
idiosyncratic use of words or phrases
(d) Lack of varied spontaneous make-believe play or
(when young) social imitative play
(3) Restricted, repetitive, and stereotyped patterns of
behavior, interests, and activities are manifested in at least
one of the following:
(a) An encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that are
abnormal in content or focus, or one or more interests that
are abnormal in their intensity and circumscribed nature
though not in their content or focus
(b) Apparently compulsive adherence to specific,
nonfunctional routines or rituals
(c) Stereotyped and repetitive motor mannerisms that
involve either hand or finger flapping or twisting or
complex whole-body movements
(d) Preoccupations with part objects or nonfunctional
elements of play materials (such as their odor, the feel of
their surface, or the noise or vibration they generate)
(continued)
D 1004 DSM-IV
DSM-IV, Table 1 (continued)

C. The clinical picture is not attributable to the other
varieties of pervasive developmental disorders; specific
development disorder of receptive language (F80.2) with
secondary socio-emotional problems’ reactive attachment
disorder (F94.1) or disinhibited attachment disorder
(F94.2); mental retardation (F70-F72) with some
associated emotional or behavioral disorders;
schizophrenia (F20) of unusually early onset; and Rett’s
syndrome (F84.12)
F84.1 Atypical autism
A pervasive developmental disorder that differs from
autism in terms either of age of onset or of failure to fulfill
all three sets of diagnostic criteria. Thus, abnormal and/or
impaired development becomes manifest for the first time
only after age 3 years and/or there are insufficient
demonstrable abnormalities in one or two of the three areas
of psychopathology required for the diagnosis of autism
(namely, reciprocal social interactions, communication,
and restrictive, stereotyped, repetitive behavior) in spite of
characteristic abnormalities in the other area(s). Atypical
autism arises most often in profoundly retarded individuals
whose very low level of functioning provides little scope
for exhibition of the specific deviant behaviors required for
the diagnosis of autism; it also occurs in individuals with
a severe specific developmental disorder of receptive
language. Atypical autism thus constitutes a meaningfully
separate condition from autism and includes:
• Atypical childhood psychosis
• Mental retardation with autistic features
F84.1 Atypical autism A. Abnormal or impaired development is evident at or after
the age of 3 years (criteria as for autism except for age of
manifestation)
B. There are qualitative abnormalities in reciprocal social
interaction or in communication, or restricted, repetitive, and
stereotyped patterns of behavior, interests, and activities.
(Criteria as for autism except that it is unnecessary to meet the
criteria for number of areas of abnormality)
C. The disorder does not meet the diagnostic criteria for
autism (F84.0). Autism may be atypical in either age of
onset (F84.10) or symptomatology (F84.11); the two types
are differentiated with a fifth character for research
purposes. Syndromes that are typical in both respects
should be coded F84.12
F84.10 Atypicality in age of onset A. The disorder does not meet criterion A for autism
(F84.0); that is, abnormal or impaired development is
evident only at or after age 3 years
B. The disorder meets criteria B and C for autism (F84.0)
F84.11 Atypicality in symptomatology A. The disorder meets criterion A for autism (F84.0); that is,
abnormal or impaired development is evident before age 3 years
interactions or in communication, or restricted, repetitive,
and stereotyped patterns of behavior, interests, and
activities. (Criteria as for autism except that it is
unnecessary to meet the criteria for number of areas of
abnormality.)
(continued)
DSM-IV 1005 D
DSM-IV, Table 1 (continued)
C. The disorder meets criterion C for autism (F84.0)
D. The disorder does not fully meet criterion B for autism
(F84.0)
F84.12 Atypicality in both age of onset and A. The disorder does not meet criterion A for autism
symptomatology (F84.0); that is, abnormal or impaired development is
evident only at or after age 3 years
interactions or in communication, or restricted, repetitive, D
and stereotyped patterns of behavior, interests, and
activities. (Criteria as for autism except that it is
unnecessary to meet the criteria for number of areas of
abnormality)
C. The disorder meets criterion C for autism (F84.0)
D. The disorder does not fully meet criterion B for autism
(F84.0)
Source: World Health Organization (2003). Diagnostic Descriptions and Criteria for Autism and Related Pervasive
Developmental Disorders from International Classification of Diseases, 10th Edition. Geneva, Switzerland: WHO
of the time. A standard coding system was used with a series of data analyses that confirmed the
with information on the case and rater as well as importance of social features). At least one feature
ratings of various diagnostic criteria. The DSM-III must be present from the other two groups
approach was noted to be developmentally less (impaired communication/play and restricted inter-
sensitive than DSM-III-R, although that system ests). Onset before age 3 was also specified.
appeared to overdiagnose autism in individuals The inclusion of various condition as well as
with more severe intellectual handicap (i.e., relative autism and “subthreshold autism” was a major
to clinician judgment). The ICD-10 draft approach change from DSM-III-R. Although the substan-
appeared more reasonable although overly detailed. tive work on these other conditions was less
Reliability of criteria was generally good with clin- advanced than that for autism, there appeared to
ical diagnosis also noted to have excellent reliabil- be sufficient data for their inclusion; this further
ity for more experienced clinicians (Klin, Lang, enhanced compatibility with ICD-10. Conver-
Cicchetti, & Volkmar, 2000). A series of analyses gence of the final ICD-10 and DSM-IV defini-
suggested that a modification of the draft ICD-10 tions of autism represented a major shift (i.e.,
approach could be adopted with reasonable sensi- with the same system being used around the
tivity and specificity and good coverage over the world) and facilitated subsequent research and
IQ range. clinical work as reflected, in part, in the explosion
Although not primarily focused on disorders of work in the area over the subsequent decade.
other than autism, the field trial also provided These criteria are provided in Table 1.
data regarding the inclusion and definition of
Asperger’s disorder, Rett’s disorder, and child-
hood disintegrative disorder. The final DSM-IV Future Directions
definition had good sensitivity and specificity
over the IQ range. Diagnostic criteria adopted At the time of this writing, preparation for DSM-
were essentially the same as in ICD-10 (see V was underway with the two major preliminary
Table 1). At least six criteria had to be rated posi- proposals suggesting a change of the class of
tive for a diagnosis of autism with at least two of disorder to autism spectrum disorder and collaps-
these from the “social” category (this was consis- ing the various disorders currently listed in DSM-
tent with Kenner’s original view of autism and also IV within one overarching disorder type.
D 1006 DSM-IV Field Trial
See Also research. In contrast to previous DSM definitions

of autism, this effort was done in conjunction
▶ DSM-III with the ICD-10 revision 21 sites and 125 raters
▶ DSM-III-R participated from around the world.
▶ ICD 10 Research Diagnostic Guidelines
The DSM-IV field trial arose as a result of con-
American Psychiatric Association. (1987). Diagnostic cerns about the definition of autism adopted in
and statistical manual. Washington, DC: APA Press. DSM-III and DSM-III-R. For the latter definition,
Klin, A., Lang, J., Cicchetti, D. V., & Volkmar, F. R.
a small field trial had been conducted but suffered
(2000). Brief report: Interrater reliability of clinical
diagnosis and DSM-IV. Journal of Autism & Develop- from some deficiencies. Several published papers
mental Disorders, 30(2), 163–167. suggested that while the DSM-III-R definition
Volkmar, F. R., Cicchetti, D. V., Cohen, D. J., & Bregman, J. was more developmental in nature, it also
(1992). Brief report: Developmental aspects of
appeared to be more likely to give an autism
DSM-III–R criteria for autism. Journal of Autism &
Developmental Disorders, 22(4), 657–662. diagnosis to individuals with greater levels of
Volkmar, F. R., & Klin, A. (2005). Issues in the classifi- intellectual disability.
cation of autism and related conditions. In F. R.
Volkmar, A. Klin, R. Paul, & D. J. Cohen (Eds.),
orders (Vol. 1, pp. 5–41). Hoboken, NJ: Wiley. Current Knowledge
Volkmar, F. R., Klin, A., Siegel, B., Szatmari, P., Lord, C.,
Campbell, M., et al. (1994). Field trial for autistic This field trial followed a period of considerable
disorder in DSM-IV. American Journal of Psychiatry,
work including targeted literature reviews and
151(9), 1361–1367.
World Health Organization. (1994). Diagnostic criteria data reanalyses (e.g., Frances, Davis, Kline,
for research. Geneva: Author. Pincus, First & Widiger, 1991; Mayes, Volkmar,
World Health Organization. (2003). Diagnostic descrip- Hooks, & Cicchetti, 1993; Szatmari, 1991,
tions and criteria for autism and related pervasive
1992a, b; Tsai, 1992; Volkmar, 1991, 1992;
developmental disorders from international classifica-
tion of diseases (10th ed.). Geneva: Author. Volkmar, Cicchetti, Bregman, & Cohen, 1992;
Volkmar, Cicchetti, Cohen, & Bregman, 1992).
As part of the field trial, 21 sites and 125 raters
participated. Each site had some clinical program
DSM-IV Field Trial for individuals with autism and raters with
a range of experience and professional back-
Fred R. Volkmar grounds; about half the rates report relatively
Director – Child Study Center, Irving B. Harris extensive experience allowing for comparison
Professor of Child Psychiatry, Pediatrics and of issues of reliability and clinical utility in both
Psychology, School of Medicine, more and less experienced clinicians. Over the
Yale University, New Haven, CT, USA course of a year, nearly 1,000 cases were submit-
ted (with about 10% of cases rated by more than
one evaluator). In general, the preference was
Definition that bases currently being seen be provided (i.e.,
rather than ratings based on past experience),
The DSM-IV field trial for autism (Volkmar and by design, five of the participating sites con-
et al., 1994) was an international effort with the tributed about 100 consecutive cases. To be
goal of establishing a definition with a reasonable included, the case had to exhibit difficulties in
balance of sensitivity and specificity that could which autism was a reasonable part of the differ-
be used to facilitate both clinical work and ential diagnosis. Smaller groups of cases were
DSM-IV Field Trial 1007 D
specifically solicited to identify potential gaps DSM-IV Field Trial, Table 1 DSM-IV autistic disorder
relative to much less frequent conditions (e.g., field trial group characteristics*
Rett’s and childhood disintegrative disorders). Clinically
However, consecutive cases constituted the bulk autistic Other PDDs Non-PDD
(N ¼ 454) (N ¼ 240) (N ¼ 283)
of the sample. Typically multiple sources of
Sex ratio 4.49:1 3.71:1 2.29:1
information were available (e.g., parents, past (M:F)
records, as well as current assessment) and raters % Mute 54% 35% 33%
indicated that in the majority (75%) of cases, the
information available was good or excellent.
Age 8.99 9.68 9.72
D
IQ 58.1 77.2 66.9
A standard system of coding was created for Note: Cases grouped by clinical diagnosis
each deidentified case rating including informa- Diagnoses of the “other PDD”cases included: Rett
tion on the individual being examined (age, IQ, syndrome (13 cases), childhood disintegrative disorder
communicative ability, educational placement), (16 cases), Asperger syndrome (48 cases), PDD-NOS
(116 cases) and atypical autism (47 cases).
basic information on the evaluator(s), and Diagnoses of the non-PDD cases included mental retarda-
explicit ratings of diagnostic criteria both from tion (132 cases), language disorder (88 cases), childhood
previous (DSM-III, III-R) and potential new schizophrenia (9 cases), other disorders (54 cases).
criteria. The evaluator was also asked to provide Adapted from Volkmar et al. (1994). Reprinted from
Volkmar et al. Issues in classification, Chapter in
his/her best judgment of clinical diagnosis – the F. Volkmar, A. Klin, R. Paul, & D. Cohen (Eds.),
latter serving as the “gold standard” against Handbook of autism and pervasive developmental
which comparisons would then be made. disorders, Vol I, page.
The rating form also provided possible criteria
for Asperger’s syndrome, Rett’s syndrome, and
childhood disintegrative disorder, based on the whereas the DSM-III-R erred on the site of over-
draft ICD-10 definitions. diagnosis of autism associated with more severe
Sample information is presented in Table 1. intellectual deficiency. An explicit goal for the
Clinicians’ primary diagnosis of the “nonautistic” development of a final criteria set was that the
PDD cases included Rett’s syndrome (13 cases), final criteria for autistic disorder should work
childhood disintegrative disorder (16 cases), reasonably well over the entire range of IQ. A
Asperger’s syndrome (48 cases), and PDD-NOS result more consistent with the much more
(116 cases) or atypical autism (47 cases) (the latter detailed ICD-10 (research) draft definition.
group was included as possible clinical diagnosis These results are presented in Table 2.
given the ICD-10 draft inclusion of such a category In looking at other sources of diagnostic dis-
which, essentially, referred to “subthreshold” agreement, it appeared that DSM-III-R’s failure
autism or autism that was atypical in somewhat – to include age of onset as an essential feature
cases that in US terminology would have been said contributed to its difficulties, while, on the other
to have PDD-NOS). In comparison (nomad), cases hand, its great developmental orientation and
with primary clinical diagnoses included mental flexibility appeared to be a plus. Indeed, if onset
retardation (N ¼ 132), language disorder (N ¼ 88 of the condition by age 3 years was included as an
cases), schizophrenia of childhood onset (N ¼ 9), essential feature, the sensitivity of that system
and other or mixed developmental disorders was increased.
(N ¼ 54). The available data also allowed for examina-
A series of cases were addressed in a range of tion of clinician agreement on diagnosis based on
different analyses, and in addition to the main various factors including clinician experience.
report of the field trial (Volkmar et al., 1994), Using chance-corrected statistics, the inter-rater
many of these analyses were published in their reliability of individual diagnostic criteria was
own right. Consistent with previous reports, it examined and in the good to excellent range.
appeared that the DSM-III approach was insuffi- Typically more detailed criteria had greater
ciently developmental and overly stringent, reliability. More experienced raters also had
D 1008 DSM-IV Field Trial
DSM-IV Field Trial, Table 2 Sensitivity/Specificity by for more detailed coding of the “atypicality” of
IQ Level – a comparison of DSM-IIIa DSM-III-R ICD-10b the presentation, e.g., failing to meet age or spe-
Overall Se Sp Se Sp Se Sp cific criteria cutoffs, while DSM-IV adopted
0.82 0.8 0.86 83 0.79 89 a broader view of this as a “subthreshold” cate-
By IQ Level N Se Sp Se Sp Se Sp gory that, today, would be equated with autism
<25 64 .90 .76 .84 .39 .74 .88 spectrum disorder.
25–39 148 .88 .76 .90 .60 .88 .92 The field trial data suggested that age of onset
40–54 191 .79 .76 .93 .74 .84 .83 as an additional feature would have strengthened
55–69 167 .86 .78 .84 .77 .78 .89 the DSM-III-R definition. A series of alternatives
70–85 152 .79 .81 .88 .81 .74 .96
were considered, and in the end, a final definition
>85 218 .78 .83 .78 .78 .78 .91
was developed in coordination with IDD-10
Table adapted, with permission, from Volkmar et al. (see Appendix). This definition balanced clinical
(1994) Field Trial for Autistic Disorder in DSM-IV.
American Journal of Psychiatry, 151, 1361–1367. and research needs, was reasonably concise, user
Reprinted from Volkmar et al. Issues in classification, friendly, and had good coverage over both age
Chapter. In F. Volkmar, A. Klin, R. Paul, & D. Cohen and developmental level.
(Eds.), Handbook of autism and pervasive developmental Several changes in proposal for other catego-
disorders. Vol I, page.
a
“Lifetime” diagnosis (current IA or “residual” IA) ries (notably Asperger’s disorder and PDD-NOS)
b
Original ICD-10 criteria and scoring were made in the final stages of the DSM process;
these have raised other issues of concern to the
field (e.g., see Buitelaar, Van der Gaag, Klin, &
excellent reliability both on the broader autism Volkmar, 1999; Miller & Ozonoff, 1997).
spectrum and narrower autistic disorder diagno- Some of these concerns were addressed in the
ses; this was much less true for inexperienced DSM-IV text revision, which appeared in 2000;
raters (see Klin, Lang, Cicchetti, & Volkmar, for Asperger’s disorder, the text was very exten-
2000). In addition to inter-rater reliability, sively revised, although no changes in the formal
temporal stability was examined in a small num- criteria were made.
ber of cases and generally high; diagnosis stabil-
ity was more problematic for very young
children, those with lower IQ, and with the Appendix
DSM-III-R system.
Before a final decision could be made about ICD-10 Research Criteria*. Source: Diagnostic
the definition of autistic disorder in DSM-IV, descriptions and criteria for autism and related
it was important to decide whether other disor- pervasive developmental disorders from interna-
ders would be included in the PDD class (see tional classification of diseases, 10th Edition
Szatmari, 1992a, b; Tsai, 1992; Volkmar, 1992; (World Health Organization, Geneva, Switzer-
Volkmar, Cicchetti, Bregman, & Cohen, 1992). land, 2003).
While these disorders were not a primary focus of
the field trial, some data relevant to their inclu- Pervasive developmental disorders
sion had been collected. Data from the field trial A group of disorders characterized by qualitative
abnormalities in reciprocal social interactions and
supported the inclusion of these conditions in patterns of communication, and by a restricted,
(Asperger’s disorder, Rett’s disorder, and child- stereotyped, repetitive repertoire of interests and
hood disintegrative disorder), and their inclusion activities. These qualitative abnormalities are
had some advantages relative to compatibility a pervasive feature of the individual’s functioning
in all situations.
with ICD-10 and for deriving a better diagnostic
Use additional code, if desired, to identify any
approach for autistic disorder. One area of differ- associated medical condition and mental
ence between ICD-10 and DSM-IV was left retardation.
unresolved; this had to do with the concept of F84.0 Childhood autism
atypical autism vs. PDD-NOS. ICD-10 allowed (continued)
DSM-IV Field Trial 1009 D
A type of pervasive developmental disorder that is development before the onset of the disorder,
defined by: (a) the presence of abnormal or followed by a definite loss of previously acquired
impaired development that is manifest before the skills in several areas of development over the
age of 3 years, and (b) the characteristic type of course of a few months. Typically, this is
abnormal functioning in all the three areas of accompanied by a general loss of interest in the
psychopathology: reciprocal social interaction, environment, by stereotyped, repetitive motor
communication, and restricted, stereotyped, mannerisms, and by autistic-like abnormalities in
repetitive behavior. In addition to these specific social interaction and communication. In some
diagnostic features, a range of other nonspecific cases the disorder can be shown to be due to some
problems are common, such as phobias, sleeping associated encephalopathy but the diagnosis D
and eating disturbances, temper tantrums, and should be made on the behavioral features.
(self-directed) aggression. Dementia infantilis
Autistic disorder Disintegrative psychosis
Infantile: Heller’s syndrome
Autism Symbiotic psychosis
Psychosis Use additional code, if desired, to identify any
Kanner’s syndrome associated neurological condition.
Excludes: Autistic psychopathy (F84.5) Excludes: Rett’s syndrome (F84.2)
F84.1 Atypical autism F84.4 Overactive disorder associated with mental
A type of pervasive developmental disorder that retardation and stereotyped movements
differs from childhood autism either in age of onset An ill-defined disorder of uncertain nosological
or in failing to fulfil all three sets of diagnostic validity. The category is designed to include
criteria. This subcategory should be used when there a group of children with severe mental retardation
is abnormal and impaired development that is (IQ below 35) who show major problems in
present only after age 3 years, and a lack of sufficient hyperactivity and in attention, as well as
demonstrable abnormalities in one or two of the three stereotyped behaviors. They tend not to benefit
areas of psychopathology required for the diagnosis from stimulant drugs (unlike those with an IQ in
of autism (namely, reciprocal social interactions, the normal range) and may exhibit a severe
communication, and restricted, stereotyped, dysphoric reaction (sometimes with psychomotor
repetitive behavior) in spite of characteristic retardation) when given stimulants. In
abnormalities in the other area(s). Atypical autism adolescence, the overactivity tends to be replaced
arises most often in profoundly retarded individuals by underactivity (a pattern that is not usual in
and in individuals with a severe specific hyperkinetic children with normal intelligence).
developmental disorder of receptive language. This syndrome is also often associated with
Atypical childhood psychosis a variety of developmental delays, either specific
Mental retardation with autistic features or global. The extent to which the behavioral
Use additional code (F70-F79), if desired, to pattern is a function of low IQ or of organic brain
identify mental retardation. damage is not known.
F84.2 Rett’s syndrome F84.5 Asperger’s syndrome
A condition, so far found only in girls, in which A disorder of uncertain nosological validity,
apparently normal early development is followed characterized by the same type of qualitative
by partial or complete loss of speech and of skills abnormalities of reciprocal social interaction that
in locomotion and use of hands, together with typify autism, together with a restricted,
deceleration in head growth, usually with an onset stereotyped, repetitive repertoire of interests and
between seven and 24 months of age. Loss of activities. It differs from autism primarily in the
purposive hand movements, hand-wringing fact that there is no general delay or retardation in
stereotypies, and hyperventilation are language or in cognitive development. This
characteristic. Social and play development are disorder is often associated with marked
arrested but social interest tends to be maintained. clumsiness. There is a strong tendency for the
Trunk ataxia and apraxia start to develop by age 4 abnormalities to persist into adolescence and adult
years and choreoathetoid movements frequently life. Psychotic episodes occasionally occur in
follow. Severe mental retardation almost early adult life.
invariably results. Autistic psychopathy
F84.3 Other childhood disintegrative disorder Schizoid disorder of childhood
A type of pervasive developmental disorder that is F84.8 Other pervasive developmental disorders
defined by a period of entirely normal F84.9 Pervasive developmental disorder, unspecified
(continued)
D 1010 Due Process
See Also DSM-III-R criteria for autism. Journal of Autism and

Volkmar, F. R., Klin, A., Siegel, B., Szatmari, P., Lord, C.,
▶ Asperger’s disorder Campbell, M., et al. (1994). Field trial for autistic
▶ Autistic Disorder disorder in DSM-IV. The American Journal of
▶ Childhood Disintegrative Disorder Psychiatry, 151(9), 1361–1367.
▶ DSM-IV
▶ Rett’s Disorder
References and Readings Due Process
Buitelaar, J. K., Van der Gaag, R., Klin, A., & Volkmar, F. Kristin Ruedel
(1999). Exploring the boundaries of pervasive devel- Department of Special Education, University of
opmental disorder not otherwise specified: Analyses of Maryland Washington State University,
data from the DSM-IV autistic field trial. Journal of
Richland, WA, USA
Frances, A., Davis, W. W., Kline, M., Pincus, H., First, M.,
& Widiger, T. (1991). The DSM-IV field trials:
Moving towards an empirically derived classification. Definition
European Psychiatry, 6(6), 307–314.
Klin, A., Lang, J., Cicchetti, D. V., & Volkmar, F. R.
(2000). Brief report: Interrater reliability of clinical The due process hearing and other procedural
diagnosis and DSM-IV criteria for autistic disorder: safeguards provide a system of checks and bal-
results of the DSM-IV autism field trial. Journal of ances for schools and parents. The due process
Mayes, L., Volkmar, F. R., Hooks, M., & Cicchetti, D. V.
principle essentially aims to ensure that schools
(1993). Differentiating pervasive developmental and parents are held accountable to each other
disorder not otherwise specified from autism and lan- for carrying out the student’s rights as outlined
guage disorders. Journal of Autism and Developmental in the Individuals with Disabilities Education Act
Disorders, 23(1), 79–90.
Miller, J. N., & Ozonoff, S. (1997). Did asperger’s cases
(IDEA). A due process hearing may be requested
have asperger disorder? A research note. Journal of by the parents or the school district if they are in
Child Psychology and Psychiatry, 38(2), 247–251. disagreement about any of the following: identi-
Szatmari, P. (1991). Asperger’s syndrome: Diagnosis, fication, evaluation, placement, the IEP docu-
treatment, and outcome. The Psychiatric Clinics of
ment, or the provision of a free and appropriate
Szatmari, P. (1992a). A review of the DSM-III-R criteria education (FAPE) to a child.
for autistic disorder. Journal of Autism and A due process complaint must be filed in writ-
Developmental Disorders, 22(4), 507–523. ten form and must contain the following specific
Szatmari, P. (1992b). The validity of autistic spectrum
disorders: A literature review. Journal of Autism and
information: the name of the child, the address of
Developmental Disorders, 22(4), 583–600. the residence of the child, the name of the school
Tsai, L. (1992). Is Rett syndrome a subtype of pervasive the child is attending, a description of the nature
developmental disorder? Journal of Autism and of the child’s problem related to the proposed
Volkmar, F. R. (1991). DSM-IV in progress. Autism and
action, a statement of how requirements of part
the pervasive developmental disorders. Hospital & B of IDEA or its implementing regulations have
Community Psychiatry, 42(1), 33–35. been violated, the facts upon which the statement
Volkmar, F. R. (1992). Childhood disintegrative disorder: is based, and a proposed resolution of the prob-
Issues for DSM-IV. Journal of Autism and
lem. A copy of the due process complaint must be
Volkmar, F. R., Cicchetti, D. V., Bregman, J., & provided to the other party, and a copy must be
Cohen, D. J. (1992). Three diagnostic systems for forwarded to the state educational agency.
autism: DSM-III, DSM-III-R, and ICD-10. Journal of A due process hearing is like a mini-trial
Volkmar, F. R., Cicchetti, D. V., Cohen, D. J., & Bregman,
before an impartial, third-party, hearing officer
J. (1992). Brief report: Developmental aspects of and is similar to a regular courtroom trial. The
Due Process 1011 D
hearing officer is responsible for listening to both to seek a review of any decisions they think
sides of the dispute, examining all related issues, are appropriate. The procedural safeguards are
and settling the dispute. Parents have the right to grounded in the 5th and the 14th Amendments
be accompanied or advised by counsel, present of the US Constitution, which guarantee that
evidence, cross-examine witnesses, and see the no person shall be deprived of life, liberty, or
evidence presented by the school district 5 days property without due process of the law.
prior to the hearing. Parents also have the right to
have the child present at the due process hearing,
but it is not required. Only a small number of Current Knowledge D
disagreements between parents and schools result
in parents filing a due process petition. Even The recent 2004 amendments to IDEA empha-
fewer cases actually proceed to a hearing. If sized the importance for parents and school
either the parent or the school district is dissatis- districts to resolve disputes collaboratively and
fied with the outcome of the hearing, they have quickly. IDEA encourages parents and schools to
the right to appeal the decision to state or federal utilize alternative methods for resolving their dis-
courts. pute prior to proceeding to a due process hearing.
The school district is responsible for schedul- First, the IDEA recommends resolution and then
ing a resolution or mediation meeting with the mediation as methods for resolving agreements
parents within 15 days of receiving a due process prior to proceeding to a due process hearing.
complaint. Under the IDEA provisions, the Under the current 2004 amendments to IDEA,
school district and parents have 30 days from parents and school districts have up to 2 years to
the date that the due process complaint was filed file a due process complaint. Exceptions to the
to reach an agreement through the process of 2-year timeline may apply if the parent was
resolution or mediation. If the parties are not prevented from filing the due process complaint
able to reach an agreement by the end of these due to misrepresentations by the school district or
30 days, then a due process hearing must be held if the school district withheld information that
and final decision issued within the next 45 was required to be provided to the parent under
calendar days. In some cases, the parents or the statutes and regulations of IDEA. States do
the school district may choose to expedite the have the right to change the 2-year timeline as
due process hearing. If this is the case, then they desire. If a state decides to shorten or
a due process hearing must be conducted within lengthen the timeline, this information must be
20 school days after receiving the due process included and explained in the procedural safe-
complaint and the decision must be issued within guards notice that the school district is required
10 school days after the hearing. to provide to parents so that parents are fully
informed of the timeline limitations within their
individual state.
Historical Background Key changes implemented under the amend-
ments to the IDEA 2004 statutes and regulations
The due process provision has been a part of include the following:
IDEA since its inception. Under the procedural 1. Notification: Parents and/or school districts fil-
safeguards provision in IDEA, parents and school ing a due process complaint must provide
districts have the right to a due process hearing notice to the other party as well as the state
and the rights that go along with those hearings. educational agency. Further, school districts
Procedural safeguards are the protections in are required to provide parents with notice of
IDEA that ensure that students with disabilities their procedural safeguards and information
and their parents or guardians are meaningfully about free or low-cost legal services in the area.
involved in all decisions related to the student’s 2. Specific timelines for responding to a due
special education and that they have the right process complaint: If the school district has
D 1012 Due Process
not already provided parents with written resolution period, the due process hearing
notice regarding their actions relating to the and final decision must be conducted within
issue addressed in the due process complaint, 45 days. By the end of the 45-day period,
the school district must now respond within not only must the hearing be conducted but
10 days of receiving the due process also a final decision issued by the hearing
complaint. The response must include an officer, and a copy of the decision must be
explanation of why the school district has pro- mailed to the parents and the school dis-
posed or refused to take the action addressed trict. The IDEA amendments also allow
in the complaint. The response must include a states the opportunity to review the deci-
description of (a) options that the IEP team sion of the hearing officer. The state has
considered and why those reasons were 30 days to review the decision and provide
rejected; (b) the evaluation procedure, assess- a written copy of their review decision to
ments administered, and reports reviewed by the parents and school district.
the IEP team; and (c) any additional factors 7. Hearing officer requirements and decisions:
related to the case. The hearing officer cannot be an employee of
3. Specific timelines for conducting a resolution the state or school district where the child
meeting: The school district must convene attends school. The hearing officer must not
a meeting with the parent within 15 days of only have knowledge of the provisions of the
receiving the due process complaint. The IDEA as well as federal and state regulations
purpose of the meeting is to resolve the dispute related to the IDEA statutes but also the
if possible. This meeting may be waived if the ability to conduct hearings and document
parents and school district agree in writing to decisions according to standard legal practice.
waive the meeting or if the parent and school The decision of the hearing officer in the due
district agree to use the mediation process process hearing must be based on substantive
as opposed to a resolution meeting. If the school grounds. A hearing officer may determine that
district fails to respond to the due process com- a child did not receive a free and appropriate
plaint or fails to participate in a resolution meet- education (FAPE) if the procedural inadequa-
ing within 15 days of receipt of the complaint, cies of the school district obstructed the
the parent may contact the hearing officer to parent’s opportunity to participate in the
begin the due process hearing timeline. identification, evaluation, and IEP develop-
4. Request by the school district to dismiss the ment process; interfered with the child’s
case: If a school district has made reasonable, right to a FAPE; or caused a deprivation of
documented efforts to schedule a resolution educational benefit.
meeting with the parent and the parent has
been nonresponsive, the school district may
request that the hearing officer dismiss the See Also
case after 30 days.
5. Requirements for resolution meeting agree- ▶ Procedural Safeguards
ments: In the case that the parents and school
district are able to resolve the dispute during
a resolution meeting, both parties are required
to sign a legally binding document stating the
agreement. This document may be voided Due process complaints, in detail, (2010). National Dis-
by either party within 3 business days but semination Center for Children with Disabilities.
otherwise if enforceable in any state of Retrieved from http://nichcy.org/schoolage/disputes/
dueprocess/regs
district court. Due process hearings, Wrightslaw. Retrieved June 10,
6. Timelines for conducting the hearing and 2011, from http://www.wrightslaw.com/info/dp.index.
issuing a final decision: After the 30-day htm
Dynamic Assessment 1013 D
Questions and answers on procedural safeguards and child’s performance. As such, DA provides
due process procedures for parents and children with information regarding the child’s ability to
disabilities. (2009). U.S. Department of Education.
Retrieved June 10, 2011, from http://idea.ed.gov/ benefit from these contextual and linguistic
explore/view/p/,root,dynamic,QaCorner,6 manipulations, including the level and type of
Topic: Procedural safeguards: Due process hearings. US support that is needed to facilitate performance
Department of Education. Retrieved June 10, 2011, (Peña, 1996).
from http://idea.ed.gov/explore/view/p/,root,dynamic,
TopicalBrief,16 Dynamic assessment contrasts with tradi-
Yell, M. L. (2006). The law and special education tional or static assessment (SA), which mea-
(2nd ed.). Upper Saddle River, NJ: Merrill/Prentice sures an individual’s independent, unaided D
Hall. performance at a specific point in time (Lidz,
Zirkel, P., & Scala, G. (2010). Due process hearing systems
under the IDEA: A State-by-State survey. Journal of 2003). During SA, the examiner acts as
Disability Policy Studies, 21(1), 3–8. Retrieved June 10, a neutral observer; the examiner does not pro-
2011, from http://www.directionservice.org/cadre/pdf/ vide the individual with feedback regarding
Due%20Process%20Hearing%20Systems.pdf. performance or assistance to complete the
assessment. As such, SA provides the examiner
with information regarding the individual’s
learning products (Lidz, 2003). Dynamic
Durability of Treatment Effects assessment, when used in conjunction with
static assessment, can provide the examiner
▶ Maintenance of Treatment Effects with an understanding of an individual’s devel-
oping and developed skills (Jeltova et al.,
2007).
Dynamic Assessment
Amy Donaldson
Speech & Hearing Sciences Department, Dynamic assessment is based on the work of
Portland State University, Portland, OR, USA Russian psychologist, Lev Vygotsky, who advo-
cated studying how children’s social interactions
with others shape their individual development.
Synonyms Vygotsky proposed that the organizational prop-
erties of the individual’s mental processes reflect
DA; Learning potential assessment; Mediated those of his/her social life. As such, Vygotsky
learning experience (1978) suggested that static measures of assess-
ment could not fully describe an individual’s
understanding, as static assessment only mea-
sures what the individual can perform indepen-
Description dently. This independent performance is known
as the individual’s level of actual development.
Dynamic assessment (DA) is an assessment In contrast to the individual’s level of actual
methodology that measures an individual’s development (as measured by static assessment),
performance with the assistance of an experi- the individual’s level of potential development is
enced peer or adult. As such, DA provides the measured by his/her performance within a social
examiner with information regarding the indi- interaction framework that provides the assis-
vidual’s learning process (Lidz, 2003). During tance of a more experienced peer or adult (i.e.,
DA, the assessor manipulates the interaction dynamic assessment). The distance between the
(e.g., contextual and/or linguistic prompts and individual’s level of actual development and
cues) for the specific purpose of optimizing the level of potential development defines the
D 1014 Dynamic Assessment
individual’s zone of proximal development how support is offered to the individual (Brown,
(ZPD; Vygotsky, 1986/1934). Campione, Webber, & McGilly, 1992). Budoff’s
An individual’s ZPD may be narrow, which intent was to improve diagnoses of children who
indicates that the individual is not yet ready to may have been mislabeled as developmentally
participate in the activity at a more advanced disabled due to differing background experiences
level than his/her unaided performance. Con- (i.e., children whose upbringing did not expose
versely, an individual’s ZPD may be wide, them to information assessed by standard psycho-
which indicates that, when given appropriate sup- metric measures). As such, this approach to DA is
ports, the individual may demonstrate more often used with individuals from culturally and
advanced skills than revealed by his/her unaided linguistically diverse backgrounds (Peña, 2000).
performance (Campione, Brown, Ferrara, Jones, Use of graduated prompting is another form
& Steinberg, 1985). of DA. Campione and Brown’s (1987) approach
Dynamic assessment has been utilized with utilizes a graduated prompt procedure that focuses
a variety of populations in a number of ways. on the individual’s ability to learn a specific skill
Feuerstein developed a dynamic assessment bat- through provision of increasing specific prompts
tery, the Learning Potential Assessment Device and his/her ability to transfer learning to novel
(LAPD; Feuerstein, 1979), to assess the cognitive situations. In this pretest-posttest format, the pur-
skills of children from diverse cultures entering pose of assessment is to determine the level of
a new country (e.g., immigrants) and children support necessary for the individual to achieve opti-
with developmental disabilities. The “dynamic mum performance (Brown et al., 1992).
goal” of his approach was to measure the degree Testing the limits is a DA approach intended to
of modifiability, or learning potential, of the indi- address a possible mismatch between the individual
vidual during a focused learning experience. In and the assessment measure. Carlson and Wiedl
this training-assessment model, a test item is (1992) discussed two factors that may result in
presented and the individual’s performance is poor performance on ability tests, these include
carefully observed to provide information regard- (1) the individual’s personal characteristics
ing how to proceed with training (the focused (e.g., test anxiety, personality traits) and (2) the
learning experience, also known as mediated individual’s difficulty understanding the tasks
learning experience (MLE)). During MLE, required by the assessment measure (i.e., the test
Feuerstein follows the learner’s responses, offer- directions). Given these factors, testing the limits
ing verbal, tactile, and visual instructions with the approach requires analysis of the fit between the
intent of developing a particular skill. The expec- individual and the measure; when a mismatch
tation of this type of approach would be that the occurs, manipulation of the testing situation is indi-
individual will demonstrate improved perfor- cated. That is, the examiner may use feedback and
mance following training, as compared to his/ extended explanations to determine the individual’s
her initial performance. understanding of the task and the nature of his/her
Another type of DA is known as the test-teach- response.
retest approach. Budoff (1987) followed this for- Finally, the aforementioned DA methods have
mat to determine an individual’s learning poten- been used to assess an individual’s performance
tial. One major difference between Budoff’s related to his/her school curriculum. Lidz (2003)
approach and that of Feuerstein was that Budoff’s developed a curriculum-based approach to DA
intervention was standardized to allow for con- during which tasks are taken from an individual’s
sistent comparison across groups, whereas classroom, pretest/posttest measures are devel-
Feuerstein’s approach has been viewed as more oped based on the specific task, and intervention
of a clinical evaluation whereby the examiner following the MLE model and best teaching prac-
follows a scripted procedure, but may vary in tices is provided to the individual. According to
Dynamic Assessment 1015 D
Lidz (2003), this approach focuses on generating contextual and linguistic variables that may influ-
quantitative and qualitative information regard- ence performance, it provides an appropriate
ing the individual’s performance and learning to framework for examining the learning potential
be used in intervention planning. (and learning process) of at-risk learners, individ-
uals with disabilities, and individuals from lin-
guistically and culturally diverse backgrounds.
Psychometric Data
Given the objective of DA, to determine an indi- D

vidual’s learning process or potential given assis- References and Readings
tance, DA measures utilize interrater reliability
Bain, B. A., & Olswang, L. B. (1995). Examining readi-
(agreement between examiners/coders) with ness for learning two-word utterances by children with
regard to the individual’s performance and the specific expressive language impairment: Dynamic
use of examiner supports. assessment validation. American Journal of Speech-
The predictive validity of DA with regard to Language Pathology, 4(1), 81–91.
Barnhill, G. (2001). Behavioral, social, and emotional
future achievement has been investigated across assessment of students with ASD. Assessment for
DA methods. DA has been found to predict fur- Effective Intervention, 27(1–2), 47–55.
ther achievement more accurately than SA under Brown, A., Bransford, J., Ferrara, R., & Campione, J.
the following conditions: when the examiner’s (1983). Learning, remembering and understanding. In
P. Musse (Ed.), Handbook of child psychology (Cog-
feedback is noncontingent (standard response to nitive development 4th ed., Vol. 3, pp. 77–166). New
an individual’s failure vs. an individualized York: John Wiley & Sons.
response); when the individuals tested are stu- Brown, A. L., Campione, J. C., Webber, L. S., & McGilly, K.
dents with disabilities, rather than at-risk or typ- (1992). Interactive learning environments: A new look at
assessment and instruction. In B. R. Gifford & M. C.
ically developing students; and when the measure O’Connor (Eds.), Changing assessments: Alternative
of achievement includes DA posttests and crite- views of aptitude, achievement and instruction. Evalua-
rion-referenced tests versus norm-referenced tion in education and human services. (pp. 121–211).
measures and teacher report (Caffrey, Fuchs, & New York: Kluwer Academic/Plenum Publishers.
Budoff, M. (1987). Measures for assessing learning poten-
Fuchs, 2008). tial. In C. S. Lidz (Ed.), Dynamic assessment: An
interactional approach to evaluating learning poten-
tial (pp. 173–195). New York: Guilford Press.
Clinical Uses Caffrey, E., Fuchs, D., & Fuchs, L. S. (2008). The predic-
tive validity of dynamic assessment: A review. Journal
of Special Education, 41(4), 254–270.
Given dynamic assessment’s focus on an individ- Campione, J. C., & Brown, A. L. (1987). Linking dynamic
ual’s potential to learn, it has been used to assessment with school achievement. In C. S. Lidz
increase equity, accuracy, and fairness in assess- (Ed.), Dynamic assessment: An interactional
approach to evaluating learning potential (pp. 82–
ment of individuals with special needs as well as 115). New York: Guilford Press.
individuals from linguistically and culturally Campione, J. C., Brown, A. L., Ferrara, R. A., Jones, R. S.,
diverse backgrounds (Peña, 1996; Tzuriel & & Steinberg, E. (1985). Differences between retarded
Feurstein, 1992). and non-retarded children in transfer following equiv-
alent learning performances: Breakdowns in flexible
As noted above, DA and its application can use of information. Intelligence, 9, 297–315.
come in several forms. Regardless of the specific Carlson, J., & Wiedl, K. H. (1992). Use of testing-the-limits
DA orientation, the environment is manipulated procedure in the assessment of intellectual capabilities in
in an effort to improve the child’s performance. children with learning difficulties. American Journal of
Mental Deficiency, 82, 559–564.
These environmental variables typically include Day, J. D., Englehart, J. L., Maxwell, S. E., & Bolig, E. E.
contextual and linguistic manipulations. Overall, (1997). Comparison of static and dynamic assessment
because DA allows for the manipulation of procedures and their relation to independent
D 1016 Dysarthria
performance. Journal of Educational Psychology, (Eds.), Interactive Assessment (pp. 187–206).

89(2), 358–368. New York: Springer-Verlag.
Donaldson, A. L., & Olswang, L. B. (2007). Investigating Vygotsky, L. S. (1978). Mind in society: The development
requests for information in children with autism spectrum of higher psychological processes. (M. Cole,
disorders: Static versus dynamic assessment. Advances in V. John-Steiner, S. Scribner, & E. Souberman, Eds.).
Speech-Language Pathology, 9(4), 297–311. Cambridge, MA: Harvard University Press.
Feuerstein, R. (1979). Cognitive modifiability in retarded Vygotsky, L. S. (1986). Thought and language
adolescents: Effects of instrumental enrichment. (A. Kozulin, Trans.). Cambridge, MA: The MIT
American Journal of Mental Deficiency, 83(6), Press. (Original work published 1934).
539–550.
Feuerstein, R., Hoffman, M. B., Rand, Y., & Jensen, M. R.
(1986). Learning to learn: Mediated learning experi-
ences and instrumental enrichment. Special Services in
the Schools, 3(1–2), 49–82. Dysarthria
Haywood, H. C., Brooks, P., & Burns, S. (1983). Stimu-
lating cognitive development at developmental level: Allison Bean
A tested, non-remedial preschool curriculum for pre-
schoolers and older retarded children. Special Services Speech and Hearing Science, The Ohio State
in the Schools, 3(1–2), 127–147. University, Columbus, OH, USA
Jeltova, I., Birney, D., Fredine, N., Jarvin, L., Sternberg, R. J.,
& Grigorenko, E. L. (2007). Dynamic assessment as
a process-oriented assessment in educational settings.
Advances in Speech-Language Pathology, 9(4), 273–285. Definition
Kaczmarek, L. A. (2002). Assessment of social-
communicative competence: An interdisciplinary model.
In H. Goldstein, L. A. Kaczmarek, & K. M. English
Dysarthria is a motor speech disorder caused by
(Eds.), Promoting social communication: Children with generalized weakness to the oral musculature that
developmental disabilities from birth to adolescence occurs as a result of damage to the central and/or
(pp. 55–116). Baltimore: Paul H. Brookes. peripheral nervous system (Duffy, 1995; Freed,
Law, J., & Camilleri, B. (2007). Dynamic assessment and
its application to children with speech and language
2000; Vinson, 2007; Zemlin, 1998). This damage
learning difficulties. Advances in Speech-Language may occur as a result of stroke, head injury,
Pathology, 9(4), 271–272. cerebral palsy, muscular dystrophy, or other
Lidz, C. S. (1991). Practitioner’s guide to dynamic assess- brain injury (American Speech-Language-
ment. New York: Guilford Press.
Lidz, C. S. (2003). Early childhood assessment. Hoboken,
Hearing Association, n.d.; Freed, 2000). As
NJ: Wiley. a consequence of oral musculature weakness,
Peña, E. (2000). Measurement of modifiability in the speech of individuals with dysarthria is slow
children from culturally and linguistically diverse and labored, and their articulation is imprecise
backgrounds. Communication Disorders Quarterly,
21(2), 87–97.
(Freed, 2000; Zemlin, 1998). Other areas of
Peña, E. D. (1996). Dynamic assessment: The model and its speech may also be affected including respira-
language applications. In K. N. Cole & P. S. Dale (Eds.), tion, voicing, and prosody (Duffy, 1995).
Assessment of communication and language, communi-
cation and language intervention series (Vol. 6, pp. 281–
307). Baltimore: Paul H. Brookes.
Peña, E. D. (2000). Measurement of modifiability in See Also
children from culturally and linguistically diverse
backgrounds. Communication Disorders Quarterly, ▶ Articulation Disorders
21(2), 87–97.
Rogoff, B., & Wertsch, J. V. (1984). Children’s learning
▶ Speech
in the “zone of proximal development” (New direc-
tions for child development series). San Francisco:
Jossey-Bass Publishers. References and Readings
Sternberg, R. J., & Grigorenko, E. L. (2002). Dynamic
testing. Cambridge: Cambridge University Press. ASHA (n.d.). Dysarthria. In American-Speech-Language-
Tzuriel, D., & Feuerstein, R. (1992). Dynamic group Hearing-Association Speech Disorders. Retrieved
assessment for prescriptive teaching: Differential January 5, 2011 from http://www.asha.org/public/
effect of treatment. In H. C. Haywood & D. Tzuriel speech/development/language_speech.htm
Dyscalculia 1017 D
Duffy, J. R. (1995). Motor speech disorders: Substrates, more of the following: poor automatic recall of
differential diagnosis, and management. St. Louis, basic facts, such as multiplication tables; poor
MO: Mosby.
Freed, D. (2000). Motor speech disorders: Diagnosis and knowledge of or poor fluency in procedures for
treatment. San Diego, CA: Singular. multidigit calculation, such as addition with
Vinson, B. (2007). Language disorders across the lifespan regrouping; visuospatial weaknesses that result
(2nd ed.). Clifton Park, NY: Thomson Delmar in place errors in written calculations and in dif-
Learning.
Zemlin, W. R. (1998). Speech and hearing science: ficulty with geometry; language deficits in areas
Anatomy and physiology (4th ed.). Boston, MA: requiring higherorder thinking, thus interfering
Allyn and Bacon. with carrying out word problems; and insufficient D
attention, impairing short-term memory
necessary for mental arithmetic (e.g., Rapin,
2010). Furthermore, those with dyscalculia not
Dyscalculia only struggle with mathematics in school
but even have difficulty with numbers in
Diana B. Newman everyday tasks, such as telling time and remem-
Communication Disorders Department, Southern bering phone numbers (Butterworth, 2008).
Connecticut State University, New Haven, However, some individuals with dyscalculia
CT, USA often perform without difficulty in other
academic areas, although there are individuals
who struggle with reading and spelling, as well
Synonyms as mathematics.
Possible causes of dyscalculia are numerous;
Developmental dyscalculia; Mathematics these include but are not necessarily limited to
disability poor instruction, low intelligence, anxiety about
numbers, behavioral and/or attentional problems,
poor working memory, language-based learning
Definition disabilities, impaired visuospatial abilities, and
motor skill deficits (e.g., Butterworth, 2008;
Dyscalculia is a learning disability characterized Zager & Donaldson, 2010). Apart from environ-
by an inability to acquire the mathematical skills mental causes (e.g., poor teaching or behavioral
that would be expected for a given chronological issues), developmental dyscalculia may be brain-
age, cognitive ability, and educational level. based, for example, associated with a familial-
Mathematics skills are typically broken down genetic predisposition (Shalev & Gross-Tsur,
into mathematics calculation (i.e., computation) 2001). Developmental dyscalculia also
and mathematics reasoning (i.e., problem frequently occurs in neurologic disorders such
solving). Given the cumulative nature of as attention-deficit/hyperactivity disorder, devel-
mathematics, initial difficulty in learning and opmental language disorder, and fragile
becoming fluent in basic numerical concepts X syndrome (Shalev & Gross-Tsur). Dyscalculia
impedes the later development of more complex is also often associated with either a nonverbal
arithmetic concepts (Butterworth, 2008). learning disability, that is, performance is
For example, proficiency with whole numbers poor only in mathematics (but also reading and
and fractions (including decimals, percent, and spelling), or a comorbid condition of reading/
negative fractions) as well as measurement and spelling and mathematics disabilities.
geometry has been identified as being founda- Particular to autism spectrum disorder (ASD),
tional for later academic success (National studies have found that on mathematics assess-
Mathematics Advisory Panel, 2008). ments, approximately 25% of those students
Specific characteristics of dyscalculia vary with high-functioning ASD perform at least
among individuals but commonly include one or one standard deviation below their vocabulary
D 1018 Dyschezia
scores, thereby presenting with a mathematics

disability (e.g., Mayes & Calhoun, 2008; Zager Dysexecutive Syndrome
& Donaldson, 2010). The fact that nearly one-
quarter of this population has a developmental ▶ Frontal Lobe Syndrome
dyscalculia contradicts the commonly held belief
that persons with ASD have high mathematical
ability levels (Williams, Goldstein, Kojkowski,
& Minshew, 2008). Dysfluency
Interventions for students with dyscalculia
must address specific areas of difficulty using ▶ Fluency and Fluency Disorders
explicit and systematic teaching of skills.
Practice and cumulative review are especially
important. Often the use of visuals and/or manip-
ulatives is of benefit in teaching and practicing Dysgenesis (Malformation)
mathematics concepts.
▶ Agenesis of Corpus Callosum
Butterworth, B. (2008). Developmental dyscalculia. Dysgraphia

In J. Reed & J. Warner-Rogers (Eds.), Child neuro-
psychology: Concepts, theory, and practice Diana B. Newman
(pp. 357–376). Hoboken, NJ: Wiley-Blackwell.
Communication Disorders Department, Southern
Mayes, S. D., & Calhoun, S. L. (2008). WISC-IV and
WIAT-II profiles in children with high-functioning Connecticut State University, New Haven,
autism. Journal of Autism and Developmental CT, USA
Disorders, 38(3), 428–439.
National Mathematics Advisory Panel. (2008). Founda-
tions for success: The final report of the national
mathematics advisory panel. Washington, DC: U.S. Synonyms
Department of Education.
Rapin, I. (2010). Disorders of motor and mental develop- Handwriting difficulty
ment. In L. P. Rowland & T. A. Pedley (Eds.), Merritt’s
neurology (12th ed., pp. 568–575). Philadelphia:
Shalev, R. S., & Gross-Tsur, V. (2001). Developmental Definition
dyscalculia. Pediatric Neurology, 24, 337–342.
Williams, D. L., Goldstein, G., Kojkowski, N., &
Dysgraphia is a specific learning disability in which
Minshew, N. J. (2008). Do individuals with high-
functioning autism have the IQ profile associated writing letters by hand is impaired, thereby affecting
with nonverbal learning disability? Research in Autism the acquisition and use of written language. Spelling
Spectrum Disorders, 2, 353–361. difficulties may also be present in dysgraphia. Thus,
Zager, D., & Donaldson, J. B. (2010). Mathematics interven-
an individual with dysgraphia may have problems
tions for students with high-functioning autism/
Asperger’s Syndrome. Teaching Exceptional Children, with handwriting or spelling or both.
42, 40–46. Importantly, handwriting (i.e., letter produc-
tion) is not a simple motor act. Letter production
requires visuospatial integration and motor plan-
ning for controlling the size of strokes and align-
Dyschezia ment of letters on paper, motor control and
memory for hand movements involved in writing
▶ Constipation letters, and working memory for holding letters
Dysgraphia 1019 D
while motor acts are being planned and carried with fine and gross motor functions that make
out (Berninger, 2004). Similarly, spelling is not precise manipulations of writing difficult; with
simply a visual skill. It requires both orthographic proprioception, thus making it difficult to accu-
(i.e., letter-sound associations) and phonological rately develop fluid, automatic handwriting; and
processes (i.e., short-term memory for spoken with vision that affects how letters are perceived
information) (Berninger, 2004). and reproduced (Fuentes, Mostofsky, & Bastian,
The defining characteristic of dysgraphia is 2009). Research has found that some children
poor or slow handwriting, though additional char- with ASD have problems forming letters, but
acteristics are possible; thus, clinical subtypes of not sizing, spacing, or aligning them (Fuentes D
dysgraphia have been suggested: language-based et al., 2009).
or dyslexic dysgraphia, motor-executive It is important to address dysgraphia with
dysgraphia, and visuospatial dysgraphia (e.g., appropriate treatment. Mechanics of writing,
O’Hare, 1999). In dyslexic dysgraphia, writing especially handwriting fluency, are predictive of
difficulties arise from impairments in phonologi- both the fluency (rate) and quality of written
cal processing (e.g., phonological awareness), compositions. Difficulties with the mechanics of
semantics (e.g., word knowledge), and/or syntax writing (i.e., constructing letters and spelling)
(e.g., grammar). Writing is characterized by both interfere with the same attentional resources
poor legibility and weak spelling, though copying necessary to generate meaningful composition
is typically relatively intact. Differently, a motor- (Berninger et al., 1997).
executive dysgraphia is associated with a
motor-planning weakness, that is, difficulty
remembering the sequence of kinesthetic move- See Also
ments necessary to form letters correctly. As in
dyslexic dysgraphia, handwriting is illegible; ▶ Agraphia
however, spelling is not affected and copying is
impaired. Visuospatial dysgraphia results from
impairment in understanding space. Characteris-
tics are similar to motor-executive dysgraphia; References and Readings
however, in addition to letter formation, weak-
Berninger, V. W. (2004). Understanding the “graphia”
nesses also occur in margin consistency and spac- in developmental dysgraphia. In D. Dewey &
ing of letters. Further, along with handwriting D. E. Tupper (Eds.), Developmental motor disorders:
difficulty, visuospatial dysgraphia also includes A neuropsychological perspective (pp. 328–350).
New York: Guilford Press.
difficulty with drawing and motor-free visuospa-
Berninger, V., Vaughan, K., Abbott, R., Abbott, S.,
tial tasks (e.g., visually perceive [recognize] Rogan, L., Brooks, A., & Graham, S. (1997). Treat-
letters in the correct direction). Regardless of ment of handwriting fluency problems in beginning
the clinical subtype, because those with writing: Transfer from handwriting to composition.
Journal of Educational Psychology, 89, 652–666.
dysgraphia focus more energy on handwriting,
Fuentes, C. T., Mostofsky, S. H., & Bastian, A. J. (2009).
in order to shorten the handwriting process, they Children with autism show specific handwriting impair-
use as few words as possible in written ments. Neurology, 73(19), 1532–1537. doi:10.1212/
communication. WNL.0b013e3181c0d48c.
Miyahara, M., Tsujii, M., Hori, M., Nakanishi, K.,
The high prevalence of writing disabilities in
Kageyama, H., & Sugiyama, T. (1997). Brief report:
individuals with autism spectrum disorders Motor incoordination in children with asperger syn-
(ASD) has been well documented (e.g., Miyahara drome and learning disabilities. Journal of Autism and
et al., 1997). Impairments in any or several Developmental Disorders, 27, 595–603.
O’Hare, A. (1999). Dysgraphia and dyscalculia. In
domains that contribute to handwriting account W. Kingsley, H. Hart, & G. Willems (Eds.), A
for the frequency of dysgraphia in the population. neurodevelopmental approach to specific learning dis-
These include but are not limited to problems orders (pp. 96–118). London: Mac Keith Press.
D 1020 Dyslexia
occurs in related family members. Current genetic

Dyslexia research suggests that a number of genes exist that
may predispose a child to developing dyslexia. Dys-
Moira Lewis lexia is usually detected and diagnosed in early
Speech-Language Pathologist, Marcus Autism elementary years, when affected children demon-
Center Children’s Healthcare of Atlanta, Atlanta, strate difficulties with classroom demands related to
GA, USA alphabet learning, word recognition, reading com-
prehension, spelling, and writing. It is thought to
affect between 5% and 10% of the population
Synonyms although there have been no studies to indicate an
accurate percentage. In adults, symptoms associated
Developmental reading disorder; Specific read- with dyslexia can occur following a brain injury/
ing disability stroke, or as a result of developing dementia.
Short Description or Definition Natural History, Prognostic Factors, and

Outcomes
The National Institute of Neurological Disorders
and Stroke defines dyslexia as “a brain-based Although typically not diagnosed until middle
type of learning disability that specifically elementary grades, dyslexia is frequently associ-
impairs a person’s ability to read. These individ- ated with delayed language development during
uals typically read at levels significantly lower the preschool period. Although the language
than expected despite having normal intelligence. delay often appears to resolve in primary grades,
Although the disorder varies from person to per- learning to read and write is often slow and labo-
son, common characteristics among people with rious. Children with dyslexia demonstrate diffi-
dyslexia are difficulty with spelling, phonologi- culties in phonological awareness during primary
cal processing (the manipulation of sounds), school years; they have trouble identifying
and/or rapid visual-verbal responding. In adults, rhymes, recognizing words that start or end with
dyslexia usually occurs after a brain injury or in the same letter, and breaking words down into
the context of dementia. It can also be inherited in component sounds (hit ¼ /h/ + /I/ + /t/). Although
some families and so on, and recent studies have in multisensory interventions children “experi-
identified a number of genes that may predispose ence” letters and words in various tactile modal-
an individual to developing dyslexia.” ities (such as feeling sandpaper letters or making
letters in finger paint), the approach with the best
evidence base is prolonged, intensified exposure
Categorization to phonological awareness training, letter-sound
correspondence, sound analysis (what sounds are
Learning disability in the word cat?), and sound-word synthesis
Neurological disorder (What word do these sounds make s-u-n?). With
intensive instruction, many children with dys-
lexia learn to read and write, although both may
Epidemiology remain slow and labored. For students with
severe dyslexia, educational practice requires
Dyslexia is known as a neurological disorder in that alternative access to curricular texts by means
there appear to be differences in brain functioning of material to be read to the student, or recorded
associated with language, learning, and reading in for listening. Computer applications that translate
this population. Dyslexia is typically not acquired text to speech are also used. With appropriate
but related to congenital factors and frequently compensations, individuals with dyslexia can
Dyslexia 1021 D
achieve high levels of independence and achieve- word recognition, and short-term memory. In
ment. However, many suffer from poor self- young children learning to read, these skills develop
esteem if compensations and support are not along a continuum and work together for successful
provided. reading acquisition. For a child suspected of dys-
lexia, these skills should be carefully assessed in
order to detect what areas are underdeveloped and/
Clinical Expression and or causing the most difficulty. As typical children
Pathophysiology acquire these skills, their reading becomes more
fluent and with a quicker pace. Pacing and fluency D
The symptoms of dyslexia may vary, depending does not tend to come as naturally for children with
on the age of the individual and the severity dyslexia and remains a chronic difficulty for many
of their difficulties. In young children, delayed adults with dyslexia.
language, trouble identifying and segmenting Symptoms associated with dyslexia can also
sounds, rhyming, and letter-sound matching are occur in children with other language and learning
often seen. Children with dyslexia are commonly disabilities; therefore, a comprehensive assessment
thought to simply “reverse” letters in their read- is necessary to evaluate areas of reading, writing,
ing and writing; however, many typical children comprehension, and verbal expression. Many
reverse letters when learning to read and write. In children with reading problems also have spoken
fact, a person with dyslexia may show no pattern language deficits.
of letter reversal at all. Although children and
adults with dyslexia tend to have average to
above-average cognitive skills, they may demon- Treatment
strate associated difficulties with reading com-
prehension, writing, as well as math, as these Depending on the varying degrees of difficulty
areas also require connection and understanding and the areas most impaired in an individual with
of letters/graphics. dyslexia (i.e., letter/word recognition, reading
fluency, comprehension), treatment methods and
intensity of approach will vary. For children,
Evaluation and Differential Diagnosis strategies and supports in developing phonologi-
cal skills (e.g., letter-sound recognition, sound
Thorough measures of neuropsychological separation, segmentation, rhyming) will ulti-
assessment exist in order to detect and treat dys- mately assist with reading and writing deficits.
lexia in children from an early age. Assessment For school-aged children who have acquired
for a child showing delayed or impaired reading reading but continue to struggle, teaching strate-
acquisition may include cognitive and academic gies should address pacing, processing, and com-
achievement testing, as well as an evaluation of prehension. Regardless of student age, a team of
the critical underlying language skills closely professionals should consult and collaborate to
linked to dyslexia (phonological awareness, letter develop an educational plan with specific teach-
naming, fluency). Developmental history, family ing methods and accommodations to meet the
history of dyslexia, and early development of needs of the child.
speech and language should also be investigated. School professionals and clinicians, particularly
The presence of vision, auditory, and attention reading specialists, special educators, and speech-
impairments are unrelated to the reading and language pathologists, are trained to develop
comprehension signs of dyslexia and should be interventions and treat dyslexia. Multisensory
ruled out and treated as separate disorders. approaches that target auditory, visual, and tactile
There are a number of underlying skills that areas associated with reading and comprehension
comprise a person’s ability to read, including pho- offer thorough methods to address difficulties
nological awareness, alphabet decoding, automatic caused by dyslexia. A thorough assessment and
D 1022 Dysphasia
teacher report can also offer information related to Moats, L., & Dakin, K. (2008). Basic facts about dyslexia
individual learning styles. For example, individuals and other reading problems. Baltimore: The Interna-
tional Dyslexia Association.
who benefit from visual versus purely auditory National Institute of Neurological Disorders and Stroke.
teaching methods. (2010). Dyslexia information page.
Assessment can also reveal the specific read- Rumsey, J. M., & Hamburger, S. (1990). Neuropsycho-
ing skills that require remediation for a child or logical divergence of high-level autism and severe
dyslexia. Journal of Autism and Developmental Dis-
adult, including: orders, 20(2), 155–168. doi:10.1007/BF02284715.
• Phonemic awareness: recognition of the letter Schaywitz, S. (2003). Early clues to dyslexia. In S. Schaywitz
sounds in words (Ed.), Overcoming dyslexia (pp. 93–101). New York:
• Phonological awareness: understanding that Random House.
Shapiro, J., & Rich, R. (1999). Facing learning disabil-
words can be broken down into phonemes ities in the adult years: Understanding dyslexia,
and those phonemes can be manipulated, ADHD, assessment, intervention and research.
such as segmenting sounds in words, blending New York: Oxford University Press.
sounds, and rhyming (sounds are distinct from
meaning)
• Reading fluency: spelling, speed, accuracy,
and ease Dysphasia
• Oral reading: proper expression and fluency
• Reading comprehension: includes vocabulary ▶ Aphasia
knowledge and understanding the meaning of ▶ Global Aphasia
passages
For adults, individualized tutoring can provide
both structured and tailored teaching to address
problem areas and monitor progress. Counseling Dysphoria
sessions with a trained clinician familiar with dys-
lexia can provide a supportive arena to develop and Micaela Violette
discuss strategies for home and career settings Yale Child Study Center, New Haven, CT, USA
where reading is involved. Counseling is also ben-
eficial for individuals with dyslexia who demon-
strate fear or anxiety surrounding their reading Definition
difficulties.
A negative emotional state characterized by dissat-
isfaction, restlessness, anxiousness, irritableness,
References and Readings and depression. Dysphoria is a symptom of various
psychiatric disorders such as major depressive dis-
American Speech, Language and Hearing Association, order, dysthymia, generalized anxiety disorder,
ASHA. (2010). Language based learning disabilities. body dysmorphic disorder, bipolar disorder, and
Retrieved from http://www.asha.org/public/speech/
premenstrual dysphoric disorder. Dysphoria is usu-
disorders/LBLD.htm
Clark, D. B., & Uhry, J. K. (1995). Dyslexia: Theory & ally experienced during states of depression, but
practice of remedial instruction. Baltimore: York people with bipolar disorder may also experience
Press. dysphoria during manic or hypomanic episodes.
Healey, J. M., & Aram, D. M. (1986). Hyperlexia and
dyslexia: A family study. Annals of Dyslexia, 36(1),
Dysphoria is the opposite of euphoria.
237–252. doi:10.1007/BF02648032.
International Dyslexia Association. (2007). Dyslexia
basics. Retrieved from http://www.ldonline.org/ See Also
article/Dyslexia_Basics
McCardle, P., & Chhabra, V. (2004). The voice of
evidence in reading research. Baltimore: Paul H. ▶ Depressive Disorder
Brookes. ▶ Mood Disorders
Dystonia 1023 D
References and Readings ▶ Oral-Motor Apraxia
▶ Verbal Apraxia
Blazer, D., & Williams, C. (1980). Epidemiology of ▶ Verbal Dyspraxia
dysphoria and depression in an elderly population.
The American Journal of Psychiatry, 137, 439–444.
Roberts, J., Gilboa, E., & Gotlib, I. (1998). Ruminative
response style and vulnerability to episodes of References and Readings
dysphoria: Gender, neuroticism, and episode duration.
Cognitive Therapy and Research, 22(4), 401–423. Darley, R. (1969, November). Aphasia: Input and output
disturbances in speech and language processing. D
Presentation at the American Speech and Hearing
Association, Chicago, IL.
Darley, F., Aronson, A., & Brown, J. (1975). Motor
Dyspraxia speech disorders. Philadelphia: W.B. Saunders.
Kent, R., & Rosenbek, J. (1983). Acoustic patterns of
apraxia of speech. Journal of Speech and Hearing
Susan Latham Research, 26, 231–249.
Department of Communication Disorders, St. Liepmann, H. (1900). Das Krankheitsbild der Apraxie
Mary’s College (IN), Notre Dame, IN, USA (motorischen Asymbolie) auf Grund eines falles von
einseitiger Apraxie. Monatsshrift fur Psychiatrie und
Neurologie, 8, 15–40.
Shriberg, L. D., Paul, R., Black, L. M., & van Santen, J. P.
Synonyms (2011). The hypothesis of apraxia of speech in children
with autism spectrum disorder. Journal of Autism and
Apraxia
Definition
Dystaxia
The term “dyspraxia” is often used to describe less
severe forms of apraxia. Apraxia is the disruption in ▶ Ataxia
the ability to plan and execute volitional (purpose-
ful) movements despite intact muscle strength
and coordination. Involuntary movements remain
intact. Importantly, apraxia is not associated with Dysthymia
weakness, slowness, or incoordination. Apraxia is
a motor disorder resulting from neurological dam- ▶ Depressive Disorder
age. There are three types of apraxia: limb, oral, and
verbal. In a limb apraxia, the volitional movements
of the extremities are affected. In an oral apraxia,
nonspeech movements of the oral mechanism are Dystonia
affected. Verbal apraxia (or Apraxia of Speech) is
a disorder in which an individual has difficulty Claudia Califano
positioning and sequencing muscles for the voli- Yale-New Haven Hospital, New Haven,
tional production of speech. CT, USA
See Also Definition
▶ Apraxia A movement disorder characterized by involuntary

▶ Developmental Coordination Disorder movements and prolonged muscle contraction,
▶ Developmental Dyspraxia resulting in twisting body motions, repetitive
D 1024 Dytan™
movements, or abnormal posture (Fahn, Bressman, Treatment of dystonias is based upon the
& Marsden, 1998; Geyer & Bressman, 2006). symptomatology. There are no curative therapies,
These movements may involve the entire body or although in the case of medication-induced
only an isolated area. Dystonia can be hereditary or dystonia, discontinuation of the medication may
occur sporadically without any genetic pattern; it result in a resolution of some dystonic symptoms.
can occur as a result of birth related or other trauma Management of dystonia includes medications such
or may be associated with medications, particularly as levodopa, anticholinergics, tetrabenazine, clo-
neuroleptics, or diseases. The gene responsible for nazepam, and baclofen. Botulinum toxin injections
at least one form of dystonia has recently been and deep brain stimulation are also recognized
identified. Some types of dystonia respond to dopa- treatments.
mine or can be controlled with sedative-type med-
ications or surgery. Dystonias may be classified by
the age of onset, by the part(s) of the body affected, See Also
or by the cause (primary or secondary dystonia).
Primary dystonia presents with signs only ▶ Anticholinergic
related to the dystonia and is thought to be caused ▶ Dopamine
by pathology in parts of the brain that are concerned
with movement (basal ganglia) and the GABA
(gamma-aminobutyric acid) producing neurons. References and Readings
This dystonia occurs without additional neurologic,
laboratory, or imaging abnormalities. The precise Fahn, S., Bressman, S. B., & Marsden, C. D. (1998). Classi-
fication of dystonia. Advanced Neurology, 78, 1–10.
cause of primary dystonia is unknown. In many
Friedman, J., & Standaert, D. G. (2001). Dystonia and its
cases, it may involve some genetic predisposition disorders. Neurologic Clinics, 19(3), 681–705. vii.
towards the disorder combined with environmental Geyer, H. L., & Bressman, S. B. (2006). The diagnosis of
conditions. dystonia. Lancet Neurology, 5(9), 780–790.
Secondary dystonia refers to dystonia associated
with a known cause or additional neurologic find-
ings. It usually arises as the result of a specific
underlying condition such as insufficient oxygen Dytan™
at birth and exposure to medications that block
dopamine receptors (Friedman & Standaert, 2001). ▶ Diphenhydramine
E
Early Childhood Tutor until the age of 3 or 4 years, and sometimes

considerably later (Howlin & Asgharian, 1999).
▶ Itinerant Teacher This was despite the fact that the DSM and ICD
diagnostic systems (American Psychiatric
Association [APA], 2000; World Health Organi-
sation [WHO], 1993) require that the symptoms
Early Diagnosis be evident in the first 3 years of life, although in
the proposed modifications in DSM-5, this
Tony Charman requirement has been changed to “Symptoms
Centre for Research in Autism and Education, must be present in early childhood (but may not
Department of Psychology and Human, become fully manifest until social demands
Institute of Education, University of London, exceed limited capacities).” However, nowadays
London, UK many children are now first identified in the
toddler and preschool period (Charman &
Baird, 2002; Mandell, Novak, & Zubritsky,
Definition 2005; Manning et al., 2011), although others, in
particular those with average or above average
Although autism spectrum disorders can be language and cognitive abilities, are not diag-
diagnosed at any age, the classification sys- nosed until school age or older. Several factors
tems require onset prior to 3 years of age or have driven this change, including efforts to
in early childhood. The term “early diagnosis” improve earlier identification with the recogni-
refers to diagnosis in the second and third year tion that earlier-delivered intervention may
of life. improve outcomes and prevent “secondary”
neurodevelopmental disturbances (Dawson,
2008; Mundy, Sullivan, & Mastergeorge, 2009):
Historical Background the development of prospective screening instru-
ments to identify possible cases of autism from
Notwithstanding progress in understanding of the the first few years of life (Barbaro &
genetic and neurodevelopmental processes that Dissanayake, 2009); and the use of the genetic
lead to autism spectrum disorders (ASD), clinical “high-risk” research design of prospectively
diagnosis is reliant on the developmental and studying younger siblings of children with
behavioral presentation. Until the 1990s, it was a diagnosis of ASD from the first year of life
rare for children to receive a diagnosis of autism (Rogers, 2009; Yirmiya & Charman, 2010).

E 1026 Early Diagnosis
Current Knowledge judgment is more reliable than the standard diag-

nostic instruments. Several studies also found
One of the most significant challenges and con- that behaviors from the third symptom cluster
cerns of this new era of prospectively studying that defines autism – restricted and repetitive
children with autism spectrum disorders from the behaviors and activities – were less evident at 2
age of 2 and 3 years concerns diagnosis. Given years of age than at 3–5 years of age (Cox et al.,
the relatively lack of experience of applying the 1999; Moore & Goodson, 2003; Stone
diagnostic criteria to children of this age, even et al., 1999).
among the relatively expert clinical teams The more recent studies differ in a number of
conducting such research programs, one critical features, most notably in that some have consid-
question was whether the diagnosis was possible, erably larger sample sizes (N ¼ 172, Lord et al.
accurate, and stable when applied to toddlers at 2006; N ¼ 89, Chawarska, Klin, Paul, Macari, &
the age of 2 or 3? Over the past decade, a number Volkmar 2009; N ¼ 77, Kleinman et al. 2008)
of research teams have followed up children first and that the follow-up periods extend to age 7
seen at the age of 2 years into early, and more years in the Charman et al. (2005) study and to
recently middle, childhood and provided an age 9 years in the Lord et al. (2006) and Turner
answer, to some extent, to this important et al. (2006) studies. Broadly, the lessons are the
question. same – that the diagnosis of autism is highly
A number of studies have examined the sta- stable in these samples but that of broader ASD
bility and accuracy of diagnosis, both in samples is less so see Rondeau et al. (2011); for a review).
of children referred for assessment at an early age Lord et al. (2006) found that age 2 scores on
and from screening studies. Over the past decade, measures of repetitive and restricted behaviors
these diagnostic outcome studies have followed and activities predicted an autism diagnosis at
cohorts of children from initial diagnostic assess- age 9 years. In some of these more recent studies,
ments around the age of 2 years into the preschool there was greater movement from having an ASD
years and in several of the more recent studies diagnosis at age 2 years to a non-spectrum diag-
(Charman et al., 2005; Lord et al., 2006; Turner, nosis at age 4 (Kleinman et al., 2008; Turner &
Stone, Pozdol, & Coonard, 2006) into the school Stone, 2007). While the authors report the factors
age years. The first series of studies (Cox et al., associated with these “good outcomes” – princi-
1999; Lord, 1995; Moore & Goodson, 2003; pally higher IQ and better language competency
Stone et al., 1999) all showed high stability of – it is important to remain cautious regarding
diagnosis in particular for “core” autism, with predictors of poorer or better outcomes in chil-
somewhat lower stability for broader autism dren diagnosed at such a young age.
spectrum disorder (ASD) and pervasive
developmental disorder not otherwise specified
(PDD-NOS). The movement across the ASD/ Future Directions
PDD-NOS diagnostic category boundary was
somewhat different in the different studies, with For clinicians, the lesson is to accept that autism
Stone et al. (1999) finding that 4 out of 12 chil- is a developmental disorder and at a very young
dren who met broader ASD criteria at the initial age, there may be less certainty regarding the
assessment did not meet criteria for an autism pattern of behavior that a child is showing and
spectrum disorder at follow-up, whereas Cox the likelihood of them continuing to meet diag-
et al. (1999) found that 7 from 31 children who nostic criteria into the future. Charman and Baird
did not receive an autism spectrum diagnosis at (2002) discuss the importance of understanding
the initial assessment met criteria for broader the diagnostic process as an iterative process to
ASD at follow-up. Several of the early studies be worked out between clinician teams and
(Cox et al., 1999; Lord, 1995; Stone et al., 1999) parents over time and that concepts such as
concluded that for 2-year-olds, expert clinical a “working diagnosis” can be helpful. An
Early Diagnosis 1027 E
important aspect of early diagnostic consultation in-depth assessment, low IQ predicted those who
is an open and straightforward approach to the had not received a clinical diagnosis by local
negotiation of the diagnostic view with parents clinical services by age 10 years.
over time. At the same time, clinical teams need One final caveat is that the studies summarized
to be aware of the need to provide sufficient have largely come from expert research clinical
certainty regarding the child’s condition centers specifically studying young cohorts of
that they are not refused services following children. In community settings in many coun-
assessment. tries, there is evidence including from recent
Clinical work is often concerned with those studies that for many children and their families,
children who do not clearly meet full criteria for a diagnosis is not confirmed until children are
E
childhood autism but who have apparently milder well into the school age years and this has
social problems or where there are mixed devel- implications for the training of community
opmental difficulties. Clinical experience also practitioners (Wiggins, Baio, & Rice, 2006).
suggests that some children who show definite
features of autism earlier make remarkable devel-
opmental progress. Therefore, caution must be
used, especially under 3 years, for those children See Also
with features of the broader autistic spectrum
who may attract a PDD diagnosis. Experienced ▶ Diagnosis and Classification
clinicians report that parents understand the ▶ Diagnostic Process
difficulties of certainty in developmental assess-
ment. Most appreciate honesty on professionals’
part about the difficulty of reaching a precise References and Readings
prognosis on a very young child and can under-
stand a frank discussion about the possible American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders (4th Ed. –
outcomes if accompanied by appropriate advice
Text Revision) (DSM-IV-TR). Washington, DC:
and help for intervention. Understanding why Author.
one’s child behaves as he or she does is half Baird, G., Simonoff, E., Pickles, A., Chandler, S., Loucas,
way to doing something about it. T., Meldrum, D., et al. (2006). Prevalence of disorders
of the autism spectrum in a population cohort of chil-
One other important clinical reminder is that
dren in South Thames: The Special Needs and Autism
while the trajectory of early emerging impair- Project (SNAP). Lancet, 368, 210–215.
ments in social and communication development Barbaro, J., & Dissanayake, C. (2009). Autism spectrum
accompanied by rigid and repetitive behaviors disorders in infancy and toddlerhood: A review of the
evidence on early signs, early identification tools, and
and interests characterizes many children on the
early diagnosis. Journal of Developmental and Behav-
autism spectrum, there is a subgroup of particu- ioral Pediatrics, 30, 447–459.
larly verbal and able children who go on to Charman, T., & Baird, G. (2002). Practitioner review:
receive a diagnosis of autism (sometimes called Diagnosis of autism spectrum disorder in 2-and
3-year-old children. Journal of Child Psychology and
“high functioning autism”) or Asperger syn-
Psychiatry and Allied Disciplines, 43, 289–305.
drome who may not receive a diagnosis in the Charman, T., Taylor, E., Drew, A., Cockerill, H., Brown,
preschool years. There is also another group who J. A., & Baird, G. (2005). Outcome at 7 years of
might meet diagnostic criteria for an autism spec- children diagnosed with autism at age 2: Predictive
validity of assessments conducted at 2 and 3 years
trum disorder who do not receive an explicit of age and pattern of symptom change over time.
diagnosis – those individuals with moderate to Journal of Child Psychology and Psychiatry, 46,
severe intellectual disability or those with an 500–513.
already identified preexisting associated medical Chawarska, K., Klin, A., Paul, R., Macari, S., & Volkmar,
F. (2009). A prospective study of toddlers with ASD:
condition. In a recent epidemiological study,
Short-term diagnostic and cognitive outcomes. Jour-
Baird et al. (2006) found that for cases meeting nal of Child Psychology and Psychiatry, 50,
research diagnostic criteria for an ASD following 1235–1245.
E 1028 Early Intensive Behavioral Intervention (EIBI)
Cox, A., Klein, K., Charman, T., Baird, G., Baron-Cohen, Turner, L. M., Stone, W. L., Pozdol, S. L., & Coonard,
S., Swettenham, J., et al. (1999). Autism spectrum E. E. (2006). Follow-up of children with autism spec-
disorders at 20 and 42 months of age: Stability of trum disorders from age 2 to age 9. Autism, 10,
clinical and ADI-R diagnosis. Journal of Child Psy- 243–265.
chology and Psychiatry, 40, 719–732. Volkmar, F. R., State, M., & Klin, A. (2009). Autism and
Dawson, G. (2008). Early behavioral intervention, brain autism spectrum disorders: Diagnostic issues for the
plasticity, and the prevention of autism spectrum disor- coming decade. Journal of Child Psychology and Psy-
der. Development and Psychopathology, 20, 775–803. chiatry, 50, 108–115.
Howlin, P., & Asgharian, A. (1999). The diagnosis of Wiggins, L. D., Baio, J., & Rice, C. (2006). Examination
autism and Asperger syndrome: Findings from of the time between first evaluation and first autism
a survey of 770 families. Developmental Medicine spectrum diagnosis in a population-based sample.
and Child Neurology, 41, 834–839. Journal of Developmental and Behavioral Pediatrics,
Johnson, C. P., Myers, S. M., & The American Academy of 27, S79–S87.
Pediatrics Council on Children with Disabilities. (2007). World Health Organisation. (1993). Mental disorders:
Identification and evaluation of children with autism A glossary and guide to their classification in accor-
spectrum disorders. Pediatrics, 120, 1183–1215. dance with the 10th revision of the International Clas-
Kleinman, J. M., Ventola, P. E., Pandey, J., Verbalis, sification of Diseases: Research Diagnostic Criteria
A. D., Barton, M., Hodgson, S., et al. (2008). Diagnos- (ICD-10). Geneva: Author.
tic stability in very young children with autism Yirmiya, N., & Charman, T. (2010). The prodrome of
spectrum disorders. Journal of Autism and Develop- autism: Early behavioral and biological signs, regres-
mental Disorders, 38, 606–615. sion, peri- and post-natal development and genetics.
Lord, C. (1995). Follow-up of two-year-olds referred for Journal of Child Psychology and Psychiatry, 51,
possible autism. Journal of Child Psychology and 432–458.
Psychiatry and Allied Disciplines, 36, 1365–1382.
Lord, C., Risi, S., DiLavore, P. S., Shulman, C., Thurm,
A., & Pickles, A. (2006). Autism from 2 to 9 years of
age. Archives of General Psychiatry, 63, 694–701.
Mandell, D. S., Novak, M. M., & Zubritsky, C. D. (2005). Early Intensive Behavioral
Factors associated with age of diagnosis among Intervention (EIBI)
children with autism spectrum disorders. Pediatrics,
116, 1480–1486.
Manning, S. E., Davin, C. A., Barfield, W. D., Kotelchuck,
Susan Hepburn
M., Clements, K., Diop, H., et al. (2011). Early diag- Department of Psychiatry & Pediatrics,
noses of autism spectrum disorders in Massachusetts JFK Partners, University of Colorado at Denver,
birth cohorts, 2001–2005. Pediatrics, 127, 1043–1051. Aurora, CO, USA
Moore, V., & Goodson, S. (2003). How well does early
diagnosis of autism stand the test of time? Follow-up
study of children assessed for autism at age 2 and devel-
opment of an early diagnostic service. Autism, 7, 47–63. Definition
Mundy, P., Sullivan, L., & Mastergeorge, A. M. (2009).
A parallel and distributed- processing model of joint
attention, social cognition and autism. Autism
Early intensive behavioral intervention (EIBI) is
Research, 2, 2–21. a treatment approach that is based upon the
Rogers, S. J. (2009). What are infant siblings teaching us principles of applied behavior analysis (ABA)
about autism in infancy? Autism Research, 2, 125–137. and the research of Ivar Lovaas and colleagues
Rondeau, E., Klein, L. S., Masse, A., Bodeau, N., Cohen,
D., & Guile, J. M. (2011). Is pervasive developmental
at the UCLA Young Autism Project. The EIBI
disorder not otherwise specified less stable than autis- approach has been extensively studied
tic disorder? A meta-analysis. Journal of Autism and and actively debated in the scientific literature,
Developmental Disorders, 41, 1267–1276. popular media, and policy arena.
Stone, W. L., Lee, E. B., Ashford, L., Brissie, J.,
Hepburn, S. L., Coonrod, E. E., et al. (1999). Can
autism be diagnosed accurately in children under 3
years? Journal of Child Psychology and Psychiatry Historical Background
and Allied Disciplines, 40, 219–226.
Turner, L. M., & Stone, W. L. (2007). Variability in
outcome for children with an ASD diagnosis at age 2.
Developed by Lovaas and colleagues across
Journal of Child Psychology and Psychiatry, 48, several years of research and development at the
793–802. University of California–Los Angeles, the EIBI
Early Intensive Behavioral Intervention (EIBI) 1029 E
approach has been extensively studied and different aspects of instruction. (8) Teaching strat-
actively debated in the scientific literature, popu- egies are then dynamically revised based upon this
lar media, and policy arena. Influenced by theo- analysis, (9) implemented consistently across
ries of learning and motivation, practitioners of providers, and (10) evaluated again for effective-
EIBI refer to it as “the science of teaching.” ness by monitoring the child’s trajectory of skill
acquisition. The built-in evaluation system
enables families and providers to make dynamic
Rationale or Underlying Theory decisions about how and where to modify
approaches, as the child progresses and/or faces
Applied behavior analysis is the overarching new challenges. Young children participating in
E
philosophy underlying EIBI. Integrating princi- this treatment usually spend 6–8 h per day
ples from learning theory, operant conditioning, in treatment sessions, with breaks every 2–3 h.
behavioral economics, and motivational theory, Often, the sessions happen in the child’s home.
proponents of EIBI value the power of changing
aspects of the teaching context in order to
promote child gains. By providing systematic, Efficacy Information
direct instruction in an intensive manner
(i.e., 30–40 h per week, 1:1 with an adult), There is a debate between the proponents and
proponents of EIBI suggest that young children critics of the effectiveness research documenting
with autism can improve significantly. EIBI, as summarized below (see References and
Readings).
Treatment Participants Proponents’ View

1. Meta-analytic methods (i.e., statistically
Early intensive behavioral intervention (EIBI) is analyzing all available data across several dif-
a treatment approach that is thought to benefit ferent studies) and comprehensive scientific
children with autism who are younger than reviews support the effectiveness of EIBI for
5 years of age. Developers of the intervention some, but not all, children (Eldevik et al.,
emphasize the importance of beginning when 2011; Howlin, Magiati, & Charman, 2009;
a child is as young as possible, hopefully younger Matson & Smith, 2007; Peters-Scheffer
than 3 1/2 years. et al., 2011; Reichow & Wolery, 2009).
There is some evidence that children who are 2. Many of the teaching strategies used in EIBI
more intellectually competent respond best to are evidence-based (National Standards
EIBI. Project, 2010), including discrete trial train-
ing, frequent reinforcement, and ongoing
assessment of child behavior.
Treatment Procedures
Critics’ Views of EIBI
Based upon the principles of applied behavior 1. It can be difficult to implement an intensive
analysis (ABA), an EIBI program usually includes treatment model for many families, both with
these characteristics: (1) active engagement of the regard to time, family stress, and financial
child for 40 + h per week in (2) planful interven- resources (Gresham & MacMillan, 1998;
tion, (3) delivered primarily in direct, 1:1 child- Schopler, Short & Mesibov, 1989).
adult instruction (4) with specific individual goals, 2. Some of the studies that are in the literature
(5) carefully operationalized instructional objec- do not demonstrate a lot of improvement, and
tives and procedures, and a (6) data collection it is difficult to know which children will
system to promote objective observation and respond best to this particular model of
(7) analysis of a child’s behavioral responses to intervention.
E 1030 Early Intensive Behavioral Intervention (EIBI)
3. Some researchers are critical of features of the Siegel, 1998; Smith, Groen & Wynn, 2000).
studies which are frequently cited as demon- There is some evidence that children who
strative of effectiveness of EIBI (i.e., Lovaas, are more intellectually competent respond
1987; McEachin et al., 1993; Smith et al., best to EIBI.
2000). For example, some early outcome stud- 2. Several studies examined school placement
ies reported a return to normal functioning for and report that children receiving EIBI
a substantial number of children (Lovaas, were likely to be fully included in general
1987), which has been refuted by other scien- education classrooms at first grade (Sallows
tists (Shea, 2004). Some researchers have & Graupner, 2005).
expressed caution in interpreting the findings
for effectiveness of EIBI, in part due to the
ways the outcomes were measured and how Qualifications of Treatment Providers
decisions about group membership were
made, issues of sample size, variability of EIBI is most effective when delivered and
characteristics of children across studies, lack supervised by a team of well-trained profes-
of intervention fidelity across sites, and some sionals (Bibby et al., 2001; Smith et al., 2000).
inconsistent findings in studies conducted at EIBI teams tend to be multidisciplinary, with
replication sites (Bassett et al., 2000; Gresham team members who are certified behavior ana-
& MacMillan, 1997a, b; Howlin et al., 2009; lysts, speech therapists, educators, occupational
Myers et al., 2007; Spreckley & Boyd, 2008). therapists, and paraprofessionals.
4. Developmentally oriented practitioners
suggest that the curricula are not sequenced/
implemented in a way that is consistent with
principles of effective early childhood See Also
education.
5. Prioritizing 1:1 direct instruction with the ▶ Applied Behavior Analysis
child usually means foregoing instruction in ▶ Direct Instruction
group settings (i.e., preschool), and the child ▶ Lovaas Approach
may lack opportunities to learn social and ▶ UCLA Young Autism Project
communication skills in real-life settings
with other children.
6. Some children become passive learners, coop-
erative in instructional sessions but not able to References and Readings
spontaneously practice the targeted skill in
natural settings. Scientific Studies Examining Effectiveness
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G.,
7. Parent and family involvement is not neces- & Stanislaw, H. (2005). A comparison of intensive
sarily a part of the intervention program. behavior analytic and eclectic treatments for young
children with autism. Research in Developmental
Disabilities, 26, 359–383.
Lovaas, O. I. (1987). Behavioral treatment and normal
Outcome Measurement educational and intellectual functioning in young
autistic children. Journal of Consulting and Clinical
1. Many young children make significant gains Psychology, 55, 3–9.
in overall developmental functioning with Sallows, G. O., & Graupner, T. D. (2005). Intensive
behavioral treatment for children with autism: Four-
this approach, with improvements in IQ year outcome and predictors. American Journal on
scores ranging from 15 to 25 points after 2 Mental Retardation, 110, 417–438.
years of intensive intervention during early
childhood (see Fenske et al., 1985; Lovaas, Critiques of EIBI
1987; McEachin et al., 1993; Sheinkopf & Shea, V. (2004).
Early Intervention 1031 E
Publications That Review EIBI and Other Early statewide EI program in Connecticut is often
Intervention Programs referred to by parents and professionals as
Harris, S. L., & Handleman, J. S. (2001). Preschool edu- “Birth-to-three,” while those in Georgia use the
cation programs for children with autism (2nd ed.,
program name “Babies Can’t Wait.” EI programs
pp. 23–39). Austin, TX: Pro-Ed.
National Research Council, Committee on Educational receive both federal and state funding, in order to
Interventions for Children with Autism. (2008). Edu- offer services to families free of charge.
cating children with autism. Washington, DC: To be eligible for services, children must be
National Academy Press.
less than 3 years of age and have a confirmed
Vismara, L.A. & Rogers, S.J. (2007). Early intervention:
Teaching approaches with demonstrated success. disability or established developmental delay, as
defined by their state of residence, in one or more
Autism Advocate, 48, Autism Society of America.
E
of the following areas of development: cognitive,
Books for Parents communication, social-emotional, motor skills,
Maurice, C., Green, G., & Luce, S. L. (1996). Behavioral and/or adaptive skills.
intervention for young children with autism: A manual
Following developmental evaluation to deter-
for parents and professionals. Austin, TX: Pro-Ed.
mine eligibility, services are typically delivered
to children in their home, or within community
Websites
http://www.autismspeaks.org/whattodo/index.php and center-based programs, or other natural envi-
For a list of questions to ask about treatments: http://www. ronments. EI service providers include special
nimh.nih.gov/health/publications/autism/treatment- educators, social workers, speech therapists,
options.shtml
physical therapists, occupational therapists,
nurses, psychologists, and nutrition specialists.
EI programming may also be provided to chil-
Early Intervention dren who are considered to be at risk of develop-
ing substantial delays if services are not provided.
Moira Lewis The following are considered overarching
Speech-Language Pathologist, Marcus Autism goals of EI: to reduce the likelihood of delays
Center Children’s Healthcare of Atlanta, Atlanta, among at-risk children, support improved out-
GA, USA comes and independence among children with
developmental disabilities throughout the
lifespan, empower and educate families, and to
Synonyms provide intervention to children, regardless of
race, ethnicity, or income.
Birth-to-three; EI; Early intervention
See Also
Definition
▶ Early Diagnosis
Early intervention (EI) refers to publicly funded ▶ First Words Project
programs available to infants and toddlers with
disabilities and their families, through the Indi-
viduals with Disabilities Education Act (IDEA),
first authorized by congress in 1986. EI programs
offer specialized health, educational, and thera- American Speech-Language-Hearing Association.
peutic services designed to meet the needs of (2008). Roles and responsibilities of speech-language
children, from birth up until age 3, who have pathologists in early intervention: Guidelines
(Guidelines). Retrieved from www.asha.org/policy
a developmental delay or disability, and their Matson, J. L., & Minshawi, N. F. (2006). Early interven-
families. EI programs often have various names tion for autism spectrum disorders: A critical analysis.
among different states. For example, the Oxford, UK: Elsevier.
E 1032 Early Language Milestone Scale
National Dissemination Center for Children with Disabil- Psychometric Data

ities, Help for Babies (0–3) (n.d.). Overview of early
intervention. Retrieved from: http://www.nichcy.org/
babies/overview/Pages/default.aspx The measure has a relatively small normed sam-
National Dissemination Center for Children with ple of under 200 children under 3 years of age
Disabilities (n.d.). State specific information. with no breakdown by age within the sample.
Retrieved from: http://www.nichcy.org/Pages/ Eighty percent of the sample is classified as
StateSpecificInfo.aspx
white and 20% is classified as “nonwhite.” Eighty
percent of the sample is classified as middle-class
socioeconomic background and 20% from
“lower” socioeconomic background groups. The
Early Language Milestone Scale manual reports higher inter-rather reliability, but
lower test-retest specificity. Concurrent validity
Moira Lewis data reported supports the use of the ELMS-2 as
Speech-Language Pathologist, Marcus Autism a screening instrument, to be completed prior
Center Children’s Healthcare of Atlanta, to a more thorough communication assessment,
Atlanta, GA, USA if warranted. Although specificity is high,
suggesting the measure is valid for identifying
24-month-old children who have normal
Synonyms language development, sensitivity is lower, so
that it may be less useful for identifying children
Early language milestone scale-2; ELM scale-2 with the possibility of language delay.
Clinical Uses
Description
This test is quick and easy to administer with little
The Early Language Milestone Scale-2 (ELM training. Aside from standardized, comprehen-
Scale-2) was developed for use in pediatric clin- sive language assessments administered by
ical settings as a brief screening of the language trained speech-language pathologist, the ELM
abilities of children under the age of 3 years Scale-2 can be administered by other medical
(Coplan, 1993). Responses are obtained from and healthcare practitioners in pediatric clinical
a combination of parental/caregiver report, settings and early intervention settings.
examiner observation, and direct testing. This The ELM Scale-2 contains scoring options, as
assessment has three sections: auditory expres- it may be administered using a “pass/fail” or
sive, auditory receptive, and visual. It also a point scoring method. The pass/fail method
provides screening for speech intelligibility yields a global pass or fail rating for the test as
(how understandable the child’s speech is) at a whole, whereas the point scoring yields percen-
3–4 years of age. The instrument is composed of tile values, standard scores, and age equivalents
43 items and takes approximately 10 min to for each area of language function mentioned
administer. The ELM Scale-2 is available in above. Its properties suggest it is a viable screen-
English only. ing measure; however, due to the small and lim-
ited normative sample, standard scores provided
for the ELM Scale-2 must be used with caution.
Historical Background See Also
The ELM Scale-2 was published in 1993, ▶ Expressive Language

authored by James Coplan, M.D. ▶ Receptive Language
Early Social-Communication Scales (ESCS) 1033 E
References and Readings Description
Coplan, J. (1993). Early language milestone scale-2. The Early Social Communication Scales is
Austin, TX: Pro-Ed.
a structured assessment designed to provide
Paul, R., & Lewis, M. (2007). Assessing communication
disorders. In A. Martin, F. Volkmar, & M. Lewis (Eds.), measures of individual differences in nonverbal
Child and adolescent psychiatry (pp. 371–376). communication skills in children with mental
New York: Guilford Press. ages between 8 and 30 months of age. The admin-
istration requires 15–25 min involving the
presentation of approximately 17 tasks which
provide opportunities for social communication.
E
Tasks include the presentation of object spectacle
Early Language Milestone Scale-2 toys (e.g., a wind-up toy), turn-taking tasks (e.g.,
ball play), social interaction (e.g., tickling), gaze
▶ Early Language Milestone Scale
following tasks, and opportunities to respond to
an invitation to play. The child is typically seated
across the table from the examiner, and may
be either seated in a chair or seated in their
Early Literacy parent’s lap.
The session is videotaped and from the record-
▶ Emergent Literacy ings, observers classify children’s behaviors into
the following mutually exclusive categories
of early social-communication: joint attention
behaviors (use of nonverbal behaviors to share
experiences), behavioral requests (use of nonver-
Early Multiword Utterances bal behavior to obtain objects or events), and
social interaction behaviors (ability to engage in
▶ Telegraphic Speech playful turn-taking behavior). These behaviors
are also classified based on whether or not they
are child-initiated bids or child responses to the
examiner.
Early Social Communication

▶ Preverbal Communication
The ESCS was first developed in 1982 and from
a Piagetian stage–based understanding of early
development, emphasizing the complexity of
a child’s social communicative skills within the
Early Social-Communication Scales
context of a child’s goals with a behavior (either
(ESCS)
communicative or interpersonal). In the previous
version, a set of 25 semi-structured situations
Amanda Steiner
were utilized to elicit social communication,
with approximately 110 possible occurrences of
child behavior rated in terms of its complexity,
goal, and degree of initiation. The current
Synonyms abridged version of the ESCS was designed to
be utilized as a more practical research and
ESCS clinical tool.
E 1034 Early Stanford-Binet, Fifth Edition (Early SB5)
Psychometric Data References and Readings
Several research studies have been conducted Mundy, P., Delgado, C., Block, J., Venezia, M., Hogan,
A., & Seibert, J. (2003). A manual for the abridged
exploring the performance of typically develop-
early social communication scales. Coral Gables, FL:
ing children and children with developmental University of Miami.
disabilities on the ESCS as well as the reliability Mundy, P., & Gomes, A. (1998). Individual differences in
of the instrument. In addition, preliminary joint attention skill development in the second year.
Infant Behavior and Development, 21, 469–482.
normative information is available within the
Mundy, P., Kasari, C., Sigman, M., & Ruskin, E. (1995).
ESCS manual (Mundy et al., 2003). In typical Nonverbal communication and language development
populations, performance in responding to joint in children with Down syndrome and children with
attention on the ESCS between 14 and 17 months normal development. Journal of Speech and Hearing
Research, 38, 1–11.
was a significant predictor of subsequent recep-
Mundy, P., Sigman, M., & Kasari, C. (1990).
tive language development (Mundy & Gomes, A longitudinal study of joint attention and language
1998). Research has been conducted on the development in autistic children. Journal of Autism
ESCS across several clinical populations, includ- and Developmental Disorders, 20, 115–128.
Mundy, P., Sigman, M., & Kasari, C. (1994). Joint
ing children with Down syndrome (Mundy,
attention, developmental level, and symptom presen-
Kasari, Sigman, & Ruskin, 1995; Mundy, tation in young children with autism. Development and
Sigman, Kasari, & Yirmiya, 1988) and also Psychopathology, 6, 389–401.
infants at risk (Sheinkopf, Mundy, Claussen, & Mundy, P., Sigman, M., Kasari, C., & Yirmiya, N. (1988).
Nonverbal communication skills in Down syndrome
Willoughby, 2004). In terms of ASD, research
children. Child Development, 59, 235–249.
suggests that children with ASD tended to Sheinkopf, S., Mundy, P., Claussen, A., & Willoughby, J.
demonstrate the greatest deficits in joint attention (2004). Infant joint attention skill and preschool
behaviors on the ESCS, although difficulties were behavioral outcomes in at-risk children. Development
and Psychopathology, 16, 273–291.
noted across all areas of nonverbal communica-
tion for children on the spectrum (Mundy,
Sigman, & Kasari, 1994). Moreover, children
with ASD displayed greater deficits in gestural
joint attention skills, and these skills significantly Early Stanford-Binet, Fifth Edition
predicted language development in children with (Early SB5)
ASD (Mundy, Sigman, & Kasari, 1990).
▶ Stanford-Binet Intelligence Scales and
Revised Versions
Clinical Uses
The ESCS is largely utilized as a research tool (as

it requires detailed offline scoring); however, it Early Start Denver Model
can also be used as a clinical tool by speech-
language pathologists, early childhood special- Sally J. Rogers
ists, and psychologists, as well as other profes- Department of Psychiatry and Behavioral
sionals trained to administer the assessment in Sciences, UC Davis M.I.N.D. Institute,
the context of a diagnostic or developmental Sacramento, CA, USA
evaluation.
Definition
See Also
The Early Start Denver Model (ESDM) is
▶ Joint Attention a comprehensive early intervention for toddlers
▶ Nonverbal Communication with autism ages 12–48 months. The model
Early Start Denver Model 1035 E
resulted from the collaboration of Sally Rogers providers; and (3) in group programs that can pro-
and Geraldine Dawson and their colleagues at the vide individual support to a child.
University of Washington Autism Center, with
Rogers’ colleagues, especially Laurie Vismara, at
the University of California, Davis, and at JFK Historical Background
Partners, University of Colorado Health Sciences
Center. The approach is manualized and Development of the Denver Model (DM) began
described in detail by Rogers and Dawson (2010). at the University of Colorado Health Sciences
The ESDM and the Denver Model (DM) that Center in 1981, in response to demonstration
preceded it were developed to target the core preschool funding from the US Department of
E
deficits seen in toddlers and preschoolers with Education. The DM had a developmental and
autism: social orientation, attention, affect shar- pragmatic approach to language acquisition and
ing and attunement, imitation, joint attention, emphasis on learning through play and through
language development, and functional and sym- positive, lively relationships. An interdisciplin-
bolic play. The ESDM has an interactive commu- ary strategy, including a strong role of occupa-
nication- and relationship-based framework that tional therapy, positive behavior supports, and
fosters active experiential learning by supporting a central role of parents, has persisted. The cur-
child spontaneity and initiative. It has riculum tool was begun during this period and
a developmental curriculum which incorporates enhanced and extended for toddlers in the ESDM.
teaching techniques that have received empirical The DM expanded into an approach suitable for
support for improving skill acquisition. use as a 1:1 home-based program during the 1990s.
The ESDM is based on a fusion of the Denver Replications in publically funded sites demon-
Model, an affective and developmentally-based strated that the model could be implemented in
intervention for children (ages 2–5) with autism community settings and that child development
(Rogers, 2000); the nature of the teaching interac- significantly accelerated with its use.
tions and the curricular priorities are influenced by Significant enhancements of the model
Stern’s model of infant interpersonal development occurred in the past 10 years, including more
(Stern, 1985) and pivotal response training (PRT), rigorous definitions of delivery and measurement
developed by Laura Schreibman and Robert and and data collection procedures when the Univer-
Lynn Koegel (Koegel et al., 1989). PRT involves sity of Washington tested the approach in
a naturalistic application of applied behavior anal- a randomized controlled trial with a focus on
ysis (ABA) to develop language and social skills. toddlers (Dawson et al., 2010).
The main differences between ESDM and DM
involve (1) focus on toddlers ages 12–48 months in
the ESDM; (2) fusion of practices and principles of Rationale or Underlying Theory
PRT with those of the DM; (3) added concept and
explicit terminology from applied behavior analy- Three theoretical models provide the foundations
sis; (4) more rigorous and defined measurement for the ESDM curriculum and teaching practices.
practices; and (5) a well-defined curriculum appro- These include Rogers and Pennington’s model of
priate for children 12–48 months of age. interpersonal development in autism (Rogers &
The ESDM and DM have been tested in class- Pennington, 1991), Dawson and colleagues’
room applications, in one-on-one delivery, in inten- model of autism as a disorder of social motivation
sive delivery of 15–20 hours a week, and via parent (Dawson et al., 2004), and the approach to learn-
delivery. The approach is flexible and designed to ing defined by PRT (Schreibman & Pierce, 1993).
be used (1) at home, embedded within typical play Rogers and Pennington (1991) hypothesized
and caretaking activities, and in child care and a developmental model of autism that began with
preschool settings; (2) in 1:1 treatment sessions biologically-based deficits in imitation abilities
including parent coaching provided by credentialed and related impairments in emotional sharing
E 1036 Early Start Denver Model
and nonverbal communication in the first year of motivation, spontaneity, and social initiation and
life. The authors were influenced by Daniel of improved language, maintenance and response
Stern’s 1985 model of interpersonal development generalization, and for concomitant reductions in
in infancy. This model presents a theory unwanted behaviors. Child motivation is optimized
concerning autism-specific impairments in three by the use of reinforcers related to the child’s goals
developmentally critical behaviors – imitation, and responses and child choice, interspersing
emotion sharing, and joint attention. A main acquired tasks with acquisition tasks, therapist rein-
focus of the ESDM is to address these critical forcement of attempts to perform the desired
behaviors within affectively rich relationships behavior, and using activities that are highly moti-
with responsive, sensitive others. vating to the child. Therapists take turns with the
The ESDM has been influenced by research on child to share control of the interaction, to capture
another core feature of autism: impaired social child attention, and to model behavior that may not
motivation. Dawson and colleagues (Dawson be in the child’s repertoire.
et al., 2004, 2005) have contributed to identifying These three orientations have in common the
this characteristic in infants who will develop view that autism impedes an infant’s interper-
autism, and they hypothesize that the biology of sonal experiences. In so doing, it creates barriers
autism involves a deficiency in social motivation to social-communicative development, which
due to the infant’s lack of sensitivity to social lead to greater impairments due to the loss of
reward. This lack of sensitivity results in social learning opportunities.
a failure to have a normal preference and active
attention to social information, including others’
faces, voices, gestures, and speech. This failure, Goals and Objectives
combined with impairments in imitation, emo-
tional sharing, and joint attention, is an obstacle Goals and Objectives
to the child’s development of socio-emotional The goal of ESDM intervention is to increase child
and communicative skills. As a result, the child social-communicative and relational learning. The
with autism becomes increasingly removed from main intervention objectives are (1) to bring the
the social world and all the learning experiences child into coordinated, interactive social relations
that exist inside that world. The child falls farther for most of his or her waking hours by supporting
behind because he or she lacks the skills needed all caregivers and therapists to embed ESDM tech-
to access the social learning environment. niques into all daily activities; (2) to provide the
Dawson and colleagues have suggested that this child with social learning tools involving imita-
lack of engagement not only alters the course of tion, joint attention, language, and social play
behavioral development but also affects the way through teaching inside all daily activities; and
neural systems, underlying the perception and (3) to embed a high frequency of specific dyadic
representation of social and linguistic informa- learning opportunities in each activity of daily life
tion, are developed and organized (Dawson, and also into each intervention activity to “fill in”
2008). Several of the strategies utilized in the the learning deficits that have resulted from the
ESDM are designed to increase the salience of past lack of social learning (Rogers, 2000). These
social rewards and enhance the child’s attention goals and objectives are accomplished with the
and motivation for social interaction. following ESDM guiding principles:
PRT involves a naturalistic use of applied (a) A positive emotional exchange between chil-
behavior analysis to develop language and social dren and key adults. ESDM intervention
skills. The approach is flexible and is designed to be activities involve a series of play routines
embedded within typical play and caretaking which facilitate the child’s pleasure and
activities at home and in child care and preschool social engagement and create many opportu-
settings. PRT is an empirically supported practice, nities for shared affect and reciprocal
given its documentation of enhanced child interactions.
Early Start Denver Model 1037 E
(b) Joint activity routines (Ratner & Bruner, In each intervention session, multiple and
1978) are the primary vehicle for teaching, varied communicative opportunities are pro-
and the teaching episodes are carried out vided and many communications, both ver-
inside this joint activity frame. The play bal and nonverbal, are elicited from the child.

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Encyclopedia of Autism

With 100 Figures and 131 Tables

ISBN 978-1-4419-1697-6 ISBN 978-1-4419-1698-3 (eBook)

Library of Congress Control Number: 2012949356

# Springer Science+Business Media New York 2013

Printed on acid-free paper

Springer is part of Springer ScienceþBusiness Media (www.springer.com)

Why an encyclopedia of autism? There are several answers to this question.

New Haven, Connecticut Fred R. Volkmar MD

A work of this complexity and scope is the product of considerable work by

Fred R. Volkmar, M.D. – Editor

Fred R. Volkmar, M.D., is Irving B. Harris Professor of Child Psychiatry,

Nirit Bauminger School of Education, Bar - Illan University, Ramat-Gan,

Susan Hyman University of Rochester, Golisano Children’s Hospital,

Tristram H. Smith Department Pediatrics, SCDD, University of Rochester

Karen Aalst University Utrecht, Utrecht, The Netherlands

Elizabeth Archer Department of Psychology, Virginia Commonwealth

Erin E. Barton University of Colorado Denver, Denver, CO, USA

Linas Bieliauskas Departments of Psychology and Psychiatry, University

Dorothy Bishop Department of Experimental Psychology, University of

Somer Bishop Cincinnati Children’s Hospital Medical Center, Cincinnati,

Vicki Bitsika Faculty of Humanities and Social Sciences, Bond University,

Amanda Blackwell School of Behavioral and Brain Sciences, Callier Cen-

Laura Bonazinga Vermont Speech Language Pathology Private Practice

Alex Bonnin Keck School of Medicine, University of Southern California,

Susan Y. Bookheimer Department of Psychiatry and Biobehavioral

Hilary Boorstein Children’s Mercy Hospital, Kansas,

Jill Boucher Developmental Psychology, Autism Research Group,

Linda Bowers LinguiSystems, Inc, East Moline, IL, USA

Dermot Bowler Autism Research Group, City University London, London,

Jessica Bradshaw Clinical Psychology, UCSB Koegel Autism Center,

John Bradshaw Faculty of Medicine, Nursing and Health Sciences,

Jennifer Brielmaier Laboratory of Behavioral Neuroscience, National

Nicolette Bainbridge Brigham Vanderbilt Kennedy Center, Treatment and

Erik Bromberg University of California, Santa Barbara, USA

Rechele Brooks Psychiatry and Behavioral Sciences, University of

Christi Carnahan University of Cincinnati, Cincinnati, OH, USA

Keith A. Coffman Department of Pediatrics, School of Medicine, Pitts-

Catherine Davies Indiana Resource Center for Autism Indiana University,

Elizabeth Howell Dohrmann Vanderbilt Kennedy Center, Treatment and

Stephen N. Elliott Learning Sciences Institute, Arizona State University,

Paul El Fishawy State Lab, Yale University Child Study Center,

Faye van der Fluit Department of Psychology, University of Wisconsin,

Renee Folsom Semel Institute for Neuroscience and Human Behavior,

Joy Fopiano Department of Elementary Education, Southern Connecticut

Danielle Forbes Psychology, University of Massachusetts Boston, Boston,

Stephanny Freeman Center for Autism Research and Treatment (CART),

Cori Fujii Division of Psychological Studies in Education, University of

Maria Fusaro Department of Psychiatry and Behavioral Sciences, UC

Cheryl Smith Gabig Department of Speech-Language-Hearing Sciences,

Sebastian Gaigg Autism Research Group, City University London, London,

Grace Gengoux Child and Adolescent Psychiatry, Stanford University

Danielle Geno The College of Arts and Sciences, The University of

Sima Gerber Department of Linguistics & Communication Disorders,

Jennifer Varley Gerdts Department of Psychology, University of Wash-

Ahmad Ghanizadeh Shiraz University of Medical Sciences, School of

Mohammad Ghaziuddin University of Michigan, Ann Arbor, MI, USA

Tobi Gilbert Quinnipiac University School of Law, Hamden, CT, USA

Christopher Gillberg Department of Child and Adolescent Psychiatry,

Walter Gilliam Child Study Center, Yale University School of Medicine,