Aveneu Park, Starling, Australia

Introduction:Developmental individual variability and co-occurrence with other psychopathological conditions.

Psychopathology (DPP) is an approach which assesses psychological problems in
the context of human development, specifically using a broader understanding of
definitions, causes, treatments, and outcomes in order to predict human growth
and maturation (Cicchetti & Toth, 1995). The process of development is
defined by cognitive, social, emotional and biological maturation, and the
level of development is typically dependent on chronological age, though
development does not occur at a steady rate nor is it homogeneous (i.e. the
same for everyone). Children and adolescents develop skills and behaviours at
varying intervals and paces, though an extreme divergence from expected
development is where problem behaviours and symptoms of psychopathology tend to
emerge. Hence, an atypical or “abnormal” development can be used as an
indicator of childhood psychopathology, and can facilitate the prediction of
future behavioural outcomes – otherwise known as a psychopathological “prognosis”.
The overall goal of DPP is therefore to develop and evaluate methods of
preventing or improving maladaptive behaviours, using an understanding of
psychopathology across the life span (Cicchetti & Toth, 2009).                                                                                    The DPP perspective
emphasises the importance of normative development, as differentiating between
behaviour that is developmentally expected and behaviour that is atypical
facilitates appropriate diagnosis of psychopathology (Drabick &Kendall,
2010). Recognising atypical, noncompliant or antisocial behaviours in children
as young as toddlers allows for an early diagnosis of psychopathological issues
such as Attention-Deficit Hyperactivity Disorder (ADHD), schizophrenia,
Tourette’s, Conduct Disorder (CD), anxiety and depression disorders, and Autism
Spectrum Disorder (ASD) (Rutter & Sroufe, 2000; Viding & Blakemore,
2007). This report will specifically assess how effective the DPP perspective is
when attempting to define and understand the progression, etiology and
prognosis of Autism Spectrum Disorder – with consideration of individual
variability and co-occurrence with other psychopathological conditions. Autism Spectrum Disorder (ASD):Historically, autism
was defined as a variant of psychosis, and there was no category in the DSM-II
for a more appropriate psychopathology outside the category of “childhood
schizophrenia”. The DSM-III first introduced autism and originally defined it as
a pervasive development disorder featuring a lack of responsiveness, poor
language development, atypical speech patterns, and an atypical response to the
environment – such as an interest/attachment to inanimate objects or a resistance
to change. In the DSM-5, autism is now recognised as Autism Spectrum Disorder
(ASD), and it is defined as a spectrum of psychopathological disorders which
arise in early development and affect social reciprocity, communication, and
sensory processing persistently across the life span. Early studies of
autism found a very low occurrence rate of 4.5 per 10,000 people, and as low as
2 per 10,000 for “classic” or “severe” cases (Lotter, 1966). More recent
research has found that 1 per 100 people may be autistic in the UK (1.1%;
Brugha et al., 2012). This is based on surveys of identifiable populations, so
whilst it is the most accurate occurrence rate, there is no exact count, as
many people with autism remain unidentified. This data is also biased to the
UK, as occurrence rates are higher in the USA at 1 per 50 (2%; Blumberg et al.,
2013), and in South Korea (2.64%; Kim et al., 2011). This means that there is a
universal median of 62 per 10,000 people who are diagnosed with ASD, which is a
much higher rate than the earliest studies suggested (Elsabbagh et al, 2012).
This can be explained through the improved understanding of autism, as earlier
definitions were not as specific or developed and therefore not as many people
were diagnosed. The earliest
understanding of autism was defined by Kanner (1943) as “Infantile Autism”,
with the criteria of emotional non-responsivity, disturbance to social
relationships, and an inability to relate to others. Autism was recognised not
as a withdrawal from pre-existing participation or present relationships, but
as a fundamental inability to relate to others from birth. The DPP perspective
considers these fundamental behaviours through-out the life span, and other associated
symptoms have been identified such as self-stimulating physical behaviours like
flapping arms and hands, rocking, mouthing objects, and an over or under responsiveness
to environmental stimuli which is sometimes reflected in pain insensitivity.
Specific early indicators of ASD have been identified as an absence of babbling
or meaningful gestures by the age of 12 months, no words by 16 months, no two
word combinations by 2 years, poor eye contact, not smiling, and also a poor
understanding of how to play with toys or an attachment to one toy/object in
particular (Carrington et al., 2014). Autism was identified
as a spectrum disorder in the late 70’s, and assessment techniques were
developed such as the Triad of Impairments (Wing & Gould, 1979). This model
explains autism to be an impairment of social behaviour and verbal
communication, alongside a narrowed social interest with a resistance to
change. This criteria is implemented when diagnosing autism universally, using
a spectrum of mild to severe symptoms and sub-disorders such as Asperger’s
syndrome, which is “high functioning” autism without language delay.  ASD is diagnosed
using the DSM-5, with assessment techniques such as the Childhood Autism Rating Scale (CARS), the Checklist for Autism in Toddlers (CHAT), the Autism Diagnostic Interview (ADI), or a Screening Tool for Autism in
Two-Year-Olds (STAT). These techniques are used to measure maladaptive behaviour
in children which may be an early indicator of ASD. Following diagnosis, the
DPP perspective is then able to assess and predict the developmental
progression for children with autism, and consider how it will differ from
typical – or “normative” – progression.  Developmental Progression of ASD:The progression of
ASD is defined as distorted rather than simply delayed. ASD is a lifelong
developmental psychopathology that can be alleviated through early intervention
but not entirely “cured”. Due to the fact that autism is recognised as a
spectrum of disorders, the DPP must consider the multifinality of the disorder.
This multifinality refers to the phenomenon in which multiple cases of ASD with
similar origins progress towards very different outcomes (Kaboski, McDonnell
& Valentino, 2017). The DPP explains this diversity of progression through
examining groups of children with similar ASD symptoms at age two, but who present
very differently in terms of behaviour and symptom severity by the age of
eight. The progression of ASD is heterogeneous, which means that some children
with ASD progress rapidly towards higher-functioning behaviour, whilst others
may regress. No two cases of ASD present exactly the same, and the best
predictors of a more normative progression for a child with ASD are their IQ
level and speech development before the age of five (Klinger & Dawson,
1996). Multiple
psychological perspectives have attempted to explain the distorted development
of ASD. One cognitive perspective suggests that people with ASD do not develop
a Theory of Mind (i.e. “mind-blindness”), which means they are unaware of the
thoughts, desires and intentions of other people (Baron-Cohen, Leslie &
Frith, 1985). An alternative psychological perspective is the enactive mind
hypothesis (Klin et al., 2003), which suggests that people with ASD are not
attuned to social stimuli, nor do they follow other people’s eye gaze, which
acts as a precursor to problems in Theory of Mind and also in joint attention
(i.e. multi-tasking). Another perspective
is the Weak Central Coherence theory (Kanner, 1949), which defines ASD as an
inability to integrate information in order to construct higher level meanings
in context. This means that people with autism are often unable to see the
“bigger picture” of a situation, and are more likely to focus on specific details
without contextualising them. Lastly, an alternative theory for the progression
of ASD is the Executive Function theory (Ozonoff, 1991), which defines autism
as a cognitive inability to problem-solve appropriately, and this does not
allow for the development of a Theory of Mind or goal-directed behaviour and
planning. Most commonly, the
Theory of Mind hypothesis is used to define ASD, as the theory fully
encompasses an understanding as to why a person with autism has an inability to
attribute a state of mind to other people, and also explains why people with
autism have difficulties communicating. The DPP explains this lack of a Theory
of Mind as an atypical progression, which separates the behaviours of children
with autism from normative development and allows for ASD to be diagnosed in
early childhood. Children can complete tasks such as the Sally-Anne task
(Baron-Cohen, Leslie & Frith, 1985) or the Tower of Hanoi task (Ozonoff,
1991) to assess their false belief, perception, planning and goal-directed
abilities. These tasks can be administered to children at a primary school age
and, using the DPP approach, can offer an insight into the different developmental
levels of children with ASD in comparison to the normative, expected
development of other children their age. Individual DifferencesThere is a huge
individual variability in the spectrum of autism, which presents significantly
in a large gender difference in occurrence rate. Currently, the occurrence of
ASD is found at a ratio of 5:1 for males and females (Fombonne et al., 2011).
Issues have been found with an under recognition of autism in females, due to a
gender bias in diagnosis, which may affect this ratio (Gould, 2017), but it is
generally believed that the significant gender difference is due to a
difference in the male brain. This is recognised as the empathizing-systemising
theory (Baron-Cohen, 2004), which suggests that foetal testosterone in boys is
negatively correlated with the development of language and social skills, and
positivity correlated with autistic symptoms. ASD is also significantly
variable because it is often found in individuals with co-occurring conditions
(i.e. “comorbidity”). This means that many people with autism are also
diagnosed with other psychopathological conditions such as learning
disabilities or mental health problems. It has been found that 44-55% of people
with autism have a comorbid learning disability (Fombonne et al., 2011), and at
least 1 in 3 experience severe mental health problems such as depression and
self-harm, due to a lack of social and psychological support (Rosenblatt,
2008). The DPP perspective
attempts to explain this variability using a framework for comorbidity amongst
youth (Drabick & Kendall, 2010). This framework encompasses contextual
factors of risk and resilience, and developmental pathways that are relevant to
diagnosis. Using this framework, it has been found that disorder co-occurrence
is associated with an increased symptom severity due to the complex
interactions amongst risk variables from multiple disorders (Angold et al.,
1999). This is consistent with the DPP perspective, as an increased symptom
severity often corresponds to a divergence from normative development (Loeber
et al., 1998), seen through problematic or antisocial behaviours which interact
with stressors associated with different developmental levels (Rutter &
Sroufe, 2000). This may mean, for example, that a young person with autism
could also have a co-occurring learning disability and this might specifically
affect their development in the context of social maturation, speech and
education level. Etiology of ASD:The earliest studies
of autism regard the disorder to be psychogenic in nature, meaning it was
believed to be caused by psychological stressors, not physical. These reports
detailed the parental role in the development of autism, due to coldness,
aloofness or obsessional behaviours (Kanner, 1943), or a negative maternal
attitude (Bettelheim, 1967). However, more recent research discredits these
psychogenic views as there is no evidence to suggest that psychological stressors
lead to autism (Gillberg, 1990). The DSM-5 now recognises autism as a disorder
that is biogenic, meaning there is supportive evidence of a biological cause
from abnormal brain scans, chromosomal abnormalities, neurotransmitter
abnormalities, and genetic factors such as heritability (Steffenburg, 1989). A
correlation has also been found between autism and congenital infections, and
also pregnancy/birth complications which affect the structure of the left brain
hemisphere. There is strong evidence for the etiology of autism having a
biological basis, and two significant associations have been found between
autism and tuberous sclerosis and Fragile X syndrome. This indicates a clear
correlation between genetics and autism. There are, however,
environmental risk factors that have been found to influence the onset and
development of autism across the lifespan. The DPP perspective has found supportive
evidence from twin studies which suggest a 41% variance in ASD that is
accounted for by environmental factors (Gaugler et al, 2014). Some risk factors
include issues at preconception, for example the age of the parents, inter-pregnancy
intervals, and sex-specific pathways that lead to ASD. There are also prenatal
environmental risks such as traffic related air pollution, pesticides, the use
of SSRI’s (anti-depressants), or the use of the epilepsy drug Valproate. Other
risks include prenatal health risks such as diabetes, hypertension, and obesity,
and postnatal health risks such as genetic susceptibility, fewer interactions
with caregivers, or an increased ASD phenotype (i.e. the interaction of
genetics and the environment) (Mandy & Lai, 2016). However, there has been
no supportive evidence for a correlation between the MMR vaccine and autism,
which was a popular theory suggested in recent years (Wright, 2003). Prognosis:­Autism Spectrum
Disorder is a lifelong disorder, and whilst there is no “cure” there are
treatments that have been found to support and ameliorate the maladaptive
symptoms. One intervention is behavioural modification, which was developed to
help children and adolescents with autism achieve normative intellectual and
educational functioning in public schools at a 47% effectiveness rate (Lovass,
1987). Other treatments include a basic improvement to diet, taking
supplements, medical interventions such as drug therapy, or a relationship-based
intervention which was developed to encourage attachment, bonding and
relatedness between a child with autism and their parents e.g. the Son-Rise
Program (LaRue, 1998). Other treatments include service-based interventions to
develop, maintain and support specific skills, e.g. PACT therapy, which is a
parent-mediated intervention used to improve social interaction skills, and was
found to reduce long-term symptoms of ASD (Pickles et al, 2016). There are also
the standard therapies such as counselling, music, art, language and speech
therapy, all which improve the health, autonomy and life-satisfaction of a
person with autism. The most effective treatment, which has found the best
prognosis for people with ASD, is a combination of drug therapy (Haloperidol)
and behavioural modification (Campbell et al., 1987).  Autism is a spectrum
disorder, and the most high-functioning people with autism – such as those with
Asperger’s syndrome – are often able to receive an education and develop social
skills in order to reach semi-independent functioning. Wing (1981) found that
20 per 10,000 adults with autism were able to be employed, and studies such as
Fountain et al. (2012) have found that many children with autism display a
resilience framework, which allows them to develop a level of behavioural
functioning that resembles a normative development. This resilience framework,
which may be achieved at any point in the life cycle, gives a person with ASD a
significantly higher-functioning prognosis, which is known from a DPP perspective
as an “Optimal Outcome” (OO).  There are, however,
many issues that people with autism face daily which directly affect their
prognosis, such as the 34% of children with autism who report bullying in
school and the 17% who have been suspended from school due to their maladaptive
behaviours (Reid, 2011). A high level of autistic psychopathology persists
across the transition from primary to secondary school education, but it has
been reported that levels of bullying did decrease across this transition
(Mandy et al., 2015). Other problems have also been reported by the 70% of
adults with autism who don’t receive the necessary help from social services in
order to feel less isolated and more supported, and only 16% of these adults
are in full-time paid employment (Bancroft et al., 2012; The National Autistic
Society, 2016).  The DPP perspective
therefore evaluates this diverse prognosis using a broader understanding on the
variability of autism, with a consideration of the social, environmental,
familial and educational risk factors, along with resilience frameworks, all
which could affect the potential progression of an individual with ASD. This
heterogeneous nature is why autism has been defined as a spectrum of different
severities in the DSM-5, as no two cases of ASD present exactly the same, and
prognosis of psychopathology is hugely affected by risk factors and adaptive
resilience.  Conclusion:Although autism is
thought to be a spectrum of disorders that are genetic in origin, the
Developmental Psychopathology approach offers a much broader perspective. It
assesses the occurrence of symptoms through-out childhood and adolescence,
including individual contexts and risk factors such as environmental, social,
familial and even gender risks. The DPP approach also provides a framework that
considers resilience which, whilst still under-studied, is a good basic insight
into how and why the progression of ASD varies so diversely and often leads to
multifinality. The approach can be used to predict the development of children
with autism and their behavioural prognosis, meaning it has benefits when
developing methods of intervention and treatment in order to reach an Optimal
Outcome (OO). Using the DPP approach, psychologists are able to understand
maladaptive and atypical behaviour in the context of the developmental process,
allowing for specific interventions and methods of support to be implemented at
specific stages of development (e.g. special needs education for primary and
second school children, or support for adults with autism who are capable of
semi-independent employment). 

One weakness of the
DPP approach is that whilst it does acknowledge the variability of individual
differences in psychopathology, it is not very specific in itself at attempting
to define the spectrum of autism. The DPP perspective must draw from biological
and cognitive approaches in order to be a more fully developed model, as it is
simplistic and descriptive rather than evaluative on its own. Ultimately,
however, using the DPP perspective as an assessor of psychopathology is an
effective approach to understanding longitudinal development and potential
outcomes. Whilst it is not as scientific or specific as a medical model, it is
much broader in terms of understanding multiple definitions and individual
variability, and it is therefore an effective tool for understanding childhood
psychopathology, including Autism Spectrum Disorder.

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