Low-functioning Individuals Research Articles

The Prevalence of Borderline Personality Disorder in a Consecutive Sample of Cardiac Stress Test Patients

The Prevalence of Borderline Personality Disorder in a Consecutive Sample of Cardiac Stress Test Patients

Evolution of Autism Support and Understanding Via the World Wide Web

Internet technology has radically changed society, widely affecting communication and the availability of information. The digital age holds unique significance for autism spectrum disorder. In this article I explore the interface between autism and the World Wide Web by reviewing evolving virtual communities pioneered by individuals with autism, exploring the online growth of advocacy organizations, and considering the positive and negative consequences that arise from autism’s fledgling voices.

Communication, interventions, and scientific advances in autism: A commentary

Autism spectrum disorders (ASD) affect approximately 1 in 150 children across the U.S., and are characterized by abnormal social actions, language difficulties, repetitive or restrictive behaviors, and special interests. ASD include autism (autistic disorder), Asperger Syndrome, and Pervasive Developmental Disorder not otherwise specified (PDD-NOS or atypical autism). High-functioning individuals may communicate with moderate-to-high language skills, although difficulties in social skills may result in communication deficits. Low-functioning individuals may have severe deficiencies in language, resulting in poor communication between the individual and others. Behavioral intervention programs have been developed for ASD, and are frequently adjusted to accommodate specific individual needs. Many of these programs are school-based and aim to support the child in the development of their skills, for use outside the classroom with family and friends. Strides are being made in understanding the factors contributing to the development of ASD, particularly the genetic contributions that may underlie these disorders. Mutant mouse models provide powerful research tools to investigate the genetic factors associated with ASD and its co-morbid disorders. In support, the BTBR T+tf/J mouse strain incorporates ASD-like social and communication deficits and high levels of repetitive behaviors. This commentary briefly reviews the reciprocal relationship between observations made during evidence-based behavioral interventions of high- versus low-functioning children with ASD and the accumulating body of research in autism, including animal studies and basic research models. This reciprocity is one of the hallmarks of the scientific method, such that research may inform behavioral treatments, and observations made during treatment may inform subsequent research.

Further Empirical Data on the Psychoeducational Profile-Revised (PEP-R): Reliability and Validation with the Vineland Adaptive Behavior Scales

The PEP-R (psychoeducational profile revised) is an instrument that has been used in many countries to assess abilities and formulate treatment programs for children with autism and related developmental disorders. To the end to provide further information on the PEP-R's psychometric properties, a large sample (N = 137) of children presenting Autistic Disorder symptoms under the age of 12 years, including low-functioning individuals, was examined. Results yielded data of interest especially in terms of: Cronbach's alpha, interrater reliability, and validation with the Vineland Adaptive Behavior Scales. These findings help complete the instrument's statistical description and augment its usefulness, not only in designing treatment programs for these individuals, but also as an instrument for verifying the efficacy of intervention.

Enhancing Emotion Recognition in Children with Autism Spectrum Conditions: An Intervention Using Animated Vehicles with Real Emotional Faces

This study evaluated The Transporters, an animated series designed to enhance emotion comprehension in children with autism spectrum conditions (ASC). n = 20 children with ASC (aged 4-7) watched The Transporters everyday for 4 weeks. Participants were tested before and after intervention on emotional vocabulary and emotion recognition at three levels of generalization. Two matched control groups of children (ASC group, n = 18 and typically developing group, n = 18) were also assessed twice without any intervention. The intervention group improved significantly more than the clinical control group on all task levels, performing comparably to typical controls at Time 2. We conclude that using The Transporters significantly improves emotion recognition in children with ASC. Future research should evaluate the series' effectiveness with lower-functioning individuals.

Perspectives on Addressing the Literacy Needs of Low-Functioning Individuals with Autism

Autism is a spectrum disorder characterized, in part, by core social communication skill deficits. Consequently, educators seek to develop interventions that address these and closely related skills, such as literacy. Accordingly, this article focuses on basic issues that pertain to designing and implementing appropriate educational programs that address the literacy needs of one segment of the autism spectrum: individuals with the disorder who have been characterized as being low functioning. Issues include the following: appropriate definitions of literacy for this population, historical approaches to this population's literacy instruction, opportunities for literacy skill development within an instructional program based on recommended evidence-based practices, and ongoing impediments to appropriate literacy instruction and practical solutions.

Best Practices: A Systematic Approach to the Management of Patients Who Refuse Medications in an Assertive Community Treatment Team Setting

A significant proportion of patients of assertive community treatment (ACT) teams will adamantly refuse medication. Whether the team should continue to encourage medication or put a hold on advocating for medication is a clinical and ethical dilemma. On the basis of their clinical experiences, the authors propose best-practices criteria that ACT teams can consider in deciding whether medications may be temporarily discontinued when a patient refuses them. The authors suggest that in some circumstances stopping medications in such a case may help in the development or repair of a therapeutic alliance over the long term.

A Comparison of Topography-based and Selection-based Verbal Behavior in Typically Developed Children and Developmentally Disabled Persons with Autism

This study is a replication of Sundberg and Sundberg (1990) that compared topography-based verbal behavior with selection-based verbal behavior in terms of acquisition, accuracy, and testing for the emergence of a new verbal relation. Participants were three typical children and three developmentally disabled persons with autism. The study sought to determine which paradigm (topography-based or selection-based) resulted in more rapid acquisition of tacts and intraverbals, which was associated with the fewest errors, and which paradigm resulted in the emergence of the highest number of new verbal relations. The results of the study showed that the six participants performed quite differently from one another. Most importantly, the results from the person with autism contradicted previous findings favoring selection-based verbal behavior over topography-based approaches for teaching verbal behavior to low-functioning individuals.

Its Not About the Muscle

We thank Dr. Wolf for his thoughtful and enthusiastic commentary on our work and especially his recognition that resistance training in neurologic populations is an effective approach for ‘brain’ training. Indeed, this is the point intended in our study design and we were rewarded to find the results confirmed our hypothesis. While the concept of strengthening is hardly novel to physical therapy practice, the most common intent of strengthening is to address muscular and mechanical factors: hypertrophy and joint stability. However, strength and strengthening involve both neural and muscular factors. The neural aspects of strength are often underappreciated as they are less well understood, especially in persons with neurologic impairment. Interestingly, weakness is among the most prominent characteristics of post-stroke hemiparesis, yet to date there is only equivocal evidence of significant muscle atrophy in persons with hemiparesis.1 Clearly, it is not about the muscle! But more to the point is the rationale that underlies resistance training. While the outward manifestations may look similar between orthopaedic and neurorehabilitative practice, resistance training constitutes a potent form of neuromotor training—with emphasis on the neuro—for persons with neurologic impairments. Data presented in our case indicate that resistance training is an effective approach to improve central motor activation. The specific mechanisms that mediate such neural adaptations remain to be elucidated, especially in persons with post-stroke hemiparesis, but are foremost among the topics of our ongoing neurophysiological research. Neural mechanisms of force production are both sophisticated and task-specific. The target movement and contraction mode are highly relevant to the nervous system and constitute critical signals for inducing training-related adaptation. This concept has been demonstrated through studies comparing: intended vs. actual movement speed (ie, ballistic vs. isometric contractions),2 and executed concentric or eccentric contractions when the intended movements were opposite (ie, eccentric and concentric, respectively). 3 EMG activation patterns precede executed contractions/movements and are consistent with the intended movement rather than the actual muscle contraction. Such findings clearly demonstrate that the primary mechanisms for force production and control are located supraspinally. As an additional piece of this puzzle, equivalent strength gains have been observed in response to training with either executed maximal voluntary contractions or imagined (ie, mental practice) maximal voluntary contractions.4 Importantly, the neural adaptations observed in each of these paradigms occurred in the absence of either actual muscle contraction or the peripheral feedback associated with muscle contraction. Taken together, these findings demonstrate that the intended movement or contraction mode drives supraspinal activity and from this central activity task-specific motor activation ultimately emerges. We assert the goal of resistance training in persons post-stroke is to optimize this central motor activation. This concept of intended movement or contraction mode bears further consideration. Intensity may indeed represent a critical element of the intervention described in this case. However, another critical parameter may be the dynamic nature of the training, that the subject was challenged to move at speeds greater than her existing capacity. Therapeutically-induced adaptations observed in force/torque, movement speed, area-under-the-curve, and EMG followed the course of the intended rather than the executed movements. We expect these mechanistic observations translate to changes at the level of movement (or ‘function’) and, as Dr. Wolf suggested, kinematic analysis documenting such outcomes will strengthen our arguments for the importance of resistance training for neural effects. Rather than its appropriateness in neurorehabilitation, the current focus has shifted to why resistance training is effective and how to improve its generality across a broad spectrum of hemiparetic individuals. Treatment parameters to optimize neural adaptations to resistance training likely differ, especially in neurologically impaired persons. A better understanding of these parameters is among the clinical deliverables anticipated from our research. Finally, Dr. Wolf underscored several mitigating factors to consider if this intervention approach is to gain acceptance in clinical neurorehabilitation practice. Among these is how the severity of motor impairment modifies the potential for positive functional outcome. Recently conducted studies5,6 examined elements of upper-extremity strengthening for persons post-stroke. Subgroup analysis revealed that higher-functioning individuals benefited more from strengthening than lower-functioning individuals. The subject presented in this case was classified by our convention as lower-functioning, yet produced a remarkable, even unexpected, positive functional outcome. Data from our larger clinical trial will afford the opportunity to determine the uniformity of strength gains and clinical/functional improvements across impairment level. We anticipate, however, that the chronicity of hemiparesis and the effects of intervention in acute rehabilitation are equally important covariates in determining the effectiveness of our experimental approach for promoting recovery of UE function.

Continuity and change from early childhood to adolescence in autism

This longitudinal study of 48 children diagnosed with autism at 2-5 years of age was designed to test the hypothesis that diagnosis would remain stable for most of the sample but that there would be improvements in symptom severity, adaptive behavior, and emotional responsiveness in adolescence. A sample of children with autism assessed in both early and middle childhood were observed in late adolescence with the Autism Diagnostic Observation Scale (ADOS) and their parents were administered the Autism Diagnostic Interview-Revised (ADI-R) and the Vineland Adaptive Behavior Scale. All but 2 adolescents (46 of 48) met lifetime criteria for autism according to the ADI-R, and all but 4 adolescents (40 of 44) met criteria for autism spectrum disorder on the ADOS. In contrast to the continuity in diagnosis, parents described improvements in social interactions, repetitive/stereotyped behaviors, adaptive behaviors, and emotional responsiveness to others' distress in adolescence compared to middle childhood. High-functioning adolescents with autism showed more improvement in these domains than low-functioning adolescents with autism. The extent to which the adolescents were observed to be socially engaged with their peers in school in middle childhood predicted adaptive behavior skills even when intelligence level was statistically constrained. The developmental trajectory of children with autism appears to show both continuity and change. In this sample, most individuals continued to be diagnosed in the autism spectrum but parents reported improvements in adolescence. The results suggest that social involvement with peers improves adaptive behavior skills, and this argues for focusing intervention programs in this area. In addition, it is clear that high-functioning adolescents improve more than low-functioning individuals not only in cognitive abilities but also in social interaction skills. Thus, any early intervention that impacts the cognitive abilities of young children with autism is likely to have a parallel influence on their social skills as they mature into late adolescence and early adulthood.

Dynamic Master Mind

Master Mind is a commercial game, popular in the 1970s, that has been extensively used in psychological and educational research. Here, a dynamic assessment format is developed in order to test metacognitive skills in individuals with mental retardation. The main objective is to obtain valid scores that adequately reflect individual differences among low-functioning individuals. Sixteen persons with mental retardation and 13 of average intelligence were compared on static and dynamic Master Mind scores. Scores for subjects of the mental retardation sample were also obtained on the ICAP adaptive functioning score (Bruininks et al., 1986), and on a metacognitive functioning scale, the Cognitively Enriched Behaviour Matrix(Mora and Mora-Merchán, 1995). The latter was administered while participating in a thinking skills programme, Comprehending and Transforming (Mora, 1997) following assessment with Master Mind. Differences between persons with average intelligence and mental retardation were statistically significant on all processes and both on dynamic and static scores. More importantly, dynamic scores on Master Mind were related to adaptive behaviour ( d= 0.482, p< 0.001), and predicted metacognitive functioning in the learning environment of the thinking skills programme ( d= 0.727, p< 0.001). Neither IQ nor static scores related significantly to these criteria.

Dr. Klin and Colleagues Reply

Back to table of contents Previous article Next article Letter to the EditorFull AccessDr. Klin and Colleagues ReplyAMI KLIN, Ph.D., WARREN JONES, B.A., ROBERT SCHULTZ, Ph.D., and FRED VOLKMAR, M.D., AMI KLINSearch for more papers by this author, Ph.D., WARREN JONESSearch for more papers by this author, B.A., ROBERT SCHULTZSearch for more papers by this author, Ph.D., and FRED VOLKMARSearch for more papers by this author, M.D., New Haven, Conn.Published Online:1 Sep 2004https://doi.org/10.1176/appi.ajp.161.9.1719-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We thank Dr. Gepner for his letter concerning our article and the letter of Drs. Kemner and van Engeland discussing their findings (1) relative to ours. A word of accuracy, however, needs to precede our reply. Drs. Kemner and van Engeland were not reacting to our review in the Journal (that included a single case illustration) but to our case-control series, which appeared in the Archives of General Psychiatry(2). And it was our suggestion (3), not that of Drs. Kemner and van Engeland, that the discrepancy in results between the two studies could be due to the type of stimuli used in the two studies: static, i.e., pictures, by Dr. Kemner and her colleagues (1) versus dynamic, i.e., videotaped social situations by us (2).Dr. Gepner’s hypothesis of a rapid visual-motion integration deficit in autism is interesting, but we must take issue with his explanations of our data. First, Dr. Gepner hypothesizes that some individuals with autism may avoid rapid physical and biological movements (considered as aversive stimuli), which would, developmentally, disrupt social interaction. In our clinical experience, young children with autism may in fact be fascinated with rapid movements, particularly if these are repetitive or create unusual sensory sensations (e.g., shining reflections as in spin-top or repetitive patterns like in a computer screensaver). As in many areas of perceptual research in autism in which a basic process was proposed to underlie more global visual attention to social stimuli, we feel that it is important to study the given process in both nonsocial and social paradigms so as to ensure that the deficit is general rather than a phenomenon that occurs only in social situations.Second, Dr. Gepner hypothesizes that our finding of increased visual fixation on the mouth region (rather than the eyes) of people in our videotaped stimuli reflects the participants’ attempt to capture information that is difficult to process accurately and efficiently in naturalistic social situations. In other words, individuals with autism would focus on the mouth because they were overwhelmed by the rapid movement nature of naturalistic social phenomena. While this is a possibility, we doubt that this is the only factor accounting for our results. For example, in some of our eye-tracking illustrations (e.g., Figure 3 in our article, p. 900), there is hardly any movement taking place. In addition, our eye-tracking studies of toddlers with autism (4) showed that young children with autism also focus a great deal on mouths, and in our video stimuli of a parent’s approach to a toddler, the mouth region is where most of the movement is taking place (because the caregivers are continuously talking).Third, Dr. Gepner’s own work (his references 3–5) suggests that lower-functioning individuals with autism (i.e., those with a degree of mental retardation) are impaired in the processing of physical environmental movement, particularly rapid movement, while higher functioning individuals with autism (i.e., those without accompanying mental retardation) are less impaired in such tasks. In other words, low-functioning children do worse than high-functioning children on visual tasks involving rapid movement. Applying this notion to the discussion of our results and those of van der Geest and colleagues, Dr. Gepner hypothesizes that the discrepancy may be due to the severity of individuals with autism included in the two studies, with our participants being more cognitively disabled than those included in the study by van der Geest and colleagues. Inspection of subject characterization data on the two studies does not support this hypothesis. The participants in our study were both older and more cognitively able than the group of participants in the study by van der Geest and colleagues. In fact, the viewer with autism whose individual eye-tracking data were described and illustrated in detail in our review article was a 38-year-old man who has been followed-up in our center for most of his life and who has a very impressive list of accomplishments, including college graduation in a competitive institution and two master’s-level degrees. He was, nevertheless, quite socially disabled and appeared to have a typical manifestation of autism in a cognitively able individual.In sum, we agree with Dr. Gepner about the importance of future research on this topic but do not believe that his suggestions account for the results obtained in our eye-tracking studies to date.

Activity Participation and Well-Being of People with Dementia in Long-Term—Care Settings

This study examines the activities engaged in by nursing home residents with dementia and their states of well-being. Dementia Care Mapping was used to record the activities engaged in by, and the well-being of, 43 participants during a 6-hour period. The average age of the group was 81 years and length of stay at the nursing home was 27 months. Fourteen percent of participants had received a Clinical Dementia Rating (CDR) score of 1 (mild level of cognitive impairment), 35% had a CDR score of 2 (moderate impairment), and 51% had a CDR score of 3 (severe impairment). Results indicated that the three CDR groups engaged differently in activities. The CDR1 group participated significantly more in therapeutic/leisure activities and activities of daily living than did the CDR2 group ( p < .001 and p < .05) and CDR3 group ( p < .001). Conversely, the CDR3 group engaged in significantly more passive activities than did the CDR1 group ( p < .001), and had fewer social interactions and displayed more negative behavior than the other two groups ( p < .05). Moreover, their well-being was significantly worse than that of the other two groups (p < .001). A majority of participants (82%) demonstrated poor to very poor well-being. Because better well-being was associated with positive and enjoyable engagement in activities (τ = +0.67, p < .001), the low level of activity participation demonstrated by low-functioning individuals with dementia needs to be addressed. Moreover, further studies are indicated to explore the possible factors influencing their limited activity participation.

Random number generation in autism.

This study explored the ability of individuals with autism to generate a unique series of digits. Fourteen low-functioning individuals with autism, 14 intellectually disabled individuals, and 14 postgraduate university students generated a series of pseudo-random digits. Individuals with autism were more likely to repeat previous digits than were either of the control groups. The normal control group, however, was less likely to attempt cycling through all digits before repeating. Accordingly, low-functioning individuals with autism may exhibit a short-fall in response inhibition. This finding supports the executive dysfunction theory of autism.

Compositional Elements in the Art of Individuals with Alzheimer's-Type Dementia

The authors asked residents (non-artists with and without Alzheimer's-type dementia) at a long-term care facility in Ohio to be pen-pals to students at a middle school in Chicago, in part, as motivation for art production. The pictures made by elderly participants were analyzed for compositional complexity and balance (symmetry vs. asymmetry). Individuals with dementia verbalized general preferences for more linear, symmetrical compositions. In the first study, asymmetry declined over sessions for individuals with dementia, but remained low across all sessions for those without dementia. Unfortunately, that effect did not reach significance in the parametric analyses. In the second study, participants at four different facilities were asked to create pictures related to upcoming seasonal events (e.g., Valentine's Day). Most compelling were the differences in compositional complexity across levels of cognitive functioning that were observed in both studies. Overall, low-functioning individuals with dementia placed significantly fewer items on a page.

Subtypes of Pervasive Developmental Disorder: Clinical Characteristics

Previous analysis of data from 505 preschool children with disordered communication, falling into the a priori categories of Pervasive Developmental Disorder (PDD), Developmental Language Disorder, and Nonautistic Low IQ, showed that PDD is statistically distinct from nonPDD. Current analyses of the 194 children with PDD also showed the existence of two subgroups within PDD. Children in these two subgroups are sharply divided on the basis of overall cognitive level; children in both groups share major symptom areas, but specific behavioral manifestations differ. Differing developmental trajectories into school age validate the distinction. A clinically usable algorithm for classifying PDD children into the two subgroups, based on social developmental level and degree of social abnormality, is provided. The findings suggest that high- and low-functioning individuals with PDD should be conceptualized as essentially distinct and should be studied separately for etiology, pathophysiology, course, and treatment.

Theory of mind and rule use in individuals with Down's syndrome: a test of the uniqueness and specificity claims.

The relationship between Theory of Mind (ToM) and rule use was explored in adults with Down's Syndrome (DS) and in non-handicapped pre-schoolers. Twelve low-functioning individuals with DS (mean mental age = 5.1 years, mean chronological age = 22.7) performed worse than 12 MA-matched non-handicapped children (mean MA = 5.1 years) on several standard ToM tasks and on a color-shape card-sorting task in which subjects were required to switch between two incompatible sets of rules. On the ToM tasks, people with DS tended to focus on a single state of affairs (e.g. the present situation). Likewise, on the card sort, these subjects tended to use a single set of rules on all trials. Performance in the two types of task was positively correlated when MA was partialed out. The results are inconsistent with the slaim that ToM reflects a domain-specific psychological function and the notion that deficits in ToM are unique to individuals with autism.

Wechsler IQ Profile and Theory of Mind in Autism: A Research Note

The unusually uneven intelligence test profile found in autism has been consistently replicated. However, few psychological theories of autism give prominence to this feature. Nor is it clear how currently influential theories, such as the theory of mind account or the executive function hypothesis, can explain the marked peaks and troughs found in the performance of both high- and low-functioning individuals with autism. The present study reports the pattern of Wechsler subtest results for subjects with autism who do or do not pass standard theory of mind tasks. The results suggest that while difficulty with the Comprehension subtest may reflect poor theory of mind, relative skill on the Block Design subtest is characteristic of subjects with autism regardless of theory of mind performance. Implications of this finding for the central coherence hypothesis are considered.

Occupational engagement of low-functioning individuals: extending the applicability of a computer-aided programme.

The present study addressed two questions concerning a computer-aided programme for supervising occupational activities for low-functioning individuals. The first question was about the possibility of using the programme for extended time periods. The second question concerned the viability of the programme for subjects who require physical prompting in addition to normal supervision (e.g. instructions and reinforcement). Three adolescents participated in the study. Two of them (who could perform under normal supervision) were selected for investigating the first question. The other subject (who required caretaker prompting) served for the second question. The results for the first two subjects showed that the computer-aided programme could easily ensure engagement in constructive activities for periods of about 30 min. The data for the third subject showed the establishment of moderate responding. The practical implications of the findings are discussed.

An automatic prompting instrument to increase task-related responding in low-functioning individuals

The present study was aimed at developing and assessing an automatic prompting instrument with three multihandicapped students who showed breaks in performance. The effects of the instrument were compared with the effects of manual prompting with simple tasks involving locomotion. The results indicated that manual and instrument prompting were both successful in reducing the amount of time spent in breaks. The effects of the instrument were replicated within subjects. The same effects were still visible during a follow-up assessment. The reliability and durability of those effects as well as the practical implications of automatic prompting are discussed.