diff --git "a/assets/Books Chunks/Encyclopedia of autism spectrum disorders/book0_cleaned_chunk_21.txt" "b/assets/Books Chunks/Encyclopedia of autism spectrum disorders/book0_cleaned_chunk_21.txt" new file mode 100644--- /dev/null +++ "b/assets/Books Chunks/Encyclopedia of autism spectrum disorders/book0_cleaned_chunk_21.txt" @@ -0,0 +1,2477 @@ +Children’s Communication Checklist, Version 2 +▶Children’s Communication Checklist (CCC-2) + +Children’s Global Assessment Scale +Benedetto Vitiello +Child and Adolescent Treatment and Preventive +Intervention Research Branch, NIMH, NIH, +Bethesda, MD, USA + +Synonyms +Developmental Disabilities – Children’s Global +Assessment Scale (DD-CGAS) + +Description +The Children’s Global Assessment Scale (CGAS) +is a clinician-rated instrument that provides a sin- +gle score for the overall level of behavioral and +emotional functioning of a child aged 4–16 years. +The CGAS is completed by a clinician based on +information acquired from direct examination +and/or derived from informants such as parents, +educators, or case managers. Raters score the +child’s most impaired level of functioning for the +period of interest (usually the past month) on a +scale ranging on a continuum from 100 +(corresponding to excellent functioning in all +areas of life) to 1 (representing very poor function- +ing with need for constant supervision). Anchoring +descriptors are provided for each decile of the +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 impair- +ment in functioning at home, at school, or with +peers. A score of 70 or below is usually considered +the threshold for the presence of definite, although +slight, functional impairment. Most children +referred for clinical evaluation and treatment have +scores of 60 or below. + +The CGAS has been further modified to meet +the need of scoring global functioning of children +with autism age 4 and older. This scale is called the +Developmental Disabilities – CGAS (or +DD-CGAS). The information used for scoring +the DD-CGAS relates to four main domain of +functioning: self-care, communication, social +behavior, and school/academic performance. In +each of these domains, the level of impairment +can range from none to extreme. The reference for +determining the level of impairment is the level of +functioning that would be expected by a typically +developing child of the same chronological age. +Impairment in the main domains of functioning is +then used by the rating clinician to formulate a final +overall score of functioning (the DD-CGAS score) +on a scale ranging from 100 (corresponding to +superior functioning) to 1 (indicating extreme +impairment). Also the DD-CGAS provides +descriptors for each decile (i.e., 100–91: superior +functioning within family, school, and peers; +90–81: adequate functioning in all areas; 80–71: +most daily living activities at age level but with +slight impairment in at least one; 70–61: most +daily living activities at age level but with moderate +impairment in at least one domain; 60–51: moder- +ate impairment in functioning in most domains; +50–41: moderate impairment in functioning in +most domains and severe impairment in at least +one domain; 40–31: severe impairment in function- +ing in some domains; 30–21: severe impairment in +all domains and settings; 20–11: extreme +impairment in at least one domain; 10–1: extreme +and pervasive impairment with danger to self or +others and need for intensive constant supervision). +The time frame for the rating can vary but typically +is in the order of several weeks or months. + +Historical Background +The CGAS was introduced by Shaffer et al. +(1983) and is a modification of the Global Assess- +ment Scale developed by Endicott and colleagues +in 1976, which, in turn, was a revision of the +Health-Sickness Rating Scale, originally +published by Luborsky in 1962. A similar scale +is the Global Assessment of Functioning (GAF), +which constitutes the axis Vof the DSM-IV multi- +axial evaluation. The DD-CGAS is a modification +by Wagner et al. (2007) of the CGAS specifically +to score the global level of functioning of children +autism and other pervasive developmental disor- +ders. Both the CGAS and DD-CGAS have been +translated in languages other than English and are +used internationally. + +Psychometric Data +When used by raters trained in the clinical evalu- +ation of children with mental illness, the CGAS +was shown to have excellent inter-rater reliability +(e.g., intraclass correlation coefficient around +0.84), good test-retest stability, and acceptable +discriminant and concurrent validity. The CGAS +can detect treatment effects. For example, it was +able to discriminate between active antidepressant +treatment and placebo in adolescent depression. +The DD-CGAS too was found to have very good +inter-rater and test-retest reliability when used by +clinicians who were experts in autism and other +pervasive developmental disorders and who had +been trained in its use. DD-CGAS scores showed +moderate correlation with indices of adaptive +behavior, intellectual functioning, and severity of +psychopathology. Preliminary data obtained +before and after 6 months of treatment indicate a +moderate correlation between changes in the +DD-CGAS scores and changes on the Aberrant +Behavior Checklist and the Clinical Global +Impressions-Improvement scores. + +Clinical Uses +The CGAS is a clinically useful instrument that +provides an overall score of the level of functioning +of a child. The DD-CGAS is specifically useful for +rating functioning in the context of autism or other +pervasive developmental disorder and is a rela- +tively simple way of indicating the observed global +functioning relative to the expected functioning +based on normal development. The DD-CGAS +allows direct comparisons to be made between +functioning of children with autism and functioning +of children with other mental disorders such as +schizophrenia, depression, or anxiety. + +See Also +▶Functional Analysis + +References and Reading +Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, +P., Bird, H., et al. (1983). A children’s global assess- +ment scale (CGAS). Archives of General Psychiatry, +40, 1228–1231. +Wagner, A., Lecavalier, L., Arnold, L. E., Aman, M. G., +Scahill, L., Stigler, K. A., et al. (2007). Developmental +disabilities modification of the Children’s Global +Assessment Scale. Biological Psychiatry, 61, 504–511. + +Children’s Psychiatric Rating Scale +Janine Robinson +CLASS, Cambridgeshire and Peterborough NHS +Foundation Trust, Fulbourn, Cambridgeshire, UK +NHS England, London, UK + +Synonyms +CPRS + +Abbreviations +ECDEU Early clinical drug evaluation unit +EMA European Medicines Agency + +Description +The Children’s Psychiatric Rating Scale (CPRS) +is a multidimensional rating scale of childhood +psychopathology. The CPRS is not diagnostic +but rather a broad-ranging rating scale of +symptoms and behaviors which may contribute to +diagnosis. In addition, the scoring system enables +the rating of severity of symptoms and +presentation. Since the scale measures the +presence or absence of symptoms over a +particular period of time, it has been a useful +instrument of treatment efficacy and has regularly +been the instrument of choice employed in clinical +trials. Owing to the established subscale structure, +an abbreviated form, comprised of 14 questions +relevant to the autism spectrum, has been +employed in studies evaluating treatment efficacy +in autistic children. However, more recently the +European Medicines Agency (EMA 2017), +Guideline on the clinical development of +medicinal products for the treatment of Autism +Spectrum Disorder (ASD), has suggested the use +of the Childhood Autism Rating Scale (CARS) for +baseline assessment and outcome measures in +clinical trials. It has also demonstrated value in +evaluating psychopathology in autism, clarifying +major behavioral dimensions and identifying +distinct subtypes (Overall and Campbell 1988; +Overall and Pfefferbaum 1982; Pfefferbaum and +Overall 1983). The CPRS is a clinician-rated scale, +based on (1) behaviors observed during clinical +interview and (2) the child’s reporting of +symptoms. The autism-specific scale is based on +observation only. + +In the Diagnostic and Statistical Manual, third +edition (DSM-III, American Psychiatric Associa- +tion [APA] 1980), a diagnosis of infantile autism +is made when four behavioral characteristics are +present: (1) pervasive lack of responsiveness to +other people, (2) gross deficits in language devel- +opment, and (3) bizarre responses to the environ- +ment. These behaviors can be rated, whereas +characteristic (4) speech deviance, such as echo- +lalia and pronominal reversal, may be more diffi- +cult to evaluate in individuals with little speech. +These behaviors are deemed well represented by +the 14 items on the autism scale of the CPRS +(Table 1). + +Historical Background +The CPRS was originally developed by the Psy- +chopharmacology Research Branch of the NIMH +as a general-purpose instrument (1976). It fea- +tured in the ECDEU Assessment Manual for Psy- +chopharmacology Revised (Guy 1976) among +other pediatric scales integral to clinical drug eval- +uation programs. At this stage, the CPRS was +regarded as experimental, and no standardization +data were available. The instrument was designed +to be employed within a semi-structured interview +format to be completed by clinicians and generally +used alongside parent- and teacher-completed mea- +sures. The rating system facilitated assessment +at various stages of a clinical trial, generally prior +to the commencement of treatment, during the +middle and at the end of treatment. It was +designed for use with children up to the age of +15 years. + +Children’s Psychiatric Rating Scale, Table 1 Items with respective numbers on CPRS (Overall and Campbell 1988) +| Withdrawal (8) | Loud voice (25) | Rhythmic motions (28) | +|---|---|---| +| Negative and uncooperative (10) | Abnormal object relationships (7) | Hypoactivity (5) | +| Unspontaneous relationship to examiner (16) | Fidgetiness (3) | Underproductive speech (2) | +| Hyperactivity (4) | Angry affect (11) | Other speech deviance (27) | +| Lability of affect (20) | Low voice (24) | | + +The first 28 items were rated on direct obser- +vation of behaviors at interview, while the latter +34 were rated on the basis of the child’s verbal +reporting of symptom presence at the time of the +interview or during the preceding 7 days. Ratings +on a Likert scale were possible from not +answered, not present, very mild, mild, moderate, +moderately severe, and severe to extremely severe. +The seven-point scale was effectively derived +from the Adult Brief Psychiatric Rating Scale +(Overall and Gorham 1962). The scoring was +further developed by Fish (1985). The rating scale +comprised of two sections (the original 63 items): +in Section A, the clinician rated both the observed +behavior at interview and the child’s reporting of +symptoms or behaviors. Section B represented the +clinician’s overall view based on the integration of +a range of data avail- able, including maternal +reports and school records. Hence, additional +areas were rated by clinicians with respect to +clusters of behavior such as withdrawal, aggressive +behavior, hyper- active behavior, inadequate or +immature behavior, and organic impairment. +Ratings were made on the degree of abnormal- +ity from 0 to 9: none, present but not significant, +significant but mild, moderate, moderately severe, +severe, very severe and may be paralyzing, item +not relevant to child, and not known or not +ascertained. The measure has been valuable owing +to the breadth of the range of symptoms and +behavioral manifestations assessed while not being +limited to the DSM diagnostic criteria, since the +scale was originally designed prior to the +publication of the DSM-III. + +Overall and Campbell (1988) proposed an +abbreviated version of the CPRS to evaluate +psychopathology in autistic children. They +evaluated a subtest of the CPRS, comprising +of 14 questions relevant to the diagnosis of +autism. Fourteen of the 28 questions of the +CPRS are included. Since these are based on +observed behaviors and symptoms, the subtest +is useful for those autistic children who have +little or no communicative language and who +are severely disturbed or severely developmen- +tally delayed. + +Psychometric Data +No normative data existed for the CPRS in its +original form (Guy 1976). Factor-analytic +studies have subsequently supported a +6-syndrome subscale structure, hence +establishing the internal validity of the CPRS +(Overall and Pfefferbaum 1982; Pfefferbaum and +Overall 1983). Evaluation of the diagnostic factor +structure of the CPRS (Overall and Pfefferbaum +1982; Pfefferbaum and Overall 1983) confirmed +the scale’s usefulness in evaluating psychopathology +and measuring treatment response in different +clinical groups. Seven core factors were identified, +namely, behavioral problems, depression, thought +disturbance, psychomotor excitation, psy- +chomotor retardation, nervous/tension, and orga- +nicity. Furthermore, cluster analysis revealed six +distinct clusters of symptoms and features, thus +enabling the grouping together of those DSM-III +diagnoses which tend to have core features and +symptom profiles in common. Treatment evalua- +tion could thus be focused on the particular +dimensions of symptom presentation. + +Studies have served to demonstrate both predic- +tive and construct validity in testing diagnostic +classifications. However, like other autism rating +scales, the CPRS was developed prior to the revi- +sion of autism diagnostic classification (APA 2013; +Thabtah and Peebles 2019). To date no data are +available regarding how well the autism subscale +maps onto the two DSM-5 domains of ASD. + +Clinical Uses +The CPRS is a general-purpose instrument for +assessment of a broad range of childhood +psychopathology. While the measure is used in its +complete form, i.e., a 63-item rating scale, +autism-specific research has focused on a subset +of 14 items relevant to the condition. The first 28 +items on the CPRS are deemed valuable since they +are items which are rated on the basis of clinical +observation of behavior at interview. Hence, they +do not rely on a particular level of language +development. Fourteen of these 28 items have been +deemed relevant for the assessment and classification +of symptoms and features observed in autistic +children (Overall and Campbell 1988). The behaviors +included in this subset are well matched with the +behavioral criteria for infantile autism first +described in the DSM-III (APA 1980), including +deficits in language development, odd responses to +the environment, and lack of responsiveness to +other people. Overall and Campbell (1988) +conducted factor analysis of the subset of the CPRS +and noted four core aspects which differentiated +autistic children, namely, autism, anger/uncooperativeness, +hyperactivity, and speech deviance. In other words, +scores on the scale differentiated subgroups. +However, these did not necessarily differentiate +autistic children from children with other psychiatric +conditions. + +The 14-item CPRS continued to be employed +as the measure of choice in clinical trials (Desousa +2010). It is generally completed by the clinician +(s) following videotaped observations of autistic +children. This is in conjunction with parental rat- +ings of behavior and symptoms, e.g., Aberrant +Behavior Checklist (ABC) and the Conners0 Par- +ent Rating Scale – Revised (CPRS-R), as well as +other clinician ratings such as the Clinical Global +Impression Scale (CGI). The rating scale has dem- +onstrated value in open-label and controlled psy- +chopharmacological trials. Improvement of 25% +or more on identified symptoms compared with +baseline ratings suggests child is a responder to +the medication. Studies have evaluated tolerability, +long-term effects, and efficacy of specific +psychotropic medication in autistic disorder as well +as comparisons of different medication within this +group. Studies of specific psychiatric features +associated with autism spectrum disorders and +effects of psychopharmacology have employed the +CPRS-14 (Gagliano et al. 2004; Desousa 2010). +More recent clinical trials (Lemonnier et al. 2017) +have followed the EMA guidelines (2017) for +evaluating efficacy and impact of treatment, +employing measures such as the Childhood +Autism Rating Scale (CARS), Social Responsive- +ness Scale (SRS), and the Clinical Global Impres- +sions (CGI). + +See Also +▶Childhood Autism Rating Scale +▶DSM-5 +▶DSM-III +▶Risperidone +▶Screening Measures +▶Social Responsiveness Scale +▶Treatment Integrity + +References and Reading +American Psychiatric Association. (1980). Diagnostic and +statistical manual of mental disorders (3rd ed.). +Washington, DC: American Psychiatric Association. +American Psychiatric Association. (2000). Diagnostic and +statistical manual of mental disorders (4th ed., Text rev.). +Washington, DC: American Psychiatric Association. +American Psychiatric Association. (2013). Diagnostic and +statistical manual of mental disorders (5th ed.). +Washington, DC: Author. +Campbell, M., & Palij, M. (1985). Documentation of +demographic data and family history of psychiatric +illness. Psychopharmacology Bulletin, 21(4), 719–721. +Desousa, A. (2010). An open-label trial of risperidone and +fluoxetine in children with autistic disorder. Indian +Journal of Psychological Medicine, 32(1), 17–21. +https://doi.org/10.4103/0253-7176.70522. +European Medicines Agency (2017). Guideline on the +clinical development of medicinal products for the +treatment of Autism Spectrum Disorder (ASD) +(EMA/CHMP/598082/2013). Retrieved from https:// +www.ema.europa.eu/en/documents/scientific-guide +line/guideline-clinical-development-medicinal-prod +ucts-treatment-autism-spectrum-disorder-asd_en.pdf +Fish, B. (1985). Children's psychiatric rating scale. Psy- +chopharmacology Bulletin, 2(4), 753–770. +Gagliano, A., Germano, E., Pustorino, G., Impallomeni, +D.'. A., Calamoneri, F., & Spina, E. (2004). Risperi- +done treatment of children with autistic disorder: Effec- +tiveness, tolerability, and pharmacokinetic +implications. Journal of Child and Adolescent Psycho- +pharmacology, 14(1), 39–47. +Guy, W. (1976). ECDEU assessment manual for psycho- +pharmacology, revised, 1976. Rockville: United States +Department of Health, Education, and Welfare, Public +Health Service, Alcohol, Drug Abuse, and Mental +Health Administration. (DHEW Publication No. (ADM) 76-338). +Guy, W. (2000). Clinical Global Impressions (CGI) scale. +Modified From: Rush, J., et al., Psychiatric measures. +Washington, DC: APA. +Lemonnier, E., Villeneuve, N., Sonie, S., Serret, S., Rosier, +A., Roue, M., Brosset, P., Viellard, M., Bernoux, D., +Rondeau, S., Thummler, S., Ravel, D., & Ben-Ari, +Y. (2017). Effects of bumetanide on neurobehavioral +function in children and adolescents with autism +spectrum disorders. Translational Psychiatry, 7, e1056. +https://doi.org/10.1038/tp.2017.10. +Malone, R. P. (2007). Ziprasidone in adolescents with +autism: An open-label pilot study. Journal of Child +and Adolescent Psychopharmacology, 17(6), 779. +Niederhofer, H. W., & Mair, S. A. (2003). Tianeptine: +A novel strategy of psychopharmacological treatment +of children with autistic disorder. Human Psychophar- +macology: Clinical and Experimental, 18(5), 389–393. +Overall, J. E., & Campbell, M. (1988). Behavioral assess- +ment of psychopathology in children: Infantile autism. +Journal of Child Psychology, 44, 708–716. +Overall, J. E., & Gorham, D. R. (1962). The brief psychi- +atric scale. Psychological Reports, 10, 799–812. +Overall, J. E., & Pfefferbaum, B. (1982). Brief Psychiatric +Rating Scale for Children. Psychopharmacology Bul- +letin, 18, 10–16. +Overall, J. E., & Pfefferbaum, B. (1984). A brief scale for +rating psychopathology in children. Innovations in +Clinical Practice: A Source Book, 3, 257–266. +Pfefferbaum, B., & Overall, J. E. (1983). Diagnostic factor +structure of the children’s psychiatric rating scale (C.P. +R.S.), Journal of Clinical Child Psychology, 12, 167– +173. https://doi.org/10.1080/15374418309533126. +Thabtah, F., & Peebles, D. (2019). Early autism screening: +A sss. International Journal of Environmental +Research and Public Health, 16, 3502. + +Children’s Social Behavior Questionnaire +▶CSBQ (Children’s Social Behavior Questionnaire) + +Children’s Unit for Treatment and Evaluation (State University of New York at Binghamton) +Raymond G. Romanczyk and Jennifer Gillis +Mattson +Institute for Child Development, Department of +Psychology, Binghamton University, +Binghamton, NY, USA + +Definition +The Institute for Child Development (ICD) at the +State University of New York at Binghamton +promotes the welfare of children who are chal- +lenged by developmental, learning, and emotional +disorders. The Institute serves as the focus for +service, research, undergraduate, and graduate +training programs and the dissemination of basic +and applied research. The Institute supports specific +units that provide treatment and educational +services for children within an evidence-based +model. The Children’s Unit for Treatment and +Evaluation provides services for children with +autism spectrum disorders and their families in +the context of Early Intervention, Preschool, and +School Age programs as well as additional com- +plimentary programs, such as its Diagnostic Eval- +uation Clinic. + +Historical Background +The ICD was founded by Dr. Raymond +G. Romanczyk, a faculty member and clinical +psychologist, in 1974, located on the State Uni- +versity of New York (SUNY) at Binghamton cam- +pus. An ICD program, the Children’s Unit for +Treatment and Evaluation, was established in +1975 in cooperation with a small group of parents +who wished to receive evidence based and inten- +sive services for their children. Given the efficacy +of the program, parents worked with local and +state legislators to provide the Unit an appropriate +connection to the region’s continuum of services. +Special status was granted in 1977 through an act +of the New York State Legislature (Senate Bill +5911-A) which allows the Unit to exist with a +dual status as a fully certified New York State +Education Department private school and at the +same time organizationally part of SUNYat Bing- +hamton. The bill permits school districts, +counties, and other state agencies to contract +directly with the Unit for services. This also +allows the Unit to function as a separate entity at +the University level, rather than as the more typ- +ical “lab school” or time-limited grant-funded +project. The Unit was the first in New York to +provide full-day intensive evidence-based ser- +vices for children in the early intervention and +preschool age range. + +At its start, the Unit served just six children +from the immediate area. The catchment area has +grown quite large and now includes the New York +State counties of Broome, Tioga, Cortland, Tomp- +kins, Chenango, and Onondaga and the Pennsyl- +vania counties of Bradford, Susquehanna, and +Sullivan, representing locations across urban, +suburban, and rural areas. Currently approxi- +mately 65 children commute daily to the program +from within an approximately 90 mile radius. +The ICD has had multiple locations on the +campus since 1973. In 2001 the Institute was +moved to a spacious specially constructed build- +ing for the sole use of the ICD. It is located next to +the campus preschool services building, permit- +ting ease of cooperative programs for peer-based +activities. In 2013 Dr. Jennifer M. Gillis, faculty +member, clinical psychologist, and licensed +behavior analyst, became the co-director. + +Rationale or Underlying Theory +An autism spectrum disorder affects not only the +individual but also the family, the community, and +the broader society as well. As a group, the impact +on families is greater and more complex than +many other disorders. This requires an intensity, +quality, and precision of educational and clinical +services that are not only directed at the individual +with an autism spectrum disorder but also the +family. Comprehensive service delivery cannot +be impeded by bias, inappropriate, and antiquated +organizational structures, low expectation, or by +compartmentalization of services. The guiding +principle of the Institute for Child Development is +that providing a caring, warm, supportive, +enriched environment that respects the dignity of +individuals and celebrates their unique qualities +and potential is the mini- mum starting point for +educational and clinical services. This principle is +paired with a comprehensive commitment to +evidence-based services drawing upon +well-conducted, methodologically sound, empirical +research. Thus, educational and clinical research is +utilized on a continuing basis, and the ICD +provides mechanisms and opportu- nities for all +program staff to acquire and use research +information on a timely basis, which includes +weekly in-service training, journal club, visiting +speakers, and consultants, as well as attendance at +professional conferences. Another priority is that +there must be extensive, precise, quantitative, and +frequent child assess- ment that permits the daily +implementation of an objective feedback loop for +decision-making regarding appropriate goals, +procedures, and progress. + +Given the emphasis on evidence-based +approaches to intervention, current practice is +based upon research in behavioral approaches +(applied behavior analysis and cognitive behav- +ioral therapy), developmental models (Early Start +Denver Model), nomothetic and ideographic +assessment (such as functional behavior assess- +ment), family systems, curriculum selection, basic +attention and learning processes, social develop- +ment, and comorbid disorders. The program +employs a comprehensive model, but it is not +based on a specific single “model” or particular +“approach,” but rather is dynamically based on +contemporary, methodologically sound, peer- +reviewed research that has been replicated. + +Goals and Objectives +The program provides full-day, 12-month services +with emphasis on individual evaluation of each +child’s assets and deficits, past history of services +and response, current functioning, the specific +parameters of the child’s learning pattern, and an +analysis of maintaining factors of current behavior +patterns using functional behavior analysis. The +goal of the program is to remediate skill deficits +that prevent children from participating at their +potential in the continuum of education services +in their community and to provide families with +training and support for their own needs. Empha- +sis is placed on acquisition of communication +skills, social interaction skills, self-regulation +skills, and reduction of stereotyped behavior and +restricted interests. The average length of enroll- +ment is 2.5 years as the emphasis is upon rapid +reintegration into services in the child’s local com- +munity. Thus the ICD is not a long-term alternate +educational placement but rather an intensive, +focused, short-term intervention program. +Prioritized goals within a comprehensive program +produce rapid transition to services in the child’s +community. + +Treatment Participants +Children between the age of 1 and 11 are eligible +to attend the program. Referrals come from phy- +sicians, county health departments, and school +districts via the NY system of Early Intervention +Officials, the Committee on Preschool Special +Education, and the Committee on Special Educa- +tion. Because the catchment area is so expansive, +admission criteria is based on a relative analysis of +the child and family’s needs in the context of the +resources of the continuum of services in the +community of residence. The majority of children +are diagnosed with autism spectrum disorder and +have a history of poor response to intervention +prior to admission. Parent willingness and ability +to participate in the child’s program and attend +family service groups are highly variable upon +admission and are not a selection criteria. It is +explicit that admission is not based on parent’s +willingness to participate in ongoing research pro- +jects, as such a requirement would be deemed +coercive. + +Treatment Procedures +Comprehensive intervention requires that at min- +imum primary focus is placed on the core ASD +areas of social communication and social interac- +tion and restricted, repetitive, and stereotyped pat- +terns of behavior, interests, and activities. Further, +salient comorbid disorders must be assessed and +addressed, e.g., anxiety disorders. +Next, a continuum model for comprehensive +intervention is used (Romanczyk and Gillis +2010) that includes several critical procedural +components: +* Assessment (nomothetic and ideographic) +* Curriculum planning (goal selection, prioriti- zation, and sequencing) +* Intervention methodology (evidence based) +* Ongoing progress monitoring (measurement for decision-making feedback loop) +* Family/caregiver involvement (to address both child and self needs) +It is these components that are used to achieve +acquisition of skills and address behavior prob- +lems with emphasis on generalization of skill rep- +ertoires in normative settings. A comprehensive +developmentally organized curriculum, the IGS +Curriculum (Romanczyk et al. 2000), is used to +guide and structure assessments and precise goal +specification. Utilization of a curriculum that pro- +vides a developmentally sequenced compendium +of goals permits identification of skills associated +with the child’s strengths and weaknesses, guides +further assessment of the limits of the child’s skills +and performance, and permits meaningful discus- +sion of goal selection and priorities with parents as +it helps in supplementing their knowledge of child +development. A comprehensive curriculum that is +developmentally sequenced such as the IGS +ensures that assessment is directly linked to func- +tional instructional goals. Appropriate staff are +also certified Early Start Denver Model (ESDM) +therapists and also trained in the use of the Verbal +Behavior Milestones Assessment and Placement +Program (VB-MAPP). + +Settings for instruction, instructional proce- +dures, and specific goals present a complex mix +of variables. Their interaction must be addressed +to allow optimal configuration from the perspec- +tive of each factor. As an example, if emphasis is +currently upon transition between two instruc- +tional settings, then goals and procedures need to +be adjusted to be appropriate within that context. +Likewise, if focus is upon acquisition of a +specific goal set, then settings and procedures +are adjusted to maximize speed and strength of +learning. This is a dynamic process, allowing +adjustment to changing child and family charac- +teristics, as well as resource factors, while devel- +oping more and more sophisticated child +repertoires. No one variable has primacy, with +emphasis placed on a coherent comprehensive +program. Social development is a priority, and the +pro- gram is designed to improve social skills and +social problem-solving. Activities are constructed +for individual strengths and deficits. Activities +and projects focus on skill strengthening via use +of modeling, rehearsal, role-playing, cognitive +behavior therapy, and anxiety reduction +approaches. + +A second component is the strong cooperation +with the University Campus Preschool which is in +a building physically adjacent to the Institute. +Children from the Institute attend the preschool +on a part-time basis as a transition step as part of +preparation for returning to program’s in their +school district of residence. Staff of the Institute +accompany the children and serve as guides for +the preschool staff to integrate the children into +typical activities. + +A third component is the “Buddy Group,” an +after school therapeutic social skills program. The +program focus is on increasing the quality of +social interactions through participating in a vari- +ety of on-site and community activities with typ- +ical peers. Peer volunteers are area middle-school +children who function as “buddies” by relating to +children with ASD as they would any other friend. +This provides realistic feedback and experiences +as would be encountered in typical casual social +settings and allows for more success in meeting +complex social expectations. Teaching objectives +focus on age appropriate activities, learning social +expectations, and responding appropriately to the +inherently variable consequences of social +interaction. + +A fourth component is an extension that we +term “SLC Saturday.” The Institute has a very +large specially constructed playground with a +state-of-the-art injury prevention focus and vari- +ous types of play areas that permit quiet self-play +as well as areas that support and encourage social +interactive play. It can accommodate more than +150 individuals comfortably and safely. It is used +on a daily basis for children enrolled at the Insti- +tute and is the focus for social development. SLC +is the acronym for Social Learning Center. This +facility is opened on Saturdays for families of the +Institute as well as the community, permitting a +safe and choreographed setting for interaction +between children with ASD and typically devel- +oping children. + +Family Focus +A separate but highly intertwined program +emphasizes individualization of services. Family +involvement is strongly encouraged and +supported. Because a child with an ASD affects +the whole family, this greatly influences the fam- +ily services provided. In addition to instruction in +specific procedures and skills so that families can +conduct teaching programs at home, measure pro- +gress on specific skills, and objectively evaluate +their child’s performance, the staff individually +tailor parent services to the needs and values of +each family. Families can choose from a variety of +ongoing services that include: +* Didactic instruction to implement intensive + language and social/emotional programs at home. +* Homework programs with parent with training + so that they can conduct more traditional + “homework” pre-academic/academic, leisure, + and self-help activities at home. +* Periodically themes are identified for a + “family-friendly” personal goal. Activities + focus on workshops for parents, individual + support meetings, and parents participating + in school activities. Staff then increase + emphasis on addressing these goals at + school and paralleling with home programs + to maximize generalization and thus family + success. + +An important additional program component is +parent wellness. Wellness sessions are devoted to +assisting caregivers in appropriately addressing +individual family member needs with particular +emphasis on stress management. Components of +the program include recognizing and quantifying +stress, changing stress responding through relax- +ation training, diaphragmatic breathing, progres- +sive muscle relaxation, guided imagery, yoga, +time management, and cognitive restructuring +approaches. + +Technological Innovation +There is significant use of technology, particularly +computer technology, with individuals with ASD. +However, great caution must be exercised in +applying a technological approach to a problem +that is at its core a social interaction disorder. +The ICD has been applying technology to the +provision of services since the 1970s and has +been acknowledged as a pioneer in this area. +Staff are provided with sophisticated organiza- +tional systems and technology to address the +program priorities. Appropriate utilization, how- +ever, requires precise matching of need with +solution. A major focus has been to provide +staff with useful tools that match their needs +and abilities for application in complex and +changing circumstances. + +From an administrative perspective, the prob- +lem of efficiently collecting, organizing, +interpreting, and monitoring the voluminous +information need to achieve comprehensive pro- +gram goals represents a continuing challenge. We +utilize a series of computer databases to organize +each student’s educational goal plan, specific +habilitative goals, daily and monthly progress on +each goal, graphs of progress, history of educa- +tional goals, and evaluation of goals. Our curric- +ulum database is connected to above the +databases, which allows the selected goals from +the IGS to be imported into a student’s goal plans’ +database. From this database, printed reports are +generated as well as large screen video projection +for staff meetings for review of individual chil- +dren’s goals and progress. The use of extensive +computer-based analytic tools for staff, high- +efficiency database software for goal selection +and monitoring, and extensive use of handheld +computing devices with custom-developed soft- +ware for numerous specialized activities is essen- +tial for efficient day-to-day operation within a +normative, constrained program budget. The +twin goals of the technology program are to +improve accuracy and speed of data-based +decision-making while simultaneously reducing +staff “paperwork” tedium which in turn allows +more time to focus on child and family needs. + +Efficacy Information +The ICD is one of the ten model programs cited in +the Educating Children with Autism report of the +National Research Council (2001) that was +commissioned by the US Department of Educa- +tion. The Committee on Educational Interventions +for Children with Autism utilized specific selec- +tion criteria in their search for model programs, +based upon published reports and frequency of +citation. They identified ten programs based +upon their criteria, to illustrate “state-of-the-art” +model approaches, which included the Children’s +Unit for Treatment and Evaluation. + +Because the ICD is an evidence-based program +as described above, there is a large body of +research studies that are constantly increasing. +Some relevant summaries of this research body +include: +National Research Council (2001). Educating +Children with Autism. Committee on Educa- +tional Interventions for Children with Autism. +Division of Behavioral and Social Sciences +and Education. Washington, DC: National +Academy Press. +National Autism Center. (2009). National Stan- +dards Project - Addressing the need for +evidence-based practice guidelines for autism +spectrum disorders, from http://www. +nationalautismcenter.org/about/national.php +The National Professional Development Center +on Autism Spectrum Disorders (2010). http:// +autismpdc.fpg.unc.edu/ +Odom, S., Boyd, B., Hall, L., & Hume, K. (2010). +Evaluation of comprehensive treatment +models for individuals with autism spectrum +disorders. Journal of Autism and Developmen- +tal Disorders, 40, 425–436. +Romanczyk, R.G., Turner, L.B., Sevlever, M. and +Gillis, J.M., (2015). The Status of Treatment +for Autism Spectrum Disorders: The Weak +Relationship of Science to Interventions. In +Lilienfeld, Lohr, and Lynn (Eds.), Science +and Pseudoscience in Contemporary Clinical +Psychology (2nd Edition). NY, NY: Guilford +Press. +Romanczyk, R.G., and McEachin (Eds), (2016). +Comprehensive Models of Autism Spectrum +Disorder Treatment: Points of Divergence and +Convergence. Springer, ISBN: 978–3–319- +40903-0. +New York State Department of Health (2017). +New York State Department of Health Clinical +Practice Guideline on Assessment and Inter- +vention Services for Young Children (Age 0–3) +with Autism Spectrum Disorders (ASD): 2017 +Update. Support from New York State’s Title +V Maternal and Child Health Block Grant, the +New York State Autism Awareness and +Research Fund, and the Far Fund. NYS Depart- +ment of Health, Albany, NY. Retrieved as: https:// +www.health.ny.gov/community/infants_children/ +early_intervention/autism/docs/report_recommen +dations_update.pdf + +Outcome Measurement +For an applied educational/clinical setting, it is +not possible to determine which specific +factor or combination of factors are the most +influential in outcome. That requires con- +trolled research with standardized procedures, +specifies duration, and appropriate control +groups. The explicit goal of the ICD is to +quickly transition children from diverse fami- +lies and communities to their home school +districts and to enable them to participate in +the services in their community. The specifics +of this transition are unique for each child and +do not represent the achievement of an abso- +lute level of functioning. The duration of par- +ticipation is variable within the average of +2.5 years. + +Within these non-research parameters, +approximately 50% transition to typical educa- +tional settings, 25% to “inclusion opportunity” +classrooms, and 25% to “self-contained” class- +rooms. Importantly, recall that our exit criteria +are specific to child, family, and school district +goals and do not reflect “absolute” criteria. Thus +a given family and school district may have +typical placement as their goal, while another +family and district have the goal of as quickly +as possible having the child participate in their +continuum of services (this is often the case for +children who must travel substantial distances +each day to the program). The formal research +that is conducted at the ICD focuses primarily +upon measurement/assess- ment, process, and +focused intervention out- comes. Some recent +examples are: +Aponte, C. & Romanczyk, R.G. (2016). Assess- +ment of Feeding Problems in Children with +Autism Spectrum Disorder. Research in +Autism Spectrum Disorders, 21,61–72. +Cavalari, R.N.S. & Romanczyk, R.G. (2015). +Quantifying Supervisory Decision Making: +Eye-Tracking Technology Applications for +the Promotion of Child Safety. Journal of +Behavioral Decision Making. DOI: 10.https:// +doi.org/10.1002/bdm.1857. +Turner, L.B.& Romanczyk, R.G (2012). Assess- +ment of fears and phobias in children with an +autism spectrum disorder. Research in Autism +Spectrum Disorders, 6, 1203–1210. +Callahan, E. H., Gillis, J. M., Romanczyk, R. G., +& Mattson, R. E. (2011). The behavioral +assessment of social interactions in young chil- +dren: An examination of convergent and incre- +mental validity. Research in Autism Spectrum +Disorders, 5, 768–774. +Gillis, J.M., Callahan, E.H. & Romanczyk, +R.G. (2010). Assessment of social behavior in +children with autism: The development of the +Behavioral Assessment of Social Interactions +in Young Children. Research in Autism Spec- +trum Disorders. + +Qualifications of Treatment Providers +All professional staff hold appropriate licenses +and certification for their respective profes- +sions. Additionally, 30% of the professional +staff are also Board Certified Behavior Ana- +lysts. The staff represent the following +professions: +Clinical Psychology +Special Education +Behavior Analysis +Nursing +Speech Pathology +Occupational Therapy +School Psychology +Adaptive Physical Education + +In addition to professional staff, there are full- +time staff in teacher aide, administrative, and tech- +nical staff positions. The ICD also has extensive +educational pro- grams. At the undergraduate +level, there is an intensive four-course sequence, +three of which have practicum components that +complement the requirements of the major in +psychology. The course sequence has been +evaluated by the Behav- ior Analyst Certification +Board as a Verified Course Sequence. Selected +graduate students in the doctoral clinical +psychology program, in addi- tion to the program +requirements, participate for 4 years as staff +members at the ICD under the supervision of +senior staff. Training is also pro- vided for select +postdoctoral fellows as well as medical students. + +References and Reading +Eagle, R., Romanczyk, R. G., & Lenzenweger, M. (2010). +Classification of children with Autism Spectrum Dis- +orders: A finite mixture modeling approach to hetero- +geneity. Research in Autism Spectrum Disorders, 4(4), +772–781. +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 +Press. +Romanczyk, R. G., & Gillis, J. M. (2008). Practice guide- +lines for autism education and intervention: Historical +perspective and recent developments. In J. Luiselli, +D. C. Russo, & W. P. Christian (Eds.), Effective prac- +tices for children with autism: Educational and behav- +ior support interventions that work. New York: Oxford +University Press. +Romanczyk, R. G., & Gillis, J. M. (2010). Continuum- +based model of behavioral treatment for children with +autism: A multi-factor and multi-dimensional perspec- +tive. In J. A. Mulick & E. A. Mayville (Eds.), Behav- +ioral foundations of effective autism treatment. +Cornwall-on-Hudson: Sloan Publishing. +Romanczyk, R. G., Lockshin, S., & Matey, L. (2000). +Preschool education programs for children with autism. +In S. Harris & J. Handleman (Eds.), Children with +autism: The preschool years (2nd ed.). Austin: Pro-Ed. + +Chile and Autism +Patricio Fischman1,2, Sonja Ziegler3, Daniela +Han2 and Ronit Fischman4 +1Yale University Child Study Center, New Haven, +CT, USA +2Private Practice, Santiago, Chile +3Marcus Autism Center, Emory University, +Atlanta, GA, USA +4Child and Adolescent Psychologist, Private +Practice, Santiago, Chile + +Historical Background +The first initiatives providing help for individuals +with Autism Spectrum Disorder(ASD) in Chile +were, as it is usually the case, spearheaded by par- +ents of autistic children, whose initiatives founded +many organizations that provide services to this day. +The largest national support organization, ASPAUT, +or the Chilean Association of Parents and Friends of +Autistics, was founded in 1983 in Santiago. Today, +the nonprofit organization has branches in five of +Chile’s 15 regions, with 1,400 members nationwide. +Its services include four schools, five family support +groups, and one vocational training center. Though +each location is associated by name, each operates +as an independent entity. + +Legal Issues, Mandates for Services +The department of special education of the Min- +istry of Education indicates that in 2009, 589 stu- +dents diagnosed with autism were receiving +educational services under the law Decreto +Supremo N° 815/1990 which guarantees special +education services to individuals with Autism, +severe Dysphasia, and/ or Psychosis. + +Overview of Current Treatments and +Centers +Multiple research findings indicate that early iden- +tification and diagnosis of ASD can improve +opportunities for children to benefit from inter- +ventions and lessen the burden on parents +(Zwaigenbaum et al. 2013). The key to early +diagnosis is access to competent and effective +diagnostic and treatment services. In Chile, health +care can be accessed through both the public and +private systems. + +Public Health Care +Though Chile does provide services through a +public health-care system, hospitals are not +equipped to attend to individuals with an ASD, +even though several laws regarding the disability +exist. Parents who do receive medical services +through the public health care system have great +difficulties in making appointments with special- +ists such as neurologists or psychiatrists, and if +they are successful, encounter very long waiting +periods, which, in turn, inhibits the possibility of +an early diagnosis and thus early intervention. +Even after a diagnosis is made, it is practically +impossible to access support and treatment from a +multidisciplinary team, on a continuous basis, +through the public health system. Furthermore, +the government does not guaranty coverage of +any treatment related to ASD. In addition to the +general public health-care system, there is also a +list of 69 illnesses or conditions for which the +government guarantees free treatment. ASD is +not included in this list (Ministerio de Salud +2010). + +Private Health Care +In Chile, there is also a private health-care system. +Unfortunately, even after paying high premiums +for private health insurance, the coverage for the +payment of specialist services is very limited, +sometimes as low as one or two sessions a year, +or the coverage of a very small percentage of the +session’s actual cost. Typically, professionals in +the private sector work independently, not in an +integrated center or fashion, leaving parents with +no choice but to shuttle their child to different +specialists, who do not communicate with one +another, for different treatments. High costs and +inadequate service provision through the private +health system places great financial, emotional, +and practical strains on families. Very few private +centers for developmental disabilities have a +multidisciplinary staff that works in an integrated +fashion. + +Obstacles to Quality Service Provision +Autism spectrum disorders place huge strains on +families. These can be quantified in terms of +financial investment, time lost from work, and +time not spent with other family members. Other +strains can only be described, such as levels of +stress experienced, impacts on relationships, the +mental health status of other family members, and +lost personal time of professional careers. In fact, +many families suffer from severe dysfunctional +relationships leading to parental separation, anx- +ious distress, and psychological problems in +siblings. + +Financial Burden +One of the most common obstacles to receiving +treatment services is that of lack of or restriction of +financial means. All but one family interviewed +for this study stated that their level of financial +resources negatively affected the quantity as well +as the quality of the treatment their child received. +Only one family, one of substantial financial +means, stated that the quantity of treatment that +their son received was adequate. +Apart from the financial burden placed on fam- +ilies by both the public and private health-care +sectors, lack of professionals trained the area of +Autism in Chile creates further obstacles to cor- +rect diagnosis and early intervention. All children +in this study were seen by various professionals +including psychologists, neurologists, and child +psychiatrists, and received varying diagnoses. +Many of these professionals have varying degrees +of training and experience in ASD and also use a +variety of classifications, nomenclature, and treat- +ment approaches. + +Diagnosis +Of four families interviewed and four further +cases reviewed, only one child in this study +received a diagnosis of Pervasive Developmental +Disorder (PDD) as a first diagnosis. Two children +received diagnosis of Dysphasia, three of a gen- +eral language disorder, one of a nonspecific +behavioral disorder, and one of Schizoid Person- +ality Disorder, respectively, all previous to their +diagnosis of ASD. Typically, the first profes- +sionals to recommend an evaluation were speech +therapists, either within the educational setting or +in private practice. At least four children received +their diagnosis of an ASD from a neurologist. +There is a cultural bias against consulting with +psychiatrists, leading to underconsultation with +these professionals until later in the process. Def- +icits in professional development and training in +the area of ASD can be seen through significant +delay in establishing an early and appropriate +diagnosis and poor management in several of +these cases. + +Cultural Aspects +Obstacles to quality service provision and care +can also be found in specific cultural aspects. +One unexpected cultural aspect that presented +itself in two interviews with center directors +interviewed in this study was that of, what could +be referred to, as cultural protectiveness. One +director commented that professionals in Chile +are often very guarded about their knowledge of +a specific area and do not want to share this or +work collaboratively with others for fear of com- +petition in the area. One director also stated that +there is a lack of trained professionals in the area +of ASD in Chile, notwithstanding, she would not +employ any foreign professional, regardless of +their training or experience, as “they would not +know the reality of Chile.” These opinions were +spontaneously expressed without prompting +through the interviewer’s questioning. Clinical +work, following the psychoanalytic method, +tends to be considered “in-doors” and “confiden- +tial,” which leads to the lack of communication +and poor team work in many instances. + +Centralization +Centralization of specialists and services that are +available, to Santiago, the capital city of Chile and +surrounding areas, poses further obstacles to diag- +nostic, treatment, and support options for families +outside the greater metropolitan Santiago area. +The limitation of access to services can be seen +in the distribution of autism-specific education +and treatment services throughout the country. +Except for Valparaiso and Concepcion, the rest +of the country lacks trained professionals. + +Service Provision +The following diagram presents the governmental +bodies responsible for service provision for indi- +viduals with disabilities, accessible in the public +sector (Fig. 1). It is important to note that no +governmental body provides direct funding or +services for the individuals with ASD. This +includes the National Service for Disability. If +organizations would like to receive support +through this office, they must apply for funding +based on a project proposal. Funding is not +guaranteed and is very difficult to obtain. + +Educational Services +According to the Ministry of Education, in 2013, +there are 15 publicly funded schools throughout +the country that offer educational services specif- +ically to children with ASD. These schools are +located in seven of Chile’s 15 geographical +regions, with five located in the Metropolitan +Region of Santiago and four in the neighboring +region of Valparaiso. Thirteen of these schools are +managed by nonprofit organizations that receive +funding from the Ministry of Education, on a +monthly basis, based on the number of children +that attend. Two of these schools receive funding +through their municipalities. There is no school +directly run by a government body. There are no +privately funded schools that specifically support +children with autism. + +Integration Programs +Chilean law guarantees access to, and integration +in, the educational system for all individuals with +special education needs. The Ministry of Educa- +tion satisfies this requirement by giving public +schools the opportunity to have an “integration +program” by way of contracting a multi- +disciplinary professional team through govern- +ment funding. Public, no profit, or municipality +schools receive funding based on what type of +disabilities their special needs students have, and +how many of them attend. Students with special +needs are either considered to have transitory +special needs or permanent special needs. Transitory +special needs include borderline cognitive +disabilities, Attention Deficit Disorders, and +specific language and learning disorders. Permanent +special needs include cognitive disabilities, physical +disabilities, auditory or visual disabilities, and +Autism. + +According to the Ministry of Education, there +are 4,500 public schools in Chile receiving +funding for integration programs in 2013. Schools +that accept students with special needs are +required to redefine their educational projects, +adapt their curricula, and implement support sys- +tems based on the needs of their students. They +must also evaluate and monitor these needs over +time as well as train teachers and staff. Students +receive a minimum of 10 h of special support +per week. However, in order to receive funding for a +multidisciplinary professional team, a school +must have at least five transitory special needs +students or two permanent special needs students +in the first grade level who wish to attend. This +begs the question of what kind of support students +with special needs in small communities or in +rural areas receive, when pure lack of population +limits their access to funding under the govern- +mental initiative. + +Some private schools also offer integration +programs. The cost of professionals such as edu- +cational psychologists is covered by the tuition of +all students. However, the parents of a student +with special needs must personally cover the +costs of any extra support their child might need +including special education teachers, classrooms +aids, tutors, or “shadows.” Private schools with +integration programs often have very strenuous +limits on the number of special education students +they accept. This may be a limit of five special +needs students for a school population of over +1,000 students. Being private institutions, they +are under no obligation to accept any student +with special needs, if they so choose. + +Organizations for ASD +There are currently seven organizations in Chile +that provide services specifically to individuals +with ASD. These services include schooling +options, diagnosis and therapeutic services, and +psychoeducation and support for parents and +families. Five of these organizations are located in +San- tiago, one in Vina del Mar, about 120 km from +the capital and one is an internet-based virtual +support and advocacy group. Two of these +organizations provide support and education +through informa- tive websites and chat rooms. One +of these spe- cifically supports individuals with +Asperger’s Syndrome and their families and only +one, ASPAUT, has centers located in various regions +of Chile. + +Figure 2 below illustrates important aspects of +services provided by these organizations includ- +ing funding, diagnostic tools used, intervention +methods utilized, and training of their directors: +Four directors interviewed for this study, three +special education teachers and one psychologist, +stated that they had not received any education or +special training about autism in their University +courses. All of them subsequently sought specific +education such as training in ABA and PECS +either outside of Chile or through visiting interna- +tional professionals, such as Theo Peeters. There +are also at least two private rehabilitation centers +in Santiago that provide diagnostic and therapeutic +services to individuals with ASD. Both provide +services through multidisciplinary teams. One +center utilizes standardized clinical diagnos- tic +tools while another utilizes its own clinical +method. One center provides treatment options +based on a mix of ABA, Floortime and TEACCH, +while the second provides group therapy, Floortime, +and occupational therapy with sensory integration, +speech therapy, medication treatment and “Bio- +Diets” in connection with two referring pediatricians. + +Overview of Research Directions +Children and adolescents under the age of +15 make up 22 % of Chile’s population (WHO +2010). As stated by the Chilean Ministry of Health, +there have been no epidemiological prevalence +studies of Autism or ASD conducted in Chile +and there is no registry of diagnosed cases. How- +ever, based on calculations using the international +estimate of prevalence of nine children with +autism in 1,000 and 240,569 registered births in +Chile in 2007, the Ministry (2011) estimates that +the approximate number of children with a diag- +nosis of an Autism spectrum disorder would be +2,156. According to the National Inquiry of Dis- +ability in 2004, 15,000 individuals presented with +severe language disorders, or one in 1,000, using +the population registry of 15,000,000 inhabitants +of the 2002 census. This estimation does not dif- +ferentiate between various possible diagnoses. +Though Autism is a global issue, affecting +individuals of all ethnicities, clinical and research +publications in the field are heavily focused in +developed countries, with the United States, Can- +ada, and the United Kingdom being leading pub- +lishers. Comparatively, publications in the area of +ASD in Latin America are rare, and almost non- +existent in Chile (OARC 2012). Thusly, little is +known about the magnitude of the problem. + +In a review of the Chilean national publication +database, only six articles related to ASD have +been published in the last 27 years. Three of +these articles are clinical descriptions, two are +case studies and one is a literature review. + +Clinical Description +Though autism is defined as a developmental dis- +order that manifests itself in the first three years of +childhood, its symptoms continue throughout an +individual’s lifespan. Irarrázaval et al. (2005) pre- +sented a clinical description of the disorder based +on diagnostic guidelines of the DSM- IV- TR, +prevalence, and psychopathology from infancy +through adolescence. Adult Autism was discussed +through a case study of a 23-year old man brought +to psychiatric evaluation by his mother. Neurobi- +ological aspects of autism and the use of psycho- +tropic medications in individuals with autism +were also discussed. Quejada (2008) presented a +clinical description of the disorder through genetic +etiology, diagnosis, differential diagnosis, and +prognosis. Flora de Barra also presented a clinical +description of ASD based on the ICD- 10, genetic +etiology, and differential diagnoses (1995). + +Genetics +Individuals with autism usually present with cog- +nitive difficulties. About 16–40 % of those with +cognitive problems present with profound defi- +cits. Flora de la Barra et al. (1986) reviewed a +case study of two identical twin girls with autism +and profound cognitive deficits, who presented +with an apparently balanced chromosomal +translocation. + +Treatment +After a definitive diagnosis of autism, it is impor- +tant to evaluate how a child’s development can be +supported and their symptoms alleviated. Morales +et al. (1995) presented a case study in which a +9 year-old institutionalized boy with autism +improved in the areas of language, social interac- +tion, and stereotypical behavior after several +months of systems-focused family therapy with +his father, mother, and older brother. + +Review of Aetiologies and Alternative +Treatments +A growing number of parents are adopting alter- +native or complementary treatments such as diet +restrictions, chelation therapy for heavy metals, +the use of hyperbaric oxygen chambers, elimina- +tion diets, as well as refusing to vaccinate their +children due to a variety of beliefs regarding ASD +aetiological hypothesis. Higuerra (2010) pre- +sented a critical literature review of studies related +to these treatments, highlighting their methodo- +logical inadequacies and inconclusiveness. This +article is very important to furthering professional +development in Latin America. From a cultural +perspective, the fact that it is written in Spanish, +by a Chilean, adds a great deal of validity and +weight to its contents. Though research in the +area of autism in Chile is scarce, the articles that +do exist seem to repre- sent the level of knowledge +of the field among some professionals, as well as +accounts of clinical work with patients. It is +important to note that there are no articles +published in PubMed specifically related to Chile +and Autism + +Government Publications +The Chilean government has published three +informative guides on ASD for teachers and +health-care professionals, respectively: two +through the Ministry of Education and one +through the Ministry of Health. + +Ministry of Education +Both guides from Ministry of Education are writ- +ten specifically for teachers. One focuses on +detection, intervention, and teaching methods for +solely children in the preschool age group, while +the second focuses on all schooling levels, includ- +ing university. For the preschool level, the guide +begins by describing ASD based on the DSM- +IV-TR diag- nostic criteria, history of the diagnosis +and the three areas of impairment. There is also a +pre- sentation of aetiological theories. The guide +also presents guidelines for early detection and +inter- vention, as well as suggestions on how to +speak to families if a need for a clinical evaluation +is suspected. Lastly, the guide presents recommen- +dations for the educational-teaching process. It +gives concrete examples for preparing lessons, +how to structure the learning environment based +on the needs presented through the disorder, how +to involve the family in the continual learning +process at home and provides examples of activ- +ity planning and execution (Ministerio de +Educación 2010). + +Though the guide can be seen as generally +helpful, it does have several and significant defi- +ciencies. One being that some information pro- +vided is conflicting and at times simply wrong, +such as the description of Asperger’s Syndrome +as a language disorder. Providing false informa- +tion to a group of professionals who are not +likely to receive any further education or training +in the area can have limitless repercussions. The +guide also gives the impression that intervention +at 5 or 6 years of age can still be considered early, +and does not emphasize the need for the earliest +intervention possible in order to obtain the +best outcome for the child (Ministerio de +Educación 2010). + +The second educator’s guide for all school +levels also speaks in length about the history of +the disorder, diagnostic criteria, and early alert +indicators. It presents examples of the M-CHAT +and ASSQ for educators’ use. The guide describes +the specific early intervention methods of Lovaas +and TEACCH. For school-aged children, the +guide discusses the need for individual evaluation +of each child’s needs and gives general tips on +supporting a child through their scholastic devel- +opment. Subsequently, it describes specific char- +acteristics of children with a diagnosis of +Asperger’s Syndrome. Lastly, the guide describes +the general abilities and impairments that young +adults with Asperger’s Syndrome typically present +in relation to their entrance into the University +setting. It provides suggestions for teachers as well +as administrators in how to best teach and provide +support for individuals with Asperger’s Syndrome +(Ministerio de Educación 2010). It is important to +note, that in speaking with the author of the guide, +she stated that the guide was commissioned as a +demonstration of best practice by the Ministry of +Education. However to her knowledge, the guide +is not actually in significant use within the school +system. + +Ministry of Health +The Ministry of Health has also published a +guide for the clinical detection and diagnosis +of ASD, for health-care professionals. All guide- +lines follow international standard. Steps of early +detection, diagnostic evaluation through multi- +disciplinary teams, and therapeutic interventions +are discussed. A multifaceted evaluation using +standardized measures is recommended. Behav- +ioral focused treatment options presented +include ABA, PTR, and early intensive behav- +ioral intervention. DIR, Floortime, and sensory +integration are also discussed. Augmentative +communication systems such as PECS, +TEACCH, and TCC are presented, and the +roles of various medical professionals in the +treatment process are explained. Though this +guide presents a best practice model of detection, +diagnosis, and treatment for ASD, its application +in practice is virtually impossible in Chile due to +the multiple hindering factors discussed previously. +Based on state- ments from the four families +interviewed and the four cases reviewed, in relation +to their diag- nostic processes and experiences, it +does not seem that the contents of this guild are +being taught to the professionals most likely to be +involved in the lives of individuals with ASD and +their families. + +Social Policy and Training +Autism profoundly affects individuals with the +diagnosis, their families, and in turn societies. In +reviewing the data collected for this chapter on +Autism in Chile, it seems as if the knowledge to +improve the lives of individuals with ASD and +their families through correct early diagnosis, +effective early intervention, and treatment as +well as long- term support provision is available. +It is the lack of implementation of this knowl- +edge that prohibits thousands of individuals with +ASD in Chile from receiving the quality and +quantity of services needed to reach their full +potential. Governments have an obligation to +provide support to individuals with ASD. In Chile, +gov- ernmental interest and investment in all areas +related to autism would be the first step to improv- +ing the outcomes for all autistic individuals. Gov- +ernment bodies must guarantee that all resources, +including proper diagnosis, high quality treat- +ment, and education are both financially and phys- +ically accessible to all its citizens. This can be +achieved through proper government investment. +This can also be achieved through the regulation +of private health sector and the services offered +within the system. + +The Ministry of Education must ensure that +their educational professionals are trained in all +aspects of autism and on how to provide students +with ASD with the best education and care possi- +ble. This would include training for all profes- +sionals currently in the field, as well as +incorporating autism education and training into +the curricula of all public and private educational +institutions. Governments also have a responsibility +in overseeing the education and training of its +med- ical professionals, regardless in which +capacity they practice or in which school of medicine +they have trained. Professionals practicing in +Chile need to be trained in the variety of aspects +of ASD, its differential diagnosis and treatment +options. Diagnosis and treatment methods must +be included in the curricula of all medical schools. +This training is vital for primary care profes- +sionals, who are typically the first professionals +to come in contact with children who present with +worrisome signs and symptoms of developmental +delays and distortions. Initiatives for early diag- +nosis and intervention must be made a national +medical priority. Correct early diagnosis and inter- +vention also reduces the financial, emotional, and +practical strains and burdens experienced by fam- +ily members. + +Governments through their Ministries of +Health and Education must also take an active +role in providing services to individuals with AS- +D. These governmental bodies must define a pro- +tocol which would clearly delineate the path of +“best care” through “best practice strategies.” +They must train health, educational professionals, +and parents about these strategies and enforce +their implementation. Government interest is also +needed to improve research in the area of autism +in Chile. Without knowing the prevalence and the +status of the disorder in a population, it is difficult +to develop effective strategies for prevention, inter- +vention, long-term care, and positive outcomes +that reflect the specific needs of the country and +culture. In regards to service provision, it is +important that all individuals have access to +support and services throughout their lifespan: +child, adoles- cence, and adulthood. This promotes +personal development, better outcomes, and +alleviates some of the strain experienced by family +members responsible for lifetime care. Each child +diag- nosed with autism today will one day be an +adult with autism. There is a great need in Chile +for more vocational training and rehabilitation cen- +ters throughout the country to accommodate the +need of adults with ASD. Lastly, there is a great +need for equalization of accessibility to quality +care provision between the public and private +sectors. Autism is a universal severe developmental +disorder that is also present in Chile. The devel- +opment of service provision for individuals with +autism has sprung from the determination and +self-reliance of parents and family members and +in most cases it seems still greatly dependent on +their resilience and fortitude. Currently, lack of +interest, investment, and regulation by govern- +ment bodies hinders the development of research +and practice in the field, as well as access to +quality medical care, treatment, and support ser- +vices for many Chileans with ASD and their +families. + +Acknowledgment +The authors of this study acknowledge that during +its preparation for publication, the Diagnostic and +Statistical Manual of Mental Disorders, 5th +Edition. (American Psychiatric Association 2013) +was published, and acknowledge that under these +new diagnostic guide- lines, the definition of +Autism and ASD has changed. However, the +authors also acknowledge that when changes occur, +the utilization of new diagnostic guidelines is a +scientific and cultural process for both professionals +and patients. Thusly, the authors chose to present +the study’s data as defined by the Diagnostic and +Statistical Manual of Mental Disorders 4th Edition, +Text Revision (American Psychiatric Association 2000). + +References and Reading +American Psychiatric Association. (2000). Diagnostic and +statistical manual of mental disorders (4th ed.). Wash- +ington, DC: Author. Text Revision. +American Psychiatric Association. (2013). Diagnostic and +statistical manual of mental disorders (5th ed.). Wash- +ington, DC: Author. +de Salud, M. (2011). Guía de Práctica Clínica de +Detección y Diagnóstico Oportuno de los Trastornos +del Espectro Autista (TEA) [Practical clinical guide the +timely detection and diagnosis of autism spectrum dis- +orders (ASD)]. Santiago, Chile: MINSAL. +Flora de la Barra, M. (1995). Aspectos Biológicos del +Autismo [Biological aspects of Autism]. La Revista +Chilena de Neuropsiquiatría, 33, 361–365. +Flora de la Barra, M., Skoknic, V., Allicnde, A., Raimann, +E., Cortes, F., & Lacassic, Y. (1986). Autism and men- +tal retardation associated with (7;20) balanced chromo- +somal translocation in a pair of female twins. La Revista +Chilena de Pediatría, 57, 549–554. +Gobierno de Chile. (2013). Ministros. Retrieved August +29, 2013 from http://www.gob.cl/ministros/ +Higuerra, M. (2010). Biological treatments of Autism, +elimination diets: A critical review. La Revista Chilena +de Pediatría, 81, 204–214. Lit review. +Irarrázaval, M. E., Brokering, W., & Murillo, G. (2005). +Autismo: An adult psychiatry perspective. La Revista +Chilena de Neuropsiquiatría, 43, 51–60. +Ministerio de Educación. (2009). Unidad de Educación +Especial. Guía de Apoyo Técnico-Pedagógico: +Necesidades Educativas Especiales en el Nivel de +Educación Parvularia Asociadas al Autismo +[Technical- pedagogical support guide: Special educa- +tional needs on the kindergarden educational level +associated with autism] (1st ed.) Santiago, Chile: +Author. +Ministerio de Educación. (2010). Unidad de Educación +Especial. Manual de Apoyo a Docentes: Educación +de Estudiantes que Presentan con Trastornos del +Espectro Autista [Support manual for teachers: Educa- +tion for students that present with an autism spectrum +syndrome] (1st ed.) Santiago, Chile: Author. +Ministerio de Educación. (2013). Unidad de Educación +Especial. Directorio de Establecimientos. Retrieved +May 16, 2013 from http://www.educacionespecial. +mineduc.cl/index2.php?id_portal¼20&id_ +seccion¼2543&id_contenido¼23559. +Excel docu- +ment “Escuelas Especiales”. [Special Education +Schools]. Excel document “Escuelas con Programa de +Intergración Escolar”. [Public Schools with an Educa- +tional Intergration Program]. +Ministerio de Salud. (2010). Acceso Universal Garantías +Explícitas [Explicit guarantees of universal access]. +Chile: Minsal. Retrieved May 27, 2017 from http:// +www.minsal.gob.cl/portal/url/page/minsalcl/g_ +gesauge/presentacion.htmlhttp://www.minsal.gob.cl/ +portal/url/page/minsalcl/g_gesauge/presentacion.html +Morales, M., Martínez, R., & Valdés, A. (1995). Un +modelo de acción con un miembro autista. A model +of action with an autistic family member]. La Revista +Chilena de Psiquiatría. 1, 26–33. Chile. +Office of Autism Research Coordination. (OARC), +National Institute of Mental Health and Thomson +Reuters, Inc. on behalf of the Interagency Autism Coor- +dinating Committee (IACC). IACC/OARC autism spec- +trum disorder research publications analysis report: +The global landscape of autism research. July 2012. +Retrieved May 23, 2013 from the Department of Health +and Human Services Interagency Autism Coordinating +Committee website: http://iacc.hhs.gov/publications- +analysis/july2012/index.shtml +Quijada, C. (2008). Espectro Autista [Autism spectrum]. +La Revista Chilena de Pediatría., 79, 86–91. +World Health Organization. (2010). Chile. Retrieved May +27, 2013 from http://apps.who.int/gho/data/view.coun +try.6300 +Zwaigenbaum, L., Bryson, S., & Garon, N. (2013). Early +identification of autism spectrum disorders. Behavioral +Brain Research. Retrieved May 27, 2013 from http:// +www.ncbi.nlm.nih.gov/pubmed/23588272 + +China and Autism +Jared Cohen +Yale Child Study Center, Yale University, New +Haven, CT, USA + +Historical Background +The history of autism in China is a brief one, as it +was not diagnosed there until 1982 (Tao 1987). +Since that point, the landscape of research and +scholarly work pertaining to the epidemiology +and clinical care of autism and related disorders +has been relatively bare. Some of this can be +attributed to the fact that dozens of dialects are +spoken throughout the mainland, leading to a +relative lack of appropriately translated materials +relating to the diagnostic and treatment practices +of autism (Ming 2013). This has left many doc- +tors, teachers, and a majority of the general public +with a lack of awareness and understanding of the +disorder. China has a long history of special +education schools, dating back to the early +twentieth cen- tury and through the times of Mao +Zedong (Deng et al. 2001). These institutions have +been mostly geared toward those suffering from +blindness and deafness, rather than those with +intellectual disabilities, however (Yang and Wang +1994). Consequently, programs and schools for +those with autism have been much more difficult +to come by. + +Legal Issues, Mandates for Services +Beginning in 1986, the Chinese Government +began enacting a slew of legislation intending to +benefit the disabled. The first landmark act was +the China Compulsory Education Law, which +aimed to require public schools to accept children +with special needs (Deng et al. 2001). This was +followed in 1990 by the Law of the People’s +Republic of China on the Protection of Persons +with Disabilities, which called for additional pro- +tections of Chinese individuals with disabilities +under the law (McCabe 2007). Moreover, through +its Ninth, Tenth, and Eleventh Five-Year Plans, +the Chinese Government continued to outline +ways in which to increase support for disabled +children as well as improve their enrollment in +schools (Ming 2013). Yet, although autism was +first diagnosed in 1982, it was not officially +included as a disability covered by Chinese law +until 2006 (Gu 2007). + +Despite these apparent attempts to increase +support for those with autism and other disor- +ders, the vague goals outlined in such legislation +have yielded minimal results. Autistic children +are still often refused an education from +government-run public schools, including spe- +cial education ones (Huang and Wheeler 2007). +Public schools can cost almost half of a Chinese +citizen’s average annual salary, while private +schools often cost two to three times the average +amount (Ming 2013). For children that live in +rural areas, it can be incredibly difficult to even +find a school that offers the proper services +(Wang et al. 2011). It is not uncommon for a +special education school to admit an autistic +child only to later declare that its teachers have +an improper background in working with chil- +dren with such conditions (Rubin 2000). Due to +the shortcomings of China’s state-run programs +and educational system, many families and autistic +individuals seek intervention from private +organizations (McCabe 2004). Such treat- ment +is paid for out of pocket by parents or fam- ilies (Gu +2007; McCabe 2007), which can become an obvious +financial burden. The cost of such services in China +is an issue for many families. + +Overview of Current Treatments and +Centers +While Chinese public and private schools have +fallen short for most autistic children, a number +of nongovernmental organizations have begun to +emerge. One of the more notable examples is +BARAC: the Beijing Association for the Rehabil- +itation of Autistic Children (Feinstein 2010). Run +completely off of fees and private donations, +BARAC offers a hotline for parents of autistic +children, publishes newsletters and journals to +raise autism awareness, and oversees two schools +specifically for autistic children, each with over +100 students (Feinstein 2010). A number of sim- +ilar centers now exist within China’s major cities, +though very few exist in China’s rural areas and +countryside. Many of these organizations have +been started by the parents of autistic children +who had difficulty finding services or getting an +education elsewhere (McCabe 2007). In terms of +the diagnosis of autism within China, many +doctors use the Chinese Classifica- tion of Mental +Disorders, Third edition (CCMD- 3) (Wu and +Zhang 2011). Professionals have argued that +changes should be made to improve the accuracy +and consistency of diagnoses of autism (Wu and +Zhang 2011). Currently, very few internationally +recognized clinical diagnostic tests, such as Autism +Diagnostic Interview- Revised (ADI-R) and the +Autism Diagnostic Observation Schedule (ADOS), +are used by doc- tors (Wu and Zhang 2011). + +Overview of Research Directions +Research on autism in China has been very lim- +ited, though the volume has been increasing as +awareness has increased. Moreover, organiza- +tions such as the Autism Consortium China are +emerging and beginning to change the landscape +of research within the nation (Wu and Zhang +2011). Launched in 2009 by a group of Chinese +research scientists and doctors, the Autism Con- +sortium China seeks to spread awareness of +autism in Chinese society, help standardize and +improve diagnostic procedures, and conduct +extensive research on autism within China +(Wu and Zhang 2011). While much of the +research that has been conducted within China +has focused on infantile autism, early interven- +tion, or special education, adults with autism +have seemed to be an area that research has +neglected. + +Overview of Training +Public schools often justify their rejection of autis- +tic children by claiming that their teachers have no +training in working with autism (Rubin 2000). +Indeed, most instructors in schools and even at +intervention programs specifically geared toward +autistic children have little to no relevant training, +mostly due to the small number of universities +throughout the country that offer such a field of +study (McCabe 2013). Many teachers even +express a strong desire for more training, espe- +cially relating to adolescent intervention (McCabe +2013). At times, passionate teachers with a will to +help autistic children are bound by China’s limited +awareness and lack of resources. + +Social Policy and Current Controversies +Autism, along with many other disabilities and +illnesses such as ADHD, schizophrenia, and +epilepsy, has been severely stigmatized in Chi- +nese culture (Kelly 2007). There are some +deeply rooted cultural explanations for such a +social context. In the times of Confucius, the +mentally and physically disabled were a part of +the lowest social status (Deng et al. 2001). In +Mainland China, many still refer to autism and +other spectrum disorders as “gudu zheng” +which translates to “lonely disease” (Feinstein +2010). Moreover, studies have suggested that +families of autistic children have experienced +increased levels of stress related to pessimism +shame (Wang et al. 2011). This social context +and intense stigmatization within Chinese cul- +ture often incentivizes families or individuals to +hide one’s autism or disability rather than treat +it. A large number of parents cut their disabled +children off from outside social interaction, +including schooling for this reason (Wang +et al. 2011). + +See Also +▶Culture and Autism + +References and Reading +Deng, M., Poon-Mcbrayer, K. F., & Farnsworth, E. B. +(2001). The development of special education in +China: A sociocultural review. Remedial and Special +Education, 22(5), 288–298. https://doi.org/10.1177/ +074193250102200504. +Feinstein, A. (2010). A history of autism: Conversations +with the pioneers. Chichester: Wiley-Blackwell. +Gu, Y. (2007). Gudu zheng ertong qidai geng duo guanzhu +[Children with autism look forward to more attention]. +Xinwen Shijie (News World) January: 11. +Hu, Y. (2010). Training Needs for Implementing Early +Childhood Inclusion in China. International Journal +of Early Childhood Special Education, 12–30. +Retrieved 2 Sept 2014. +Huang, A. X., & Wheeler, J. J. (2007). Including children +with autism in general education in China. Childhood +Education, 83(6), 356–360. https://doi.org/10.1080/ +00094056.2007.10522950. +Kelly, T. (2007). Transforming China’s mental health sys- +tem: Principles and recommendations. International +Journal of Mental Health, 36(2), 50–64. https://doi. +org/10.2753/IMH0020-7411360205. +Kuo-Tai, T. (1987). Brief report: Infantile autism in China. +Journal of Autism and Developmental Disorders, +17(2), 289–296. https://doi.org/10.1007/BF01495062. +McCabe, H. (2004). China: NGOs and education for chil- +dren with autism. In Civil society or shadow state: +State/NGO relations in education. Greenwich, CT: +Information Age Publishing +Mccabe, H. (2007). Parent advocacy in the face of adver- +sity: Autism and families in the People’s Republic of +China. Focus on Autism and Other Developmental +Disabilities, 22(1), 39–50. https://doi.org/10.1177/ +10883576070220010501. +Mccabe, H. (2013). Bamboo shoots after the rain: Devel- +opment and challenges of autism intervention in China. +Autism, 17(5), 510–526. https://doi.org/10.1177/ +1362361312436849. +Ming, J. (2013). Autism in China: A biosocial review. +Journal of Global Health. Retrieved September +2, 2014, from http://www.ghjournal.org/?p¼6140 +Rubin, K. (2000, October 19). Chinese charities’ long +March. Retrieved September 2, 2014, from http:// +philanthropy.com/article/Chinese-Charities-Long- +March/54378/ +Tao, K. (1987). Brief report: Infantile autism in China. +Journal of Autism and Developmental Disorders, 17 +(2), 289–296. +Wang, P. (2008). Effects of a parent training program on the +interactive skills of parents of children with autism in +China. Journal of Policy and Practice in Intellectual +Disabilities, 5(2), 96–104. https://doi.org/10.1111/j. +1741-1130.2008.00154.x. +Wang, P., Michaels, C. A., & Day, M. S. (2011). Stresses +and coping strategies of Chinese families with children +with autism and other developmental disabilities. Jour- +nal of Autism and Developmental Disorders, 41(6), +783–795. https://doi.org/10.1007/s10803-010-1099-3. +Wu, B., & Zhang, Z. (2011). Current status of autism +spectrum disorder in China – Summary on the 369th +Xiangshan science conferences. American Chinese +Journal of Medicine and Science, 4(3), 167. https:// +doi.org/10.7156/v4i3p167. +Yang, H. L., & Wang, H. B. (1994). Special education in +China. The Journal of Special Education, 28, +93–105. + +Chlorpromazine +Maureen Early1, Craig A. Erickson1,2,3, Logan +Wink2,3 and Christopher J. McDougle4,5 +1Christian Sarkine Autism Treatment Center, +Indianapolis, IN, USA +2Department of Psychiatry, Indiana University +School of Medicine, Indianapolis, IN, USA +3Department of Psychiatry, University of +Cincinnati School of Medicine, Cincinnati, OH, +USA +4Lurie Center for Autism, Massachusetts General +Hospital, Lexington, MA, USA +5Nancy Lurie Marks Professorship in the Field of +Autism, Harvard Medical School, Boston, MA, +USA + +Synonyms +3-(2-chloro-10 H-phenothiazin-10-yl)-N, +N-dimethylpropan-1-amine hydrochloride; +Chlorpromazine hydrochloride; Thorazine + +Definition +Chlorpromazine is a prescription drug in the +group of first-generation antipsychotics initially +FDA-approved for medical use in the year 1957 +whose active ingredients are chlorpromazine +and chlorpromazine hydrochloride which have +the chemical formulas C17H19N2SCl and +C17H19N2SCl·HCl, respectively. This drug is cur- +rently only available in generic form. This drug +can be used for the treatment of schizophrenia, +bipolar mania, some psychotic symptoms of +dementia, and serotonin syndrome. Observed +side effects include drowsiness/sedation, parkin- +sonism, orthostatic hypertension, tachycardia, +ECG abnormalities, anticholinergic effects, galac- +torrhea, weight gain, photosensitivity, rashes, and +pigmentation. + +See Also +▶Antipsychotics: Drugs + +References and Reading +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. +Stahl, S. M. (2000). Antipsychotic agents. In Essential +psychopharmacology: Neuroscientific basis and clini- +cal applications (pp. 401–458). Cambridge, MA: Cam- +bridge University Press. +Thioridazine. (n.d.). Retrieved from the ChemSpider Wiki: +http://www.chemspider.com/Chemical-Structure.5253. +html. +U.S. Food and Drug Administration. (2011). Drugs@FDA. +Retrieved from: http://www.accessdata.fda.gov/scripts/ +cder/drugsatfda/index.cfms. +Wilkaitis, J., Mulvihill, T., & Nasrallah, H. A. (2006). +Classic antipsychotic medications. In A. F. +Schatzberg & C. B. Nemeroff (Eds.), Essentials +of clinical psychopharmacology (2nd ed., +pp. 211–228). Washington, DC: American Psychiatric +Publishing. + +Chlorpromazine Hydrochloride +▶Chlorpromazine + +Cholinergic +▶Acetylcholine: Definition + +Cholinergic System +Carolyn A. Doyle1 and +Christopher J. McDougle2,3 +1Indiana University School of Medicine, +Indianapolis, IN, USA +2Lurie Center for Autism, Massachusetts General +Hospital, Lexington, MA, USA +3Nancy Lurie Marks Professorship in the Field +of Autism, Harvard Medical School, Boston, +MA, USA + +Definition +The cholinergic system utilizes acetylcholine +(ACh) neurotransmission to regulate memory, +arousal, concentration, attention, and conscious- +ness (Sadock et al. 2009). ACh projects from the +brainstem neurotransmitter center and basal fore- +brain to numerous locations, including the pre- +frontal cortex, basal forebrain, thalamus, +hypothalamus, amygdala, and hippocampus +(Stahl 2008). ACh is formed from two precursors: +choline, synthesized from the diet and +intraneuronal sources, and acetyl coenzyme +A (AcCoA), made from glucose in the neuronal +mitochondria. The enzyme choline +acetyltransferase acts on choline and AcCoA to +create ACh. ACh acts on muscarinic and nicotinic +cholin- ergic receptors. Muscarinic receptors are +so-named due to their binding preference for mus- +carine, a toxin found in poisonous mushrooms +(Sadock et al. 2009). The five muscarinic recep- +tors are M1, M2, M3, M4, and M5, and each has a +different anatomical structure. They are G +protein-linked and can be excitatory or inhibi- +tory. The M1 subtype on the postsynaptic neuron +is believed to regulate some memory functions. +M1 receptors blocked by antipsychotic medica- +tions can induce sedation and some cognitive +dysfunction. The presynaptic M2 receptor is an +autoreceptor, detecting excess ACh in the synapse +and preventing further release of ACh. M3 recep- +tors in pancreatic beta cells cause insulin +secretion, so antagonism here by atypical +antipsychotics, like olanzapine and clozapine, can +result in decreased insulin secretion. + +Nicotinic acetylcholine receptors (nAChR) +belong to a class of excitatory, ligand-gated ion +channel receptors (Sadock et al. 2009). They bind +nicotine, the main addictive substance in tobacco +smoke. These receptors have subtypes with vari- +able affinities; the highest-affinity subunits are in +the thalamus, followed by the substantia nigra, +striatum, hippocampus, and entorhinal cortex. +There are fewer high-density receptors in the cer- +ebellar, parietal, and frontal cortices. One of the +most notable subtypes is the postsynaptic alpha-4 +beta-2 subunit, which is believed to regulate dopa- +mine release in the nucleus accumbens (Stahl +2008). This is the likely target of tobacco nicotine +in the brain, strongly contributing to tobacco’s +addictive qualities. The alpha-7 subunit located +on the postsynaptic neuron is thought to regulate +cognitive function in the prefrontal cortex, +whereas the presynaptic alpha-7 subunit on cho- +linergic neurons provides positive feedback for +continued release of ACh. The alpha-7 subunit +of the nicotinic receptor located on dopamine +and glutamate neurons also regulates the release +of these neurotransmitters when ACh is present. +The neurotransmitter ACh is partly regulated +by two degradative enzymes, acetylcholinesterase +(AChE) and butyrylcholinesterase (BuChE). +These enzymes convert ACh back to choline, +which is taken back up into the neuron for +resynthesis into ACh (Stahl 2008). AChE is con- +sidered the main enzyme that inactivates ACh. It +is located throughout the brain, along the major +projections as outlined above, as well as within +the gastrointestinal (GI) tract, skeletal muscle, red +blood cells, lymphocytes, and platelets. The +highest density of AChE is located in the caudate +and putamen, with lower amounts in areas such as +the thalamus, hippocampus, and cortices (frontal, +temporal, parietal, occipital, and cerebellum). +BuChE is also located throughout the brain, +mostly in glial cells, but can also be found in the +GI tract, plasma, skeletal muscle, placenta, and +liver (Stahl 2008). ACh is partly regulated by +cholinergic vesicular transporters (VAChT) on +synaptic vesicles, which transport ACh into the +vesicle (Sadock et al. 2009). The highest densities +of VAChT are also located in the caudate and +putamen, as well as the nucleus accumbens. +Lower levels of binding occur in the cerebral +cortex and cerebellum. + +Anticholinergic medications are some of the +most well-known medications to act on the cho- +linergic system. They block the actions of ACh at +either the muscarinic or nicotinic receptors, +resulting in side effects such as sedation, analge- +sia, and management of allergies (Sadock et al. +2009). These drugs impact numerous physiologi- +cal systems, including the ocular, cardiovascular, +respiratory, GI, genitourinary, and the central ner- +vous system (CNS). In the CNS, these medica- +tions may be initially stimulating, followed by a +longer lasting sedative effect. Adverse effects +include confusion, disorientation, hallucinations, +and memory impairment. In the eye, anticholiner- +gic agents cause paralysis of the ciliary muscle, +leading to loss of accommodation, as well as +muscarinic blockade of the iris’ sphincter muscle, +causing pupillary dilation. Additional ocular +effects include blurry vision, anhidrosis, and +worsened narrow-angle glaucoma. In the cardio- +vascular system, anticholinergic agents cause +tachycardia due to muscarinic blockade of the +parasympathetic fibers in the atria. In toxic +doses, they can cause intraventricular conduction +block. In the respiratory system, muscarinic +blockade causes reduced glandular secretion of +the smooth muscle, leading to dry mouth. In the +GI tract, inhibited parasympathetic control from +anticholinergic blockade leads to decreased motil- +ity, causing constipation, delayed gastric empty- +ing, and paralytic ileus. In the genitourinary tract, +anticholinergic agents relax the smooth muscle of +the bladder and ureter, leading to urinary hesi- +tancy, but they are also known to cause urinary +retention. Despite their reputation for adverse +effects, anticholinergic agents can be therapeuti- +cally useful. They are commonly prescribed to +prevent or improve extrapyramidal side effects +(EPS) caused by dopamine antagonists. EPS reac- +tions include dystonia, akathisia, and parkinson- +ism. When antipsychotics block dopamine in the +nigrostriatal tract, cholinergic activity is +increased, resulting in the above-mentioned side +effects. Anticholinergic agents reduce the +increased cholinergic activity, restore balance to +the dysfunctioning neurotransmitter system, and +relieve symptoms of EPS. + +From a pathophysiological standpoint, the +cholinergic system is most frequently associated +with Alzheimer’s disease (AD). In AD, there is +degeneration of cholinergic neurons in the +nucleus basalis due to deposition of amyloid +plaque, leading to memory loss (Sadock et al. +2009). AChE inhibitors prevent the destruction +of ACh, which prevents further memory loss in +AD. Some AChE inhibitors only inhibit AChE, +whereas some inhibit both AChE and BuChE. +Depending on the individual, responses to these +agents vary, but the overall effect is prevention or +slowing of disease progression (Stahl 2008). +Examples of AChE inhibitors are donepezil, +amantadine, rivastigmine, and galantamine. +Another disease process implicated in the path- +ophysiology of the cholinergic system is schizo- +phrenia, as evidenced by the observation that +antimuscarinic drugs improve negative symp- +toms (Sadock et al.). Anticholinergic agents are +known to worsen positive symptoms in patients +with unstabilized schizophrenia, but they appear +to have no effect on positive symptoms in stabi- +lized patients (Sadock et al.). The cholinergic +system is also implicated in Parkinson’s disease +(PD), which results from dopamine deficiency +and cholinergic excess. Anticholinergic agents +can help reduce parkinsonian tremor via musca- +rinic receptor blockade, especially in combina- +tion with levodopa, a first-line dopaminergic +agent used to treat PD. + +Historical Background +ACh was the first neurotransmitter to be discov- +ered. The first individual to uncover its existence +was Henry Hallett Dale, a British pharmacologist +who lived between 1875 and 1968 (Raju 1999). +While studying ergot extracts, Dale found that the +extracts reversed the effects of epinephrine and +concluded that ergot contained tyramine, hista- +mine, and ACh. In 1914, Dale determined that +ACh was the “most suitable chemical” for para- +sympathetic neurotransmission, and coined the +terms “cholinergic” and “adrenergic.” Not long +after his discovery, a German physician named +Otto Loewi (1873–1961) was researching the +autonomic nervous system when he discovered +the presence of ACh and adrenaline in isolated +hearts. The year was 1921, and Loewi was the first +individual to underscore ACh’s importance in the +nervous system. Loewi initially named ACh +“vagusstoff,” referencing its release from the +vagus nerve. These two men shared the Nobel +Prize in Physiology and Medicine in 1936 “for +discoveries related to chemical transmission of +nerve impulse.” + +Current Knowledge +Impairment of the cholinergic system has been +implicated in the pathophysiology of autism. +Postmortem studies by Perry et al. (2001) show +a 30% reduction of cortical muscarinic receptor +binding in the parietal cortex in autistic individ- +uals compared with age-matched controls. Cho- +linergic neurons in the basal forebrain, an area +thought to play a role in attention, are abnormally +large and plentiful in children with autism +(Baumann and Kemper 1994). A study by Sokol +et al. (2002) found low cytosolic choline concen- +trations as measured by hydrogen proton mag- +netic resonance spectroscopy in ten children with +autism. Imaging studies have also attempted to +link neuroanatomical regions of the brain to core +domains of dysfunction observed in autism. Indi- +viduals with autism have been noted to have sig- +nificant deficits in face perception (Grelotti et al. +2002; Schultz 2005), which is believed to play a +notable role in social interaction. The neuroana- +tomical region linked to facial recognition is the +fusiform gyrus, which contains the visual path- +way. This pathway is regulated by the cholinergic +system, suggesting a possible causal relationship +between the cholinergic system and autistic social +impairment. A study by Suzuki et al. (2011) used +positron-emission tomography (PET) and a radio- +tracer to examine AChE activity in 20 autistic +adults compared to 20 age- and IQ-matched con- +trols. The results showed a deficit in cholinergic +innervations of the fusiform gyrus in the autistic +subjects, suggesting a possible explanation for +social impairment in autism. + +There is evidence to suggest that specific cho- +linergic receptor subtypes play a role in the +pathology and symptomatology of autism. It is +believed that deficits in alpha4-containing recep- +tors predominate in autism (as well as in +Alzheimer’s disease), whereas other receptor sub- +types are associated with other disorders, like the +alpha-7 subtype and schizophrenia (Graham et al. +2002). These observations may lead to drug +development targeting specific nicotinic receptor +subtypes for alleviation of symptoms in autism. +Similarly, a theory by Lippiello (2006) suggests +that autism is a disorder of “overfocused atten- +tion,” unlike attention-deficit/hyperactivity disor- +der (ADHD), which can be described as a disorder +of “underfocused attention.” These two disorders +theoretically sit at opposite ends of a spectrum +with reversed neurophysiological mechanisms +underlying their pathophysiology. Lippiello +hypothesizes that because nicotinic cholinergic +agonists have been shown to improve the symp- +toms of ADHD (Levin et al. 2001); perhaps nico- +tinic cholinergic antagonists may ameliorate the +symptoms of autism. The concept of nicotinic +receptor antagonists treating autism has not yet +been explored in the literature, but these concepts +may lead to future initiatives in studying the rela- +tionship between the anticholinergic system and +autism. + +Medications affecting the cholinergic system, +particularly AChE inhibitors, have been studied to +treat symptoms associated with autism. These +agents increase ACh in brain regions related to +attention and memory, such as the cerebral cortex +and basal forebrain (Yoo et al. 2007). Amantadine +is a drug approved for the prophylaxis of +influenza A, but is commonly used in the treat- +ment of PD and EPS due to its antiparkinsonian +effects (Sadock et al. 2009). A double-blind, +placebo-controlled study examined the effects of +amantadine in 39 autistic children aged +5–19 years (King et al. 2001). The clinician- +rated Aberrant Behavior Checklist rating scale +(ABC) showed statistical significance in the +amantadine-treated group within the domains of +hyperactivity and inappropriate speech +(Blakenship et al. 2011). The parent-rated ABC +did not show statistically significant improvement +between the amantadine and placebo groups. +Galantamine, another AChE inhibitor, was exam- +ined in 20 males with autism in a double-blind, +placebo-controlled study (Niederhofer et al. +2002). Using the ABC as a dependent measure, +there were decreases in the domains of irritability, +hyperactivity, inadequate eye contact, and inap- +propriate speech. Despite these promising obser- +vations, studies examining the effect of other +AChE inhibitors have found dissimilar results. +A double-blind, placebo-controlled study by +Handen et al. (2011) looked at the effect of +donepezil in 34 children and adolescents aged +8–17 years (IQ > 75). The results showed some +improvement on a number of measures of execu- +tive functioning, but there were no statistically +significant differences between the donepezil and +placebo groups. The researchers concluded that +short-term treatment with donepezil may have +limited impact on cognitive functioning in those +with autism. + +Retrospective and open-label trials are of lim- +ited utility in demonstrating effectiveness and +safety of a medication due to their lack of exper- +imental design, but they offer a glimpse of pos- +sible directions that can be taken in the treatment +of symptoms associated with autism. +A retrospective study by Hardan and Handen +(2002) examined the effects of donepezil, an +AChE inhibitor, in the treatment of 8 children +with autism, aged 7–19 years. The study found a +significant decrease in irritability and hyperac- +tivity according to the ABC, although attention +and memory were not measured. An open-label +study by Nicolson et al. (2006) examined the +effects of galantamine, an AChE inhibitor and +nicotine receptor modulator, in the treatment of +13 children with autism. Galantamine demon- +strated reductions in parent-rated irritability and +social withdrawal on the ABC, improvements in +emotional lability and inattention on the Conners’ +Parent Rating Scales-Revised, and reduced anger +on the clinician-rated children’s Psychiatric Rating +Scale. Hertzman (2003) reported three cases where +galantamine pro- moted verbalization in adults +with autism. Another open-label study by Chez +et al. (2004) examined the AChE inhibitor +rivastigmine tar- trate and found significant +improvements in scores of various measurements, +including the Childhood Autism Rating Scale, +Gardner’s Expressive One-Word Picture Vocabulary +Test, and Conners’ Parent Rating Scale. + +Future Directions +Future directions for research into the relationship +between the cholinergic system and autism will +likely involve investigating cholinergic receptor +subtypes, neuroimaging, and pharmacologic treat- +ment development. Cholinergic receptor subtypes +occur at variable concentrations in the brain and +are implicated in the pathophysiology of autism. +Exploring their influence on attention, memory, +and cognition, as well as the core diagnostic +domain of social impairment, will likely be a +continued area of research. Neuroimaging of +these receptors will continue to map areas of neu- +roanatomical dysfunction in autism. Medications +affecting the cholinergic system could be further +explored as treatments for autism given the mixed +results seen in existing studies. Double-blind, +placebo-controlled trials are required to draw con- +clusions about medication safety and efficacy, and +currently there are minimal studies examining the +effectiveness of AChE inhibitors. Short-term +studies of AChE inhibitors have shown mixed +results, so it may be of benefit to employ them +for longer periods before drawing definitive con- +clusions about their efficacy. Lastly, the study of +nicotinic cholinergic receptor antagonists as a +treatment for autism is another possible, untapped +direction. + +See Also +▶Amantadine +▶Anticholinergic +▶Antipsychotics: Drugs +▶Atypical Antipsychotics +▶Dopamine + +References and Reading +Baumann, M. L., & Kemper, T. L. (1994). Neuroanatomic +observations of the brain in autism (pp. 119–145). Bal- +timore: Johns Hopkins University Press. +Blakenship, K., Erickson, C. A., et al. (2011). Psychophar- +macological treatment of autism, Chapter 69. In D. G. +Amaral, G. Dawson, & D. H. Geschwind (Eds.), +Autism spectrum disorders (pp. 1194–1212). +New York: Oxford University Press. +Chez, M. G., Aimonovitch, M., et al. (2004). Treating +autistic spectrum disorders in children: Utility of the +cholinesterase inhibitor rivastigmine tartrate. Journal +of Child Neurology, 19(3), 165–169. +Graham, A. J., Martin-Ruiz, C. M., et al. (2002). Human +brain nicotinic receptors, their distribution and partici- +pation in neuropsychiatric disorders. Current Drug +Targets CNS and Neurological Disorders, 1(4), +387–397. +Grelotti, D. J., Gauthier, I., et al. (2002). Social interest and +the development of cortical face specialization: What +autism teaches us about face processing. Developmen- +tal Psychobiology, 40(3), 213–225. +Handen, B. L., Johnson, C. R., et al. (2011). Safety and +efficacy of donepezil in children and adolescents with +autism: Neuropsychological measures. Journal of +Child and Adolescent Psychopharmacology, 21(1), +43–50. +Hardan, A. Y., & Handen, B. L. (2002). A retrospective +open trial of adjunctive donepezil in children and ado- +lescents with autistic disorder. Journal of Child and +Adolescent Psychopharmacology, 12(3), 237–241. +Hertzman, M. (2003). Galantamine in the treatment of +adult autism: A report of three clinical cases. Interna- +tional Journal of Psychiatry in Medicine, 33(4), +395–398. +King, B. H., Wright, D. M., et al. (2001). Double-blind, +placebo-controlled study of amantadine hydrochloride +in the treatment of children with autistic disorder. Jour- +nal of the American Academy of Child and Adolescent +Psychiatry, 4 \ No newline at end of file