FORMERLY AUTISTIC CHILDREN

WHO HAD BECOME ADULTS: EIGHT CASES

Renato COCCHI, a neurologist and a medical psychologist

(Italian translation)

Summary

Parents asked for consultation and treatment for eight 16-25 years’ old adults, who had histories and diagnoses of Pervasive Developmental Disorder (DSM-III, R: 299.00: An early onset Autistic Disorder). The most frequent disturbing symptoms checked were sleep troubles, hyperactivity, mood instability, aggressiveness, self-abuse, binge eating.

Five Ss had neuroleptic therapies, alone or in combination, with poor results. In seven cases the parents asked for more efficient drug therapies on sleep troubles, aggressiveness and hyperactivity.

In these adult autistics, drugs used, do not appear different from what psychiatrists prescribe in psychotic mentally retarded adults. Adult autistics could have a different psychopathological frame, needing more specific drug treatments.

Key words: Autism; adulthood; psychopathology; specificity; drug therapy.

Autism

Mental retardation

index.htmHome Page  // Pagina iniziale


When they are 15-16 or more, did formerly autistic children either maintain their diagnosis or had they got a new psychopathological frame of psychotic adults with mental retardation?

Which are the followings that his/her adult life produces in the patient him/herself and in the habits of his/her family, in both cases? What might do and what can do the physician when consulted with the hope of finding solution to often quite difficult behavioural troubles?

These are some questions I asked myself when faced increasing consultations for some help in (formerly) autistic patients first seen when they were 16 or more.

Demeaning a little casuistry of eight subjects alike, I shall try to answer to these questions. I think it be an unknown land even if professionals usually travel and face it according to the adult psychosis point of view.

Casuistry

Case 1: Male, 25 years, with the autism onset before 36 months. His current weight is 115 kg because he eats every food and too much. The drug therapy regimen he takes is carbamazepine 6oo mg, chlothiapine 60 mg, levomepromazine 100 mg, chlopentixol 40 mg (daily doses). Since he has blood hypertension, he takes also 5 mg amiodipine.

He did not get any schooling. There is aggression against the parents and self-aggression. Motor stereotypies are present. He used to stay aloof but seems attentive, at least during this consultation. I did not observe gaze aversion and sameness, and no anxiety when faced with novelty.

His speech runs with 3-4 words sentences, with telegraphic style, and he used it for urgent needs regarding to eat. There are both immediate, and delayed echolalia. No concentration observed.

Being rather sedated, he used sleeping during the day and being awaked during the night. Since many years he has having a regimen of mostly neuroleptics, in various combination, but with poor results beyond the motor inhibition.

The parent’s requests are an improvement of sleep troubles, a lesser aggression and a better control of binge eating.

Case 2: Male, aged 21, with autism the onset of which and its diagnosis were both before he was three. He did not any schooling, does not have any urine and bowel problems, but recurrent masturbation.

At 2-3 in the morning he used awakening and softly singing for about two hours, or crying, then he falls again asleep. His diet varied and his mother has a careful control of it to avoid his overweight. He used little and bad chewing. After he had eaten, he becomes more irritable.

The transit of what has eaten throughout his gastrointestinal tract is quite quickly, but he used to refrain because he is suffering from painful anal rhagades. According to his mother, he has moderate social isolation, but this assertion seems doubtful. No spoken language, he makes himself understood by gestures as for the most urgent needs.

Although being more lateralized on the right side, he hears with his left ear. Evoked Potentials detected right deafness. When the object is under his eyes, he can understand simple orders referring to it. He has hyperactivity with motor stereotypies.

Rocking and fingers flexing-extension in front of his eyes are rarely present. His aggression comes out when he wants something and nobody understands what, or when other people are speaking. He does not stand noise. He has sudden variation of his mood with hypertony and some recourse to voluntary apnea. During the day he gives out a kind of frog cry (a sound stereotypy). For many years he got psychological or sociotherapic treatments without any result. A drug therapy never started because his mother has a high prejudice against drugs.

The parents asked for a reduction of his aggression and better sleep-awakening cycle.

Case 3: Male, aged 19, with autism observed and diagnosed before he was 2 years old. He did not learn anything at school. Now he shows marked social isolation, rocking, stereotyped telegraphic type language, using the second person ( = you) when speaking about himself, with immediate and delayed echolalia. Besides being hyperkinetic, he has episodes of aggression against things and self-aggression, in which he bites his hands or he hits his right temple.

His diet is nearly liquid with reduced choice, without bread, meat and vegetables. Milk, yoghourt and soft cheese are his best foods. Soon after awakening he wants to eat.

His bowel function is regular with good sphincteric control; he frequently masturbates.

He is not easy in falling asleep, with no more 6 hours sleeping and early morning awakening. During sleep he is often drooling, dreams and speaks loudly. Usually he is better in the morning. When the weather is changing, he becomes irritating as well as it happens in summer, because he does not stand the hot temperature, which causes him excessive perspiration.

Sometimes he gets angry and starts crying without any evident reason. Now he takes 80-120 mg chlothiapine daily. Parents request a decrease of aggression against things and self-aggression, and a better sleep regulation.

Case 4: Male aged 17, he had the diagnosis of autism before he was 3, mainly because his speak regression. Considered as an intelligent autistic person, he is going to school. Quite socially isolated, he shows motor stereotypies such as fingers flex and extension, fingers rubbing, habit of throwing any object under the home furniture.

His language is poor, with a low voice and difficulties in the correct use of pronouns. When has to replay "yes," he repeats the sentence, and presents immediate and delayed echolalia, besides with other verbal stereotypies.

When 2, he could read the digits seen along the street and now he can read and can also make some translation from Italian into English. As for mathematics, he shows some abilities.

He has gaze aversion, sudden changes of his mood, and can present aggression while he has poor self aggression.

As for feeding, he can do it by himself: he likes sweets, the cube bullion, some coffee, but does not stand alcoholic drinks and refuses to eat in the morning. He needs often drinking, has some rumination and easy vomiting.

As for bowel function, he suffers from spastic constipation, which needs some help. His parents reported rare bedwetting. Falling asleep is often a difficult task, and he does not show pavor nocturnus or drooling during his sleep. Suddenly he needs to be hyperactive and to get jumping. His running is clumsy but it does it much. He practices swimming and Judo, bikes well, although not is always evaluating a possible danger. His fine motility does not go in the best way, being also ambidextrous.

Although having got a special teaching, he never did learn drawing, while he likes hearing the music enough. Surely moments of a depressed mood appear but he is rarely weeping. Parents think he has a lowered pain threshold. Perspiration occurs frequently. His EEG has troubles in the temporal derivations. Parents request a reduction of psychomotor agitation, but they appear very reluctant as for a possible drug therapy.

Case 5: Female aged 20. Her diagnosis of autism took place before she was 3, following a regression after fair psychomotility and language development. She has no schooling, is very socially isolated with few motor stereotypies, no language, gaze aversion and a bit of sameness. Self-feeding, she eats much and every food (sweets too), but she is poor chewing and usually put into her mouth everything she finds. So she is much overweight. Now she is poor sleeping since at least 3 months, needs the dummy to favour falling asleep and has drooling during her sleep.

Moreover she is upset with frequent mood changes that manifests both with cries and restlessness without any aim. As for her sphincter control, she did never reach it and has periods of strong spastic constipation. Her menses come within more than 28 days, and does not appear to practice masturbation. Now she does not get aggression or self-aggression, but she did the latter in past. She understands simple orders, but not always double orders. Her drug regimen counts flunitrazepam 2 mg, levomepromazine 100 mg and chlopentixol 20 mg.

Parents request a better sleep regulation, reduced restlessness, and binge eating control.

Case 6: Female aged 16, she had her diagnoses of autism before she was 3. She had no schooling. Her menses appeared when she was 11, and now she has reduced frequency but colic pain with paleness verging to collapse. She underwent psychological and psychomotor therapies for many years with very poor results, if any. Since few years she is taking psychodrugs, mainly neuroleptics.

Now she is rather isolated, with hands stereotypies, echolalic language scarcely used to ask for. When she gets close to acquaintances is unable to talk. In new places she becomes anxious and has fear without any reason. Not loving, she has sudden mood changes going from unmotivated crying to very fatuous laughing.

Being unable to feed herself, parents have to do it. She uses to eat vegetables, ice-cream enough but she likes the yoghourt.Her bowel does not run because she has spastic constipation with little balls shaped faeces. After having taken chlothiapine, she lost the urine control. Her sleep is shortly and badly working, and she usually awakes after a few hours, in spite of the drugs she takes. Sometimes she cannot fall asleep, so is crying all the night. Her hands and feet are nearly always cold.

Restless without any apparent aim, she turns more and more newspapers and rags with her hands. She has the habit of wearing one shoe and one sock out. Haloperidol and chlopentixol are the drugs she is taking now.

Parents ask for low restlessness and better sleep regulation.

Case 7: Male, aged 21, with normal caryotype, he had his autism diagnosed before he was 3. Except some very simple drawing, he had null schooling. Left-handed, isolated, he is often rocking or needs banging, touching or smelling. Mood changes come out suddenly, and he turns from laughing to crying without any reason. In the springtime and in the autumn his psychomotor agitation grows.

Then he does not stand noise and is putting his hands on his ears, but the audiometric test ran normally. He does not display any aggression or self-aggression, and never did it. He lacks any language, says only "mama" but has two-tones vocalisation, understands simple orders.

In self-feeding he has some troubles with the cutlery, eats sweets normally, refuses vegetables and fruit. His bowel works well, and he gained his sphincteric control but needs often to urinate.

As a poor sleeper, he wastes the night time in the bathroom by playing with the water. He slightly suffers from the cold. When he was 5, his EEG was normal.

When treated with chlothiapine he has strong side-effects, so parents need to stop the drug or to use ineffective doses.

Parents request better sleeping and low psychomotor agitation.

Case 8: Male, aged 18, with illness noted in his first year of life and diagnosed as autism before he was 3. Schooling was null. Very isolated, he does stereotyped hands movements before his eyes.

His language does not go further than some disyllabic words, with repetition of one syllable. Sometimes he cries, even during the night. He understands very little, and more on the voice tone than on sense. Sudden mood changes drive him to aggression against his father or his mother indifferently.

Often he shows psychomotor agitation and throws his hand into his mouths, so stimulating his oral surface. Both his index fingers have corns, because he used to bite them. He is eating whatever he finds, by taking it directly from the refrigerator. Sphincters control is lacking, even if sometimes his mother finds him dry in his awakening.

Falling asleep is not easy, but then he sleeps enough, considering that, for 15 years, he used sleeping no more than 3 hours every night. Now, during one or two nights of every week, he is asleep till 4-5 o’clock in the morning.

He has frequent fits described as "absences", with a negative EEG, but two-tree times each year these fits become "grand-mal" seizures. For that he takes phenobarbital 50 mg twice per day. Parents request low psychomotor agitation, reduced aggression, and better sleeping.

I have summarized the most important data of this little casuistry on the following table.

Table 1: Summary of the most significant data

Evaluated datum	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8
Sex	M	M	M	M	F	F	M	M
Age (years)	25	21	19	17	20	16	21	18
Retrospect. Diagnosis DSM-III, R: 299.00
	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Onset < 36 months	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Schooling	Null	Null	Null	Some	Null	Null	Null	Null
Sleep troubles	+++	++	+	+	++	+++	+++	++
Aggression	+++	++	+++	++				+++
Self-aggression	++		+++	+				+++
Psychomotor agitation	+ (#)	++	+++	++	+++	++	++	+++
Mood troubles	(?)	++	+++	++	+++	+++	++	+++
Neurol. drugs regimen	+++		++		++	++	++	($)
Parents' requests
Sleep improvement	Yes	Yes	Yes		Yes	Yes	Yes	Yes
Aggression decreasing	Yes	Yes	Yes					Yes
Less psychomotor agitatation		Yes	Yes	Yes	yes	Yes	Yes	Yes
Reduced binge eating	Yes				Yes

Keys: (+) moderate; (++) severe; (+++) profound; (#) sedated; ($) antiepileptic therapy with barbiturates, so sedated too.

Discussion

The little casuistry I have surveyed drives to many condiderations. First we can note the usual male prevalence, being here equal to 3:1, which is the average gender distribution as reported by the DSM-III, R (1987). I already wrote about the case 2, in a previous investigation on the use of naltrexon, and there he was the first one I described. After 12 months of treatment with naltrexon he did not have any improvement (Cocchi, 1991).

According to the symptoms reported in their clinical histories, I could reconfirm the diagnosis, even if I did no point out the same symptoms, when not currently present. For example, it is what happens with the symptom of "sameness."

All these eight cases - according to DSM-III, R - could have the diagnosis of Infantile Autism, the onset of which was before 36 months of age. The schooling stands for severe to profound mental retardation in 7 cases, but for moderate to severe retardation in the case 4. Sleep troubles, sudden mood changes (possible also in the case 1, with aggression as a derived symptom) and psychomotor agitation - although heavily sedated in case 1 - are common symptoms. On the other hand, aggression lacks in two females and one male.

The psychopathological condition of adults who had been autistic children seemed not have deserved punctual attention.

The same DSM-III, R wrote only few lines about, and did mainly approach these subjects to psychotic adults without pointing out peculiar features by which they differentiate. Its idea, that mentally retarded autistic persons who become adult suffer from depression as reaction to the socio-psychological situation, seems more theoretical than pragmatic.

In the 8 subjects here described the outcome was anything but the best, even in the subject with less mental retardation (case 4). In 5 cases parents had to have resort to a psychiatrist, because frequent and disturbing symptoms such as heavy sleep troubles, psychomotor agitation, aggression and/or self-aggression. The drug therapy prescribed was mainly of neuroleptic drugs, except the case 8 that got barbiturates for possible temporal lobe epilepsy.

It is curious to note the mood troubles, which were clearly different from a depressive reaction jotted down by the DSM-III, R, did not get any specific treatment. Moreover because they were present in 7 cases out of 8, and quite surely even in the case 1, the only one doubtful in this respect.

We are allowed to think that Italian psychiatrists who prescribed the regimens, faced the psychopathological pictures as they were equal to psychotic troubles in mentally retarded adults. Actually the psychiatrist mainly neuroleptics, aiming to a sedative and perhaps antipsychotic activity.

Supposing that therapeutic conduct like this works in mentally retarded adults - a surely debatable fact - we can ask whether it can be transferred as well to autistic adults. As a second question, why occurred so?

By referring to the Italian situation, we can put forward two explanations of this simplistic transfer.

The first is that from 16 years of life the competence for mental illnesses passes from the child neuropsychiatrist to the psychiatrist. This latter professional nearly always does not have any direct experience of infantile autism.

Parents, often exhausted after many inconclusive if not absurd therapeutic approaches set out during their son’s or daughter’s childhood, finally resign themselves. They only ask for a more viable condition for their offspring and for themselves, since they have become older and often the only ones facing that heavy illness.

The second explanation is the psychiatrist works as usual, how he knows.

If he was taught and maintains that infantile autism is a psychological illness, he faces the troubles of an autistic adult in a prevailing sedative way. So he hopes to act at least on psychomotor agitation, aggression and autoaggression.

The casuistry I reported here seems denying the efficacy of that guideline.

On the contrary, it confirms that drugs that work in adults’ psychoses, not only do not fit for autistic children, but give a poor help, or null, even in autistic adults. (Cocchi, 1990).

On the other hand, whoever treated mentally retarded can note that autistic adults are not equal to simple mentally retarded adults. Although a clear mentally retarded, an autistic adult shows behaviour and approaches to the reality differently from an even psychotic and mentally retarded adult.

Moreover autistic adults differ from autistic children, a fact that the DSM-III, R already guessed.

We deal with very typical and soundly visible aspects that usually allow to make a diagnosis soon after few minutes of observation, before the case history end.

Conclusions

The parents of eight adults already diagnosed as autistic children before they were 3, brought their offspring for consultation mainly for sleep troubles, psychomotor agitation, aggression or self-aggression. The regimens of neuroleptics did not control these symptoms in the so treated 5 cases.

I think that autistic adults who were formerly autistic children, have an autonomous and specific psychopathological form. This needs an adequate drug treatment, not imitating on that used in adults’ psychoses.

References

American Psychiatric Association: Diagnostic and statistic manual of mental disorders. Third edition, revised. A.P.A., Washington D.C., 1987.

Cocchi R.: The pharmacological approach to treating childhood psychoses. Theoretical basis. Ital. J. Intellect. Impair. 1990, 3: 185-193.

Cocchi R.: Esperienze sull’uso del naltrexone in soggetti autistici. Uno studio clinico. Riv. Ital. Disturbo Intellet. 1991, 4: 261-266.

Printed in Italian on Riv. It. Disturbo Intellet. 1994, 7: 241-248. On Internet on July 2001. Copyright by Renato Cocchi, 2001.

Author’s address: dr. Renato COCCHI, via Rabbeno, 3

42100 Reggio Emilia (Italy)

renatococchi@libero.it

Italian translation

Autism

Mental retardation

Home Page  // Pagina iniziale