自閉症的定義和界定準則

 

英文字義

源自希臘語”autor”, 原意為自我。最早由瑞士精神病醫生Eagen Bleuer於1911年提出autistic一詞并引入專業文獻中。

 

Kanner (1943) 的定義

l          children’s inability to relate themselves in the ordinary way to people and to situations from the beginning of life

l          failure to use language for the purpose of communication

l          an anxiously obsessive desire for the maintenance of sameness, resulting in a marked limitation in the variety of spontaneous activity

 

通用的國際診斷準則

World Health Organization’s International Classification of Diseases, 10th edition (ICD-10) – abstract only

A.     Presence of abnormal/impaired development from before the age of 3 years in at least 1 out of the following areas :

1.      receptive and/or expressive language as used in social communication

2.      2. the development of selective social attachments and/or of reciprocal social interaction

3.      3. functional and/or symbolic play

B.     Qualitative impairments in reciprocal social interaction. Demonstrable abnormalities in at least 3 out of the following 5 areas:

1.      failure to use eye-to-eye gaze, facial expression, body posture and gestures adequately to regulate social interaction

2.       failure to develop 9in a manner appropriate to mental age, and despite ample opportunities) peer relationships that involve a mutual sharing of interests, activities, and emotions

3.      3. rarely seeking and using other people for comfort and affection at times of distress and/or offering comfort and affection to others when they are showing distress or unhappiness

4.       lack of shared enjoyment in terms of vicarious pleasure in other people’s happiness and/or a spontaneous seeking to share their own enjoyment through joint involvement with others

5.      a lack of socio-emotional reciprocity, as shown by an impaired or deviant response to other people’s emotions; and/or lack of modulation of behavior according to social context and communicative behaviors

C.     Qualitative impairments in communication. Abnormalities in at least 2 out of the following 5 areas:

1.      a delay in, or total lack of development of spoken language that is not accompanied by an attempt to compensate through the use of gesture or mime as alternative modes of communication

2.      relative failure to initiative or sustain conversational interchange (at whatever level language skills are present) in which there is reciprocal to-and-from responsiveness to the communications of the other person

3.      stereotyped and repetitive use of language and/or idiosyncratic use of words or phrases

4.      abnormalities in pitch, stress, rate, rhythm, and intonation of speech

5.      a lack of varied spontaneous make-believe play, or (when young) in social imitative play

D.     Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. Demonstrable abnormalities in at least 2 out of the following 6 areas:

1.      an encompassing preoccupation with stereotyped and restricted patterns of interest

2.      specific attachments to unusual objects

3.      apparently compulsive adherence to specific, nonfunctional routines or rituals

4.      stereotyped and repetitive motor mannerisms that involve either hand/finger flapping or twisting, or complex whole body movements

5.      preoccupations with part-objects or nonfunctional elements of play materials

6.      distress over changes in small, nonfunctional details of the environment

E.      the clinical picture is not attributable to other disorders.

 

Diagnostic and Statistical Manual, fourth edition, 1994 (DSM-IV), American Psychiatric Association

A1. Qualitative impairment in social interaction as manifested by at least two of the following:

l          Marked impairment in the use of multiple non-verbal behaviors such as eye-to-eye gaze, facial expression, body postures and gestures to regulate social interaction.

l          Failure to develop peer relationships appropriate to developmental level.

l          Lack of spontaneous seeking to share enjoyment, interests or achievements with other people (e.g. by a lack of showing, bringing, or pointing at objects).

l          Lack of social or emotional reciprocity.

2. Qualitative impairments in communication as manifested by at least one of the following;

Delay in, or total lack of, the development of spoken language(not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).

In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.

Stereotyped and repetitive use of language or idiosyncratic language

Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

3. Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:

l          Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.

l          Apparently inflexible adherence to specific, non-functional routines or rituals

l          Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements).

l          Persistent preoccupations with parts of objects.

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

l          Social interaction

l          Language as used in social communication

l          Symbolic or imaginative play

C. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.

 

這兩個準則叫自閉症及其關連症狀為Pervasive Developmental Disorder (PDD) 。它們的內容和Kanner’s的定義與及1979年Wing & Gould從人口普查歸納出來的The triad of impairments in socialization, communication and imagination and repetitive behavior/obsessive interests是符合的。香港採用了World Health Organization’s International Classification of Diseases, 10th edition (ICD-10)的準則作為界定標準。

 

Lorna Wing 進一步解釋The triad of impairments：(Autistic Spectrum 2001 Berkeley : Ulysses Press)

There can be no doubt that a yet more fundamental impairment of psychological function underlies the triad. It is likely that there is an inability to put together all kinds of information derived from past memories and present events, to make sense of experiences, to predict what is likely to happen in the future and to make plans. People with autistic disorders do not make sense of the world and find it hard to learn from experience. They find it difficult to organize themselves in time and space. It is possible that, at an even deeper level, there is a disturbance of the normal built-in system for assigning different degrees of emotional significance to different experiences. There are various theories concerning how the brain originally assigns emotional value to the biological necessities for survival and reproduction and then, building on these, develops over the years a complex system of values related to the culture in which the individual lives. In all those affected, the lack of interest in others is a defining feature. Coupled with this is the idiosyncratic fascination for specific objects or experiences that appear trivial and meaningless to others.

For the present, recognizing autistic spectrum disorders has to depend on detecting the triad of impairments because the three impairments can be identified from knowledge of an individual’s development and behaviour.

 

譯文：

無可置疑的是：三合一認知障礙顯示一個更基本的心理功能缺失問題，自閉症人士不能將記憶中的資料和目前發生的事整合，不懂得如何總結經驗，不會訂定計劃，不能推測將會發生的事，他們不知道如何在時間和空間方面有條理地組織和表現自己，他們不明白這世界上的一切，難以從經驗中學習。

 

眾多的心理學理論認為人類的腦部原先為了生存和繁殖的生理需要，才產生感情的作用，它隨著年齡的增長和生活的文化背景，逐漸發展成為一套複雜的價值系統。所以更有可能的是，在心理功能的更深層面，自閉症人士不能如常人般，賦予各種經驗不同的感情意義。

 

自閉症最突出的徵狀，就是對他人缺乏興趣，另一個行為特徵，是對一些普通不過的事物表現得極為沉迷。就目前來說，我們須憑藉三合一障礙來辨認自閉症失調系列，因為這些障礙可以從個人的行為和發展階段中發現。