BALTIMORE – Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.
“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.
Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.
In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9)
In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.
One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.
“This is a very exciting study,” Dr. Fein said.
In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.
In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.
Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).
In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.
In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not.