Infantile psychosis in children. Psychosis in children is atypical

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In 1999, the ICD-10 version of the WHO revision (1994) was adapted for the practice of domestic psychiatry. The first section included: General (pervasive) disorders of mental development (F84.0), which includes: childhood autism, as a distinct disorder, and a number of other types of autistic disorders, and in particular atypical autism (F84.1). Similar manifestations of autism previously had a slightly different verification and interpretation: “early childhood autism” (Kanner L, 1943; Wing L., 1972; Bashina V.M., Pivovarova G.N., 197); "autistic disorder" (Rutter M., 1979), "childhood or infantile psychosis" (Mahler M., 1952), "early childhood schizophrenia" (Vrono M.S. Bashina V.M., 1975 Bender L., 1972) ; autistic-like disorders” (Szatamari P., 1992, Bashina V.M. et al., 1999).

Term "pervasive" first became used in American psychiatry (Campbell M., Shay J., 1995), and was introduced as early as 1987 in the DCM-III-R, American Psychiatric Association (APA). Many specialists in childhood autism, such as L, Wing (1989 ), Ch.Gillberg (1995), B.Rimland (1996), considered this term to be unsuccessful, since this definition emphasized the distortion of mental development, and, as it were, the structure of autistic states was leveled, such a main feature as autism was taken out of the main definition . Therefore, some psychiatrists have suggested that the whole group of different autistic disorders be called "autism spectrum disorders", or defined as "autistic-like disorders". The wish remained unfulfilled.

Definition "atypical autism" was also formulated for the first time by APA, introduced in DCM-III - R in 1987. and borrowed from there in ICD-10.

Purpose of this publication - to consider the current state of the problem of atypical autism in children, to give clinical and psychopathological characteristics of its forms studied to date. In accordance with this, the results of a clinical and dynamic study and treatment of sick children with various types of autistic disorders (about 7,000 people) were used on the basis of outpatient and inpatient departments for children with autism at the SCCH RAMS in the period 1984-2007. An attempt will be made to briefly outline the basic approaches to the main range of therapeutic and rehabilitation interventions for atypical autistic disorders in children.

There are several main stages in the development of the problem of atypical autism. The first of them covers the period after the definition of the concept of "autism as a sign" in adult patients with schizophrenia (Bleuler E., 1911, 1920). When the possibility of the formation of similar signs of autism in the circle of childhood schizophrenia, schizoid (Simson T.P., 1929; Sukhareva G.E., 1930), "empty autism" in children was established (Lutz J., 1937). The second stage covers 40 - 50 years, L. Kanner in 1943 described "autism" as a separate pathological condition in children, in which, from the first years of life, they showed an inability to verbal, affective contact with loved ones and others, observed monotonous behavior, stereotypes in motor skills (such as "hand-rolling and jumping"), behavior, speech disorders and mental retardation. This complex of symptoms began to be called - "early childhood autism" (RAA), "Kanner's childhood autism" or "syndrome Kanner".

L. Kanner (1943) suggested that this syndrome is based on congenital affective disorders, and later, in 1977, based on follow-up studies, suggested that this pathology belongs to “schizophrenic spectrum disorders”, but is not identical to schizophrenia.

A further thorough study of autism in children showed that it can be not only a specific clinically defined syndrome - such as early childhood autism, but be as separate features in Asperger's, Rett's syndromes, schizophrenia, and, most importantly, be detected in a range of diseases caused not endogenous, and other chromosomal, metabolic pathology, organic brain lesions (Mnukhin S.S., Isaev D.N., 1969; Marincheva G.S., Gavrilov V.I. 1988; Krevelen van Arn D., 1977). Recently, attention has been drawn to autistic conditions that develop due to exogenous causes, post-stress situations in children from orphanage, incomplete home (Proselkova M.O., Bashina V.M., Kozlovskaya G.V., 1995; NissenG, 1971) . As a result, by the age of 70-90, there was an idea that autistic disorders constitute a group with a heterogeneous, heterogeneous background, against which there are only partially similar clinical manifestations of autism. From this group, atypical autism was singled out, which was reflected in the relevant national and international classifications.

Epidemiology of atypical autism. The prevalence of atypical autism is 2 cases per 10,000 population (Popov Yu.V., Vid V.D. (1997). The prevalence of autistic disorders, including atypical forms of autism, is 54 or more per 10,000 children, Remschmidt H. (2003 ).

The introduction of the ICD-10, WHO (1999) into the practice of domestic psychiatry, led to a sharp increase in the prevalence of autistic disorders in both domestic and foreign psychiatry, the incidence of schizophrenia in children significantly decreased (in fact, new approaches to the standardization and systematization of autistic disorders were imposed on clinicians). disorders).

Classification atypical autistic disorders was developed not only by WHO, APA, in a number of other countries, but also in domestic psychiatry, the Scientific Center for Mental Health of the Russian Academy of Medical Sciences (1999, 2004).

In order to reveal the essence of new trends in the interpretation of autism in children, let us consider in a comparative aspect ICD-10, WHO (1999) and the latest classification of autistic disorders of the Scientific Center for Mental Health of the Russian Academy of Medical Sciences (Tiganov A.S., Bashina V.M., 2005).

1. Childhood autism is endogenous:

1.1 Childhood autism, evolutionary, non-procedural:

(Kanner syndrome, infantile autism, autistic disorder)

1.2 Childhood autism process:

1.21 - forming in connection with schizophrenic psychosis with onset before 3 years (early childhood schizophrenia, infantile psychosis)

1.22 - formed in connection with schizophrenic psychosis, in the period from 3 to 6 years (early childhood schizophrenia),

2. Asperger's syndrome (constitutional), the formation of schizoid psychopathy

3. Autism is non-endogenous, atypical:

3.1 - with organic damage to the central nervous system (cerebral palsy, etc.)

3.2 - with chromosomal pathology (Martin-Bell syndrome (X-FRA), Down syndrome, tuberous sclerosis)

3.3 - with metabolic disorders (phenylketonuria)

4. Rett syndrome

5. Psychogenic autism, exogenous (deprivation autism)

6. Unexplained autism

The taxonomy of autistic disorders of the NTSPZ RAMS (2005) was created, as in previous years, on the basis of evolutionary-biological and clinical-nosological theoretical concepts (Snezhnevsky A.V., 1972, Smulevich A.B., 1999, Tiganov A.S. , 1999, Panteleeva G.P., 1999). Taking into account these ideas, endogenous and non-endogenous types of autism are distinguished. Endogenous childhood autism, in turn, was subdivided into - childhood autism, evolutionary, non-procedural and processual childhood autism, in connection with endogenous psychosis (attacks of early childhood schizophrenia, in the period from 0 to 3 years and from 3 to 6 years). Non-endogenous forms of autism correspond to its atypical types (before they were defined as autistic-like) and are subdivided, depending on the soil on which they occur, into genetic (chromosomal), metabolic, organic groups of atypical autism. Asperger's syndrome, Rett's syndrome, psychogenic autism are highlighted in separate headings, we will not dwell on the description of which in this message.

F84 General disorders of psychological development

F 84.0 Childhood autism (onset 0 to 3 years),

F 84.02 Autism, processual (onset before age 3)

F 84.1 Atypical autism

Atypical childhood psychosis (onset between 3-5 years)

Moderate mental retardation (UMR) with autistic features.

F 84.2 Rett's syndrome.

F 84.3 Other childhood disintegrative disorder (disintegrative psychosis; Heller's syndrome; childhood dementia; symbiotic psychosis)

F 84.4 Hyperactive disorder associated with mental retardation and stereotyped movements

F 84.5 Asperger's syndrome

ICD-10 (1999) is based mainly on syndromic and age-related principles. At the same time, it can be said that both classifications in terms of coverage of different types of autism turned out to be close, and in approaches to assessing the nature and genesis of psychopathologically similar autistic disorders, they were noticeably different. The main feature of the ICD-10 (1999), and its difference from both the ICD-9 and the Autism Classification of the National Center for Disease Control and Prevention of the Russian Academy of Medical Sciences, is the rejection of attempts to consider the origin, genesis of autistic disorders from an endogenous perspective, the rejection of clinical and nosological approaches, in the aspect of which up to still in the general domestic psychiatry the nature of schizophrenia, autism of the schizophrenic spectrum of Kanner is considered.

The introduction of a new section in the ICD-10: “Pervasive (general) disorders of psychological development” (F84.), Which includes all types of autistic disorders and a new group of so-called atypical autism, clearly confirms the refusal to consider the autistic circle of disorders in terms of psychoses of the schizophrenic spectrum. Not only atypical autism, but also other autistic disorders (childhood autism, childhood process autism), in this classification are removed from the circle of endogenous disorders, or "Kanner schizophrenia spectrum disorders". In addition, the very principle of including autistic disorders in "atypical autism" F84.1 turned out to be unclear not only in terms of nosology, but also in the syndromic and age assessment of these disorders. So, childhood psychosis, with an onset at 3-5 years old, classified as atypical autism, differs from childhood processual autism, starting at the age of 0-3 years, only by the age of onset of psychosis, but not structurally psychopathologically. Another group of disorders, introduced under the heading of atypical autism, as "UMO with autistic features", remains insufficiently developed, in which the alleged genesis of autism, as it were, correlates with different pathological soil - organic, genetic, metabolic types, against which these types of atypical autism arise. . In these cases of atypical autism, the question of the cause of their psychopathological similarity is explained by the result of phenocopy, equifinality (Mnukhin S.S., Isaev D.N., 1969, Simashkova N.V. et al., 2007), the question of the possible comorbidity of the actual manifestations of autism with disorders of a different nature remains undeveloped (Tiganov A.S., Bashina V.M., 2004).

The evolution of views on the nature of autism in domestic and foreign child psychiatry, as we can see, is especially noticeable when comparing autistic disorders included in both of these taxonomy: ICD-10, WHO (1999) and the Classification of Autism of the National Center for Health and Human Development of the Russian Academy of Medical Sciences (2005). In conclusion, we can once again emphasize that if in the previous definitions of autism, starting with Bleuler E. Kanner's "schizophrenic spectrum of childhood autism" was excluded. In the deontological aspect, such an approach may have its advantages, but in therapy, prognosis is not without drawbacks.

It can be assumed that the recognition of different types of autistic disorders, with the ongoing revision of their clinical nature and ongoing attempts to make changes in approaches to their verification limits of treatment in foreign and domestic psychiatry, most of all reflects the continuing lack of knowledge of this problem, knowledge of the causes of various types of autism that arise. during childhood..

Etiology and pathogenesis. As can be seen from the discussion of the classifications of autism, there is no generally accepted concept of the etiology and pathogenesis of autistic disorders at this stage, the most common theories of psychogenesis and biological ones.

"Atypical Autism" (AA) (F84.1).

It includes: atypical childhood psychosis (Group 1) and UMO with autistic features (Group 2).

"Atypical childhood psychosis" (group 1).

It includes child psychosis, which develops in children in the period of 3-5 years of age.

clinical picture. Psychosis develops after a period of normal, stigmatized, or distorted mental development. Changes of the autistic type are formed autochthonously - in behavior, communication, a stop in mental development, but in some cases psychosis is provoked by exogenous, stressful, somatic factors. Psychotic manifestations deepen gradually. At the very beginning, features of detachment appear, communication disappears, speech regresses, play, interaction with others becomes impoverished and gradually or subacutely, erased neurosis-like, more pronounced in some cases, affective disturbances sharply join, then the features of regression, or stop (developmental fading) become noticeable in development, all children develop catatonic, catatonic-hebephrenic, polymorphic positive symptoms characteristic of childhood schizophrenia.

Course of psychosis of different length: from several months, on average from 6 m to 2 - 3 or more years, it can have a continuous, paroxysmal - progredient, with exacerbations and paroxysmal character. In addition to positive psychotic symptoms during the course of psychosis, there is a stop in mental and speech development, the appearance of motor stereotypes, a disorder of self-awareness, symptoms of identity, emotional impoverishment with persistent autism. Recovery from psychosis is usually prolonged. As a result, in the clinical picture, autistic manifestations acquire an erased character slowly and partially begin to overcome the features of mental retardation, changes in the motor sphere, in the form of remaining athetosis-like and other types of motor stereotypes. With active learning, speech, cognitive functions, and emotional recovery are restored. Special deficient states are formed with varying degrees of severity of the defect, similar to the syndrome of childhood autism, psychopathic manifestations, as well as deeper personality changes of the Vershroben type, symptoms of infantilism, mental underdevelopment and other deficient type damage.

In these cases, residual positive disorders of the catatonic, affective, neurosis-like type can be observed, which tend to revive again in exacerbations, become more complicated and subside. A similar course is found in the states of child process autism, with the onset of the disease in the period from 0 to 3 years, as well as atypical childhood psychosis, with the onset of 3-5 years. In the latter cases, positive symptoms in the psychosis itself are more formalized and polymorphic, due to the higher mental development of the child preceding psychosis. In these cases (in terms of the ideas that have developed in general psychiatry), as we see, an acquired deficient state is formed, similar to YES, but not identical to it. It is characterized by a different beginning and a more psychopathologically complex picture of psychosis, as well as a complex of residual psychopathological disorders, rather than DA.

The considered “atypical autism (F84.1), “atypical childhood psychosis”, according to the autism classification of the NTSPZ RAMS (2005), proceeds as a process disorder of the autistic circle, and accounts for approximately 50% of cases in the total cohort of patients with autistic disorders.

Atypical autism (F84.1) Various forms of ULV with autistic features ( group 2). According to ICD-10, the manifestations of autism in the structure of ULV with autistic features are comorbid with mental retardation of various origins. This type of disorder has not yet been studied enough and continues to be studied, the final list of such disorders has not been established (Bashina V.M., 1999; Simashkova N.V., Yakupova L.P., Bashina V.M., 2006; Simashkova N.V. 2006; Gillberg C., Coleman M., 1992).

Syndrome J. Martin, J. Bell, X-FRA with autistic features. This syndrome was first described in 1943. In 1969, H. Lubs discovered in this disease X - a chromosome with a gap in the subtelomeric region of the long arm of CGG in Xq27.3. Hence the main name of the syndrome is the syndrome of the fragile, fragile X chromosome. In 1991, it was possible to show that in this syndrome there are multiple repeats of the CGG sequence in Xq27.3, which cause local hypermethylation and damage to protein synthesis. In the general population, healthy individuals have between 5 and 50 of these trinucleotide repeats. Carriers of the mutant FMR1 gene have from 50 to 200 repeats. If the number of repeats exceeds 200, then the complete phenotype of fragile chromosome syndrome - X is formed, and the methylated FMR1 gene does not produce protein. The functions of the protein are unknown, it is only assumed that the developmental processes of the central nervous system are distorted in such cases. In the brain, this protein is present in all neurons, most fully represented in the gray matter. During embryonic development, the concentration of FMR1 is especially high in the basal nuclei (giant cell nuclei), which are the supplier of cholinergic neurons for the limbic system. Males with a complete mutation are less preserved than females, the latter do not have mental retardation in 30% of cases. Frequency of occurrence 1:2000 in males and 2.5 to 6 per 100 among those with ULV.

clinical picture. Patients are characterized by a specific psychophysical phenotype, determined by special dysontogenetic stigmas. IQ varies from 70 to 35. In the first months of life, children usually develop normally, by six months a lag in mental development becomes noticeable, the formation of speech, large motor acts, and walking slows down.

At this stage, limited communication gradually appears, rejection of tactile contact with the mother, the formation of eye reaction, tracking is delayed, which is combined with timidity, avoidance of gaze. After the formation of walking, motor disinhibition and attention deficit may be detected. By 2–3 years, there is a noticeable lag in the formation of fine motor skills of the hands. Motor acts are impoverished, primitive, stereotypical movements in the fingers are possible, vaguely resembling mannerisms in the fingers and hands in children with AD. Game activity is primitive, proceeds in solitude. The behavior is autistic, with the rejection of social interactions with relatives and peers.

Flow. A feature of autism in FRA-X is the oscillating nature of detachment over short periods of time, with a periodic tendency to restore more meaningful communication. Against the background of a sluggish course, periods of more delineated psychotic states are possible. Over the years, interests and activities become simpler, becoming more monotonous, torpidity increases in thinking and actions, behavior acquires a stereotypical cliché-like character. Mastery of new forms of activity falls sharply. Easily there are reactions of protest, outbursts of irritability. The structure of mental underdevelopment is simplified, has a fairly uniform character, with a tendency to further aggravation.

Diagnosis is based on the signs characteristic of the underlying disease (genetic and somatic markers) and on autistic symptoms inherent in this group of patients.

Down syndrome with a utistic features , (or trisomy on chromosome 21, in 5% a translocation between chromosomes 21 and 14 is detected). AA in DS is observed in no more than 15% of cases (Gillberg Ch., 1995), after 2-4 years; according to Simashkova N.V., Yakupova L.P. (2003) in 51% of cases, from an early age. This is characterized by refusal to communicate, avoiding peers, stereotyped repetition of the same actions in protopathic games. The severity of autistic manifestations is different, from a small, easily autochthonous leveling at different periods of ontogenesis, to a significant one, approaching DA in character, with some leveling in the prepubertal period. In other cases, in children with DS, it is in the pubertal period, dysthymic disorders, empty manias with disinhibition of drives, anxiety, elementary deceptions, close to abortive, non-expanded psychotic states, and pronounced psychoses are possible. Autistic manifestations in this age period in patients are more likely to resemble the symptoms of autism in the structure of erased psychotic episodes.

Tuberous sclerosis (TS) with autistic traits. The clinical picture is characterized by an increase in dementia from the first years of life, lesions of the skin and other organs, and the presence of convulsive seizures. In almost half of the cases, these patients, from the second year of life, have periods of motor excitation, general anxiety, which resembles field behavior in DA. Children become detached, refuse to play, with difficulty move from one type of activity to another. There is a low level of motivation, negative reactions. Stereotypes in motor skills replace manual skills. Periodically there comes the block, reaching an immobility. Decreased mood with discontent is replaced by dysphoric - with foolishness. Sleep disorders are typical: difficulty falling asleep, waking up at night. Over the years, these children become more emotionally devastated by sobriety, withdrawal into themselves.

The combination of symptoms of underdevelopment and the decay of acquired skills, absurd in content speech used in an emotionally significant situation - create a complex picture of a mental defect, with autism-type disorders. In such cases, a misdiagnosis of childhood autism is often made.

Phenylketonuria with autistic behavioral traits (PKU). The disease was first described in 1934 by pediatrician -A. Foling. In 1960 C.E. Venda in PKU revealed autistic manifestations similar to early childhood autism in schizophrenia. Subsequently, similar facts were reported in the works of many authors (Marincheva G.S., Gavrilov V.I., 1988; Bashina V.M., 1999; Gillberg Ch., 1995, etc.]. These children have somatic and mental development is close to those in the normal child population.From 2-3 months hypersensitivity, tearfulness appears, later - signs of mental retardation, from borderline to severe.After a year, the desire for communication disappears, up to its active avoidance with detachment.Emotional deepens impoverishment, joylessness Characterized by stereotypes in the motor skills of the hands Hyperkinetic symptoms with impulsivity are replaced by states of akinesia with withdrawal Sleepiness during the day is combined with sleep disturbance.

D diagnostics these states is difficult. In addition to autistic phenomena, asthenia with irritable weakness, prolonged dysthymia with discontent, hysteroform reactions, hyperesthesia, neurosis-like symptoms in the form of enuresis, stuttering, fears are always found. In 1/3 of cases, epileptiform syndromes occur.

UMO in cases of combination of organic lesions of the central nervous system with autistic features. In the clinical picture, there are signs characteristic of an organic lesion, the depth of autistic withdrawal is insignificant, the ability for more uniform mental development is preserved (Mnukhin I.S. et al., 1967, 1969; Skvortsov I.A., Bashina V.M., Roytman V. A., 1997; Krevelen van Arn D., 1977). Clinical conditions in patients of this group in the ICD - 10 (1999), with their great severity, are often verified as "Hyperactive disorder, combined with mental retardation and motor stereotypes." This condition does not meet the criteria for "Infantile Autism" (F84.0) or "Attention Deficit Hyperkinetic Disorder" (F90).

Differential diagnosis in the range of different forms of autistic disorders.

In order to differentiate different forms of autism, the structure of dysontogenesis and symptoms of autism in children with childhood autism, atypical autism, and psychogenic autism was clarified. Along with psychopathological autistic manifestations, indicators of the development of the cognitive, speech, motor, emotional, play areas of the child's activity were analyzed in the dynamics of age development, which made it possible to come to the following conclusions (Bashina V.M., 1980).

I). Childhood autism, or "classic childhood autism of the schizophrenic spectrum according to L. Kanner it is determined by disintegrativity, asynchrony in the development of the main areas of activity. At the same time, the repression of archaic functions - by more highly organized ones - in the process of child development is upset. It is the disintegrative, dissociated type of dysontogenesis that is the main diagnostic marker of endogenous childhood autism. A.V. Snezhnevsky (1948) emphasized that the pathogenetic difference between dementia and psychosis is that dementia is characterized by persistent loss, and psychosis by disintegration, i.e. reversible mental disorder. This is the difference between dysontogenesis in nosologically different (endogenous and non-endogenous) groups of autistic disorders. The disintegrative process in the circle of childhood autism is not always reversible.

A similar type of dysontogenesis, i.e. also disintegrative dissociated - observed in atypical autism in connection with the transfer of psychosis.

2) Atypical autism in the UMO circle with autistic traits of metabolic, chromosomal, organic origin (with Martin-Bell, Down, Rett, TS, PKU syndromes) o It is determined mainly by the features of a total, evenly delayed and deeper dysontogenesis. In the structure of such a grossly disturbed development, there are almost no features of asynchrony, manifestations of interlayering. The stigmas of dysgenesis specific to the given nosological soil are always found in the physical status of the child.

3) For psychogenic autistic conditions characterized by shallow uniformly distorted dysontogenesis, mostly without features of asynchrony.

As you can see, convincing facts have been obtained confirming that in the circle autistic disorders specifically dissimilar types of dysontogenesis of the type are formed - disintegrative, dissociated underdevelopment; - uniform, total underdevelopment; - Uniform distorted development, which are the diagnostic criteria for their delimitation. The difference between different types of autism, as already emphasized earlier, is also confirmed by other psychopathological clinical, specific genetic and neurophysiological features.

At the same time, it turned out that in the circle of autistic disorders under consideration, with nosologically different soil, the main manifestations of “autism” itself, as a symptom, are phenotypically relatively similar those. features of equifinality are noted in it, and clinically they are determined primarily by mental symptoms of detachment, the child’s immersion in himself, isolation from the surrounding reality, the transition to stereotypical, primitive forms of behavior and activity, up to protopathic and even more ancient archaic levels in all spheres (motor, emotional , somatic, speech, cognitive).

(Let's give the diagnostic criteria for childhood autism in ICD-10 (1999), presented by a number of basic features. game activity, c) development of mutual interaction; 2. Among the pathological signs, at least six of the following symptoms. Of these, at least two signs belong to the first subgroup and at least one in the others - a) qualitative changes in social interaction: - inability to use gaze, facial reactions, gestures and posture in communication for the purpose of mutual understanding, - inability to form social interaction with peers on the basis of common interests, activities, emotions, inability, despite the existing formal prerequisites, to establish age-appropriate forms of communication, inability to socially mediated emotional response, lack or deviant type of response to the feelings of others, violation of the modulation of behavior in accordance with the social context, or unstable integration of social, emotional, and communicative behavior, - the inability to spontaneously empathize with joy, interests, or activities with others; b) qualitative changes in communication - a delay or complete stop in the development of conversational speech, which is not accompanied by compensatory facial expressions, gestures, as an alternative form of communication, - a relative or complete impossibility to enter into communication or maintain verbal contact, at an appropriate level, with other persons, - stereotypes in speech, or inadequate use of words and phrases, word contours, - the absence of symbolic games, at an early age, games of social content; c) limited and repetitive, stereotypical patterns in behavior, interests, activities - appeal to one or more stereotypical interests, abnormal in content, fixation on non-specific, non-functional behavioral forms, or ritual actions, stereotypical movements in the upper limbs, or complex movements of the whole body, - predominantly occupied by individual objects or non-functional elements of the game material; 3) the clinical picture does not meet the criteria for other developmental disorders, specific receptive language disorder, secondary socio-emotional problems, reactive or disinhibited attachment disorder of childhood, mental retardation, with emotional or behavioral disorders, with features of autism, schizophrenia. Rett syndrome).

differential diagnosis.

With predominantly perceptual speech disorders, there are no autism phenomena, there is no rejection of surrounding people, there are attempts at non-verbal forms of contact, articulation disorders are less characteristic, and there are no speech stereotypes. They have no manifestations of disintegrativity, a more even IQ profile.

Children with hearing impairments do not reject relatives, they prefer to stay in a crib rather than in their arms.

With ULV without autism features, the intellectual decline is more total and uniform, children use the meaning of words, and the ability to communicate emotionally is found, especially in Down syndrome.

In Rett's syndrome, there are specific stereotypical violent movements in the hands, such as "washing, rubbing", a progressive neurological pathology is growing.

Patients with Tourette's syndrome have more intact and different speech skills, awareness of the painful nature of behavioral disorders and the ability to mitigate tics and violent movements in therapy (cited by ICD-10).

Additionally, as a basis for the differential diagnosis of childhood autism with atypical autism, the principle of the presence or absence in the clinic of pathological signs of organic, genetic, metabolic, exogenous genesis, as is the case with atypical autism against the background of cerebral palsy, with Down syndrome, X-FRA, phenylkentonuria, paraautistic states due to early orphanhood and other exogenous pathology.

Treatment and organization of care for patients with different types of autism. There is no specific therapy for autistic disorders, and therefore therapy is predominantly symptomatic. .

The combination in the vast majority of cases of atypical autism of mental retardation of varying severity, with dissociation and disintegration in the development of certain areas of mental activity, as in a number of forms of atypical autism (atypical psychosis) - the presence of positive psychopathological disorders, confronted the fact of the need to use complex pharmacotherapy, including not only antipsychotics, but also substances with a neuroprotective, neurotrophic effect (I.A. Skvortsov, Bashina V.M., Simashkova N.V., Krasnoperova M.G. et al., 1993, 2000, 2002, 2003). The main goal of treating these patients is to influence the psychopathological symptoms and associated behavioral disorders, as well as the somato-neurological manifestations of the disease, stimulate the development of functional systems, cognitive functions, speech, motor skills, necessary skills or maintain their safety, create prerequisites for learning opportunities. For these purposes, pharmacotherapy is used (psycho- and somatotropic agents, in combination with nootropic agents). The complex method also necessarily includes specific sensory stimulation of the analyzers of vision, hearing, motor system, through the use of hardware effects and methods of psychological, pedagogical, speech therapy correction (by working with a speech therapist, defectologist, psychologist).

All types of therapeutic effects in childhood autism are applied on the basis of an individual clinical assessment of the condition of patients. When conducting psychopharmaceutical therapy special care is required, since patients with autistic disorders, due to age immaturity and the nature of the disease itself (which includes numerous somatic and neurological abnormalities), are often hypersensitive to drug effects. To prevent the latter, in all cases, a thorough examination is required, including biochemical blood tests, liver and kidney function, computed tomography, electroencephalographic and other examinations.

The presence of autistic disorders in children, leading to a delay, arrest of mental development serves as the basis for the rehabilitation of these groups of patients, the constant search for new therapeutic approaches.

Pharmacotherapy in patients with autism, it is indicated for severe aggressiveness, self-damaging behavior, hyperactivity, catatonic stereotypes and mood disorders. In these cases, neuroleptics, tranquilizers, antidepressants and sedatives are used.

To correct sleep disorders, tranquilizers can be used, for a short time due to getting used to them, hypnotics and drugs aimed at normalizing the circadian rhythm of sleep - wakefulness.

Nootropics, biotics, amino acids (instenone, glycine, cogitum, biotredin, gliatilin and others) have justified themselves quite well, as well as such complex drugs as cerebrolysin, cortexin, which carry nerve growth factors and affect the development and functional recovery of higher nervous activity.

Psychotherapy in autism is directed both at the child himself and at his relatives. In the first case, its goal is to correct behavioral disorders and relieve the child of anxiety, fears, in the second - to alleviate emotional tension and anxiety among family members, especially parents, and involve them in daily work with the child after familiarizing themselves with the methods of proper treatment with him, teaching the features of education.

Psychotherapy for childhood autism is an inseparable part of a multifaceted, general correctional work and is therefore carried out by various specialists. The optimal composition of a group of specialists providing treatment and psychological and pedagogical correction of autistic children: child psychiatrists, neurologists, speech therapists, psychologists, speech pathologists, educators, nurse educators, music workers (eurythmists).

At the preliminary stage in correctional programs, based on the simplest tactile, pantomimic and other types of contacts with the child in conditions of free choice and field behavior, an assessment of the level of his development, stock of knowledge and behavioral skills is carried out by specialists of various profiles. This assessment serves as the basis for the development of an individual plan of pedagogical and correctional work.

Correctional work in general, it can be considered as a rehabilitation covering physiologically favorable terms for the development of the child - in the period of 2-7 years. Corrective measures must be continued for all subsequent years (8-18 years), they should consist in the systematic conduct of pedagogical and speech therapy correctional classes, daily for months and years, because only in this case can social adaptation of patients be achieved.

It is desirable to supplement clinical and pedagogical work throughout its entire duration with neurophysiological studies (electroencephalography, which make it possible to objectify the structural and functional maturation of the CNS in children with autism in the process of ontogenesis and therapy.

Bashina V.M. General disorders of mental development. Atypical autistic disorders // Childhood autism: research and practice. pp. 75-93. Copy

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A pervasive developmental disorder defined by the presence of abnormal and/or impaired development that begins before the age of 3 years and abnormal functioning in all three areas of social interaction, communication, and restricted, repetitive behaviour. In boys, the disorder develops 3-4 times more often than in girls.

Diagnostic instructions:

There is usually no preceding period of undoubtedly normal development, but if there is, then anomalies are detected before the age of 3 years. Qualitative violations of social interaction are always noted. They appear in the form of an inadequate assessment of socio-emotional signals, which is noticeable by the absence of reactions to the emotions of other people and / or the absence of modulation of behavior in accordance with the social situation; poor use of social cues and little integration of social, emotional, and communicative behaviour; the absence of socio-emotional reciprocity is especially characteristic. Qualitative disturbances in communication are equally obligatory. They act in the form of a lack of social use of existing speech skills; violations in role-playing and social simulation games; low synchronicity and lack of reciprocity in communication; insufficient flexibility of speech expression and the relative lack of creativity and fantasy in thinking; lack of emotional response to verbal and non-verbal attempts by other people to enter into a conversation; impaired use of tonalities and expressiveness of the voice to modulate communication; the same absence of accompanying gestures, which have an amplifying or auxiliary value in conversational communication. This condition is also characterized by limited, repetitive and stereotyped behavior, interests and activities. This is manifested by a tendency to establish a rigid and once and for all routine in many aspects of daily life, usually this applies to new activities, as well as old habits and play activities. There may be a special attachment to unusual, often hard objects, which is most characteristic of early childhood. Children may insist on a special order for non-functional rituals; there may be a stereotypical preoccupation with dates, routes, or schedules; motor stereotypes are frequent; characterized by a special interest in the non-functional elements of objects (such as smell or tactile surface qualities); the child may resist changes to routines or details of his environment (such as decorations or home furnishings).

In addition to these specific diagnostic features, children with autism often exhibit a number of other non-specific problems, such as fears (phobias), sleep and eating disorders, temper tantrums, and aggressiveness. Self-injury (for example, as a result of biting the wrists) is quite common, especially with concomitant severe mental retardation. Most children with autism lack spontaneity, initiative, and creativity in leisure activities and find it difficult to use general concepts when making decisions (even when tasks are well within their abilities). The specific manifestations of the defect characteristic of autism change as the child grows, but throughout adulthood this defect persists, manifesting itself in many respects by a similar type of problems of socialization, communication and interests. To make a diagnosis, developmental anomalies must be noted in the first 3 years of life, but the syndrome itself can be diagnosed in all age groups.

In autism, there can be any level of mental development, but in about three-quarters of cases there is a distinct mental retardation.

Differential Diagnosis:

In addition to other variants of general developmental disorder, it is important to consider: specific developmental disorder of receptive language (F80.2) with secondary socio-emotional problems; reactive attachment disorder in childhood (F94.1) or childhood attachment disorder of the disinhibited type (F94.2); mental retardation (F70 - F79) with some associated emotional or behavioral disorders; schizophrenia (F20.-) with unusually early onset; Rett syndrome (F84.2).

Included:

autistic disorder;

Infantile autism;

Infantile psychosis;

Kanner syndrome.

Excluded:

Autistic psychopathy (F84.5)

F84.01 Childhood autism due to organic brain disease

Included:

Autistic disorder caused by an organic brain disease.

F84.02 Childhood autism due to other causes

AUTISM CHILDREN

a property of a child or adolescent whose development is characterized by a sharp decrease in contacts with others, poorly developed speech and a peculiar reaction to changes in the environment.

F84.0 Childhood autism

A. Abnormal or impaired development manifests before the age of 3 years in at least one of the following areas:

1) receptive or expressive speech used in social communication;

2) development of selective social attachments or reciprocal social interaction;

3) functional or symbolic play.

B. A total of at least 6 symptoms from 1), 2) and 3) must be present, with at least two from list 1) and at least one from lists 2) and 3):

1) Qualitative violations of reciprocal social interaction are manifested in at least one of the following areas:

a) inability to adequately use eye contact, facial expressions, gestures and body postures to regulate social interaction;

b) inability to establish (in accordance with the mental age and contrary to the available opportunities) relationships with peers, which would include common interests, activities and emotions;

c) the absence of socio-emotional reciprocity, which is manifested by a disturbed or deviant reaction to the emotions of other people and (or) the absence of modulation of behavior in accordance with the social situation, as well as (or) the weakness of the integration of social, emotional and communicative behavior.

d) the absence of a spurious search for shared joy, common interests or achievements with other people (for example, the child does not show other people the objects of interest to him and does not draw their attention to them).

2) Qualitative anomalies in communication appear in at least one of the following areas:

a) delay or complete absence of colloquial speech, which is not accompanied by an attempt to compensate for this lack of gestures and facial expressions (often preceded by the absence of communicative cooing);

b) relative inability to start or maintain a conversation (at any level of speech development) that requires communicative reciprocity with another person;

c) repetitive and stereotyped speech and/or idiosyncratic use of words and expressions;

d) the absence of spontaneous diverse spontaneous role-playing games or (at an earlier age) imitative games.

3) Restricted, repetitive, and stereotyped behaviors, interests, and activities that manifest themselves in at least one of the following areas:

a) preoccupation with stereotypical and limited interests that are anomalous in content or direction; or interests that are anomalous in their intensity and limited nature, though not in content or direction;

b) externally obsessive attachment to specific, non-functional acts or rituals;

c) stereotyped and repetitive motor mannerisms that include clapping or twisting fingers or hands, or more complex whole body movements;

d) increased attention to parts of objects or non-functional elements of toys (to their smell, touch of the surface, noise or vibration emitted by them).

B. The clinical picture cannot be explained by other types of general developmental disorder: specific developmental disorder of receptive speech (F80.2) with secondary socio-emotional problems; childhood reactive attachment disorder (F94.1) or disinhibited childhood attachment disorder (F94.2), mental retardation (F70-F72) associated with certain emotional and behavioral disorders, unusually early onset schizophrenia (F20) and Rett syndrome (F84.2)

Childhood autism

see also Autism) - early childhood autism (English infantile autism), first identified as a separate clinical syndrome by L. Kanner (1943). Currently, it is considered as a pervasive (general, multilateral) disorder, a distortion of mental development, due to the biological deficiency of the central nervous system. child; revealed its polyetiology, polynosology. R.d.a is noted in 4-6 cases per 10 thousand children; more common in boys (4-5 times more common than in girls.). The main features of R.d.a. are the child's congenital inability to establish affective contact, stereotyped behavior, unusual reactions to sensory stimuli, impaired speech development, early onset (before the 30th month of life).

Autism in children (infantile)

a relatively rare disorder, the signs of which are already detected in infancy, but usually established in children in the first 2 to 3 years of life. Childhood autism was first described by L. Kanner in 1943 in a work under a poor translation of its title “Autistic Disorders of Affective Communication”. L. Kanner himself observed 11 children with this disorder. He insisted that it had nothing to do with schizophrenia and was an independent form of mental disorder. This opinion is shared at the present time, although it is not argued in any way. Meanwhile, in some patients, affective mood disorders are detected, some symptoms of the disorder are actually identical to the manifestations of catatonia and parathymia, which may indicate an attack of schizophrenia suffered in infancy (E. Bleiler, as you know, believed that 1% of all cases of onset of schizophrenia belong to the first year of life after birth). The prevalence of childhood autism, according to various sources, ranges from 4-5 to 13.6-20 cases per 10,000 children under the age of 12, there is a tendency to increase. The causes of childhood autism have not been established. It is reported that it is more common in mothers who have had measles rubella during pregnancy. Indicate that in 80-90% of cases, the disorder is caused by genetic factors, in particular, the fragility of the X chromosome (see Fragile X Syndrome). There is also evidence that children with autism develop or experience cerebellar abnormalities in early childhood. In boys, the disorder occurs 3-5 times more often than in girls. In most cases, the signs of the disorder are detected at the age of children under 36 months, its most striking manifestations are between the ages of 2 and 5 years. By the age of 6-7 years, some manifestations of the disorder are smoothed out, but its main symptoms persist in the future. The symptom complex of the disorder is represented by the following main features:

1. the infant’s lack of a readiness posture when picking him up, as well as the absence of a revival complex when the mother’s face appears in his field of vision;

2. sleep disturbances, digestion, thermoregulation and other, usually numerous somatic dysfunctions, difficulties in the formation of neatness skills, in other words, severe neuropathic manifestations observed already in the first year of life;

3. ignoring the child of external stimuli, if they do not hurt him;

4. lack of need for contacts, attachment, isolation from what is happening with an extremely selective perception of reality, detachment from others, lack of desire for peers;

5. lack of a social smile, that is, an expression of joy when the face of the mother or another close person appears in the field of view;

6. long-term lack of ability in a number of patients to distinguish between living and inanimate objects (up to 4-5 years). For example, a 5-year-old girl is talking to a working vacuum cleaner or refrigerator;

7. egocentric speech (echolalia, monologue, phonographisms), incorrect use of personal pronouns. Some patients show mutism for a long time, so that parents consider them to be suffering from muteness. Half of the children have significant speech development disorders, especially those related to the communicative aspects of speech. So, children cannot learn such social speech skills as the ability to ask questions, formulate requests, express their needs, etc. Up to 60-70% of patients are unable to master satisfactory speech. Some of the patients do not speak at all and do not respond to the speech of others until the age of 6-7 years;

8. neophobia, or more precisely, the phenomenon of identity (the term of L. Kanner), that is, fear of the new or irritation, dissatisfaction with changes in the external environment, the appearance of new clothes or unfamiliar food, as well as the perception of loud or, on the contrary, quiet sounds, moving objects. For example, a child prefers the same, almost utterly worn out clothes or eats only two types of food, protesting when parents offer him something new. Such children do not like new words and phrases either; they should be addressed only with those to which they are accustomed. Cases of a pronounced reaction of children's indignation even to omissions or substitutions of words in the lullabies of their parents are described;

9. monotonous behavior with a tendency to self-stimulation in the form of stereotypical actions (multiple repetition of meaningless sounds, movements, actions). For example, a patient runs up dozens of times from the first to the second floor of his house and just as rapidly descends, without pursuing any goal that is understandable to others. The monotony of behavior will most likely continue, and in the future, the life of such patients will be built according to some rigid algorithm, from which they prefer not to make any exceptions that cause them anxiety;

10. strange and monotonous games, devoid of social content, most often with non-game items. Most often, patients prefer to play alone and whenever someone interferes with their game or is even present, they are indignant. If they use toys at the same time, then the games are somewhat abstract from social reality. For example, a boy, playing with cars, lines them up in a row, along one line, makes squares, triangles out of them;

11. sometimes excellent mechanical memory and the state of associative thinking, unique counting abilities with delayed development of the social aspects of thinking and memory;

12. refusal of patients from sparing conditions during illness or the search for pathological forms of comfort during malaise, fatigue, suffering. For example, a child with a high temperature cannot be put to bed, he finds for himself the place where he sees the most;

13. underdevelopment of expressive skills (a mask-like face, an expressionless look, etc.), inability to non-verbal communication, lack of understanding of the meaning of acts of expression of others;

14. affective blockade (in this case, the poverty of emotional manifestations is meant), underdevelopment of empathy, compassion, sympathy, that is, the disorder mainly concerns prosocial emotional manifestations, especially positive social emotions. Most often, patients are fearful, aggressive, sometimes show sadistic tendencies, especially in relation to the closest people and / or prone to self-harm;

15. the presence of significant, clinically significant motor restlessness in many patients, including various hyperkinesis, epileptic seizures are observed in a third of patients, serious signs of organic pathology of the brain are detected;

16. lack of eye contact, patients do not look into the eyes of the person who comes into contact with them, but, as it were, somewhere in the distance, bypassing him.

There is no specific treatment for the disorder; mainly special methods of education and upbringing are used. It is difficult to judge the results of work with patients, but there are very few publications reporting significant successes, if any. Some of the children subsequently fall ill with schizophrenia, in other, the most frequent cases, the diagnosis is limited to ascertaining mental retardation or autistic personality disorder. There are known cases of a combination of early autism with Lennox-Gastaut syndrome (Boyer, Deschartrette, 1980). See Lennox-Gastaut syndrome. See: Children's autistic pichopathy.

Psychosis in children atypical Various psychotic disorders in young children, characterized by some of the manifestations characteristic of early childhood autism. Symptoms may include stereotypically repetitive movements, hyperkinesis, self-injury, speech delay, echolalia, and impaired social relationships. Such disorders can occur in children with any level of intelligence, but are especially common in mentally retarded children.

Brief explanatory psychological and psychiatric dictionary. Ed. igisheva. 2008 .

See what "Psychosis in children atypical" is in other dictionaries:

"F84.1" Atypical autism- A type of pervasive developmental disorder that differs from childhood autism (F84.0x) either in age of onset or in the absence of at least one of the three diagnostic criteria. So, one or another sign of abnormal and / or disturbed development for the first time ... ... Classification of mental disorders ICD-10. Clinical descriptions and diagnostic instructions. Research Diagnostic Criteria

List of ICD-9 codes- This article should be wikified. Please, format it according to the rules for formatting articles. Transition table: from ICD 9 (Chapter V, Mental disorders) to ICD 10 (Section V, Mental disorders) (adapted Russian version) ... ... Wikipedia

Delirium- (lat. delirium - madness, insanity). A syndrome of clouding of consciousness, characterized by severe visual true hallucinations, illusions and pareidolia, accompanied by figurative delirium and psychomotor agitation, disorders ... ... Explanatory Dictionary of Psychiatric Terms

Autism - firstly, the extreme loneliness of the child, the violation of his emotional connection even with the closest people; secondly, extreme stereotyping in behavior, manifested both as conservatism in relations with the world, fear of changes in it, and as an abundance of the same type of affective actions, attraction of interests; thirdly, a special speech and intellectual underdevelopment, not associated, as a rule, with the primary insufficiency of these functions. ... a special, extremely characteristic type of mental dysontogenesis. It is based on the severe deficiency of the affective tone, which prevents the formation of active and differentiated contacts with the environment, a pronounced decrease in the threshold of affective discomfort, the dominance of negative experiences, a state of anxiety, fear of others.

(V.V. Lebedinsky, O.S. Nikolskaya, E.R. Baenskaya, M.M. Liebling)

Autism is a symptomatic manifestation of brain dysfunction, which can be caused by various lesions. In some cases, disorders are combined and presumably due to some pathological conditions, among which the most common are: 1. children's spasms; 2. congenital rubella; 3.tuberous sclerosis; 4. cerebral lipidosis; 5. X-chromosome fragility. The disorder should be diagnosed on the basis of behavioral features, regardless of the presence or absence of pathological features. (ICD-10)

Diagnostic criteria

lack of socio-emotional reciprocity (especially characteristic);

lack of reactions to the emotions of other people and / or lack of modulation of behavior in accordance with the social situation;

lack of social use of existing speech skills, insufficient flexibility of speech expression and the relative lack of creativity and imagination in thinking;

impaired use of tonalities and expressiveness of the voice to modulate communication; the same lack of accompanying gestures;

violations in role-playing and socially imitative games.

a tendency to establish rigid, once and for all established order in many aspects of daily life;

in a special order for performing rituals of a non-functional nature;

motor stereotypes;

a special interest in the non-functional elements of objects (smell or tactile surface qualities).

Developmental anomalies should be noted in the first three years of life, but the syndrome itself can be diagnosed in all age groups. Lack of antecedent apparently normal development.

Disorders that are not specific to autism are often observed, such as fears (phobias), sleep and eating disorders, outbursts of anger and aggressiveness, and self-harm.

Lack of spontaneity, initiative and creativity both in the performance of tasks and instructions, and in the organization of leisure;

The specific manifestations of the defect characteristic of autism change as the child grows, but this defect persists throughout adulthood, manifesting itself in many ways in similar disorders.

In boys, the disorder develops 3-4 times more often than in girls.

Included:

autistic disorder; infantile autism; infantile psychosis; Kanner syndrome.

Excluded:

autistic psychopathy (F84.5 Asperger).

atypical autism

Atypical autism is defined as a general developmental disorder that, unlike early childhood autism, manifests itself after the age of 3 years or does not meet the diagnostic criteria for early childhood autism.

The ICD-10 identifies 2 types of atypical autism.

 Onset at an atypical age . With this type of autism, all the criteria for early childhood autism (Kanner syndrome) are met, but the disease begins to clearly manifest itself only at the age of over 3 years.

 Autism withatypical symptoms . With this type of disease, deviations appear already at the age of 3 years, but no complete clinical picture early childhood autism does not cover all 3 areas - violation of social interaction, communication and specific stereotypes of behavior). Occurs more often in children with severe specific developmental disorder of receptive language or with mental retardation. Included:

mild mental retardation with autistic features;

atypical childhood psychosis.

There are no data on the prevalence of atypical autism in the medical literature.

In relation to the causes and treatment of this disorder, everything said about early childhood autism is relevant. As with the latter, the dynamics and prognosis depend on the degree of intellectual underdevelopment and on whether speech develops and how much it can be used for communication purposes.

Differential diagnosis of autism syndromes

Autistic syndromes should be differentiated from sensory defects and mental retardation. The first can be excluded by a detailed study of the sense organs. With mental retardation, autistic symptoms are not central to the clinical picture, but are accompanied by intellectual underdevelopment. Besides, in mentally retarded children and adolescents, to a lesser extent, the emotional attitude to animate and inanimate objects of the surrounding world is disturbed or not completely disturbed. Often there are also no speech and motor manifestations of early childhood autism.

This differentiation is essential for practical work. There are always parents who, consulting a psychiatrist or psychologist about their children, are interested in what kind of disorder the child suffers from - autism or intellectual underdevelopment. It is often easier for parents to accept that their child, even if he is intellectually disabled, is diagnosed with autism than to come to terms with the diagnosis of "mental retardation".

Of practical clinical importance is the differential diagnosis with schizophrenia. It can be carried out both on the basis of symptoms and on the basis of anamnesis and dynamics. Children with schizophrenia, unlike autistic children, often have delusional symptoms or hallucinations, but until the moment of their appearance, the anamnesis is usually without features; in any case, this applies to psychotic symptoms proper.

Finally, autism must be differentiated from hospitalism(deprivation syndrome). Hospitalism is understood as a disorder that develops as a result of a pronounced neglect and deficiency of factors that stimulate development. These children may also be impaired in the ability to contact, but this manifests itself in a different way: more often in the form of depressive symptoms. Sometimes there is no distance in behavior, but there are no typical symptoms of childhood autism.