Osservatorio Autismo Regione Lombardia, Azienda USSL n. 8 Merate (Lecco)
*Chair of Child Neuropsychiatry, University of Pavia & IRCCS C. Mondino
**Department of Neurology, University of Milan & IRCCS H San Raffaele
Neuroradiology has suggested a role of cerebellar anomalies in autistic syndromes (Courchesne et al, 1989). Histochemistry has shown cerebellar cell loss (Arin et al, 1991) and cerebellar autoimmunity in autistic cases (Zimmerman et al, 1993). With the aim to evaluate how specific a role of anticerebellar antibodies may be in autism, blind assays were performed on affected cases and some relatives. Methods included binding of the patients' sera to sections of rat cerebellum and examination by light microscopy and indirect immunoperoxidase staining. Ultra-thin slices were stained, washed with phosphate buffered salixie, incubated with normal goat serum, and with the patient's serum at different dilutions. After further washes, the sections were then incubated with anti-human IgG or IgM and then examined. Sera from normal volunteers, patients with diabetic neuropathy, and autistic patients' relatives served as controls. 29% of studied patients were definitely positive to components of the Purkinje cells that constitute the cerebellum. One patient's relative also appeared positive. Most of the patients had had seizures, and all had received drugs, including neurolepties. Because of the observed sample eterogeneity, case recruitment was suspended at n=15. An epidemiological study to control for case selection was considered necessary before continuing immune testing, and how resources are employed in this direction is summarised.
This presentation will be brief on the methodological specialized aspects of immunopathology so that important changes in the general actitudes towards autism in Italy can be reported, as evidenced by the fact that the Regional Government of Lombardy has initiated the implementation of a Study Center for autism and related disorders in the surroundings of Milan.
In short, when infantile onset autism was decided as the target for a major population study in Northern Italy back in 1992, our point of departure was the discrepancy between internacional assumptions that pervasive developmental disorders are not so excepcional (about half per thousand people), and our national leading actitudes towards autism, which if pure, must be very rare, and if associated with organic findings, then it was not to be considered autism. Our research position wanted to question things from an empirical point of view, and we began asking where do cases disappear in Italy? where do they go and hide?
Changing actitudes towards autism in Italy
A lot of things could be learned in this way, going after cases in the field, including privase and public, religious and lay organizations. Something very interesting for epidemiology was apparent: people once diagnosed with autism did not fit current (psychogenetic) theories any longer, and contrariwise there were many patients with other disorders (epilepsy, brain lesions and sensory abnormalities) who fit autistic criteria.
Was autism autism to be changed, or patients had to be forced to fit to theories? We inherited our teachers' scientific methods, but we had to forget all parochialism. We went after cases in schools, helth administrations, psychiatric and neurological services, pediatric wards, and finally parents associations, which have been quite rewarding in many occasions.
In fact, based on health and school statistics, and a pilot study on a general population in the first year of elementary school, we have been able to count well over the expected 45 out 100,000 people impaired by this disorder. However no clear diagnostic consensos could be established in a research team heterogeneous in its theoretical option. Moreover, many feel that if an autistic spectrum is to be accepted, and up to near 1% are to be included with extended criteria, as Lorna Wing has recently stated in her BMJ editorial last February, then psychiatric and neurology textbooks need to be extensively rewritten in the chapters on psychotic disorders, epilepsy, mental retardation, congenital malformations, metabolic disease, and developmental dispraxias, agnosias and disphasias. Certainly we approached this intriguing topic with enthusiasm, but also with prudence.
Since this task was undertaken, more acceptance has gradually been given to the general idea that autism is no longer a pure psychological condition exclusively based on early toxic social interactions. Zealous clinicians, including ourselves, have succeeded in demonstrating some non specific neurological abnormalities in all cases with autism, including non specific CT or MRI abnormalities, and varied so calied "rare" morphological syndromes.
Mixed parents and professionals committees in Bologna, Milan, Rome, Naples and other areas have helped to make autism be considered as a neurobehavioral disorder, originating from multiple factors, and leading to a range of variable clinical outcomes. As elsewhere in the world, many interesting hypotheses compete with each other nowadays in Italy, and a personal preferences inevitably play a role until reliable data are gathered and solid results are produced in favor of one scientific explanation rather than another.
Why a cerebellar role is plausible
Some preference for a cerebellar role in mental functioning has been proposed many years ago, that is as backward as in the Second Century, the times of Claudius Galenus, the Greek physician from Pergamon, who was one of the most distinguished doctor! of antiquity. Eighteen centurias ago he moved to imperial Rome and, after fighting his colleagues envy, he succeeded to be directly employed by Commodus and his descendants. They granted him enough support to continue his anatomical studies, and to inaugurase the first methods of experimental physiology in the history of medicine. To him, that miniature brain located just below and behind the major cerebral hemispheres, and above the neck, =t appeared a suitable candidate for the human soul, according to second century models of mental functioning.
That the cerebellum may be the site of anything more than muscle zone, equilibrium during walking and finger-to-nose maneuvers in neurological examinations, it arrived as a very unexpected notion for the student generation who has graduated before the 90's, the brain decade. Very shortly, waiving a fascinating chapter in the history of mind-body relationships, up to very recently, current views had describes cerebellar functions as "only" limited to coordinating sensory input with muscular responsos, disregarding any involvement in the development of learning skills. The tradicional two-handed theory sounded as follows: on the one hand, the biological equivalents of the "soul", the mind and the psyche, were positioned somehow in the complex layers of the cerebral cortex; on the other hand, non-reductionist approaches maintained considering the true site of the soul in the relation and communication between people. In fact, the two-handed theory has not been disproved, but it has been strongly criticized in neurobiology, for instance by Antonio Damasio in Descartes' error (1994).
Being considered a "pure" motor center, the cerebellum was excluded from the upper mental functions of attention, memory, volition, planning and so forth. When the cerebellum and its innumerable Purkinje cells have eventually been included in the picture, the model has become immeasurably more complex. This is so, particularly if we consider that cerebellar development is not accomplished before about the same length of time which is needed also for acquiring standard requisites for verbal language. The same age is the deadline criterium for the diagnosis of a pervasive developmental disorder, too.
Today we do not forget the social relation aspects of any handicap, but we look at autism more as a cognitive disorder, possibly based on delayed individual owns' theories of mind. Today we can also think of the cerebellum as the high frequency mathematical coprocessor of every movement and postural attitude. Enough scientific literatura is available to convince us of a role of cerebellum in cognition and language, and many consider it plausible that autism is a movement disorder.
Clues from Kanner to neuroimaging studies
To add on the credibility of the issue relating cerebellum and autism, we may read Leo Kanner's prime paper again, where he underlined that mothers reported that there infants lacked of any anticipatory postural attitude when they were offering to pick or hold them up. We now know that cerebellar cortex neurons fire anticipatorily in regards to cerebral cortex neurons, and this is most evident in more complex movements requiring attention, memory, volition, planning and so forth.
Cerebellar anomalies and, in particular, the observed reduction of the number of Purkinje cells, which are the output units of the cerebellar cortex, have been reported in autism since Neurology published an autoptic study by Bauman and Kemper in 1985 concerning a 29 year old drown patient. Clinical-radiological investigations by the Courchesne group, widely diffused since its New England paper in 1988, and pathological and immunological studies (Arin et al, 1991; Zimmerman et al, 1993) have yielded non invasive results on the hypothetical role of cerebellum in the pathogenesis of autism.
Anticerebellar autoantibodies
The neuropathology laboratory at the University Hospital of San Raffaele in Milan developed a method for the determination of autoantibodies to Purkinje cells, which are usually found in some paraneoplastic disease and peripheral neuropathies. Blind assays were then planned in a group of affected cases and a group of members of their families. Methods included binding of the patients' sera to sections of rat cerebellum and examination by indirect immunoperoxidase microscopy. Cryostat cut sections (10 microns thick) were stained for 5 minutes. Sections were washed with phosphate buffered saline (PBS), incubated with 50% normal goat serum in PBS, and for 1 hour with the patient's serum at a dilution of 1:80 to 1:2,560 in PBS. After washes with PBS, the sections were incubated with peroxidase-conjugated goat anti-human IgG or IgM affinity-purified at a dilution of 1: 1 00. Tlie sectiotis were tlien exai-nitied at the iilicroscope. Sera froi-n normal volunteers and patients with diabetic neuropathy served to establish the threshold between positive and negative cases.
This University Hospital offered many opportunities to look for neurobiological correlates of autism, including functional MRI and PET scan. However standard routines and invasive techniques are neither suited nor accepted by people with autism and their families. And the high cost and many hours of organizing appropriate setting, and training cases to obtain neuroimaging compliance, were discouraging barriers for both hospital staff
and patients families.
An immunological technique appeared less expensive and less invasive, so that parents would not be concerned about exposing their children to unnecessary radiation or stress. And blood could be taken during other medical examinations, provided an informed consent was given. As it happens with new techniques, the laboratory people were keen to fish for possible serendipitous findings. Therefore blind assays were rigorously defined, and no laboratory staff knew whose sample was assessed in that moment.
Results and comments
Only 14 cases of autism could be included, before the observed sample heterogeneity advised to suspend the recruitment of cases. Another case could not be tested, because of his opposition, but his parents could, and therefore we had 10 control relatives.
29% (4/14) of studied patients were definitely positive to components of the Purkinje cells that constitute the cerebellum. One patient's relative (1/10) also appeared positive. Most of the patients had had seizures, and all had received drugs, including neuroleptics.
Antibodies against both the nucleus and the cytoplasm were observed, although in different proportions depending the cases. However no clear trend could be ascertained, and no other specific cause was investigated in the control relative - a talented brother who appeared positive for anticerebellar antibodies.
In order to evaluate the sensitivity and specificity of the test in autism, many more cases were needed. However, the recruitment of cases had to be suspended after one year because of institutional changes. Available time and resources were spent trying to establish an epidemiological study.
Now we may reconsider cerebellar immune testing in a better position than when we began considering this issue. First of all a Regional Research Unit on Autism was born this Spring, half an hour from Milan. It is called Osservatorio Autismo, and it is expected to build up a documentation center and a case registry. When a large case series is available, it will be possible to control for case selection, age of patients and controls, neurological comorbidities and other factors.
At the present time, on the topic of cerebellar antibodies and autistic syndromes, we may neither accept or reject the hypothesis that nuclear or cytopiasmic Purkinje celis antigens are exposed for some reasons in some cases of autism. It remains an intriguing aspect on this complex issue, and we may go back to this issue with homogeneous and a larger number of cases from the regional case registry.
An official Act on autism
This is the time, in fact, that the Region of Lombardy is setting up continuing education programs for mental health workers, besides the new documentation center and the epidemiological case registry for the autistic disorders. Expectations are that good quality diagnostic services and integrated treatments can be offered to a wide population that up to now was poorly identified and very often humiliated by guilt-carrying diagnoses.
This is the outcome of an Act promulgated by the Regional Council of Lombardy in 1995. The Act approved an experimenta] initiative, and it was the first time that autism had been referred to under its proper label in an official act in Italy. The Lombardy Act on autism included a document written by an ad-hoc committee, with the ethical contribution of parents' representativas.
The aim of the project was to reflect the changes that have occurred in the study of the autistic disorders and to promote a wider range of treatments than currently available in the regional health organizations. A history of the concept was provided, and the opinion that autism is the product of defense mechanisms was disapproved. Available internacional epidemiological were given to estimate local figures, thus expecting a total of 4-8000 people with autism in the Lombardy Region, and about 90 new cases per year based on the ICD-10 definition.
Remarkably, the Lombardy Region document stated that - as so far - no primary level prevention was possible, because of the present frustrating lack of evidence for any specific causal agent. Neither any single physical, nor certainly any psychological factor, should be considered at fault when explaining health workers and families the etiology of autism.
Other levels of prevention, however, are possible and necessary, namely secondary and tertiary forms of prevention, which include early diagnosis, early treatment, and paying attention to the quality of life of the affected people and families. Diagnosis is to be based on observed behaviors, rather than on perceived feelings and interpretations. ICD-10 criteria should be applied, including differentiation froni Rett and Asperger syndromes, and the remaining F84 categories. All F84 disorders, liowever, are to be covered by the project. An integrated "prise en charge" was encouraged, including tlie search for neurological correlates, correct explanations of the diagnoses, help to families, use of drugs, training of educators, and care for tlie whole life cycle.
From continuing education to novel research
The Autism Act continues stating that medical, social, and educational work are to be outlined in an integrated way. Child and adult services, and health and school systems are expected to bridge up on this issue. Families of people with autism should be able to see that there unique expertise on their own child is accepted, and there requests are reasonably met within the local health districts. In other words, parents and professionals should be one team.
Four major tasks are indicated: (1) educating and training mental health professionals on autism, (2) developing a comprehensive database, (3) contributing to the epidemiology of autism, and (4) evaluating intervention on autism in terms of cost-benefits.
These goals are to be accomplisbed by the implementation of continuing education courses and a documentation center. The documentation center is also have tlie function of a case registry, which will allow researchers from qualified institutions, on an informedconsent basis, to have access to specific case series for studies andr controlled experiments. Non profit organizations and parents associations are invited to audit and participase in each project.
The name of this center is Osservatorio Autismo della Regione Lombardia, and it starts to work this month.
The Lombardy Act on autism appears to be a quite important step towards better standards in the field of neuropsychiatric care. lt occurs at the moi@nent when Italy moves from a 20-year old National Health Systeni to financially independent local Trusts. The transition from a welfare state to a business oriented - rather private - market has been influenced by the changes that liave occurred elsewhere in Europe. Therefore, as the clients of the new health organizations have the opportunity to choose were to buy the services they need, the role of scientifically sound and promptly available inforniation is crucial.
The expected outcomes of the Lombardy Act on autism are better coordination among child and adult mental health services at the local level, possibly for all disorders, and improved co-operation for research at the European level, particularly in the epidemiology of neuropsychiatric conditions. One of the main criticism that people involved or interested in autism receive is that they do not agree among themselves on what autism really is. If the same child or adult is diagnosed the same neuropsychiatric disorder, and he or she can receive similar treatment in different parts of Europe, then it is an accomplishment.
What about cerebellar antíbodies?
Cerebellar antibodies in autism is a small contribution, but it is having some resonance, and perhaps it is a lead that will continue. Cerebellum and cognitive functions is a huge and challenging topic. We look forward to receive feedback, and make a decision whether cerebellar antibodies are worthwhile to pursue in autism.
Preseitter: dr Stefano Palazzi
OSSERVATORIO AUTISMO REGIONE LOMBARDIA
Child Neuropsychiatry,
H San Leopoldo Mandic via San Vincenzo 6 -
22055 Merate (LC). Italy
Tel. +39 39 5916.526/7
Fax. +39 39 5916.365