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The Autistic Spectrum



 
Source: Johns Hopkins Medical Institutions
Date: 2004-11-17
URL: http://www.sciencedaily.com/releases/2004/11/041117004123.htm

Brain’s Immune System Triggered In Autism

A Johns Hopkins study has found new evidence that the brains of some people with autism show clear signs of inflammation, suggesting that the disease may be associated with activation of the brain’s immune system. “These findings reinforce the theory that immune response in the brain is involved in autism, although it is not yet clear whether the inflammation is a consequence of disease or a cause of it, or both,” said Carlos Pardo-Villamizar, M.D., assistant professor of neurology and pathology at Johns Hopkins and senior author of a report on the study published early on-line in the journal Annals of Neurology on Nov. 15.

Whatever the cause of the inflammation, it may provide a good target for developing new treatments, adds Pardo.

Autism is a disorder of the developing brain that appears in early childhood. According to the American Neurological Association, it is estimated to afflict between two and five of every 1,000 children and is four times more likely to strike boys than girls. Children with autism have difficulties in social interaction and communication and may show repetitive behaviors and have unusual attachments to objects or routines.

Autism has a strong genetic component in some families, although other causes likely play a role, possibly including birth complications, diet, toxins or infections, says Pardo.

“Scientists have found hints that the immune system may be involved in autism, but not all studies have confirmed this,” said Pardo. “We wanted a more definitive answer, so rather than looking at the overall immune system, we focused on immune responses inside the relatively sealed environment of the nervous system.”

Led by first author Diana L. Vargas, M.D., a postdoctoral fellow working in Pardo’s laboratory, the researchers examined tissue from three different regions of the brain in 11 people with autism, ages 5 to 44 years, who had died of accidents or injuries. They also measured levels of two immune system proteins, called cytokines and chemokines, found in the cerebrospinal fluid - the clear substance that surrounds, bathes and nourishes the brain and spinal cord - in six living patients with autism, ages 5 to 12 years.

Compared with normal control brains, the brains of people with autism showed evidence of an ongoing inflammatory process in different regions of the brain and produced by cells known as microglia and astroglia, says Pardo. Cytokine and chemokine levels in the cerebrospinal fluid also were abnormally elevated in patients with autism.

“These findings suggest that the inflammation is localized to specific regions within the brain and not caused by immune system abnormalities from outside the brain,” says Pardo.

Pardo and colleagues are now studying how the genetic background of patients and families may influence immune system reactions in the brain associated with autism.

Other authors are Andrew Zimmerman, Caterina Nascimbene, and Chitra Krishnan. The study was funded by the Cure Autism Now Foundation, the Autism Research Foundation, the National Institutes of Health, Dr. Barry and Renee Gordon and an anonymous donor.

On the Web:

http://www3.interscience.wiley.com/cgi-bin/jhome/76507645

http://www.neuro.jhmi.edu/

Editor's Note: The original news release can be found here.

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Autism and Biology

Dustin Hoffman's portrayal in the movie Rain Man may have turned public focus to autism but scientists have been scrutinizing it for years. Following decades of research, significant advances have confirmed that biology is behind this brain disorder that is marked by deficits in the higher order cognitive abilities involved in social, communication and problem-solving behavior. New findings on the genetic and anatomical roots of autism are helping researchers piece together how the disorder evolves, which could lead to new treatments.

Kids burst off swings like pop-corn popping. They argue over who jumped the farthest. Another child details to a play-mate his adoration for a fish-shaped Beanie Baby. A group of youngsters conduct a game of jail tag under a jungle gym. All of this is normal behavior. 

But a completely different scenario emerges for children with the brain disorder autism.

Aloof, detached and withdrawn, many autistic children find everyday social interactions are beyond their reach.

All find them difficult. They have trouble showing or detecting emotion. Some do not even speak. Others talk too much and seem odd because they go on and on about one topic, such as highways, and report inane facts like the lengths of dinosaurs' necks. Cognitive abilities are impaired in most autistic children. Their problem-solving is hindered and at times their attention seems unusually narrow and focused. They tend to have no common sense. Many of their activities are repetitive and others seem to have no purpose - such as jumping while twiddling their fingers.

For years, faulty parenting was to blame. Now accumulating science shows that the disorder is born of biology. New genetic and anatomical data are leading to:

  • A better understanding of how faulty biology can lead to autism's symptoms.
  • Improved behavioral interventions and drug therapies.

Approximately one in 500 Americans has some form of autism, perhaps 540,000 people, according to the Autism Society of America. Several decades ago, their parents were told that a terrible experience of rejection or not enough mother-child bonding made their child turn inward and shut off the outside world. Research starting in the 1960s, however, unearthed important evidence that suggested autism had a biological root and was not a result of inadequate parenting. In the 1980s, autopsy and neuroimaging studies directly demonstrated that abnormalities existed in the brains of those with autism. 

Since that time, research is indicating that people with autism are born with altered genes. For example, in families with one autistic member, researchers found evidence that suggests versions of a gene may be linked to the disorder. This gene produces a specific protein that normally works to reabsorb the chemical serotonin into nerve cells for reuse. The linkage has not been found, however, in families with more than one autistic member. In another example, a new study implicates a second gene. This gene may relate to a receiving area, known as a receptor, for the chemical gamma-amino butyric acid. Currently researchers are trying to confirm these and other genetic findings, and understand how they may relate to the disorder. In addition, a number of other large-scale studies are underway. 

Researchers suspect that several different groups of altered genes cause autism by interfering with the brain's chemical message systems that guide brain development and later serve as chemical messengers, or neurotransmitters, between nerve cells in the mature brain.

Additional genetic insights may explain research that indicates multiple brain regions are involved in autism. For example, examinations of autistic patients indicate that there are abnormalities in cerebellar brain regions implicated in motor, sensory, language, cognitive and attention functions. In another example, researchers found from autopsy studies that the overall brain size of a subset of autistic patients appeared extremely large, which suggests that the projections and wiring of cells in the outermost brain layer known as the cerebral cortex are involved in causing this disorder.

These and many additional lines of research are helping scientists get closer to characterizing the brain and cognitive abnormalities of autism.


For more information please contact Leah Ariniello, Science Writer, Society for Neuroscience, 11 Dupont Circle, NW, Suite 500, Washington DC, 20036.

http://apu.sfn.org/content/Publications/BrainBriefings/autism.html

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Does Autism Results From Failure of Brain Areas To Work Together? -Adelle Tilton

The Issue

In contrast to people who do not have autism, people with autism remember letters of the alphabet in a part of the brain that ordinarily processes shapes, according to a study from a collaborative program of the National Institute of Child Health and Human Development of the National Institutes of Health.

The study was conducted by researchers in the NICHD Collaborative Program of Excellence in Autism (CPEA) at the University of Pittsburgh and Carnegie Mellon University. It supports a theory by CPEA scientists that autism results from a failure of the various parts of the brain to work together. In autism, the theory holds, these distinct brain areas tend to work independently of each other. The theory accounts for observations that while many people with autism excel at tasks involving details, they have difficulty with more complex information.

Latest Developments

The study and the theory are the work of Marcel Just, Ph.D., Professor of Psychology at Carnegie Mellon University in Pittsburgh, Pennsylvania and Nancy Minshew, M.D., Professor of Psychiatry and Neurology at the University of Pittsburgh School of Medicine and their colleagues. The study is scheduled for on-line publication November 29 in the journal Neuroimage, at Science Direct.

Background

"This finding provides more evidence to support a promising theory of autism," said Duane Alexander, M.D., Director of the NICHD. "If confirmed, this theory suggests that therapies emphasizing problem solving skills and other tasks that activate multiple brain areas at the same time might benefit people with autism."

People with autism typically have difficulty communicating and interacting socially with others. The old saying "unable to see the forest for the trees" applies to people with autism, describing how many of them excel at matters of detail, yet struggle to comprehend the larger picture. For example, some children with autism may become champions at spelling bees, but have difficulty understanding the meaning of a sentence or a story.

"The language pattern in autism is a microcosm for the disorder," Dr. Just said. "People with autism are good at a lower level of analysis but have a deficit at the higher level."

Remembering Letters as Shapes

In the current study, the researchers used a brain imaging technique known as functional magnetic resonance imaging (fMRI) to measure the brain activity of 14 individuals with high functioning autism while they performed a simple memory task involving letters of the alphabet. Specifically, the study volunteers were shown a sequence of letters. After each letter, they were asked to name the letter that preceded it. In some cases, they were asked to name the letter that appeared two letters previously. The autism volunteers' brain activation patterns were compared to a control group of people who did not have autism, but were of a similar age and I.Q. level.

Both groups successfully completed the task. However, the fMRI scans revealed different brain activation patterns between the two groups. Compared to the control group, the volunteers with autism showed more activation in the right hemisphere, or half, of the brain, and less activation in the left hemisphere. The left hemisphere takes the lead in processing letters, words and sentences, whereas the right hemisphere plays a larger role in processing shapes and visual information.

Dr. Just said that the brain could interpret letters either spatially, as geometric shapes, or linguistically, by the names of the letters. The imaging data indicated that the volunteers with autism remembered letters as shapes, while the control group remembered them by their names.

Brain Synchronization Lacking

The brain activation patterns of the two groups also differed in other ways. While performing the task, the group with autism showed less activation in the anterior, or front, parts of the brain, and more activation in the posterior, or rear parts of the brain. Dr. Just explained that the brain's anterior portions carry out higher-level thinking and reasoning while the posterior portion is more involved with perceiving details.

Compared to the control group, the different brain areas of the people with autism were less likely to work in synchrony (at the same time) while recalling the letters. Such synchronization between brain areas takes place during many kinds of higher-level thinking and analysis that prove difficult for many people with autism.

These current findings provide evidence in support of the theory developed by these researchers. Called the theory of underconnectivity in autism, it maintains that autism results from a failure of the brain's neurological wiring — the fibers of nervous system tissue that interconnect the individual parts of the brain. Deprived of effective connections, the different brain areas must work independently, sometimes performing at a higher level individually than they do in people who do not have autism. This may allow some people with autism to excel at spelling and other detail-oriented tasks but make it difficult for them to comprehend more complex material.

Where it Stands

The researchers published their theory in the July issue of Brain, in conjunction with the results of another fMRI study of volunteers with autism. In that study, volunteers were asked a question about a simple sentence that they had just read. When the people with autism performed the task, their brains showed less synchronization than did the brains of the control group. Moreover, the brains of the group with autism had less activation in an anterior part of the brain that integrates the words of a sentence, and more activation in a posterior brain area that comprehends individual words.

Many behavioral therapies to treat autism stress rote learning, Dr. Minshew explained. Such strategies are helpful, particularly early in a child's development. However, if the theory of underconnectivity proves valid, therapies that stimulate brain areas to work in synchrony might also offer some benefit. Such therapies might stress problem solving skills and creative thinking, and attempt to foster flexibility in thinking.

Dr. Just noted that more evidence to support the theory might come from the group's on-going studies of other cognitive abilities. The researchers are attempting to determine if underconnectivity is a general feature of the brain in autism, and are using brain imaging studies to examine the brain's white matter in people with autism. White matter is the part of the brain that consists of the larger neurological connections spanning different parts of the brain.

Source:  http://autism.about.com/od/autisminprint/i/brainprocessing_2.htm

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MGH study details brain changes in autism, language disorder
Imaging allows identification of specific areas where white matter is enlarged

BOSTON - March 22, 2004 - Using advanced imaging technology, a research team based at Massachusetts General Hospital (MGH) has identified specific portions of the brain's white matter that are abnormally large in children with autism and developmental language disorder (DLD). The findings confirm that the previously observed overgrowth of white matter occurs after birth and suggest that it may be related to the process of myelination, in which portions of nerve cells called axons are covered with a material called myelin. The report appears in the April issue of Annals of Neurology and is now available
online.

The researchers noted that the factor most closely associated with the areas showing the greatest volume increase is when the axons in those areas myelinate, a key step in maturation that allows nerve impulses to be transmitted properly. In both autistic and DLD patients, the most enlarged areas were those that myelinate latest in normal development and where myelination takes a longer period of time.

"Knowing that white matter is most enlarged in the area that develops myelin latest will help us narrow the time window in which to look for the cause of these problems and should help focus future research," says Martha Herbert, MD, PhD, of MGH Neurology and the Center for Morphometric Analysis, the paper's lead author.

Autism is a serious developmental disorder characterized by a lack of normal social interaction, language abnormalities and repetitive, ritualistic behavior. Many earlier studies have shown that autistic children often have unusually large brains and experience rapid brain growth in the first years of life. This increased brain volume appears to be concentrated in the white matter. Primarily made up of axons - long processes that extend out from brain or other nerve cells - the white matter is located in the interior of the brain, beneath the cerebral cortex which contains the bodies of brain cells.

The same white matter abnormality is found in developmental language disorder, a condition in which language is abnormal but intelligence and behavior are normal. Few studies have measured brain volume in DLD patients, and some have shown increased brain volume in these children as well.

The current study used advanced techniques for analyzing magnetic resonance imaging (MRI) studies to subdivide white matter into distinct regions related to the pathways taken by axon fibers. Imaging studies were made on 63 children - 13 with autism (all boys), 24 with DLD (14 boys, 7 girls), and 29 normal controls (15 boys, 14 girls). The participants were about ages 8 and 9, and all were high functioning, with IQs over 80.

The results showed that in both the autistic and DLD participants, the outer layer of white matter was significantly larger than among controls, while the inner areas were no different from controls. While all portions of the outer layer of white matter were enlarged in autistic participants, the frontal lobe area (behind the forehead) showed the greatest enlargement. White-matter enlargement in the DLD participants was seen in the frontal, temporal (behind the temples) and occipital (back of brain) areas, but not in the parietal lobe (upper, lateral area). Both groups of children showed the greatest white matter enlargement in the prefrontal area, the very front of the brain. Of particular interest, white matter in the corpus callosum, which connects the right and left hemispheres, showed no volume increase.

"Finding a change in these children's brains that occurs after birth may give us better targets for preventing and treating these disorders. If we develop methods for early detection, we may be able to treat these conditions before they get too advanced," says Herbert, an instructor in Neurology at Harvard Medical School.

Herbert's co-authors are senior author Verne Caviness, MD, DPhil, David Ziegler, Nikos Makris, MD, PhD, Joseph Normandin, and David Kennedy, PhD, of the MGH; Pauline Filipek, MD, University of California at Irvine; Thomas Kemper, MD, Boston University School of Medicine; and Heather Sanders, University of Pittsburgh School of Medicine. The research was supported by grants from the National Institute of Neurological Disorders and Stroke, the Cure Autism Now Foundation, the National Institutes of Health, the Human Brain Project, the Fairway Trust, and the Giovanni Armenise-Harvard Foundation for Advanced Scientific Research.

Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $400 million and major research centers in AIDS, cardiovascular research, cancer, cutaneous biology, medical imaging, neurodegenerative disorders, transplantation biology and photomedicine. In 1994, MGH and Brigham and Women's Hospital joined to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups, and nonacute and home health services.

Media Contact:
Julie Bergan, MGH Public Affairs

Physician Referral Service: 1-800-388-4644
Information about Clinical Trials

Source: http://www.massgeneral.org/news/releases/032204herbert.html

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Source: University Of Washington
Date: 2001-04-20
URL: http://www.sciencedaily.com/releases/2001/04/010418072256.htm

Mother Is Just Another Face In The Crowd To Autistic Children

Unlike normally developing and mentally retarded children, autistic 3- and 4-year-olds do not react to a picture of their mother but do react when they see a picture of a familiar toy, a University of Washington psychologist has found.

Geraldine Dawson will report her result Thursday in Minneapolis at the annual meeting of the Society for Research in Child Development. Her finding suggests that an impairment in face recognition may turn out to be one of the earliest indicators of abnormal brain development in autism.

Dawson, who directs the UW Autism Center, said human brains seem to be wired to be interested in faces and there appears to be a specialized system for face recognition.

"We know that even newborn babies are drawn to face-like stimuli. This inborn interest in faces is the start of social development," she said. "This new study tells us something very fundamental about abnormalities in autism. It may be an important clue to actual brain circuits that are not functioning properly. Since all of the children in the study reacted similarly to toys and only the children with autism had problems with face recognition, it tell us autism is not a global problem. Rather, it indicates an abnormality in those brain circuits responsible for social function. It highlights that autism is a disorder of the social brain." Dawson said the idea that face recognition may be hard-wired, or something people are born with, is controversial.

"Just as with language, the brain comes with a readiness to recognize faces. But it also requires experience. With autism there may be some other reason why children don't pay attention to faces. They may not find it rewarding, and then that part of their brain does not develop further."

The region of the brain that appears to be specifically devoted to face recognition is the right fusiform gyrus, located in the temporal lobe, according to Dawson.

To learn how the brain operates, Dawson used a device called a geodesic net that looks like a hairnet and fits over the head. It records electrical brain impulses from 64 places on a child's scalp. Similar devices for adults record data from 128 locations. Dawson's study involved 34 children with autism, 21 normally developing children and 17 with mental retardation but no autism. Some autistic children also are mentally retarded.

Each of the children was shown two sets of images - faces and objects - about 50 times. First they were shown digitized photos of their mother or a stranger. Then they were shown digitized photos of a favorite or an unfamiliar toy. The net measured brain activity half a second after each image was shown and picked up the specific brain signal to that stimulus.

Earlier research has shown that normally developing children as young as 6 months old show different brain activity when they see their mother and when they see a stranger. Dawson's research revealed a similar pattern among normal and mentally retarded 3- and 4-year-old children, but the autistic children failed to recognize their mother. However, all three groups exhibited similar reactions when they saw images of a favorite toy versus an unfamiliar one. She believes the ability to recognize faces may turn out to be a key tool in identifying children with autism. Previous research by Dawson has shown that a child's failure to look at faces at age 1 is the best predictor of autism.

"Today we can reliably identify autism in children at age 2, but it is difficult to identify babies with autism," she said. "What usually catches parents' attention around 12 months is that their child is not picking up language. Parents are also especially sensitive to picking up autism symptoms in a younger sibling. Siblings of children with autism have 1-in-20 odds of having autism."

Dawson, whose research was funded by the National Institute of Child Health and Human Development, next plans to replicate the mother-stranger picture study with 18-month-old autistic toddlers to see if this identification process operates at an earlier age. Also being reported at the Minneapolis meeting is related research by Dawson and UW doctoral student James McPartland that shows adults and adolescents with autism have abnormal reactions to faces. The Autism Center is part of the UW's Center on Human Development and Disability. Dawson and an interdisciplinary team are attempting to find the neurobiological and genetic causes of autism and design interventions to help autistic children.

Autism and related disorders are among the most common developmental disabilities, occurring in one in 500 people. Autism is characterized by an impaired ability to communicate or relate socially with others. People with the disorder typically have a limited range of activities and interests.

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Binstock's Anterior Insular Cortex Hypothesis for Linkage Between Gut and Brain.

Binstock (http://www.jorsm.com/~binstock/insular.htm) has developed a hypothesis to explain the gut-brain relationships for autistic children.

The anterior insular cortex (aIC) links visceral sensation from the gastrointestinal tract with the amygdala and the hypothalamus (1-6). The anterior insular cortex also participates in oral phenomena, object recognition, and naming (5) along with "apraxia of speech" (7,8).

Twenty-five stroke patients with articulatory deficits all had a lesion within "a discrete region of the left precentral gyrus of the insula", whereas this area was "completely spared" in 19 stroke patients without these deficits (7).

Autism-spectrum children with atypical oral habits and/or disorders of naming and of language (9-10) also tend to have a typical gastrointestinal symptoms (11-12). There is also a growing volume of anecdotal data that a small subgroup of autism-spectrum children experiences improved sound production and language use in response to treatments whose focus and effects are gastrointestinal. These treatments include gluten-free and casein-free diets, anti-Candida therapies, anti-viral therapies, and antibiotic therapies (13-19,31,32) suggesting that the underlying neuronal circuitry is intact.

Binstock suggests that the aIC and associated nuclei could become disrupted by at least two mechanisms: (I) intraneuronal migration of a neurotropic virus and/or (II) chronic hyperstimulation of the gastrointestinal tract.

Gesser and colleagues have documented (I) the translocation of HSV from the gastrointestinal tract into the mesenteric nervous system (rats and humans), and (II) the migration of mesenteric HSV as far as theamygdaloid nuclei in rats (20-23). In this theory, viruses could migrate from the gastrointestinal tract through neural pathways into the central nervous system.

Given a high rate of stimulation of neuron pathways reporting gastrointestinalconditions to limbic regions and cortex, neurotransmitter or intracellular-messenger use in excess of their production or recirculation could occur, thereby inducing a change of function of neurons within the aIC.

This hypothesis provides a basis for helping autistic children through treating their gastrointestinal disturbances.

References:

  1. Krushel LA, van der Kooy D. Visceral cortex: integration of the mucosal senses with limbic information in the rat agranular insular cortex. J Comp Neurol 270.39-54 1988.
  2. Mesulam MM, Mufson EJ. Insula of the Old World Monkey. I. Architectonics of the insulo-orbito-temporal component of the paralimbic brain. J Comp Neurol 212.1-22 1982.
  3. Mesulam MM, Mufson EJ. Insula of the Old World Monkey. II. Afferent cortical inputs and comments on the claustrum. J Comp Neurol 212.23-37 1982.
  4. Mesulam MM, Mufson EJ. Insula of the Old World Monkey. III. Efferent cortical output and comments on function.
  5. Augustine JR. Circuitry and functional aspects of the insular lobe in primates including humans. Brain Res Rev 22.229-44 1996.
  6. Morecraft RJ, Geula C, Mesulam MM. Cytoarchitecture and neural afferents of orbitofrontal cortex in the brain of the monkey. J Comp Neurol 323.341-58 1992.
  7. Dronkers NF. A new brain region for coordinating speech articulation. Nature 384.159-61 1996.
  8. Donnan GA et al. Indentification of brain region for coordinating speech articulation. Lancet 349.221-2 1997.
  9. Peeters T, Gillberg C. Autism: Medical and Educational Aspects. Whurr Pub Ltd 1999.
  10. [Additional Citation]
  11. D'Eufemia PD et al. Abnormal intestinal permeability in children with autism. Acta Paediatrica 85.1076-9 1996.
  12. Horvath K et al. Gastrointestinal abnormalities in children with autistic disorder. J Pediatr 1999 135.5.559-63 1999.
  13. Bolte ER, personal communication; see also Sandler RH, Bolte ER et al. Possible gut-brain interaction contributing to delayed onset autism symptomatology. Abstract #18, Fourth Int Symp on Brain-Gut Interactions; Neurogastroenterol Mot 10.363 1998.
  14. BR..., Ph.D., Personal communication.
  15. Jane El-Dahr, MD, Personal communication.
  16. Ray Kopp, Personal communication based upon his internet experience with hundreds of parents of autism-spectrum and/or gfcf children.
  17. WM..., MD, Personal communication.
  18. PS..., Ph.D., Personal communication.
  19. Amy Holmes, MD, Personal communication.
  20. Gesser RM et al. Oral-oesophageal inoculation of mice with herpes simplex virus type 1 causes latent infection of the vagal sensory ganglia (nodose ganglia). J Gen Virol 1994 Sep;75 ( Pt 9):2379-86.
  21. Gesser RM et al. Oral inoculation of SCID mice with an attenuated herpes simplex virus-1 strain causes persistent enteric nervous system infection and gastric ulcers without direct mucosal infection. Lab Invest1995 Dec;73(6):880-9.
  22. Gesser RM, Koo SC. Oral inoculation with herpes simplex virus type 1 infects enteric neuron and mucosal nerve fibers within the gastrointestinal tract in mice. J Virol 1996 Jun;70(6):4097-102.
  23. Gesser RM, Koo SC. Latent herpes simplex virus type 1 gene expressionin ganglia innervating the human gastrointestinal tract. J Virol 1997 May;71(5):4103-6.
  24. Bourdois PS, McCandless DL, MacIntosh FC. A prolonged after-effect of intense synaptic activity on acetylcholine in a sympathetic ganglion. CanJ Physiol Pharmacol 1975 Feb;53(1):155-65.
  25. Michael Goldberg, MD, NeuroImmune Dysfunction conference; Bethesda,Maryland, 1999.
  26. Sid Baker, MD, Defeat Autism Now! conference; Cherry Hills, New Jersey,1999.
 
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Neurobiology of Disease
The Amygdala Is Enlarged in Children But Not Adolescents with Autism; the Hippocampus Is Enlarged at All Ages

Cynthia Mills Schumann,1 Julia Hamstra,1 Beth L. Goodlin-Jones,1 Linda J. Lotspeich,2 Hower Kwon,2 Michael H. Buonocore,3 Cathy R. Lammers,4 Allan L. Reiss,2 and David G. Amaral1,5

1Department of Psychiatry and Behavioral Sciences, Center for Neuroscience and the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute, University of California Davis, Sacramento, California 95817, 2Stanford Psychiatry Neuroimaging Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305, 3Department of Radiology, University of California Davis School of Medicine, University of California Davis Imaging Research Center, Sacramento, California 95817, 4Department of Anesthesia and Pain Medicine, University of California Davis School of Medicine, Sacramento, California 95817, and 5California National Primate Research Center, University of California Davis, Davis, California, 95616


   Abstract
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Autism is a neurodevelopmental disorder characterized by impairments in reciprocal social interaction, deficits in verbal and nonverbal communication, and a restricted repertoire of activities or interests. We performed a magnetic resonance imaging study to better define the neuropathology of autistic spectrum disorders. Here we report findings on the amygdala and the hippocampal formation. Borders of the amygdala, hippocampus, and cerebrum were defined, and their volumes were measured in male children (7.5-18.5 years of age) in four diagnostic groups: autism with mental retardation, autism without mental retardation, Asperger syndrome, and age-matched typically developing controls. Although there were no differences between groups in terms of total cerebral volume, children with autism (7.5-12.5 years of age) had larger right and left amygdala volumes than control children. There were no differences in amygdala volume between the adolescent groups (12.75-18.5 years of age). Interestingly, the amygdala in typically developing children increases substantially in volume from 7.5 to 18.5 years of age. Thus, the amygdala in children with autism is initially larger, but does not undergo the age-related increase observed in typically developing children. Children with autism, with and without mental retardation, also had a larger right hippocampal volume than typically developing controls, even after controlling for total cerebral volume. Children with autism but without mental retardation also had a larger left hippocampal volume relative to controls. These cross-sectional findings indicate an abnormal program of early amygdala development in autism and an abnormal pattern of hippocampal development that persists through adolescence. The cause of amygdala and hippocampal abnormalities in autism is currently unknown.

Key words: Asperger; amygdaloid complex; development; mental retardation; MRI; neuroanatomy


   Introduction
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Autism is a lifelong neurodevelopmental disorder that is diagnosed in early childhood and characterized by a core deficit in social interaction (American Psychiatric Association, 1994
). Other components of the disorder may include language impairments, stereotypical behaviors, and unusual fear or anxiety. Since Kanner (1943) initially described the disorder over 60 years ago, the definition of the autistic spectrum has evolved and now encompasses a wide range of severity of social and emotional abnormalities with varying levels of cognitive and linguistic functioning. The disorder ranges from low functioning with mental retardation [low-functioning autism (LFA)] to high functioning with normal intelligence quotient (IQ) [high-functioning autism (HFA)]. Almost simultaneously with Kanner, Asperger (1944) described a group of children with a narrow range of interests and impaired social interaction similar to high-functioning autism but whose development of verbal ability was not delayed. The distinction of Asperger syndrome (ASP) from high-functioning autism is controversial (Klin et al., 1995; Ozonoff et al., 2000; Howlin, 2003).

The neuropathology of autism has not yet been clearly established. Among the brain regions that have been implicated are the cerebellum, brainstem nuclei, amygdala, hippocampal formation, and various cortical areas. Bauman and Kemper (1985) were the first to observe neuropathology of the amygdala and hippocampus in postmortem cases. They reported abnormally small and densely packed cells, particularly in the medial portion of the amygdala and CA1 and subiculum of the hippocampal formation. However, their findings have not yet been replicated.

Structural magnetic resonance imaging (MRI) studies of the amygdala have provided inconsistent results (for review, see Cody et al., 2002). Some studies have reported decreased volumes (Aylward et al., 1999; Pierce et al., 2001), whereas others have reported increased volumes (Howard et al., 2000; Sparks et al., 2002); still others have found no difference (Haznedar et al., 2000). Abell et al. (1999) used voxel-based morphometry and demonstrated decreased gray matter at anterior levels of the amygdala but increased gray matter through posterior levels. Structural MRI studies of the hippocampus have also provided inconsistent results (for review, see Cody et al., 2002). Some studies have reported decreased volumes of the hippocampus (Aylward et al., 1999), whereas others have reported increased volumes (Sparks et al., 2002), and still others have found no significant differences (Piven et al., 1998; Haznedar et al., 2000; Howard et al., 2000). A number of factors may contribute to the inconsistent findings, including subject diagnostic criteria (e.g., whether study participants with autism or Asperger syndrome were included), exclusionary criteria (e.g., whether study participants with a seizure disorder were included), the age group measured, and the neuroanatomical definition of the amygdala and hippocampus.

Although individuals diagnosed with mental retardation make up ~70% of the population of children on the autistic spectrum (Fombonne, 2003), no MRI study to date has evaluated children with autism and mental retardation separately from those without mental retardation. The two major objectives for this study were: (1) to compare volume measurements of the amygdala and hippocampus in children across the autistic spectrum and (2) to attempt to reconcile contradictory results in previously published MRI studies on the autistic amygdala and hippocampus.


   Materials and Methods
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
A parent or guardian for each study participant gave informed consent and children with typical cognitive development gave their assent to participate in these studies as approved by the Institutional Review Boards of the University of California Davis and Stanford University. Study participants were recruited through local advocacy groups, the Stanford Neuropsychiatry-Pervasive Developmental Disorders Clinic, and the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute Clinic. Ninety-eight male volunteers between the ages of 7.5 and 18.5 participated in this study. All participants were healthy volunteers who met criteria in one of four diagnostic groups: LFA (n = 19), HFA (n = 27), ASP (n = 25), and typically developing controls (CON) (n = 27). Autism is diagnosed in four times as many males as females (Fombonne, 2003
). To eliminate variability in brain measurements attributable to gender, only males were included in this study.

Diagnostic assessments were conducted either at the M.I.N.D. Institute Clinic of the University of California Davis Medical Center or at Stanford University in the Division of Child and Adolescent Psychiatry and Child Development. Clinicians (B.L.G.-J. and L.J.L.) experienced in the diagnosis of autism spectrum disorders were formally trained to administer the Autism Diagnostic Interview-Revised (ADI-R) (Lord et al., 1994) and Autism Diagnostic Observation Schedule-Generic (ADOS-G) (DiLavore et al., 1995; Lord et al., 2000) and obtained reliability with an author of these measures (C. Lord) before beginning this study. The ADI-R is a comprehensive parent interview administered by a trained clinician using a semistructured interview format that probes for symptoms of autism. It is closely linked to the diagnostic criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (American Psychiatric Association, 1994) and relies on cutoff scores for the diagnosis of autism. The ADOS-G is a semistructured interactive assessment conducted with the child during an evaluation for autism spectrum disorders.

An IQ exam was also administered to all participants; the particular test used was based on their verbal ability. Higher-functioning children and typically developing controls were given either the Wechsler Intelligence Scale for Children (Wechsler, 1991) or the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999). Participants who were nonverbal, including all those in the low-functioning autism group, were given the Leiter International Performance Scale-Revised (Roid and Miller, 1997).

Participants who met criteria for autism with a full-scale IQ of >70 were included in the high-functioning autism group. Participants with a diagnosis of autism and a full-scale IQ of <70 were included in the low-functioning autism group. A diagnosis of Asperger syndrome was given to study participants who met the criteria for high-functioning autism, as determined by the ADOS-G, met DSM-IV criteria for Asperger syndrome, and had developed phrase language before 36 months of age. A more detailed description of the clinical protocol used in this study has been published previously (Lotspeich et al., 2004).

Typically developing control participants had a full-scale IQ of >70 and did not have a family member with an autism spectrum disorder. Participants were excluded from the study if they had a diagnosis of fragile X, seizure disorder, tuberous sclerosis, obsessive-compulsive disorder, bipolar disorder, or any other major neurological illness. All volunteers with an IQ of <70 who had not been tested previously for fragile X were tested before MRI (Kimball Genetics, Denver, CO); none of the participants in the study tested positively for fragile X.

Neuroimaging
After completion of the diagnostic process, MRI scans were performed at one of three possible sites: University of California Davis Hospital (using a 1.5 T GE Signa Horizon system; GE Healthcare, Waukesha, WI), the University of California Davis Imaging Research Center (using a 1.5 T GE Signa NV/I system; GE Healthcare), or the Richard M. Lucas Center for Magnetic Resonance Spectroscopy and Imaging at Stanford University (using a 3 T GE Signa VH/I system; GE Healthcare).

Because volume measurement accuracy is related to the linearity of magnetic field gradients in each of the MRI systems, an intersite comparison and calibration were conducted before imaging study participants. Images were collected from three healthy adult volunteers (one male and two females) at each of the three MRI sites for in vivo validation of volume measurement accuracy. Images were acquired with the same pulse sequence and analyzed at the Stanford Psychiatry Neuroimaging Laboratory using BrainImage 5.x software (developed by A. L. Reiss in 2002). Total brain and segmented tissue volumes were compared between the three systems. The percentage difference between MRI systems for each participant was averaged across participants to arrive at a mean percentage difference for each volumetric measure. The a priori requirement for combining volume measurements across sites was a difference of no more than 5%. A 1.2% difference for total cerebral tissue and a 1.8% difference for cerebral gray matter were found. Lotspeich et al. (2004) have presented a more detailed description of site comparisons.

The protocol for scanning each participant included a three-dimensional coronal spoiled gradient recalled echo (SPGR) series (repetition time, 35 msec; echo time, 6 msec; field of view, 24 cm; matrix, 256 x 256; section thickness, 1.5 mm; number of slices, 124; total scan time, 14 min and 24 sec) that was used for the volumetric assessment of the amygdala. In addition, a two-dimensional (2D) sagittal T1 spin echo, a 2D proton density/T2 interleaved double echo, and a diffusion tensor sequence were collected on all participants for other analyses.

A parent or guardian for each participant signed consent before the child entered the MRI scanner and was present throughout the duration of the scan in an adjacent waiting room. Those study participants requiring anesthesia (isoflurane) to undergo MRI (19 LFA, 13 HFA, and 7 ASP) were imaged at University of California Davis Hospital. All remaining participants were scanned at either the University of California Davis Research Imaging Center (6 HFA, 9 ASP, and 18 CON) or at Stanford University (8 HFA, 9 ASP, and 9 CON). After reviewing the images, 13 participants were excluded from the study (1 LFA, 6 HFA, 1 ASP, and 5 CON) because of excessive movement, distorted images resulting from orthodontics, or additional diagnostic information that precluded the series from being used. Within each diagnostic group, excluded participants did not differ from included participants with respect to age, IQ, or symptom severity.

Volumetric analysis of the amygdala
After completion of the MRI acquisition, all images were transferred to the University of California Davis for volumetric analysis of the amygdala and cerebrum. Each coronal SPGR series was imported into Analyze 5.0 (Biomedical Imaging Resource, Rochester, MN) (Robb et al., 1989
) and converted to cubic voxel dimensions of 0.469 mm using a cubic spline interpolation algorithm. Images were reoriented so that the horizontal axis was parallel to a line from the rostral to the caudal pole of the hippocampus (Fig. 1b). Coronal sections were viewed perpendicular to the horizontal axis (Fig. 1d).



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Figure 1. Orthogonal views for segmenting the amygdala and hippocampus on MRI sections. A three-dimensional reconstruction of images (a) in which lines indicate the position of the horizontal plane (b), sagittal plane (c), and coronal plane (d) is shown. The arrow in b indicates the best-fit line along the white matter separating the amygdala from the putamen; the arrow in c represents the white matter that forms the ventral border of the rostral amygdala. A, Amygdala; EC, entorhinal cortex; H, hippocampus; PU, putamen; TLV, temporal horn of the lateral ventricle; WM, subamygdaloid white matter.

 
On each coronal image that contained the amygdala, the amygdala was manually outlined based on a detailed set of tracing guidelines. These guidelines were developed by first studying the anatomy of the human amygdala and surrounding structures in histological sections cut perpendicular to the horizontal axis of the hippocampus. Two raters (C.M.S. and J.H.) who were blind to subject identity manually traced the amygdala after establishing reliability on MRI scans from 30 subjects with an inter-rater reliability correlation of 0.92 for the left amygdala and 0.93 for the right amygdala. Each rater obtained an intrarater reliability of >0.95.

The initial tracing process involved defining the borders in coronal sections starting with the most caudal level in which the amygdala was visible. Outlines were also checked in horizontal (axial) and sagittal views (Fig. 1) that were simultaneously available to the rater while tracing the amygdala. The following guidelines detail the procedures used for systematic outlining of the amygdala.

Caudal third of the amygdala. At its caudal extent (Fig. 2a), the amygdala is bordered dorsally by the substantia innominata, laterally by the putamen, and ventrally by the temporal horn of the lateral ventricle. The medial surface of the amygdala abuts the optic tract. The outline (Fig. 2a) at this level started at the dorsolateral extent of the optic tract and extended laterally to the junction of the amygdala and putamen. The outline continued ventrally along the lateral border of the amygdala until the lateral ventricle was reached. The outline was then extended medially along the dorsal surface of the ventricle to the ventrolateral extent of the optic tract and completed along the optic tract to the starting point. The lateral border of the amygdala with the putamen is not always clear in the coronal views. Therefore, the border was first drawn in the coronal views and further edited in the horizontal view during the revision process (see below) (Fig. 1b).



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Figure 2. Series of coronal images arranged from caudal (a) to rostral (f), indicating boundaries of the amygdala. A, Amygdala; AC, anterior commissure; H, hippocampus; EC, entorhinal cortex; EXC, external capsule; MS, medial surface of the brain; OT, optic tract; PU, putamen; SAS, semiannular sulcus; SI, substantia innominata; VC, ventral claustrum; WM, subamygdaloid white matter.

 
Proceeding rostrally, the amygdala increases in size (
Fig. 2b). It is bordered dorsally by the substantia innominata and fibers of the anterior commissure. The lateral border is formed by white matter of the temporal lobe. The ventral surface is formed by the temporal horn of the lateral ventricle. However, because the hippocampus often appears to be fused with the ventral surface of the amygdala, a more reliable boundary is the alveus, the white matter that forms the dorsal surface of the hippocampus. The amygdala forms part of the medial surface of the brain.

The starting point of the outline at this level is the dorsomedial extent of the amygdala. If the medial extent of the optic tract extends more laterally than the medial surface of the brain formed by the temporal lobe, then this remains the starting point as described for the caudal section. However, if the surface of the brain extends farther laterally than the optic tract, then the starting point becomes the dorsolateral extent of the medial surface. The outline of the amygdala then extends from this point laterally until it meets the fibers of the anterior commissure. The outline follows the white matter along the lateral surface of the amygdala to the ventricle (or dorsal surface of the hippocampus) and is then drawn medially along the alveus to the medial surface of the brain. The outline was completed along the medial surface of the amygdala.

Midrostrocaudal third of the amygdala. At midrostrocaudal levels (Fig. 2c), the amygdala is outlined in much the same way as just described. In more rostral sections (Fig. 2d), the hippocampus decreases in size and the entorhinal cortex begins to form part of the medial surface of the amygdala. At this point, a thin band of white matter separates the amygdala from the entorhinal cortex.

Outlining at this level was initiated at the dorsolateral extent of the medial surface of the brain and continued laterally to the white matter of the temporal lobe. The outline then follows the white matter along the lateral surface of the amygdala until it reaches the ventricle (or dorsal surface of the hippocampus). The outline continues medially along the alveus of the hippocampus to the white matter tract that separates the amygdala from the entorhinal cortex. The outline then follows the white matter tract to a point on the medial surface of the brain that coincides with the semiannular sulcus. The outline is then completed along the medial surface of the amygdala.

Rostral third of the amygdala. In rostral sections (Fig. 2e), the dorsomedial surface of the amygdala forms a portion of the medial surface of the brain. The amygdala is bordered laterally by white matter of the temporal lobe, ventrally by the temporal horn of the lateral ventricle and by subamygdaloid white matter, and ventromedially by the entorhinal cortex. The outline begins at the semiannular sulcus on the medial surface of the brain and continues laterally along the dorsal surface of the amygdala. It is then extended ventrally along the white matter that lines the lateral surface of the amygdala to the ventricle. The outline is then drawn medially along the white matter that forms the ventral surface of the amygdala and dorsomedially along the white matter that separates the amygdala from the entorhinal cortex until the semiannular sulcus is reached. However, the white matter that separates the amygdala from the entorhinal cortex is not always clear. In this case, a diagonal line is drawn from the most medial point of the subamygdaloid white matter that is visible to the semiannular sulcus.

At the rostral pole of the amygdala (Fig. 2f), the outlining rules are very similar to what has just been described above. However, the gray-matter-white-matter boundaries are more difficult to delineate. Therefore, it was necessary to confirm the rostral boundary of the amygdala by reviewing the outlines in sagittal images (see below) (Fig. 1c).

Editing the amygdala in horizontal and sagittal views. The outline was then reviewed systematically in the horizontal and sagittal planes (Fig. 1b,c, arrows). Two areas consistently needed revision. These included (1) the dorsolateral border of the amygdala with the putamen and (2) the rostral extent of the amygdala. The horizontal plane provided a more reliable view of the border between the amygdala and putamen. In cases in which the putamen had been included in the original outline of the amygdala, the boundary between the structures was straightened by providing a best-fit line along the white matter separating the amygdala from the putamen (Fig. 1b, arrows). This line was determined by connecting the white-matter tracts on the medial and lateral portions of the rostral pole of the putamen.

As noted above, the rostral pole of the amygdala was also difficult to define in coronal sections. Thus, the rostral border was reviewed in sagittally oriented sections. The white matter that forms the ventral border of the rostral amygdala (Fig. 1c, arrows) can be followed dorsally around the rostral limit of the amygdala and was used to correct the rostral border of the amygdaloid complex.

Finally, we again reviewed the amygdala in coronal sections to ensure that the outlines had not been erroneously altered. Once the outlines were completed, we used Analyze software to calculate the volume of the left and right amygdala.

Volumetric analysis of the hippocampus
After measurement of the amygdala, the hippocampus was outlined manually on each coronal image in which it was present based on a detailed set of tracing guidelines (see below). Before outlining the hippocampus, the z-axis for each set of images was converted to 0.938 mm slice thickness to reduce the number of images in which the hippocampus was defined.

In previous experimental studies from our laboratory, the hippocampal formation has included the dentate gyrus, the CA fields of the hippocampus, the subiculum, presubiculum, and parasubiculum, and the entorhinal cortex (Amaral, 1994). For the current study, the entorhinal cortex was not included in volume measurements, and the remaining regions (i.e., dentate gyrus, CA fields, subiculum, presubiculum, and parasubiculum) of the hippocampal formation will be referred to as the hippocampus. The fornix, fimbria, and alveus were not included in the volumetric measurements.

Two raters (C.M.S. and J.H.) who were blind to subject diagnosis manually traced the hippocampus after establishing reliability of tracing methods on MRI scans from 30 subjects with an inter-rater correlation of 0.96 for the left hippocampus and 0.97 for the right hippocampus. Each rater obtained an intrarater reliability of >0.96.

The hippocampus was initially defined in coronal sections starting with the most caudal level in which it was visible (Fig. 3). Outlines were reviewed in the horizontal and sagittal views (Fig. 1) that were simultaneously available while tracing the hippocampus. The following guidelines detail the procedures used for systematically outlining the hippocampus.



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Figure 3. Series of coronal images arranged from caudal (a) to rostral (f), indicating boundaries of the hippocampus. A, amygdala; EC, entorhinal cortex; F, fornix; H, hippocampus; LV, Lateral ventricle; MS, medial surface of the brain; RSC, retrosplenial cortex; SAS, semiannular sulcus; T, pulvinar of the thalamus; TLV, temporal horn of the lateral ventricle.

 
Caudal third of the hippocampus. At its caudal extent (
Fig. 3a), the hippocampus has a dorsoventral orientation and is primarily encapsulated by white matter. The retrosplenial cortex appears along the medial surface of the hippocampus and is separated from it by a thin band of white matter. The dorsal border is also formed by white matter. The hippocampus is bordered laterally by the fornix. White matter of the temporal lobe forms the ventral surface of the hippocampus. The outline at this level (Fig. 3a) started at the dorsomedial extent of the hippocampus and extended laterally to the white matter of the fornix. It extended ventrally from the fornix along the lateral surface of the hippocampus to subhippocampal white matter. The outline continued along the subhippocampal white matter to the starting point.

Proceeding rostrally (Fig. 3b), the dorsomedial extent of the hippocampus forms a portion of the medial surface of the brain. The pulvinar of the thalamus also appears along the dorsomedial surface. The ventral surface of the thalamus is separated from the dorsal surface of the hippocampus by CSF on the medial surface of the brain. The dorsolateral surface of the hippocampus is formed by the fornix. The lateral border is formed by the temporal horn of the lateral ventricle. The ventral surface of the hippocampus is formed by white matter of the temporal lobe. The outline at this level (Fig. 3b) began at the medial extent of the hippocampus, which is ventral to the thalamus. It was extended laterally along the dorsal surface of the hippocampus until it reached the fornix. The outline continued ventrally along the temporal horn of the lateral ventricle to the subhippocampal white matter and continued medially along the white matter to the starting point.

Midrostrocaudal third of the hippocampus. In the body of the hippocampus (Fig. 3c), the medial surface of the hippocampus forms the medial surface of the brain. At this level, white matter (the alveus) makes up the dorsal surface of the hippocampus. A small section of the temporal horn of the lateral ventricle may be visible along the dorsolateral surface of the hippocampus. The ventral border is formed by subhippocampal white matter. The starting point of the outline at this level (Fig. 3c) is the medial extent of the hippocampus on the medial surface of the brain. The outline was drawn laterally along the dorsal surface of the hippocampus, ventral to the alveus, to the temporal horn of the lateral ventricle. The outline continued ventrally and then medially along the white matter of the temporal lobe to the starting point.

Proceeding rostrally (Fig. 3d), the hippocampus is outlined in much the same way as just described. The starting point for the outline at this level (Fig. 3d) was the medial surface of the hippocampus. The outline was drawn dorsally along the medial surface of the hippocampus to the alveus. The outline continued laterally along the dorsal surface of the hippocampus until it reached either the temporal horn of the lateral ventricle or the white matter of the temporal lobe. The outline was then drawn ventrally along the lateral ventricle or temporal lobe white matter to the subhippocampal white matter. It was completed medially along the white matter to the medial surface of the brain.

Rostral third of the hippocampus. In rostral sections (Fig. 3e), the hippocampus forms part of the medial surface of the brain and is limited dorsally by the alveus, laterally by the temporal horn of the lateral ventricle, and ventrally by white matter of the temporal lobe. The outline (Fig. 3e) was started at the medial surface of the brain and extended laterally along the alveus to the temporal horn of the lateral ventricle. The outline was continued ventrally along the lateral ventricle to the subhippocampal white matter. The outline was completed by tracing medially along the subhippocampal white matter to the medial surface of the brain.

At its rostral extent (Fig. 3f), the hippocampus decreases in size and is mainly subiculum. The entorhinal cortex begins to form part of the medial surface of the hippocampus. The two structures are separated by a band of fibers extending from the subhippocampal white matter to the semiannular sulcus on the medial surface of the brain. The dorsal surface of the hippocampus often appears to be fused with the ventral surface of the amygdala at this level, but the two structures are separated by the alveus or by a thin portion of the lateral ventricle. The hippocampus continues to be bordered laterally by the temporal horn of the lateral ventricle and ventrally by white matter of the temporal lobe. The outline (Fig. 3f) began at the dorsomedial extent of the hippocampus. This point is found at the junction of the alveus and the band of fibers extending from the subhippocampal white matter toward the semiannular sulcus. From this point, the outline continued laterally along the alveus, then ventrally along the temporal horn of the lateral ventricle, until the subhippocampal white matter was reached. The outline was completed medially along the white matter, which separates the hippocampus from the entorhinal cortex, to the starting point. Once the outlines were completed, we used the Analyze software package to calculate the volumes of the left and right hippocampus.

Total cerebral volume measurement
To obtain a measure of total cerebral volume, each series of images was edited manually to remove nonbrain structures, the brainstem, and the cerebellum. Using a Gaussian cluster multispectral thresholding tool, the ventricles were defined and excluded. The remaining brain tissue was considered to be a measure of total cerebral volume. Two raters established reliability with an inter-rater reliability correlation of 0.96. Total cerebral volume was then measured with Analyze software.

Statistical analyses
Differences between study participant diagnostic groups for age, IQ scores, and unadjusted amygdala, hippocampal, and total cerebral volume were tested by ANOVA using Statistical Program for the Social Sciences Edition 12.0 statistical software (SPSS, Chicago, IL). Post hoc comparisons were performed using a Tukey test to identify differences between groups. Using an ANCOVA, a comparison was performed to explore effects of amygdala and hippocampal volume after adjusting for covariates such as MRI site (University of California Davis vs Stanford University), total cerebral volume, and age. In a separate analysis, performance IQ was used as a covariate for analyzing the HFA, ASP, and CON groups. The LFA group was not included in this analysis, because performance IQ was not acquired. Full-scale IQ was not used as a covariate because (1) a score of <70 is inherently part of the diagnosis for LFA and (2) it includes a verbal IQ score and verbal ability is taken into account when distinguishing HFA from ASP. A Pearson correlation was performed to detect a potential relationship of amygdala and hippocampal volume to the age of the participant at the time of MRI.


   Results
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Age and IQ measures: all subjects
Participant demographic information was analyzed for the four clinically defined diagnostic groups (
Table 1). There was no difference in the age of the groups at the time of MRI acquisition. However, there was a significant group effect for full-scale IQ (F = 58.7; p < 0.01). As would be expected, post hoc tests found that the full-scale IQ for LFA was lower than all other groups (p < 0.01). The full-scale IQ for HFA was lower than for ASP (p < 0.05) and for CON (p < 0.01). There was no difference in full-scale IQ between the ASP and CON groups.


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Table 1. Mean diagnostic data for all male participants 7.5-18.5 years of age

 
We found a significant group effect (F = 14.1; p < 0.01) when verbal IQ was evaluated in the HFA, ASP, and CON groups. Verbal IQ was lower in the HFA group than in the ASP and CON groups (p < 0.01). There was no difference in verbal IQ between ASP and CON. There was a trend for a group effect for performance IQ (F = 2.8; p = 0.06).

Volumetric measures: all subjects
Mean volumetric data for all participants are given in
Table 2. There was no difference across diagnostic groups in terms of total cerebral volume (Fig. 4). However, there was a significant main group effect for absolute right (F = 3.8; p < 0.05) amygdala volume. Post hoc tests indicated that the LFA group had a larger right amygdala volume than the CON group (p < 0.05). There was also a significant main group effect for absolute right (F = 5.4; p < 0.01) and left (F = 3.5; p < 0.05) hippocampal volume (Fig. 5). Post hoc tests indicated that the LFA group had a larger right hippocampal volume than CON subjects (p < 0.01). There was a trend for the left hippocampus to be larger in the LFA group than in the CON group (p = 0.06). HFA subjects had larger right and left hippocampal volumes than the CON groups (p < 0.05). When MRI site (i.e., University of California Davis vs Stanford University) was considered as a covariate for analyzing amygdala or hippocampal volumes, no diagnostic group-by-site interactions were found. Therefore, the MRI site was not included as a covariate in additional analyses. When total cerebral volume was included as a covariate, there was no diagnostic group-by-total cerebral volume interaction, and the volume of the right amygdala remained significantly larger in the LFA group versus the CON group (p < 0.05). Right hippocampal volume also remained significantly larger in the HFA and LFA groups than in the CON group (p < 0.05). When performance IQ was considered as a covariate, the right hippocampus remained significantly larger in the HFA group compared with the CON group (p < 0.05).


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Table 2. Mean volumetric (cm3 SD) data for all male participants 7.5-18.5 years of age

 



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Figure 4. Total cerebral volume (in cubic centimeters) for subjects 7.5-18.5 years of age by diagnostic group.

 



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Figure 5. Absolute left (a) and right (b) hippocampal volume (in cubic centimeters) by diagnostic group for subjects 7.5-18.5 years of age (*p < 0.05; **p < 0.01).

 
Age was considered as a covariate to determine whether the volume of the amygdala or hippocampus was associated with the age of the participant. There was a significant diagnosis-by-age interaction for right (p < 0.05) and left (p < 0.01) amygdala volume (LFA: right, r = -0.00, left, r = 0.40; HFA: right, r = 0.23, left, r = 0.26; ASP: right, r = 0.16, left, r = 0.24; CON: right, r = -0.09, left, r = -0.07) but not for the hippocampus. Correlation analyses for age and amygdala volume were also performed for each diagnostic group (
Fig. 6). Age did not correlate with right or left amygdala volume in the LFA (right, r = 0.14; left, r = 0.21), HFA (right, r = -0.21; left, r = -0.32), or ASP (right, r = 0.32; left, r = 0.20) groups. However, in the CON group, age significantly correlated with right (r = 0.67; p < 0.05) and left (r = 0.77; p < 0.05) amygdala volume.



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Figure 6. Linear regression scatterplot for absolute amygdala volume (in cubic centimeters) by age. Typically developing subjects show a positive correlation (*p < 0.05) of age with amygdala volume for both the left amygdala [a; CON, r2 = 0.59] and right amygdala [b; CON, r2 = 0.45]. Amygdala volume in participants with autism was not correlated with age. c, Left amygdala: LFA, r2 = 0.05; HFA, r2 = 0.10; ASP, r2 = 0.04. d, Right amygdala: LFA, r2 = 0.02; HFA, r2 = 0.05; ASP, r2 = 0.10.

 
Given the observation that the volume of the amygdala appears to be increasing with age from 7.5 to 18.5 years in typically developing children, we performed additional analyses of the amygdala by dividing the study groups into two age ranges: 7.5-12.5 years of age and 12.75-18.5 years of age (see below). When the control group is broken up into participants in these two age ranges, the volume of the right and left amygdala in the older group is significantly greater than in the younger group (right: younger mean SD, 1.81 0.18 cm3, older mean SD, 2.10 0.22 cm3, F = 11.8, p < 0.01; left: younger mean SD, 1.77 0.18 cm3, older mean SD, 2.11 0.25 cm3, F = 13.6, p < 0.01). In no other group was this difference significant. For total cerebral volume, the older control group is significantly smaller than the younger control group (younger mean SD, 1231 78 cm3; older mean SD, 1150 99 cm3; F = 7.9; p < 0.05). There was no difference in total cerebral volume between the younger and older children with autism or Asperger syndrome.

Analyses of 7.5- to 12.5-year-old subjects
Amygdala and cerebral mean volumetric data for male participants in the 7.5- to 12.5-year-old age range are given in
Table 3. When only subjects in this age range were considered, there was a main group effect for the volume of the right amygdala (F = 10.8; p < 0.01) and for the volume of the left amygdala (F = 6.4; p < 0.01). Post hoc tests indicated that the volumes of the right amygdala in the LFA and HFA groups were significantly larger than in the CON group (p < 0.01) (Fig. 7). There was also a trend for the volume of the right amygdala to be larger in the ASP group relative to the CON group (p = 0.06). The volume of the left amygdala in the LFA and HFA groups was larger than in the CON group (p < 0.05 and p < 0.01, respectively).


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Table 3. Amygdala and cerebral mean volumetric (cm3 SD) data for male participants 7.5-12.5 years of age

 



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Figure 7. Absolute left (a) and right (b) amygdala volume (in cubic centimeters) by diagnostic group for subjects 7.5-12.5 years of age (*p < 0.05; **p < 0.01).

 
There was no significant main effect for total cerebral volume in the 7.5-12.5 age range (
Fig. 4). It is interesting to note, however, that for LFA, the estimates of total cerebral volume seemed to partition the group into those whose brains were approximately similar in volume to the controls and a group with brain volumes that were larger and outside of the range of typically developing children. When total cerebral volume was included as a covariate, LFA and HFA right amygdala volume remained significantly different from CON (p < 0.01). For the left amygdala volume, both the LFA group and the HFA group also remained significantly different from the CON group (p < 0.05). Covarying the performance IQ with amygdala volume produced the same pattern of results.

Analysis of 12.75- to 18.5-year-old subjects
Amygdala and cerebral mean volumetric data for male participants in the 12.75- to 18.5-year-old age range are given in
Table 4. When this older subject group was analyzed, there was no main group effect for right or left amygdala volume (Fig. 8) or total cerebral volume (Fig. 4). There were no significant group differences even when total cerebral volume or performance IQ was included as a covariate.


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Table 4. Amygdala and cerebral mean volumetric cm3 SD) data for male participants 12.75-18.5 years of age

 



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Figure 8. Absolute left (a) and right (b) amygdala volume (in cubic centimeters) by diagnostic group for subjects 12.75-18.5 years of age.

 

   Discussion
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
We used structural MRI to analyze the volume of the amygdala, hippocampus, and total cerebrum in male children 7.5-18.5 years of age. There were four subgroups: children with autism and with mental retardation, children with autism without mental retardation, children with Asperger syndrome, and typically developing controls.

The amygdala in autism
One striking finding was that the amygdala in typically developing children increased in size from ~1.7 cm3 at age 8 to ~2.3 cm3 at age 18, representing a nearly 40% increase over this age range. This growth occurred in the context of a slight decrease in overall cerebral volume. Our cross-sectional findings closely replicate structural MRI results from Giedd (1997
) and Giedd et al. (1996), who reported that the amygdala increases in volume by 50% in typically developing males (but not females) from 4 to 18 years of age with little change in overall cerebral volume.

In our clinical populations, we found that younger children with autism plus mental retardation had a 16% larger right amygdala and a 13% larger left amygdala than typically developing controls. Younger children with autism but without mental retardation also had a 17% larger right and left amygdala than controls. These findings indicate not only that the amygdala in autism is initially larger than typically developing controls but also that the increase is related to autism rather than mental retardation. An enlarged amygdala in autism is not paralleled by an overall enlarged brain, because there were no group differences in cerebral volume.

Our results extend previous findings by Sparks et al. (2002) pertaining to children 3-4 years of age. The amygdala in male children with an autism spectrum disorder was 14% larger on the left and 22% larger on the right than in typically developing children of the same age, and the right amygdala remained significantly different when corrected for total cerebral volume.

In our older group of children with autism, there was no difference in either amygdala or cerebral volume. Thus, it appears that the amygdala in children with autism is initially larger than normal but does not undergo the age-related increase in volume that takes place in typically developing children. These findings help explain variability in previous structural MRI studies of autism. Studies that focus on young children (Sparks et al., 2002) have found that the amygdala is larger in autism. However, studies on adults or on a wide age range find that the autistic amygdala is no different (Haznedar et al., 2000) or even possibly smaller (Aylward et al., 1999; Pierce et al., 2001) than controls. These data are entirely consistent with the results of the present study.

Our data also indicate that the magnitude of amygdala enlargement relates to the clinical diagnosis. We found that young children with autism on average have a 16% larger amygdala than controls, whereas young children with Asperger syndrome have a 9% larger amygdala than controls. The hypothesis that abnormal amygdala volume may be more pronounced in autism relative to other diagnoses on the autistic spectrum is again consistent with the findings of Sparks et al. (2002). They found that when the autism spectrum group was differentiated into autism and pervasive developmental disorder-not otherwise specified (PDD-NOS), the children with autism had an even larger amygdala than those with PDD-NOS. In children with an autism diagnosis, the amygdala was 14% larger on the right and 12% larger on the left compared with children with a PDD-NOS diagnosis.

We found that the amygdala of older children with autism is approximately the same size as older typically developing children. However, the amygdala of children with autism reaches adult size before adolescence, whereas typically developing children undergo a progressive growth of the amygdala through adolescence. We would predict that although the amygdala is of equal size, fundamental aspects of its neuroanatomical or functional organization are different in children with autism compared with typically developing controls. Many factors contribute to brain volume, including number and size of neurons and glial cells, number and collateralization of afferent and efferent fibers, myelination, and even the density of vasculature. These factors are affected by various influences, including genetics, growth factors, hormones, nutrients, and environmental stimulation of the developing nervous system (for review, see McAllister, 2000). Although Bauman and Kemper (1985) observed increased packing density of neurons in the amygdala, there have been no quantitative studies published to date that provide accurate estimates of the number of neurons in the normal and autistic amygdala. Thus, the cause of the enlarged amygdala in autism is currently unknown.

If the amygdala does develop abnormally in autism, what behavioral symptoms might be expected? The amygdala has been implicated in the mediation of social behavior (Brothers et al., 1990) and many other cognitive processes in humans. These include face processing (Grelotti et al., 2002; Haxby et al., 2002), recognition of emotions (Adolphs, 2002; Adolphs et al., 2003), enhancement of memory for emotionally significant events (Cahill et al., 1995; Canli et al., 2000), and predicting reward values (Gottfried et al., 2003). This has lead some to suggest that the amygdala might be the primary structure responsible for the social impairments in autism (Baron-Cohen et al., 2000). However, studies of human and nonhuman primates with amygdala lesions argue against this conclusion (Amaral et al., 2003). Human patients with Urbach-Wiethe, a disease that results in destruction of the amygdala, do not display core autistic symptomotology. In addition, nonhuman primates that sustained amygdala damage early in development are able to produce species-typical social behaviors (Prather et al., 2001). The view from our animal studies, which is consistent with human lesion studies, is that dysfunction of the amygdala is not responsible for the core social deficits of autism.

There is an abundance of evidence from animal (LeDoux, 2000; Davis et al., 2003) and human (Adolphs et al., 1994, 1995; Buchel and Dolan, 2000) studies to implicate the amygdala in the detection of danger and the production of fear and anxiety. In fact, children with generalized anxiety disorder have a 16% larger right amygdala than typically developing controls (De Bellis et al., 2000). The presence of anxiety has been noted in descriptions of autism (Wing and Gould, 1979; American Psychiatric Association, 1994), and recent studies suggest that anxiety is a common feature of the autism spectrum disorders (Muris et al., 1998). Abnormal processing of fear during development may contribute to behavioral symptoms seen in autism. The role of the amygdala in processing stimuli related to potential threat may extend to complex judgments on whether to approach or trust other people, a function in which both human patients with amygdala lesions and individuals with autism are impaired (Adolphs et al., 1998, 2001).

The hippocampus in autism
We found that male children with low-functioning autism have a 12% larger right hippocampus and a 9% larger left hippocampus relative to age- and sex-matched typically developing children. Male children with high-functioning autism have a 10% larger right and left hippocampus than typically developing controls. Consistent with Giedd (1997
) and Giedd et al. (1996), we also found that the hippocampus does not increase in size through adolescence in typically developing controls or in children on the autistic spectrum.

There have been relatively few studies of autism to date that have published volumetric analyses of the hippocampal formation. In general, studies focusing primarily on adults have found no difference in hippocampal volume between autism and control subjects (Piven et al., 1998; Haznedar et al., 2000; Howard et al., 2000). One exception is Aylward et al. (1999), who reported a decrease in hippocampal volume in adolescents and adults with autism after controlling for total cerebral volume. Saitoh et al. (2001) measured the cross-sectional area of the dentate gyrus and CA4 in three contiguous 5 mm sections and found that it was smaller than normal in children and adults with autism, with the most significant difference in subjects 2-4 years of age.

Sparks et al. (2002) have published the only study of hippocampal volume that focused on young children. They found that the right and left hippocampus of their cohort of male children 3 and 4 years of age with an autism spectrum disorder was 9% larger than typically developing controls. Our results extend these findings through late childhood and adolescence.

An enlarged hippocampal formation in autism may be a precursor to, or a consequence of, autistic symptomotology. The increased size could result from pathological development or experience-dependent increase of function. The smaller size and increased packing density of neurons reported by Bauman and Kemper (1994) suggest that development of the autistic hippocampal formation has been disrupted, perhaps because of reduced programmed cell death. This could be confirmed by using stereological techniques to count the total number of neurons in the postmortem autistic hippocampus. Another possibility is that the increased size of the hippocampus indicates a use-dependent expansion of hippocampal connections. There is substantial evidence in the animal literature that the volume of the hippocampus is correlated with spatial memory function. Species that develop complex spatial maps, such as food-caching birds, have larger hippocampi than members of the same species who do not engage in food caching (Clayton and Krebs, 1994). Similar data have been demonstrated for London taxi-cab drivers who must memorize the complex roadway system of the city (Maguire et al., 2000, 2003). If the larger size of the autistic hippocampal formation was evidence of use-dependent enlargement, one might expect enhanced spatial or episodic memory function in autism. This possibility has not yet been fully explored, but there is some evidence that this might be the case.

Several studies have shown that declarative memory function is fairly normal in higher-functioning autistic subjects (Ameli et al., 1988; Rumsey and Hamburger, 1988; Bennetto et al., 1996; Minshew and Goldstein, 2001). Dawson et al. (1998) have studied visual object recognition in children with autism using "delayed nonmatching to sample" (DNMS) and found that the children with autism were impaired on DNMS. Recently, however, Dawson et al. (2001) performed a "paired comparison task" study to selectively test object recognition without requiring the child to form a stimulus-reward association (Diamond, 1995) and found that children with autism were not impaired.

In contrast to the notion that autism may be associated with impaired hippocampal memory function, Kanner (1943) originally described children with autism as having an extraordinary ability to learn geography and recite long lists of items or facts. Recently, Caron et al. (2004) found that individuals with autism are not only equally capable of learning a route on a map but are superior to typically developing controls on the speed and accuracy at which they memorize and reproduce the map. These studies support the hypothesis that an abnormally large hippocampus in autism may result from or yield enhanced function. This hypothesis is in need of comprehensive assessment.

Conclusions
The present study provides additional evidence that the amygdala and hippocampus are structurally abnormal in autism. It will be of interest to determine whether an enlarged amygdala and hippocampus are characteristic of all children with autism or distinguish a particular phenotype. Understanding the genesis and functional implications of an early enlargement may be amenable to molecular neurobiological approaches using animal models. The consequences of an abnormal amygdala and hippocampus in autism, and how these might be effectively treated, will be elucidated by both animal and human studies on the normal function of these structures.


   Footnotes
 
Received April 6, 2004; revised May 24, 2004; accepted May 29, 2004.

This work was supported by National Institutes of Health Grants MH41479, MH01832, MH01142, MH50047, NS16980, and HD31715 and by the M.I.N.D. Institute. We thank Meridith Brandt for participant recruitment and scheduling at University of California Davis and John Ryan for assistance in carrying out MRI acquisition. We also thank the study participants and their families for their contribution.

Correspondence should be addressed to Dr. David G. Amaral, University of California Davis, M.I.N.D. Institute, 2825 50th Street, Sacramento, CA 95817. E-mail: dgamaral@ucdavis.edu .

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The Analysis of Autism Facilitates Neuroanatomical Investigations - Karen Taverna

Studying the functions of the various structures of the brain is best carried out through analysis of brain defects. For example, individuals with autism exhibit particular behaviors that are not considered normal. Assuming that behavior originates from the brain, then it becomes clear that in order to discover the causes of the abnormal behavior a comparison must be made between and healthy brain and the brain of an autistic person. By finding structural differences such as size and composition, the role that the structures play in the behavior of the autistic can be inferred while also investigating the normal functions of brain structures.

There are several differences between a healthy brain and the brain of an autistic person. Dr. Joseph Piven from the University of Iowa noticed a size difference . In the autistic brain, the cerebellum is larger and the corpus callosum is smaller. Another study showed that the amygdala and the hippocampus are different in an autistic brain. In an autistic these structures have densely packed neurons and the neurons are smaller than those in a healthy brain. Also, in the cerebellum there is a noticeable reduction in the number of Purkinje cells.

Structure and function can not be separated from one another and changes in one indicate alterations in the other. Because an autistic person has brain defects, a reasonable assumption is made that changes in structure will alter the behavior. An autistic person is characterized by having impaired social interaction, difficulty with communication both verbal and nonverbal, trouble with imagination, and limited activities and interests. By analyzing the abnormal behaviors of the autistic person, the roles that the cerebellum, the corpus callosum, the amygdala, and the hippocampus play in the disease can be inferred.

The cerebellum is usually associated with motor movements. Concerning this topic it is interesting to note the research of Dr. Eric Courchesne. He found that the VI and VII lobes of the cerebellum were smaller in autistics than those of a normal brain. This condition is called hypoplasia. The reverse condition, which is what Piven encountered, is called hyperplasia. Courchesne linked the cerebellum with attention shifting . He proposed that the autistic takes longer time to change the focus of his attention. He believed that this condition was caused by lack of development of the cerebellum in utero caused by perhaps oxygen deprivation, infection, toxic exposure, or genetically. Normal individuals take a second to shift attention but an autistic person may take up to five seconds.

The other difference found in the cerebellum had to do with a reduction in Purkinje cells. These cells are important because they contain seratonin. Seratonin is a neurotransmitter which is responsible for inhibition. It is proposed that the lack of seratonin can be associated with faulty arousal and abnormal mood regulation . However, there is controversy over this issue and its relevance to autistics. According to Celia M. Bibby, autistic children have abnormally high levels of seratonin not low. In fact, when an autistic eats foods with high levels of seratonin an attack is often triggered. Bibby proposes that this is because seratonin plays a role in conditioned reflexes.

The corpus callosum has smaller middle and back lobes in an autistic individual. The function of the corpus callosum is predominately that of intercommunication within the brain. It allows the front of the brain to communicate to the back. It is intuitive that the difference in size also indicates a difference in connectivity. Piven said, "The expected size relationships of various parts of the brain to one another seems to be disproportionate or distorted in autism...This makes you think that those areas might be disconnected functionally." Any difference in connectivity among the neurons is going to result in a defect in communication within the brain and the processing of both outputs and inputs. This indicates general changes in behavior such as responding to inputs in a usual manner. All aspects of autism are most likely caused directly or indirectly by the decreased connectivity within the corpus callosum because the brain's internal communication is diminished.

Two structures of the limbic system are markedly different in the autistic brain. The first is the amygdala which is generally associated with the regulation of emotions and aggression. When the amygdala is removed from an animal, the behavior of the animal is similar to that of an autistic person. Also, the amygdala is linked with response to sensory stimuli. Bibby expands this statement in her essay with the example of face cells. Face cells are found in the amygdala and also in the superior temporal sulcus. Autistic individuals avoid eye contact. This is linked to face recognition because when forced to maintain eye contact, the autistic begins to act aggressively. Face cells enable humans to identify dangerous situations and then the appropriate signals are sent to various brain structures to cause the appropriate response. In the case of autism, the person begins a fight response. This becomes the conditioned response but the autistic recognizes the negative effects such as a feeling of vulnerability and tries to prevent similar reactions by avoiding eye contact which diminished the development of social skills and language.

The second structure of the limbic system that is abnormal in the autistic brain is the hippocampus. The hippocampus is linked to learning and memory. When the amygdala is removed from an animal the behaviors that are exhibited include failure to learn about dangerous situations, and difficulty retrieving information from memory. These behaviors are associated with the hippocampus so it can be inferred that the two structures are connected. Autistics have difficulty learning and storing new information into memory. When the hippocampus is removed from an animal, it will express a series of behaviors classified as self-stimulatory. These behaviors are repetitive body movements or movements of objects . For example, tapping ears, sniffing people, hand flapping, scratching, or rocking back and forth. Two hypotheses of this behavior have been drawn. Either the actions are to stimulate (hyposensitive) or to calm (hypersensitive). In the case of the autistic person, the second hypothesis makes sense. To the autistic the environment is too stimulating and by doing a repetitive motion the environment can be blocked out. The environment is too stimulating because the brain can not process the sensory inputs as fast as they are being received. New information can not be entered into the memory quick enough.

Brain disorders, such as autism, offer scientists a chance to investigate the brain and its functions. When looking at a healthy brain it is difficult to find which structure is responsible for what behavior but by comparing the normal to the abnormal and looking at the difference in behavior and brain structure many conclusions can be drawn. The previously mentioned structures, the cerebellum, the corpus callosum, the amygdala, and the hippocampus clearly play a role in the abnormal behaviors autistics but there are most likely many other parts of the brain that are effected by the disease also. Autism is clearly not a disease that is caused by a defect in only one section of the brain. Many scientists have accepted the idea that autism is caused by a malfunction in the development of the brain which encompasses many regions. Research is still being done to figure out the cause of autism whether it is genetic, or for example caused by biochemical toxicity trauma. Studying diseases is both necessary for trying to find a cure and also useful for gaining insight into neuroanatomy.

WWW Sources

Bibby, Celia M. Autism: A Conditioned Response to Biochemical Toxicity?

Research Finds Size Differences in the Brains of Autistic Individuals.

Edelson, Stephen M. Ph.D. Autism and the Limbic System, The Cerebellum and Autism, Stereotypic (Self-Stimulatory) Behavior.

National Institute of Neurological Disorders and Stroke.

Source: http://serendip.brynmawr.edu/bb/neuro/neuro98/202s98-paper1/Taverna.html






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