Understanding the Autism Spectrum

1. Understanding the Autism Spectrum Amy Cohen, Ph.D, BCBA Clinical Director Autism Spectrum Program HowardCenter

2. What is Autism? • A neuro-developmental disorder characterized by challenges in: • social interaction • communication • the existence of stereotyped and/or repetitive behavior, interests and activities

3. The Autism Spectrum includes: • Autistic Disorder (“classic” autism) • Asperger syndrome • Pervasive Developmental Disorder Not Otherwise Specified

4. Autistic Disorder: Diagnostic Criteria • Marked social impairment characterized by ( at least 2): • failure to develop peer relationships • lack of spontaneous seeking to share enjoyment, interests, etc. • lack of social or emotional reciprocity • impairment in the use of nonverbal behaviors to regulate social interaction

5. Common Social Characteristics in Children with ASD • limited eye contact • little interest in social interactions • active avoidance of social interactions • poor peer interactions • socially inappropriate responses • poor reading of social cues

6. Autistic Disorder: Diagnostic Criteria • Qualitative impairment in communication characterized by (at least 1): • delay in or lack of development of spoken language • impaired ability to initiate or sustain conversation • stereotyped, repetitive use of language • lack of varied spontaneous make-believe play

7. Language/ Communication Characteristics • maybe non-verbal • may use challenging behaviors to communicate • impaired comprehension of language • echolalic speech is common • use language primarily to make requests • abnormal prosody • immature grammar • difficulty with humor, non-literal language

8. Autistic Disorder: Diagnostic Criteria • Restricted, repetitive and stereotyped patterns of behavior, interests and activities (at least 1): • preoccupation with stereotyped, restricted pattern of interests that is abnormal in intensity or focus • inflexible adherence to routines, rituals • repetitive motor mannerisms • preoccupation with parts of objects

9. Behavioral Characteristics • limited interests • preoccupations • stimulus over-selectivity • repetitive routines/rituals • attachment to selected objects/activities • good rote learners/visual learners • difficulty generalization of skills • attentional challenges: focusing, scanning & sustaining attention

10. Sensory Characteristics • over/under arousal to certain forms of sensory stimulation • self-stimulatory behaviors are common • difficulty modulating sensory input • unpredictable behavior when exposed to varying forms of sensory stimulation • auditory sensitivity is common • delayed processing of sensory information

11. PDD-NOS • pervasive social impairment • either impairment in communication or presence of stereotyped, behaviors interests, activities • used for individuals who do not meet criteria for autism

12. Asperger Syndrome • severe & sustained social impairment • Restricted, repetitive interests and activities • no significant delays or deviance in language development • subtle aspects of communication affected • typically higher cognitive skills

13. Asperger’s Syndrome: Diagnostic Criteria • No general delay in language • No delay in cognitive development or development of self-help skills • No delay in curiosity about the environment during childhood • Impairment in social, occupational, other functioning

14. Common Social Characteristics in Children with AS • socially isolated, not unaware • express interest in social relationships • limited/different use of gesture & facial expression to communicate socially • poor empathy • rely on rigid rules and conventions for social behavior • maybe skilled at identifying/describing emotions • difficulty acting appropriately on emotions

15. Language/ Communication Characteristics-AS • more subtle characteristics of communication may be impaired - abnormal prosody - modulation of rate and volume - immature grammar • difficulty with humor, non-literal language • verbose • tangential, one-sided, ego-centric conversation

16. Common Behavioral Characteristics- AS • frequent, unusual, behavioral expression of stress • difficulty monitoring and controlling expression of excitement • tantrums, neurological storms, rage, meltdowns

17. Motor Functioning • delayed acquisition of motor skills • awkward or poorly coordinated • may have odd gait or posture • impaired manipulation skills • deficits in visual-motor skills

18. Associated Conditions with ASD • learning impairment (mild to profound) • uneven cognitive skills • hyperactivity, impulsivity • aggression, self-injurious behavior, temper tantrums • challenges with motor planning, motor control • seizure disorders (25% of the population) • depression

19. Onset of ASD • By definition, prior to age 3 • generally no period of normal development • noticeable differences in development by age 2 or earlier

20. Prevalence of ASD • 1 in 91 (1 in 58 boys) • fastest growing developmental disability • most common of developmental disability among children in the US • More common among males • 4 males: 1 female • In females, ASD is often associated more severe learning impairment • Increased risk among siblings (~20%)

21. Course of ASD • developmental gains are common • nature of impairment changes • over time • with developmental level • language and IQ are strong prognostic indicators • functional outcomes vary widely- depending on the intensity, quality and response to intervention

22. Change is coming soon… • New DSM-V later this year • Will change PDD to Autism Spectrum Disorder • Proposal to drop subthreshold diagnoses • Rationale for changes: Diagnosing autism has becomes more complicated due to more referrals of: • Toddlers and 2-year olds • Older children without intellectual disabilities • Adolescents and adults with psychiatric comorbidities

23. Goals of the New DSM-V Criteria • Not to change who is included • Make the framework more useful for all ages, developmental levels, both genders and all degrees of severity • Improve differential diagnosis • Allow separate ways of describing behaviors and noting etiology and associated conditions

24. Autism Spectrum Disorder • Must meet criteria A, B, C, and D: • A.    Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1.     Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, 2.     Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3.     Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and  in making friends  to an apparent absence of interest in people

25. Autism Spectrum Disorder • B.    Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of  the following: 1.     Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).  2.     Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3.     Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4.     Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

26. Autism Spectrum Disorder • C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) • D. Symptoms together limit and impair everyday functioning.

27. Autism Spectrum Disorder • Will be severity classifiers (Levels 1-3) based on amount of support required • Requires very substainial support • Requires substantial support • Requires some support