Class 13 (Autism spectrum disorder: Asperger’s, diagnostic precision, and intervention)

What are the basic features of ASD?

• deficits/impairments in social interactions and social communication

• restrictive, repetitive behaviors, interests, or activities (routines, rituals)

Prevalence of ASD has gone up in recent years - why?

• ASD has not had much of a historical record - not a clearly described psychopathology until 20th cen

• prevalence has shifted as we define the diagnosis

Ex. Donald Triplett

• unusual behavior as a child

  • strong rxn when toys out of place

  • indifferent to parental affection

• psychiatrist Kanner had never seen these symptoms before

Kanner 1943 study

• n=11 children

• diagnosed w a range of conditions from deafness to feebleminded to schizophrenia (wide range of symptoms and different developmental timelines)

• all had difficulty relating to other people and a strong preference for ritual and sameness

• was the initial criteria for autism in DSM-3

What was the issue with the criteria from Kanner’s paper?

as time passed, researchers realized there were many ppl who resembled those children but did not qualify for autism diagnosis == “near misses”

What were the new diagnoses added to the DSM-4 to capture “near misses”?

• Asperger’s disorder

• pervasive developmental disorders NOS

• Rett’s disorder

• childhood disintegrative disorder

Asperger’s disorder (one-DSM wonder)

Syndrome characterized by impairments in social interactions, impairments in social communication, and repetitive and stereotyped behavior

In the DSM-4, was Asperger’s distinct enough from autism?

diagnostic criteria for these symptoms were identical to criteria for autistic disorder and there were no clear discrepancies in the criteria for Asperger’s and autistic disorder

What are some elements of Asperger’s highlighted in Tim Page’s memoir?

• could establish no connection with most of his classmates

• awareness of his own strangeness

• bullied by other children

• “unsatisfactory” grade in social development

• dislike being touched, overstimulation

• restricted, repetitive, intense interests

• prefers time alone

• thrives on routine and structure

• difficulty making connections with people

• childhood rages/tantrums

• frequent assessments and evaluations

• could only complete work he was interested in

• difficulty articulating feelings

• noticed “wrong” things on school field trip (e.g. who manufactured the bus, transportation routes)

Why is there a single diagnosis for autism vs Asperger’s?

• No consistent differences between individuals diagnosed with mild autism and those with Asperger’s or other “near miss” diagnoses

• Not uncommon for individuals to change criteria from autistic disorder to Asperger’s to PDD-NOS at different points in life.

• Not uncommon for different practitioners to diagnose same person with different disorders

What was the perspective of clinicians and researchers on putting autism and Asperger’s in the same diagnosis?

Since there were no consistent differences between the two, it made sense to clarify diagnostic system.

• Better inter-rater reliability

• Can determine better access to services in some states

Concerns with the new taxonomy (putting autism and Asperger’s into the same box)

people believed:

• It’s “worse” to have autism than Asperger’s

  • the GP felt that Asperger’s was a more socially acceptable, less severe condition

  • “genius” quality

• Individuals previously diagnosed with Asperger’s would be stigmatized, because autism is perceived as more severe

• Asperger’s is an identity, linked with other individuals such as Einstein who possessed great brilliance and creativity as well as problems

• Fostered mistrust in mental health system

although labels can create stigma, they can also ___

be sources of relief and/or comfort

How do new diagnoses reflect that the ways researchers conceptualize and study autism have changed?

• narrow → wide

  • description of symptoms (e.g. language → communication)

• rare → common

  • ASD is common (possible that it’s being underdiagnosed)

• childhood → lifespan

  • not just a disorder of childhood

• discrete → dimensional

  • characteristics of ASD can and do exist in ppl who are not diagnosed w ASD

• one → many

  • no single way ASD presents

  • no single cause for ASD

copy number variations and ASD

• CNVs are DNA mutations

  • some sections of a chromosome are repeated and others are not included

  • can be inherited or spontaneous (de novo)

• documented in about 30% of cases of ASD

• in families where one child has ASD, only that child shows CNVs

• CNVs associated with autism are in regions of chromosomes that facilitate comm across diff part of brain

  • more CNVs in these regions of chromosomes are associated w more severe symptoms are autism

CNVs and parental age

higher prevalence of autism has been documented in children born to older parents

• age (especially paternal) is assoc. w/ greater likelihood of CNVs

treating autism spectrum disorder

idiographic approach bc of breadth of symptoms and severity across autism spectrum

• variations in symptoms and severity contribute to success in treatment

• only one core approach to treatment with strong empirical support for ASD currently == ABA

Applied behavior analysis (ABA) or early intensive behavioral intervention

• developed by Ivar Lovaas

• begins w intensive relationships and rapport building

• based on operant conditioning (shaping, rewards, punishments)

  • Careful observation of child’s environment to determine what triggers an undesirable behavior, what are effective reinforcers for child, and what makes desirable behavior more likely to occur

  • Removal of triggers, implementation of rewards

two techniques of ABA

1. discrete trial learning

2. incidental learning

Discrete trial learning

breaks down large tasks into lots of small, manageable ones

• “Show me the truck”

• Each completed request is positively rewarded and praised (“Great job! Here is a sticker!”)

• If request is not completed, child is prompted and sometimes guided (e.g., hand is placed on truck)

Incidental learning

Naturalistic, real-world

• Can occur in breaks, when child is not paying attention, outside therapy session, etc.

• for example: child sees something he wants and runs to grab it; therapist or parent says “can I help you get something? What do you want?”

• Goal is for child to answer “ball”

What happens in terms of procedure as ABA treatment progresses?

1:1 therapist sent with child to school to facilitate social interactions, transfer of skills to school setting, etc.

Eventually, small group setting in schools, with parent training in ABA for at home, and 1:1 work as needed

Pivotal response training (PRT)

recent update to ABA

• while therapists guide ABA, child guides PRT

• kids pick activities, topics, and toys for sessions

• instead of rewarding only correct responses, PRT rewards attempts to complete tasks too

• makes in-session rewards match out-of session results

4 pivotal areas

• motivation

• managing emotions

• initiation of speech and activity

• multiple cues (ability to absorb and respond to many diff sources of info)

components of effective treatment of ASD

• Early: Begin intervention as soon as a diagnosis is discussed

• Intensive: active engagement of child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities with specific, individualized goals

• High structure: use of predictable routines, visual activity schedules, clear physical boundaries, minimal distractions

• Family inclusion: parent training in ABA

• Ongoing assessment: monitor child’s progress and update goals

ABA was initially developed for severe autism and preventing self harm behavior (e.g. minimize repetitive scratching, head banging). Does this intervention work for people with mild autism?

ABA draws on basic principles of behavior that are shown to be helpful for change across many diff types of disorders

• targets of intervention vary w severity of symptoms

• tldr: yes

what are the targets of ABA in mild autism?

• how to converse on a variety of topics, even if they aren’t personally interesting;

• how to anticipate what others might expect;

• how to recognize and identify the facial expressions of others;

• how to moderate one’s own facial expression;

• appropriate tone and volume of voice;

• how to handle deviations from routine

the volume thermometer is an example of how to target appropriate tone and volume of voice

• therapist and child role play to determine what volume sounds right

• can emphasize diff volumes of ok for diff circumstances

  • dinner table vs playground

ABA can grow as ppl grow

• As children move into adolescence, they can still participate in ABA

• Adolescents often help determine their own ABA goals

• Social world becomes increasingly salient during adolescence

• Transitions to autonomy and adulthood can be tricky

Should we intervene with ABA at all?

ABA’s goal is to make ppl with ASD “indistinguishable from peers”

• Many people with autism feel negatively about ABA

• They believe the goal of ABA is misguided. People with autism should not be taught to mimic what is natural for others

• Rather, the social environment should be more respectful of differences across people and not emphasize that the way people with autism spectrum disorder instinctively act, move, and talk is a problem

Bad ethics/ethical violations in ABA’s history

• Lovaas regularly used electric shocks to shape behaviors

• Tested his theories on nonverbal children, some of whom were wards of the state and had no parents or family to advocate for them