Autism Spectrum Disorder Flashcards

Lyndsay's Case

Case Presentation

• Lyndsay is a 10-year-old girl attending a private all-female school.
• She is shy and small for her age, often mistaken for a 6-year-old.
• She has two older sisters and one older brother.
• Both parents are present in the home.
• Father: CEO with a strong, authoritarian personality, influencing Lyndsay’s diagnosis and therapy.
• Mother: College graduate, stay-at-home housewife, very protective of Lyndsay, avoids pushing her.
• Selective Mutism since early childhood.
• Older siblings are also protective.
• Brought to therapy for speaking only to immediate family minimally.
• Never speaks in school, public, or with extended family.
• Teachers and extended family believe she is completely mute.
• Expresses normal range of emotions nonverbally.

Selective Mutism (SM)

DSM-5 Criteria

• A. Consistent failure to speak in specific social situations where speaking is expected (e.g., school), despite speaking in other situations.
• B. The disturbance interferes with educational or occupational achievement or social communication.
• C. Duration: At least 1 month (not limited to the first month of school).
• D. Not attributable to lack of knowledge or comfort with the spoken language required.
• E. Not better explained by a communication disorder and does not occur exclusively during ASD, schizophrenia, or another psychotic disorder.

Psychodynamic Perspective of SM

*Focuses on unconscious conflicts, resolved through play.

• Offers developmentally appropriate communication of feelings about these conflicts.
• Provides supportive environment to facilitate the child’s work.
• Lyndsay and therapist explore situations and resolve issues.

Therapy Sessions

Session 1

• Themes: Hostility and aggression.
• Lyndsay uses teddy bear Simon to kick puppets.
• Therapist allows Lyndsay to succeed in "beating up" puppets.
• Displays of confidence and happiness.
• Lyndsay holds a ball, refuses to return it.
• Throws ball at a doll on the floor.

Sessions 2-5

• Same theme: Simon pulls finger puppets off therapist’s fingers, kicks them.
• Simon wins each altercation.
• Lyndsay molds a clay family; large blue piece = father, smallest piece = herself.
• Creates a smaller piece attached to herself (Simon).
• Throws clay figures, uses Simon with a toy sword to chop up the largest pieces.

Sessions 5-10

• Themes shift: aggression, hostility, and smallness begin to change.
• Clay used for plates and pretend food.
• She feeds Simon and the therapist.
• Puts Simon aside and pretends to eat.
• Wants mother to see creations at session end.
• Still nonverbal but communicates through gestures and play.
• Progress: Speaks to a teacher, asks a friend for a snack.

Psychoanalytic Analysis of Treatment

• Why is Lyndsay improving?
  • Hostility and aggression leading to winning.
  • Self-concept of being small and vulnerable.
  • Aggression leading to social interaction.
  • Communication.

Efficacy vs. Effectiveness

Efficacy

• Trained clinicians in research study.
• One form of treatment (Tx) with a structured approach.
• Patients volunteered and screened for comorbidities.
• Effects in research under ideal/controlled conditions.

Effectiveness

• Therapist isn’t specifically trained in one Tx approach.
• Not a controlled environment.
• Patients aren’t selected.
• Real-world context.

Play Therapy

• Large positive effects on treatment outcomes for various problems and diagnoses (Landreth, 2002).
• Decreased maladaptive school behaviors (Constantino, Malagady, & Roger 1986; Gaulden, 1975; Hannah, 1986; Leland, Ealker and Taboada, 1959).

Play Therapy: Efficacy

• Meta-analysis of 93 controlled outcome studies.
• Treatment effect for play therapy interventions was $0.80$. More positive for humanistic approaches.
• Parent involvement → largest effects.
• Equally effective across age, gender, and presenting issue.

Applied Behavior Analysis (ABA)

• Scientific approach to behavior change based on psychology of learning (learning principles).
• Principles intentionally used to create or decrease socially significant behaviors that are lacking or creating problems.
• Therapist must demonstrate significant and meaningful changes result from interventions.
• Not a stand-alone treatment.

Applied Behavior Analysis: Key Aspects

• Focus: Behaviors significant to the person in their specific social context.
• Observable and measurable attenuation or creation of behavior.
• Analyzing if interventions are the drivers of change.
• Interventions specifically defined in detail for everyone on the Tx team.
• Used according to learning principles.
• Changes are meaningful and applied in other situations (generalization).

*Behavior is shaped by relationship with the environment.

• Example: Child aggression for a toy leads to getting the toy, reinforcing future aggression.
• Address consequences in the least restrictive and punitive way.

Antecedent-Behavior-Consequence (ABC)

Three-Term Contingency

• Antecedent: Directly prior to behavior.
• Behavior: How the child responds.
• Consequence: Result and effect on the child; increases or decreases likelihood of future behavior.

Basic Principles

• Reinforcement: Increases Behavior.
  • Positive: Adding something desirable.
  • Negative: Removing something unpleasant.
• Punishment: Decreases Behavior.
  • Positive: Adding something unpleasant (e.g., extra chores).
  • Negative: Removing something pleasurable (e.g., taking away game time).
• Extinction: Removing something reinforcing that was previously there.
  • Behavior previously reinforced with attention is ignored; child learns behavior no longer produces desired outcome, and stops.

Using Quality Indicators: Graphs

• Graphs track:
  *Cleaning up toys
  *Respond to name
  *Sharing properly with peers/siblings
  *Following Directions

Neurodevelopmental Disorders Review

• Atypical and impairing growth of the brain and central nervous system throughout development.
• Affect learning, emotion, memory, etc.
• Include: ASD, Intellectual disability (ID), Specific Learning Disabilities, ADHD

Common Factors

• Impact all contexts of life (social, family, education, work, relationships, daily living skills).
• Prognosis: Considered lifelong.
• Major functional improvements can be made; individuals do not fully “recover.”

Neurodevelopmental Hypothesis

• Disorders (Autism, ID, ADHD, schizophrenia) are one spectrum.
• Caused by shared environmental and genetic factors.

The Vaccine Debacle

*MMR vaccination rates in UK dropped after a 1998 article.

• Published in The Lancet by A.J. Wakefield et al. suggested a link between the MMR vaccine and autism.
• The paper has since been retracted due to serious ethical and methodological flaws.
  * rates dropped from 92% in 1995 to as low as 80% in 2005
  Measles outbreaks in UK blamed on Wakefield (2002) (Calvert, Ashton, &Garnett, 2013).
  Undisclosed financial and scientific conflicts of interest.
• Lawyers for parents suing vaccine makers paid for his research.
• Wakefiled patented a measles vaccine in 1997.
  *Basic ethical violations.
• Lancet retracted the article in 2010.

What is Autism?

• DSM-5: ASD is a severe neurodevelopmental disorder with early onset.
  • Deficits in social interaction and communication skills.
  • Stereotyped patterns of behaviors, interests, and activities.

History of Autism Understanding

*1800s-Early 1900s Considered ‘feral’ or institutionalized children

• Diagnosed as developmental disabilities.
• 1943 Leo Kanner described 11 children lacking connectedness to others. Displayed resistance to change and stereotyped mannerisms.
• 1944 Hans Asperger identified socially self-centered males with intense interests.
• 1950s & 60s Childhood Schizophrenia diagnoses. Blamed parents.
• 1970s Advances in awareness of epilepsy. Imaging research and twin studies.
• Later adoption of structured educational, behavioral, and psychosocial interventions

Progression of Autism in DSM

• DSM I & II: Theory-based.
• DSM III:
  • Robert Spitzer: Research-based criteria.
  • First recognition of Infantile Autism under PDDs.
  • Issues: Didn’t account for developmental changes; required meeting all criteria.
• DSM III-IV tr:
  • Autistic Disorder: Polythetic (Social, Communication, Resistance to Change).
  • 4 possible Dx: Autistic disorder, Asperger’s disorder, Childhood disintegrative disorder, PDD-NOS.

DSM 5

• Autism Spectrum Disorder.
• Social Communication Disorder added.
• Two categories instead of three: Social Communication and Resistance to Change.
• Significantly reduced criteria combinations.

DSM 5 TR

• Very small changes for clarity; no change to diagnostic terms. (APA, 2013; Maenner et al., 2014)
• Concerns of loss of previous diagnoses; further studies underway.

Reasons for changing diagnostic criteria in DSM-5

• Improve sensitivity & specificity of criteria.
• Identify more focused treatment targets for specific impairments identified.

DSM 5 TR Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following

1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors
3. Deficits in developing, maintaining, and understanding relationships

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following

1. Stereotyped or repetitive motor movements, use of objects, or speech
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Additional DSM 5 TR Criteria

• C. Symptoms must be present in the early developmental period.
• D. Symptoms cause clinically significant impairment.
• E. Not better explained by intellectual disability or global developmental delay.

Note

• Individuals with a well-established DSM-IV diagnosis should be given the diagnosis of autism spectrum disorder.
• Individuals with marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Specifiers and Severity Levels

*Specify if:
* With or without accompanying intellectual impairment
* With or without accompanying language impairment
* Associated with a known medical or genetic condition or environmental factor
* Associated with another neurodevelopmental, mental, or behavioral problem
* With catatonia
*Severity Levels
* LEVEL 1 REQUIRING SUPPORT
* LEVEL 2 REQUIRING SUBSTANTIAL SUPPORT
* LEVEL 3 REQUIRING VERY SUBSTANTIAL SUPPORT

Why A Spectrum Disorder

*Manifestation of ASD varies widely.

Lucy and John: Across the Spectrum

Lucy

• Delayed development, walking, sitting up.
• At 2 years old, no words, unresponsive to engagement attempts.
• Strange clicking noises and screams.
• Oblivious to people unless they had something she wanted.
• Liked to feel things (e.g., women’s stockings); tantrums if stopped.
• Remained non-verbal.
• Intellectually deficient.

John

• Walked on his first birthday.
• Made sounds but did not use words.
• Limited communication; mother guessed what he wanted.
• Extreme independence; no comfort or attachment to parents.
• Non-verbal until 4.
• At 4, began speaking in complete sentences but speech was unusual (e.g., repeating phrases).
• Above average intelligence.

Similarities

• Both have defining characteristics of ASD: social relationship and communication differences.
• Repetitive interests and preoccupations

Differences

• John is more socially outgoing and talkative with however his social contacts are repetitive and unnatural.
• Lucy rarely speaks.

Social Development

*Social skills are critical for assimilation into the world.

• Early development involves looking to others for guidance.
• Primary caregiver interactions (serve and return) and joint interactions facilitate learning about the social environment.
• Usually motivated for this with an attraction to faces.
• People are important for understanding the environment and others.
• Typically adept at this by one year.

Social Cognition and ASD

*We have proclivity to look at faces and see faces where there aren't any.

Face Discrimination

• Schultz, et al.
• Fusiform Gyrus – Involved face recognition. More active during object viewing than faces.
• When shown relatives faces, the Brain responded in this region; however, it was less than controls.

Joint Attention

• Infants naturally share interests and emotions by shifting their gaze from something of interest to another person and back.
• They follow the gaze of others and point to objects.
• This is a type of social reciprocity.

Social Emotional Reciprocity

*Sharing Interest, Emotions, Affects
*Examples provided to illustrate both typical and atypical presentations in children.

Amygdala Differences

*Amygdala damage impairs recognition of social emotions.

• Effects observed in autism (Adolphs et al., 2002).

Judging the Mind in the Eyes

*Adults with HFA and normal intelligence showed impairments

• Parents of children with AS also showed less accuracy.

Social Communication

*Reduced involvement in symbolic play and limited shared imaginative play is observed in autistic children.

Restricted, Repetitive Patterns of Behavior

*DSM-5 Criteria:

• Stereotyped or repetitive motor movements, use of objects, or speech
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
• Highly restricted, fixated interests that are abnormal in intensity or focus
• Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Example

• Restrictred pattern of interest in drawing circles, rathern than interacting with others. Highly Restricted, Fixated Interests

Screening for ASD

*All children should be screened for developmental delays and disabilities at well-child visits at 9, 18, 24/30 months
*All children should be screened for developmental delays and disabilities at well-child visits at 18 and 24 months

M-CHAT

*Modified Checklist for Autism in Toddlers
*LOW-RISK: Total Score is 0-2; if child is younger than 24 months, screen again after second birthday.
*MEDIUM-RISK: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get additional information about at-risk responses.
*HIGH-RISK: Total Score is 8-20; It is acceptable to bypass the Follow-Up and refer immediately for diagnostic evaluation and eligibility evaluation for early intervention.

Evaluation

*If problems seen at screening, next step is comprehensive evaluation.
*No medical or blood test for ASD
*Complex evaluation for formal diagnosis
*Differs by age and language ability
*Behavioral observation
*Developmental and cognitive tests
*Clinical interpretation (i.e. requires subjectivity)

Diagnosis

• Earliest reliable diagnosis is at 18-24 months.
• On average, diagnosis after age 4.
• Often prerequisite for service provision, insurance coverage.

Comorbidities

*ASD is Highly Comorbid

• 70-90% of individuals with ASD have 1+ comorbid mental disorder
• ~40% may have 2+ comorbid mental disorders
• ~30-50% have 2+ physical health conditions

Why Early Intervention?

*Findings show poor outcomes without intervention.

• Neural plasticity early in development
• Intensive, structured experiences may alter developing brains beneficially
• Brain changes associated with improved social behavior.