Autism Spectrum Disorder Flashcards

Autism Spectrum Disorder

Neurodevelopmental Disorders

• Autism Spectrum Disorder (ASD), Intellectual Disability, and Specific Learning Disorder are categorized as Neurodevelopmental Disorders in the DSM-5.
• They have fundamental differences in core deficits.
  • Intellectual Disability: affects intellectual and adaptive functioning.
  • Specific Learning Disorder: affects core academic skills (reading, writing, mathematics).
  • Autism Spectrum Disorder: affects social communication, social interaction, and leads to restricted & repetitive behaviors/interests/activities.

Autism Spectrum Disorder (ASD)

• ASD is a diagnostic entity in the DSM-5.
• In DSM-IV-TR, it was previously coded as "Autistic Disorder."
• ASD incorporates what was previously referred to as "Asperger’s Disorder" in the DSM-IV-TR.
• The change from Autistic Disorder to Autism Spectrum Disorder reflects:
  • Degrees vs. all-or-nothing.
  • Severities.
  • Combinations of symptoms.

Diagnostic Criteria

Criterion A: Persistent Deficits in Social Communication and Social Interaction

• Deficits must be present across multiple contexts, currently or by history.
  1. Deficits in social-emotional reciprocity
     • Examples: Abnormal social approach, failure of normal back-and-forth conversation, reduced sharing of interests/emotions/affect, failure to initiate or respond to social interactions.
  2. Deficits in nonverbal communicative behaviors
     • Examples: Poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, deficits in understanding and use of gestures, total lack of facial expressions and nonverbal communication.
  3. Deficits in developing, maintaining, and understanding relationships
     • Examples: Difficulties adjusting behavior to suit various social contexts, difficulties sharing imaginative play or making friends, absence of interest in peers.

Criterion B: Restricted, Repetitive Patterns of Behavior, Interests, or Activities

• Must be manifested by at least two of the following, currently or by history:
  1. Stereotyped or repetitive motor movements, use of objects, or speech
     • Examples: Simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases.
  2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
     • Examples: Extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day.
  3. Highly restricted, fixated interests that are abnormal in intensity or focus
     • Examples: Strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests.
  4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment
     • Examples: Apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement.

Criteria C, D, & E

• C. Symptoms must be present in the early developmental period
  • May not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life.
• D. Symptoms cause clinically significant impairment
  • Impairment in social, occupational, or other important areas of current functioning.
• E. These disturbances are not better explained by intellectual disability
  • Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses, social communication should be below that expected for general developmental level.

Specifiers

• 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 disorder
  • With catatonia
• Specify severity:
  • Requiring support (level 1) – least severe; least interference with functioning.
  • Requiring substantial support (level 2)
  • Requiring very substantial support (level 3) – most severe; most interference with functioning.

Core Deficits

Social Interaction

• Deficits in social and emotional reciprocity.
• Unusual nonverbal behaviors.
• Impairments in social imitation, sharing focus of attention, make-believe play.
• Limited social expressiveness.
• Atypical processing of faces and facial expressions.
• Joint attention (ability to coordinate attention to a social partner and an object or event of mutual interest).

Social Communication

• Inconsistent use of early preverbal communications is one of the first signs of language impairment.
• Use protoimperative gestures rather than protodeclarative gestures.
• Miss other declarative gestures, such as showing gestures.
• About 50% do not develop any useful language.
• Those who begin to speak may regress between 12 and 30 months.
• Children with ASD who develop language usually do so before age 5.
• Qualitative language impairments:
  • Pronoun reversals.
  • Echolalia.
  • Perseverative speech.
• Impairments in pragmatics (difficulty reading the social context leading to inappropriate use of language).
• Instrumental (get someone to do something) versus expressive (convey feelings) gestures.

Restricted & Repetitive Behaviours/Interests

• Stereotyped body movements.
• Repetitive sensory and motor behaviors.
• Insistence on sameness of behaviors.
• Self-stimulatory behavior.
• Different theories:
  • A craving for stimulation to excite their nervous system.
  • A way of blocking out and controlling unwanted stimulation from the environment that is too stimulating.
  • Maintained by sensory reinforcement it provides.

Functional Consequences

• Deficits in social and communication abilities impact on learning.
• Rigidity can be disorganizing and stressful for families.
• Sensory sensitivity can interfere with eating and sleeping.
• Adaptive skills impact on independence.

Goals of Intervention for ASD

1. Minimize core problems of ASD.
2. Maximize independence and quality of life.
3. Help child and family cope effectively with the problems.

Intervention

Working with Parents

• Understanding parental emotions and the complexity involved in having a child with ASD—guilt, frustration, ambivalence, grief etc.
• Help parents come to terms with and accept the diagnosis—can vary significantly from parent to parent.
• Training programs:
  • Knowledge and psychoeducation.
  • Support groups—Autism South Africa (www.aut2know.co.za).
  • Training specifically in how to work with their child—modeling etc.
  • Pictures Exchange Communication System (PECS) training.
• Involve the siblings.

Education System

• In SA—appropriate school placement at either a specialized school for children with ASD or at a school that is able to cater specifically for children with ASD.
  • Thulasizwe School of Autism (Soweto).
  • UNICA.
  • Veritas Akademie.
  • Ernie Els Centre for Autism.

Overview of Treatment Strategies

• Engaging children in treatment.
• Decreasing disruptive behaviors.
• Teaching appropriate social behavior.
• Increasing functional, spontaneous communication.
• Promoting cognitive skills.
• Teaching adaptive skills to increase responsibility and independence.

Initial Stages

• Focus on building rapport and teaching learning-readiness skills.
• Discrete trial training involves a step-by-step approach to presenting a stimulus and requiring a specific response.
• Incidental training strengthens behavior by capitalizing on naturally occurring opportunities.

Reducing Disruptive Behaviors

• Rewarding competing behaviors
• Ignoring behavior
• Punishment

Teaching Appropriate Social Behaviors

• Priority in treatment of ASD.
• Involves teaching expression of emotions—facilitates reciprocity.
• Social skills training—initiating and maintaining interactions; turn-taking; sharing.
• Peer-focused approaches.

Teaching Appropriate Communication Skills

• A word on PECS:
  • Developed for non-verbal children with ASD
  • Aim: teach spontaneous social communication skills through symbols (pictures) in order to request desired objects.
  • Child can be trained by parents, teachers, or therapists—usually used in special school to teach children, and by occupational therapists; but not limited to these settings.
  • For more information on PECS: https://nationalautismresources.com/the-picture-exchange-communication-system-pecs/

Early Intervention

• Early
• Intensive
• Low student-teacher ratio
• High structure
• Family inclusion
• Peer interactions
• Generalization
• Ongoing Assessment

Mock Test/Exam Question

• Briefly discuss why autism spectrum disorder is best characterized as a spectrum disorder (3 marks).

Model Answer:

• The symptoms, abilities, and characteristics of ASD are expressed in many different combinations (1) and in any degree of severity (1). Therefore, ASD is not an ‘all or nothing’ phenomenon but is, rather, a matter of degree (1).