Autism Spectrum Disorders

Karen L. Weigle, Ph.D.M. Alyce Besnon, LCSW

Prevalence of ASD

4.4 per 10,000 from 1966 to 1991 12.7 per 10,000 from 1992 to 2001

(Fombonne, 2003) 7.1 per 10,000 individuals under 18 years of

age (Williams et al., 2006) Currently estimated 1 in 68 individuals 5 times more common among boys (1 in 54)

than among girls (1 in 252).

Prevalence of Autism

What is Autism?

Autism Spectrum Disorders

• Autism Spectrum Disorders represent a continuum of complex developmental disabilities that are present at an early age.

• Asperger’s Disorder• Pervasive Developmental Disorder• Autistic Disorder• Childhood Disintegrative Disorder• Rett’s Disorder

Diagnosis Research has shown that a diagnosis of

autism at age 2 can be reliable, valid, and stable.

More children are being diagnosed at earlier ages—a growing number (18%) of them by age 3.

Studies have shown that parents of children with ASDs notice a developmental problem before their child's first birthday.

DSM-IV Criteria

I. A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C)

(A) Qualitative impairment in social interactions(B) Qualitative impairments in communication(C) Restricted repetitive and stereotyped patterns of

behavior, interests, and activities

II. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (A) social interaction

(B) language as used in social communication (C) symbolic or imaginative play

ASD: DSM-VMust 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.

ASD: DSM-V

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.     Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (such as extreme distress at small changes, difficulties with transitions, rigid thinking patterns).

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).

ASD: DSM-V

C.   Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D.   Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

 Severity Level for ASD

Social Communication

Restricted interests & repetitive behaviors

Level 3 ‘Requiring very substantial support’

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.  

 Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres.  Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.

Level 2 ‘Requiring substantial support’

Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.

RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts.  Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest.

Level 1‘Requiring support’

Without supports in place, deficits in social communication cause noticeable impairments.  Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others.  May appear to have decreased interest in social interactions. 

Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.

Severity of ASD: DSM 5

Why the Changes?

Studies have generally failed to demonstrate a clear distinction between Asperger’s and autism

Genetic studies have indicated that it is better to consider autism as a spectrum ranging from persons with severe autism, at its extreme, to very non-autistic persons at its opposite, than a group of autistic subtypes

It is more advantageous to employ a single category of ASD than to employ individual autistic subtypes in treatments

3 Areas Affected by ASD:

Social Interactions/Communication Skills = Differences in Language and Theory of Mind

Restricted Interests and Patterns of Behavior/Response to Stress = Need for sameness, rigid adherence to routine

Sensory Differences

Differences in ASD

Developmental milestones, especially language

Sometimes regression Medical illnesses Sensory differences Typical social interactions Family history Intellectual functioning

Differences in Developmental History

Differences in…

Social Skills Language/Speech Sensory Perception Interests and Behavior Learning

Eye contact: ◦Is there any?◦Is it integrated with other communicative

attempts?◦Does the person attend and respond to

yours?

Differences in Social skills

Differences in Social Skills

Reciprocity Sharing/Giving Joint attention Social routine Functional and Symbolic Imitation Emotional Response

Differences in Language Receptive and expressive Voice quality Intonation/modulation Use of nonverbal language/gestures Flexibility in word use Idioms/ “sayings” Conversational skills and questions

Sensory Differences Sensitivities Food aversions Seeking proprioceptive feedback Sensory integration Body use

Differences in Interests and Behavior

Special interests Adaptation to change Response to stress Fear/nervousness

Characteristics that Impact Daily Functioning

• Cognitive Delays/Learning Disabilities• Language Delays – receptive and expressive

• Sensory Over-Sensitivity• Poor Impulse Control• Delayed Executive Functioning

Characteristics that Impact Daily Functioning

“Mind-blindness” and lack of “thinking about thinking”----------- Confusion around social interactions----------- Lack of “Theory of Mind”

----------- Emotional dysregulation----------- Need For Sameness

------------ Anxiety

Sensory dysregulation ----------- Difficulties with attention

----------- Anxiety

Adaptation to change/Response to stress

Fear/nervousnessLack of Environmental Awareness

Lack of Emotional Recognition

Characteristics that Impact Daily Functioning

Establishing a Predictable Environment◦ Schedules and Other Visual Supports◦ Consistent Routines ◦ Advanced preparation for changes◦ Greater predictability and preparation leads to

less anxiety◦ Greater ambiguity leads to more impulsive

behavior

Proactive Strategies: First Steps

AFTERNOON ROUTINE COMPLETED

Picked up by Granny

Eat Snack

Activity of choice (video game, watch cousins play)

Homework

Activity of choice (video game, watch cousins play)

Dinner with mom

Go home

Bath (if needed as determined by mom)

Put on deodorant

Pajamas

Brush teeth

Activity of choice

Go to bed

Proactive Strategies Visual Prompts

◦Verbal comprehension delays complicate communication

◦Many people with developmental disabilities learn better visually

◦Visual reminders are still present after the verbal reminder is forgotten

◦Examples: Post It notes, pictures, charts, schedules, and calendars.

Teaching Social Skills

Social skill apps on iPads and Androids◦ www.autismspeaks.org/autism-app for ideas of

good apps Role play Video self modeling

◦ Easy to record with iPads and phones Social skills groups Autism Talk TV at www.wrongplanet.net

Related Features of ASD

About 4 times more likely to develop a “clinically significant disturbance”.

Bradley et al. (2004)

People with Autism Spectrum Disorders are

Comorbid Features 75% children with autism functioning in

mentally impaired range; now felt to be 50% Epilepsy: Children 7-14%; Adults 20-35% Less than 10% have tuberous sclerosis, fragile

X syndrome, PKU, congenital rubella syndrome

Developmental regression 25-30% children age 15-21 months

Unspecified increase in constipation Sleep Disturbance

74% prevalence of comorbid and often multiple comorbid psychiatric diagnoses in 9- to 16-year-old subjects

44% Behavioral disorders 42% Anxiety disorders 26% Tic disorders

Matilla et. al.

DepressionAnxiety Disorders/Panic DisorderBipolar DisorderADHD Tic Disorder

Common Comorbid MH Diagnoses

These diagnoses are determined by behavioral departures from the person’s typical behavior and profile of skills

These disorders often occur at elevated rates in relatives

Differential diagnosis should always include a thorough medical evaluation to rule out any physiological or physical basis for alternations in behavior patterns in persons who cannot reliably self-report internal states

Common Comorbid MH Diagnoses

Depression can be observed by changes in affect

Increased irritability, agitation, destructive or aggressive behavior

Increased rate of stereotypies or ritualistic/ repetitive behaviors

Diminished interest in preferred activities Changes in weight Changes in sleep Psychomotor agitation or retardation

Depression in ASD

Fatigue Negative self-statements (for persons with

mild/moderate impairments) Diminished ability to concentrate Recurrent thoughts of death or suicidal

ideation (in persons with mild to moderate impairments)

Depression in ASD

Mood during manic episode may alternate between elated and irritable

Number of symptoms of mania required for diagnosis are fewer, depending on level of expressive language and ID: for those with mild to moderate impairments, 3 or more symptoms; for those with more limited expressive language skills, 2 or more symptoms◦ Inflated self esteem, grandiosity◦ Decreased need for sleep

Bipolar Disorder in ASD

Symptoms of mania continued◦ More talkative or pressured speech◦ Flight of ideas or subjective experience of racing

thoughts◦ Distractibility◦ Increase in goal-directed activity, physical

activity◦ Excessive involvement in pleasurable activities

that have a high potential for painful consequences (often sexual in nature)

Bipolar Disorder in ASD

There are no differences in descriptions for persons with mild to moderate ASD/ID who can express internal states and experiences; however, this is almost always difficult for most persons with ASD

Observable “signs” of Anxiety include:◦ Palpitations, pounding heart, accelerated heart

rate◦ Sweating, chills, hot flushes◦ Trembling or shaking◦ Increased breathing rate

Anxiety/Panic Disorder in ASD

Panic is a discrete period of observed intense fear or discomfort

Panic symptoms develop abruptly and reach peak within 10 minutes

Panic may result in the following:◦ Irritability◦ Aggression◦ Destructive behavior◦ Lashing limbs or head banging

Anxiety/Panic Disorder in ASD

The differences in diagnostic information regarding Tic Disorders for people with ASD, ID, and difficulty with expressive language, are outlined in the next slides

Information is from the DM-ID: A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disabilities (2007)

Tics Disorders in ASD

In Persons with Mild to Moderate ID/ASD may be described as a tingle, cramp, “funny feeling” and are associated with an urge to move that is relieved with the behavior

In Persons with Severe to Profound ID/ASD can be mannerisms and other repetitive behaviors associated with simple motor tics

Motor Tics in ASD/ID

In Persons with Mild to Moderate ASD/ID ◦ complex tics overlap stereotypies, compulsions,

and other repetitive movements. ◦ Obsessions are usually lacking.◦ SIB is high frequency, low intensity◦ When SIB is more severe, commonly associated

with more severe tics

Complex Tics in ASD/ID

In Persons with Severe to Profound ASD/ID ◦ often explosive aggressive behaviors or SIB in the

presence of motor tics ◦ Waxing/waning course of target behaviors

Complex Tics in ASD/ID

In Persons with Mild to Moderate ASD/ID◦ Abrupt or explosive vocalizations◦ Exacerbation with distress◦ Repetitive words or phrases: echolalia or pallilalia

(repeating end of ones sentences)◦ Coprolalia (intrusive words without intensive

affective response)◦ Continuous complex tics (humming)

Phonic Tics in ASD/ID

In Persons with Severe to Profound ASD/ID◦ Explosive vocalizations, exacerbated by stress◦ Imitative behaviors, like echolalia◦ Waxing/waning of behaviors often parallel flare up

in motor tics

Phonic Tics in ASD/ID

In Persons with Mild to Moderate ASD/ID◦ Reports of discomfort preceding tics◦ Improvement with motor action◦ Precede self-injurious behavior◦ Complex tics or compulsive behavior◦ Do not meet criteria for OCD

Sensory Tics/Repetitive Behavior in ASD/ID

In Persons with Severe to Profound ASD/ID◦ Difficult to distinguish from stereotypies without

subjective reports◦ Rule out akathisia and restless legs syndrome

Sensory Tics/Repetitive Behavior in ASD/ID

Treatment of ASD and Related MH Diagnoses

Behavioral and Cognitive-Behavioral Intervention for persons who are verbal and have anxiety, mood disorder, panic (e.g., cognitive restructuring, graduated exposure)

Habit reversal for tics

Treatments

Applied Behavior Analysis (ABA)-Lovaas 1977

Autism/Pervasive Developmental Disorders Clinical Guideline Development Panel:

http://www.health.state.ny.us/community/infants_children/early_intervention/autismNational Research Council (2001)

Treatments

Treatments (cont’d)

Social Skills Training--Social stories: promotes social skill

development by story telling with a focus upon social situations and appropriate responses

--Social skills groups: practice in safe environment

--Circle of friends: focuses upon inclusion in groups, maps of friends, mentors to teach basic skills. See O.A.S.I.S. website.

Adapted from Sicile-Kira (2004)

Treatments (cont’d)

Picture Exchange Communication System (PECS)

Progressively uses pictures and sequences of pictures to communicate needs and desires without prompting. Can be used to teach basic concepts (numbers, colors, making choices, following instructions, etc.)

www.pecs.comAdapted from Sicile-Kira (2004)

Treatments (cont’d)

Rapid Prompting Method (RPM)A teaching method using various forms of

prompts (verbal, visual, tactile) to solicit a response and keep person focused. Most helpful with people who are non-verbal or lacking in conversational skills. (Soma Mukhopadhyay)

www.halo-soma.org

Adapted from Sicile-Kira (2004)

Treatments (cont’d)

Sensory Integration (SI)Typically implemented by Occupational

Therapists who focus upon processing and the use of sensory information. Certification available.

www.home.earthlink.net/-sensoryint/

Adapted from Sicile-Kira (2004)

Atypical Antipsychotics (Abilify, Risperidone, Olanzapine, Clozapine) for temper, aggression, SIB

SSRIs (Sertraline, Citalopram, Fluoxetine) for anxiety and repetitive behaviors

Psychostimulants (Methylphenidate, Vyvanse, Adderall) for hyperactivity

Medications of Possible Benefit

Dietary Treatments (use only if medically indicated) Gluten Free/Casein Free (GFCF) Diet-gluten

allergies Anti-Yeast (or Antifungal) Diet-overgrowth of

yeast The Feingold Diet-focuses upon removing

artificial colorings and preservatives The Ketogenic Diet-used to treat seizuresTaken from Sicile-Kira (2004)

Biomedical Treatments

Vitamin B6 & Magnesium (not harmful)-some studies show benefits with improved eye contact, improved language, reduced self-stimulatory behavior, reduced aggression, and reduced self-injurious behavior.

www.autismresearchinstitute.com

Adapted from Sicile-Kira (2004)

Biomedical Treatments (cont’d) Fatty Acids-increase Omega fats, cod-liver

oil. Sulphate Ions- People with ASD thought to

have abnormally low sulphate levels. Add magnesium sulfate (Epsom salts) to bathwater to improve absorption.

Enzymes-People with ASD thought to have trouble with low levels of stomach (peptidase) enzymes

Adapted from Sicile-Kira (2004)

Aquatic Therapy can focus on:--Therapeutic play-based functional movement--Improving range of motion--helping to facilitate neurodevelopment growth --Improved body awareness--Increased balance--Sensory integration--Mobility skills--Cardiovascular fitness--Fun

Aquatic Therapy

Other Therapeutic Approaches

Daily Life Therapy-focus upon physical education as a bridge to social development

Speech Therapy-focus on expressive and receptive language delays and pragmatic language

Occupational Therapy-focus on everyday goals and sensory problems

Adapted from Sicile-Kira (2004)

Other Therapeutic Approaches Music Therapy-can be used to increase

interaction with people who are nonverbal, explore and express feelings, be creative and spontaneous

Assistive Technology & Computer Programs-improve functional capabilities

Adapted from Sicile-Kira (2004)

Combined Treatment Approaches Treatment and Education of Autistic and

Related Communication handicapped CHildren (TEACCH)-available in North Carolina

Provides “Structured Teaching” using visual processing (due to difficulties with verbal processing) to help autistic children understand expectations

Assesses social characteristics in pre-arranged environment: proximity, object/body use, social imitation, social response, interfering behavior, adaptation to change

Assessed in five social contexts: structured time, leisure time, travel, meal time, meeting others

Treatment: Arranging the environment to increase the best possible chance of realizing their full potential

Aaron & Gittens (1992); Olley (1986); Greenway (2000)

Combined Treatment (TEACCH cont’d)

“Eighty percent of adults with Asperger’s Syndrome do not have full-time work. This (is) not because they can’t do the work.

It’s that they can’t manage to be socially acceptable while they get the work done.”

http://blog.penelopetrunk.com/2009/10/2 ... -meetings/

Why Diagnose?

“Research in 2001 by the U.K.’s National Autistic Society indicated that only 12% of those of with high-functioning autism or Asperger’s Syndrome had full-time jobs.

In contrast, 49% of people with other disabilities, and 81% of people who are not disabled were in employment.”

-Daniel Tammet in “Born on a Blue Day”

Why Diagnose?

The unemployment rate for adults with Asperger’s Syndrome was reported at

75 to 85% in 2012. The lifetime cost of caring for just one individual with autism can be as high as $2.4 million

Autism is costing society $137 billion annually, according to new (2012) estimates that suggest a three-fold

increase in less than a decade.

Why Diagnose?

Early intervention is critical to help kids on the spectrum become successful,

self-reliant adults.

Once identified, the child can receive other support services.

Once identified, the individual can understand himself.

Why Diagose?

Autism is not a demon to be battled and overcome. It is a difference that can cripple or render extraordinary. Most

autistics are disabled as children because our sensory apparatus is

different, our communication skills are weak, and we have not yet learned coping strategies, or found our gifts.

-John Elder Robison in “Jerry Seinfeld and Autism”

Final Thought

Acceptance….

Asperger’s Syndrome: An Owner’s Manual 2 for Older Adolescents and Adults. Ellen S. Heller Korin, M.Ed. Autism Asperger Publishing Co., 2007.

The Procrastination Workbook. William Knaus, Ed.D. New Harbinger Publications, Inc., 2002.

Thinking Connections: Learning to Think & Thinking to Learn. David N. Perkins, Heidi Goodrich, Shari Tishman, & Jull Mirman Owen. Addison-Wesley Publishing Co., 1994.

The Way I See It: A Personal Look at Autism and Asperger’s. Temple Grandin. Future Horizons, Inc.

References and Resources

Website with lots of books: http://store.fhautism.com

Movie: Temple Grandin. HBO Films. Attwood, Tony (September, 1999). The Pattern of

Abilities and Development of Girls with Asperger's Syndrome. http://www.tonyattwood.com.au

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). Washington, DC: Author.

www.aspergerfoundation.org.uk/infosheets/ta_girls.pdf

Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (Eds., 2007). Diagnostic Manual: a Clinical Guide for Diagnosis of Mental Disorder in Persons with Intellectual Disability. Kingston, NY: NADD Press

References and Resources

Resources Asperger’s Syndrome Education Network

(ASPEN)-www.aspennj.org Tony Attwood-www.tonyattwood.com.au Autism-Europe-www.autismeurope.org Autism Network International (ANI)-

http://ani.autistics.rog/ Autism Research Institute (ARI)-

www.autismresearchinstitute.com Autism Society of America (ASA)- www.autismsociety.org

Resources Center for the Study of Autism (CSA)-

www.autism.org Cure Autism Now Foundation (CAN)-

www.canfoundation.org Families for Early Autism Treatment (FEAT)-

www.feat.org Interactive Autism Network www.iancommunity.orgNational Alliance for Autism Research (NAAR)-

www.naar.org

Resources National Autism Organization (NAO)-

www.naionalautismassociaion.org National Autism Society (NAS)-

www.nas.org.uk/ O.A.S.I.S. (Online Asperger Syndrome

Information and Support)-www.udel.edu/bkirby/asperger/

Organization for Autism Research (OAR)-www.researchautism.org/

Safe Minds-www.safeminds.org

Resources

Schafer Autism Report-www.sarnet.org Talk About Curing Autism (TACA)-

www.tacanow.com University Students with Autism and

Asperger’s Syndrome-www.users.dircon.co.uk/-cns

World Autism Organization (WAO)-www.worldautism.org

The Complete Guide to Asperger’s Syndrome by Tony Attwood (2007)

1400 McCallie, Suite 100Chattanooga, TN 37404423-531-6961

chattanoogaautismcenter.org

Further help:

Karen L. Weigle, PhDLicensed Clinical Psychologist, HSPkweigle@gmail.com

M. Alyce Benson, MSSWLicensed Clinical Social Worker423-531-6961abensonsocialworker@gmail.com

Contact Information