Autism Spectrum Autism Spectrum Disorders (ASD)Disorders (ASD)

Cara Kimberg, M.S.Cara Kimberg, M.S.

What is Autism?What is Autism?

Four ways to “define” autismFour ways to “define” autism DSM-IVDSM-IV Parents with a child with autismParents with a child with autism Individuals with autismIndividuals with autism What we know (i.e. stereotypes of What we know (i.e. stereotypes of

autism)autism) Let’s take a look at each one to get a Let’s take a look at each one to get a

more comprehensive idea of this more comprehensive idea of this disorderdisorder

DSM-IV criteriaDSM-IV criteria

First, important to note that autism is a First, important to note that autism is a spectrumspectrum disorder characterized by: disorder characterized by: Impairments in Impairments in social interactionsocial interaction Impairments in Impairments in communicationcommunication Presence of Presence of restricted, repetitive behaviorsrestricted, repetitive behaviors

(RRBs)(RRBs) Spectrum = variability within and across Spectrum = variability within and across

these areasthese areas 1 in 150 children diagnosed with autism 1 in 150 children diagnosed with autism

includes the entire spectrumincludes the entire spectrum

DSM-IV criteria DSM-IV criteria (continued)(continued)

Umbrella term is really Pervasive Umbrella term is really Pervasive Developmental Disorders (PDD)Developmental Disorders (PDD) 5 different subtypes of PDD5 different subtypes of PDD

Autistic DisorderAutistic Disorder Asperger’s DisorderAsperger’s Disorder PDD-NOSPDD-NOS Rhett’s DisorderRhett’s Disorder Childhood Disintegrative Disorder Childhood Disintegrative Disorder

Autism Spectrum Disorders

Rhett’s Disorder (299.80)Rhett’s Disorder (299.80) (A) All of the following: (A) All of the following:

apparently normal prenatal and perinatal development apparently normal prenatal and perinatal development apparently normal psychomotor development through the apparently normal psychomotor development through the

first 5 months after birth first 5 months after birth normal head circumference at birth normal head circumference at birth

(B) Onset of all of the following after the period of normal (B) Onset of all of the following after the period of normal development: development:

deceleration of head growth between ages 5 and 48 months deceleration of head growth between ages 5 and 48 months loss of previously acquired purposeful hand skills between loss of previously acquired purposeful hand skills between

ages 5 and 30 months with the subsequent development of ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand stereotyped hand movements (e.g., hand-wringing or hand washing) washing)

loss of social engagement early in the course (although loss of social engagement early in the course (although often social interaction develops later) often social interaction develops later)

appearance of poorly coordinated gait or trunk movements appearance of poorly coordinated gait or trunk movements severely impaired expressive and receptive language severely impaired expressive and receptive language

development with severe psychomotor retardationdevelopment with severe psychomotor retardation

Facts about Rhett’s Facts about Rhett’s DisorderDisorder

Complex neurological disorderComplex neurological disorder Genetic in originGenetic in origin Primarily in girlsPrimarily in girls Present at birth but more apparent during Present at birth but more apparent during

second yearsecond year Second most common cause of severe learning Second most common cause of severe learning

disability in girls disability in girls 1:10,000 to 1:23, 000 diagnosed 1:10,000 to 1:23, 000 diagnosed Period of temporary regression including loss of Period of temporary regression including loss of

communication skills, and purposeful hand communication skills, and purposeful hand movementsmovements

Childhood Disintegrative Disorder Childhood Disintegrative Disorder (299.10)(299.10)

(A) Apparently normal development for at least the first 2 (A) Apparently normal development for at least the first 2 years after birth as manifested by the presence of age-years after birth as manifested by the presence of age-appropriate verbal and nonverbal communication, social appropriate verbal and nonverbal communication, social relationships, play, and adaptive behavior. relationships, play, and adaptive behavior.

(B) Clinically significant loss of previously acquired skills (B) Clinically significant loss of previously acquired skills (before age 10 years) in at least two of the following areas: (before age 10 years) in at least two of the following areas:

expressive or receptive language expressive or receptive language social skills or adaptive behavior social skills or adaptive behavior bowel or bladder control bowel or bladder control play play motor skillsmotor skills

(C) Abnormalities of functioning in at least two of the (C) Abnormalities of functioning in at least two of the following areas: following areas:

qualitative impairment in social interaction (e.g., impairment qualitative impairment in social interaction (e.g., impairment in nonverbal behaviors, failure to develop peer relationships, in nonverbal behaviors, failure to develop peer relationships, lack of social or emotional reciprocity) lack of social or emotional reciprocity)

qualitative impairments in communication (e.g., delay or lack qualitative impairments in communication (e.g., delay or lack of spoken language, inability to initiate or sustain a of spoken language, inability to initiate or sustain a conversation, stereotyped and repetitive use of language, conversation, stereotyped and repetitive use of language, lack of varied make-believe play) lack of varied make-believe play)

restricted, repetitive, and stereotyped patterns of behavior, restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, including motor stereotypies and interests, and activities, including motor stereotypies and mannerisms mannerisms

(D) The disturbance is not better accounted for by another (D) The disturbance is not better accounted for by another specific Pervasive Developmental Disorder or by specific Pervasive Developmental Disorder or by Schizophrenia.Schizophrenia.

Facts about Childhood Facts about Childhood Disintegrative DisorderDisintegrative Disorder

Child regresses from age 2-10 Child regresses from age 2-10 (debated) in terms of language skills, (debated) in terms of language skills, social behavior, and all developmental social behavior, and all developmental motor skillsmotor skills

Can occur abruptly or over a longer Can occur abruptly or over a longer period of timeperiod of time

Sometimes child is aware of their loss Sometimes child is aware of their loss of skillsof skills

No cureNo cure

Autistic Disorder (299.0)Autistic Disorder (299.0)

(A) total of six (or more) items from (1), (2), and (3), (A) total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and with at least two from (1), and one each from (2) and (3): (3):

1)qualitative impairment in social interaction, as 1)qualitative impairment in social interaction, as manifested by at least two of the following: manifested by at least two of the following:

(a) (a) marked impairment in the use of multiple marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate expression, body postures, and gestures to regulate social interaction social interaction

(b) (b) failure to develop peer relationships appropriate failure to develop peer relationships appropriate to developmental level to developmental level

(c) (c) a lack of spontaneous seeking to share enjoyment, a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects a lack of showing, bringing, or pointing out objects of interest) of interest)

(d) (d) lack of social or emotional reciprocitylack of social or emotional reciprocity

Autistic DisorderAutistic Disorder(2) qualitative impairments in communication as (2) qualitative impairments in communication as

manifested by at least one of the following: manifested by at least one of the following:

(a) delay in, or total lack of, the development of (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to spoken language (not accompanied by an attempt to compensate through alternative modes of compensate through alternative modes of communication such as gestures or mime) communication such as gestures or mime)

(b) in individuals with adequate speech, marked (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a impairment in the ability to initiate or sustain a conversation with others conversation with others

(c) stereotyped and repetitive use of language or (c) stereotyped and repetitive use of language or idiosyncratic language idiosyncratic language

(d) lack of varied, spontaneous make-believe play or (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental social imitative play appropriate to developmental level level

Autistic DisorderAutistic Disorder

(3)restricted repetitive and stereotyped patterns of (3)restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested behavior, interests, and activities, as manifested by at least one of the following: by at least one of the following:

(a) encompassing preoccupation with one or (a) encompassing preoccupation with one or more stereotyped patterns of interest that is more stereotyped patterns of interest that is abnormal either in intensity or focus abnormal either in intensity or focus

(b) apparently inflexible adherence to specific, (b) apparently inflexible adherence to specific, nonfunctional routines or rituals nonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or (e.g., hand or finger flapping or twisting, or complex whole-body movements)complex whole-body movements)

(d) persistent preoccupation with parts of objects(d) persistent preoccupation with parts of objects

Autistic DisorderAutistic Disorder

(B) Delays or abnormal functioning (B) Delays or abnormal functioning in at least one of the following areas, in at least one of the following areas, with onset prior to age 3 years: (1) with onset prior to age 3 years: (1) social interaction, (2) language as social interaction, (2) language as used in social communication, or (3) used in social communication, or (3) symbolic or imaginative play. symbolic or imaginative play.

(C) The disturbance is not better (C) The disturbance is not better accounted for by Rett's Disorder or accounted for by Rett's Disorder or Childhood Disintegrative Disorder.Childhood Disintegrative Disorder.

Asperger’s Disorder Asperger’s Disorder (299.80)(299.80) (A) Qualitative impairment in social interaction, as (A) Qualitative impairment in social interaction, as

manifested by at least two of the following: manifested by at least two of the following: marked impairment in the use of multiple nonverbal marked impairment in the use of multiple nonverbal

behaviors such as eye-to-eye gaze, facial expression, body behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction postures, and gestures to regulate social interaction

failure to develop peer relationships appropriate to failure to develop peer relationships appropriate to developmental level developmental level

a lack of spontaneous seeking to share enjoyment, interests, a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to showing, bringing, or pointing out objects of interest to other people) other people)

lack of social or emotional reciprocity. lack of social or emotional reciprocity. (B) Restricted repetitive and stereotyped patterns (B) Restricted repetitive and stereotyped patterns

of behavior, interests, and activities, as manifested of behavior, interests, and activities, as manifested by at least one of the following: by at least one of the following:

encompassing preoccupation with one or more stereotyped encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in and restricted patterns of interest that is abnormal either in intensity or focus intensity or focus

apparently inflexible adherence to specific, non-functional apparently inflexible adherence to specific, non-functional routines or rituals routines or rituals

stereotyped and repetitive motor mannerisms (e.g., hand or stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body finger flapping or twisting, or complex whole-body movements) movements)

persistent preoccupation with parts of objectspersistent preoccupation with parts of objects

Asperger’s DisorderAsperger’s Disorder (C) The disturbance causes clinically significant (C) The disturbance causes clinically significant

impairment in social, occupational, or other impairment in social, occupational, or other important areas of functioning. important areas of functioning.

(D) There is no clinically significant general delay (D) There is no clinically significant general delay in language (e.g., single words used by age 2 in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years, communicative phrases used by age 3 years) years)

(E) There is no clinically significant delay in (E) There is no clinically significant delay in cognitive development or in the development of cognitive development or in the development of age-appropriate self-help skills, adaptive behavior age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity (other than in social interaction), and curiosity about the environment in childhood. about the environment in childhood.

(F) Criteria are not met for another specific (F) Criteria are not met for another specific Pervasive Developmental Disorder or Pervasive Developmental Disorder or Schizophrenia.Schizophrenia.

Pervasive Developmental Pervasive Developmental Disorder-NOS (299.80)Disorder-NOS (299.80)

This category should be used when there is a This category should be used when there is a severe and pervasive impairment in the severe and pervasive impairment in the development of reciprocal social interaction or development of reciprocal social interaction or verbal and nonverbal communication skills, or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities when stereotyped behavior, interests, and activities are present, but the criteria are not met for a are present, but the criteria are not met for a specific Pervasive Developmental Disorder, specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder. For example, this Avoidant Personality Disorder. For example, this category includes category includes atypical autismatypical autism --- --- presentations that do not meet the criteria for presentations that do not meet the criteria for Autistic Disorder because of late age of onset, Autistic Disorder because of late age of onset, atypical symptomatology, or subthreshold atypical symptomatology, or subthreshold symptomatology, or all of these. symptomatology, or all of these.

Parents of children with Parents of children with ASDASD

http://www.autismspeaks.org/sponsohttp://www.autismspeaks.org/sponsoredevents/autism_every_day.phpredevents/autism_every_day.php

Impact on the familyImpact on the family SocialSocial FinancialFinancial Everyday routinesEveryday routines

Variable experiences based on an Variable experiences based on an individual child and his/her individual child and his/her strengths and weaknessesstrengths and weaknesses

Anecdotal StoriesAnecdotal Stories(www.Autismspeaks. org)(www.Autismspeaks. org)

Individuals with AutismIndividuals with Autism http://www.autismspeaks.org/video/index.http://www.autismspeaks.org/video/index.

phpphp How people with autism see the worldHow people with autism see the world Life of Adults with AutismLife of Adults with Autism

Temple Grandin “Autism the way I see it”Temple Grandin “Autism the way I see it” Different types of thinking in autismDifferent types of thinking in autism

1.Visual thinking - Thinking in Pictures, like mine1.Visual thinking - Thinking in Pictures, like mine2. Music and Math thinking2. Music and Math thinking3. Verbal logic thinking 3. Verbal logic thinking

Play to strengths to be most effectivePlay to strengths to be most effective http://autisticsavant.blogspot.com/2007_0http://autisticsavant.blogspot.com/2007_0

5_27_archive.html5_27_archive.html

Story from a Teenager Story from a Teenager with ASDwith ASD ““The characteristics of people with Asperger's are the perfect ones The characteristics of people with Asperger's are the perfect ones

to make obtaining friends difficult. Asperger's Syndrome is part of to make obtaining friends difficult. Asperger's Syndrome is part of a spectrum of autistic disorders, all linked by a level of non-a spectrum of autistic disorders, all linked by a level of non-communication. At the lowest level, we have cases like my brother communication. At the lowest level, we have cases like my brother Eric, a person trapped in a void where communication is only at Eric, a person trapped in a void where communication is only at the most rudimentary level, about the level of a non-expressive the most rudimentary level, about the level of a non-expressive two or three year old. Then among several forms at the highest two or three year old. Then among several forms at the highest level, we have Asperger's syndrome. Those with Asperger's often level, we have Asperger's syndrome. Those with Asperger's often suffer from a plethora of symptoms. The most prominent ones are suffer from a plethora of symptoms. The most prominent ones are difficulty with reading people's body language, a singular interest difficulty with reading people's body language, a singular interest in a subject or several subjects (from my own life, I have one major in a subject or several subjects (from my own life, I have one major interest in rock music, compulsively looking for new reviews and interest in rock music, compulsively looking for new reviews and obsessing over the best quality of sound to listen to them), a slight obsessing over the best quality of sound to listen to them), a slight monotone voice, struggling with proper body distance, and a monotone voice, struggling with proper body distance, and a tendency to use a vocabulary that is of a slightly higher tendency to use a vocabulary that is of a slightly higher sophistication than most people would use such as when I employ sophistication than most people would use such as when I employ words like vitriolic, inundate, smorgasbord, plethora, words like vitriolic, inundate, smorgasbord, plethora, paraphernalia, and others of that variety. While obviously every paraphernalia, and others of that variety. While obviously every person with the syndrome may not experience each and every person with the syndrome may not experience each and every single trait, I have experienced all of these symptoms to some single trait, I have experienced all of these symptoms to some degree. Couple that with a fairly shy personality, a shyness that degree. Couple that with a fairly shy personality, a shyness that may or may not have anything to do with Asperger's Syndrome, may or may not have anything to do with Asperger's Syndrome, and I am often left feeling like everyone sees me as being quiet and I am often left feeling like everyone sees me as being quiet and not worth talking to.”and not worth talking to.”

(Autismspeaks.org)(Autismspeaks.org)

Stereotypes about ASDStereotypes about ASD

Head bangingHead banging Hand flappingHand flapping Non-communicativeNon-communicative Non-verbalNon-verbal ““own world”own world”

How is Autism How is Autism Diagnosed?Diagnosed?

Autism Diagnostic Observation Schedule Autism Diagnostic Observation Schedule (ADOS; Lord et al)(ADOS; Lord et al)

Autism Diagnostic Interview-Revised (ADI-Autism Diagnostic Interview-Revised (ADI-R; Rutter et al)R; Rutter et al)

Social Communication Questionnaire (SCQ; Social Communication Questionnaire (SCQ; Rutter et al)Rutter et al)

Childhood Autism Rating Scale (CARS; Childhood Autism Rating Scale (CARS; Schopler et al)Schopler et al)

Clinical judgment plays a HUGE roleClinical judgment plays a HUGE role What are the dangers of this?What are the dangers of this? Potential differential diagnoses (type of Potential differential diagnoses (type of

language/communication disorder, OCD, anxiety language/communication disorder, OCD, anxiety disorder)disorder)

Benefits of Early Benefits of Early DiagnosisDiagnosis

Treatment and intervention Treatment and intervention effectivenesseffectiveness

Skill acquisitionSkill acquisition exposureexposure

Types of Types of Treatments/InterventionsTreatments/Interventions

Interpersonal Relationship Intervnetions Interpersonal Relationship Intervnetions and Treatmentsand Treatments

Skill-Based Interventions and TreatmentSkill-Based Interventions and Treatment Cognitive Interventions and TreatmentCognitive Interventions and Treatment Physiological/Biological/Neurological Physiological/Biological/Neurological

Interventions and TreatmentInterventions and Treatment Other Interventions, Treatments and Other Interventions, Treatments and

Related AgentsRelated Agents

Interpersonal Interpersonal RelationshipRelationship

Social-affective interpretation of ASDSocial-affective interpretation of ASD Need for people with ASD to express Need for people with ASD to express

attachments to others appropriatelyattachments to others appropriately Seek to facilitate affect, attachment, Seek to facilitate affect, attachment,

bonding, sense of relatednessbonding, sense of relatedness Holding Therapy (not recommended)Holding Therapy (not recommended) Developmental, Individual-Difference Developmental, Individual-Difference

Relationship Based Model (Floortime; Relationship Based Model (Floortime; www.icdl.com)www.icdl.com)

Skill-BasedSkill-Based Most common methods used by schoolsMost common methods used by schools Intent is to develop and support functional Intent is to develop and support functional

demonstration of specific skills rather than demonstration of specific skills rather than to facilitate bondingto facilitate bonding

Target specific skills to teach to improve Target specific skills to teach to improve functioning in specific areasfunctioning in specific areas Picture Exchange Communication System Picture Exchange Communication System

(PECS)(PECS) Facilitated Communication (not recommended)Facilitated Communication (not recommended) Assistive TechnologyAssistive Technology Applied Behavior Analysis (Scientifically Based Applied Behavior Analysis (Scientifically Based

Practice)Practice) TEACCHTEACCH

CognitiveCognitive

Teaching individuals with ASD to monitor Teaching individuals with ASD to monitor their own behavior and performance their own behavior and performance

Shift control from others to the Shift control from others to the individualsindividuals

Connection between thoughts, feelings Connection between thoughts, feelings and behaviorand behavior Social StoriesSocial Stories Social Decision Making StrategiesSocial Decision Making Strategies LEAP (Scientifically Based Practice)LEAP (Scientifically Based Practice)

Physiological/Biological/Physiological/Biological/NeurologicalNeurological

Address the neurological dysfunctions or Address the neurological dysfunctions or problems thought to exist at the core of ASDproblems thought to exist at the core of ASD

Alter way in which neurological system Alter way in which neurological system processes information, the manner in which processes information, the manner in which information is received, chemistry and information is received, chemistry and processes associated with sensations, processes associated with sensations, perceptions and emotionsperceptions and emotions Irlen Lenses (limited support)Irlen Lenses (limited support) Sensory integration (promising practice)Sensory integration (promising practice) Auditory Integration Training (limited support)Auditory Integration Training (limited support) Pharmacology (promising practice)Pharmacology (promising practice)

OthersOthers

Mercury: Vaccinations and Autism Mercury: Vaccinations and Autism (limited support)(limited support)

Gluten-Casein Intolerance (limited Gluten-Casein Intolerance (limited support)support)

Music therapy (limited support)Music therapy (limited support)

Controversies with Controversies with TreatmentsTreatments

Limited scientific supportLimited scientific support Treatments as a “cure”Treatments as a “cure” Decisions regarding financial Decisions regarding financial

resourcesresources Where does research money go?Where does research money go? Autism is all over the newsAutism is all over the news

Community ResourcesCommunity Resources

Center for Autism and Related Center for Autism and Related DisabilitiesDisabilities