Austism Spectrum

Disorder
DSM-5
• A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history
1. Deficits in social-emotional reciprocity;
2. Deficits in nonverbal communicative behaviours used for social interaction;
3. Deficits in developing, maintaining and understanding relationships.
B. Restricted, repetitive patterns of behaviour, interests or activities as manifested by at least two
of the following, currently or by history:
1. Stereotyped or repetitive motor movements, use of objects, or speech;
2. Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or
nonverbal behaviour;
3. Highly restricted, fixated interests that are abnormal in intensity or focus;
4. Hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the
environment.
C. Symptoms must be present in the early developmental period (but 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 in social, occupational or other important
areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental
disorder), or global developmental delay
Neurological Illness Characterized
by Social, Communication and
Behavioral Deficits
• Motor (movement) skills develop in a more normal fashion
• Symptoms of autism are not present from birth. Most children with
autism appear to develop typically during the first year of life.
Symptoms of autism become apparent between eighteen and thirty-
six months of life. Forty percent of cases are diagnosed by age three
Communication Deficits
• Communication deficits include people with autism's difficulty using
spoken language and gestures, inability to initiate and sustain
appropriate conversation and use of inappropriate, repetitive
language.
• Sound Perception Deficits: Children with autism do not respond to
sound appropriately. For example, many do not respond when others
call their names. They may cry inappropriately as a reaction to normal
sounds, or they may be completely indifferent to unusual or loud
noises. Parents tend to notice these oddities of perception first,
before any other symptoms of autism are identified.
• Language Development Deficits. Children with autism have great difficulty
understanding spoken words. They have trouble understanding that words relate to
objects and activities. Abstract words are extremely challenging because they are not
linked to something tangible that can be inspected and pointed to. For example, the
word "from" has no meaning to autistic people. Without concrete visual connections
to objects or activities, words are nearly impossible for them to understand
• Echolalia
• Nonverbal forms of language are also negatively affected by autism. Children with
autism have great difficulty understanding nonverbal forms of communication. They
don't recognize the meaning inherent in other people's facial expressions, for
example, and they don't learn to use facial expressions to convey meaning. Children
with autism often have blank expressions or they make inappropriate expressions
Social Deficits and Empathy
Deficits.
• Social deficits manifest as people with autism's tendency towards
isolation, difficulty making eye contact, inability to develop appropriate
peer relationships and apparent lack of empathy.
• Compounding their communication difficulties, many children with
autism also show profound empathy deficits. They develop only a very
limited appreciation, or no appreciation at all, of other people's feelings
and ideas. They don't recognize and respond to faces as do normal
children, and they thus do not learn that each face belongs to an
individual separate person. To the children with severe autism, their
own feelings and ideas are the only feelings and ideas that appear to
exist.
• Behavioral Deficits. In addition, children with autism may exhibit odd
emotional behavior that is not easily understood by others. children
with autism's social fears can manifest as compulsive behaviors
and/or aggression. Many require order and routine to be maintained
as they transition from one activity to another.
Physical Deficits
• Physical deficits take the form of stereotyped repetitive movements and
unusual body posturing.
• Sensory Deficits. Children with autism tend to have extreme reactions to
sensory stimulation. Their senses may become hypersensitive (over-sensitive)
or hyposensitive (under-sensitive). Hypersensitive children find themselves
overloaded with even moderate levels of sensation, and work to block out
sensory inputs such as light, sound and touch. Hyposensitive children, on the
other hand, are not stimulated enough by normal sensory inputs and typically
seek out extra stimulation. To illustrate, children who are hypersensitive to
touch sensations may tantrum when they are touched, while hyposensitive
children may crave and seek out strong hugs that provide deep pressure.
• Gross Motor Deficits. Children with autism commonly have difficulty
walking naturally. For instance, they may "toe-walk", stepping only on
the front portion of their feet, in place of a normal relaxed walking
pattern. This practice may lead to irregular muscle development in
the calves.
• Fine Motor Deficits. Children with autism frequently show developmental delays in
developing fine motor skills. While some children enjoy fine motor activities like
lacing their shoes or coloring, others become very agitated when directed to
complete fine motor activities. Writing is especially troublesome for some children.
Many choose to use a keyboard rather than writing things out by hand.
• Children with autism with hyposensitivities to sensory stimulation constantly feel
under-stimulated, and engage in a variety of self-stimulation behaviors such as hand
flapping or rocking just to help themselves feel more 'normal'. Likewise,
hypersensitive children may engage in self-stimulation as a means of blocking out
otherwise overwhelming environmental stimulation. In either case, children with
autism find it aversive to be prevented from self-stimulating by the need to
concentrate on tasks and are likely to resist efforts to motivate them to complete such
tasks.
Developmental Deficits
• Problems with Figurative Language.
• Stilted, Scripted Conversation. In addition to difficulty with figurative
language, people with mild autism show other communication
deficits. Their conversation tends to come across as "scripted",
pedantic, artificial or somehow inauthentic or unspontaneous.
• Social Isolation
Special Autistic Abilities (Savant
Behavior)
• Savants are rare even in the population of people with autism. Only
ten percent of individuals with autism ever show any signs of savant
talents.
• Rain man (Dustin Hoffman)
Autism is not Mental Retardation or
a Lack of Intelligence
• As intelligence is communicated through skillful use of language,
people with autism's social and communication deficits can easily make
them appear unintelligent. This is not necessarily the case, however.
People with autism vary in intelligence more or less as normal people
do, only their language and social problems can make that intelligence
harder to discover.
• People with autism's ritual preoccupations and behaviors are similar to
the obsessions and compulsions characteristic of Obsessive Compulsive
Disorder (OCD), and with the need for order and perfection
characteristic of Obsessive Compulsive Personality Disorder (OCPD).
Genetic Contributions.
• Specifically, abnormalities noted on chromosomes 2, 3, 5, 7 and 15
are associated with a heightened risk for autism. Other research
suggests that mutations on the X sex chromosome (supplied by the
mother) are associated with heightened autism risk. If this latter
research finding turns out to be true, it would help explain why more
males develop autism than females.
Environmental Contributions.
• A wide variety of environmental stressors, including various
environmental pollutants, toxins, viruses and the like, have been
proposed to be capable of performing such an activating role.
Research on the environmental causes of autism is ongoing and new
developments continue to emerge.
Vaccines and Mercury Poisoning.

• One particularly controversial theory suggested that autism may be

created in vulnerable people through exposure to a mercury compound
(Thimerosal) formerly used as a preservative in normal childhood
vaccines such as the MMR (Measles, Mumps and German
Measles/Rubella) vaccine. The supposed link between autism and
vaccination was fueled by simple but inconclusive observation1. First,
many children developed symptoms of autism during the same period
of time as they received MMR vaccines. Second, mercury is a known
toxic compound that can result in neurological damage in children and
adults that appears symptomatically similar to autism.
Mirror Neurons

• . A system of "mirror neurons" located in various parts of human and

animal brains have been identified that become activated equally well
when people do something such as wave their hand or smile, and
when they simply observe those things being done. Because mirror
neurons do not discriminate between performed and viewed actions,
they are very likely the neurological means through which animals
(including people) are able to recognize the intentions of other
animals. For example, a set of mirror neurons will activate when you
smile, and also when you observe someone else smiling.
Symptoms Of Autism

• A total of six (or more) items from (1), (2), and (3), with at least two
from (1), and one each from (2) and (3):
• (1) qualitative impairment in social interaction, as manifested by at
least two of the following: (a) marked impairment in the use of multiple
nonverbal behaviors, such as eye-to- eye gaze, facial expression, body
postures, and gestures to regulate social interaction (b) failure to
develop peer relationships appropriate to developmental level (c) a lack
of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g., by a lack of showing, bringing, or pointing out
objects of interest) (d) lack of social or emotional reciprocity
• (2) qualitative impairments in communication, as manifested by at
least one of the following: (a) delay in, or total lack of, the
development of spoken language (not accompanied by an attempt to
compensate through alternative modes of communication such as
gesture or mime) (b) in individuals with adequate speech, marked
impairment in the ability to initiate or sustain a conversation with
others (c) stereotyped and repetitive use of language or idiosyncratic
language (d) lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level
• (3) restricted, repetitive, and stereotyped patterns of behavior,
interests, and activities as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal either in intensity or
focus (b) apparently inflexible adherence to specific, nonfunctional
routines or rituals (c) stereotyped and repetitive motor mannerisms
(e.g., hand or finger flapping or twisting or complex whole-body
movements) (d) persistent preoccupation with parts of objects
• B. Delays or abnormal functioning in at least one of the following
areas, with onset prior to age 3 years: (1) social interaction (2)
language as used in social communication (3) symbolic or imaginative
play.

• C. The disturbance is not better accounted for by Rett's disorder or

childhood disintegrative disorder.
• The child does not babble or coo by twelve months.
• The child does not use gestures to communicate and the child does not wave.
• The child does not grasp objects or point to objects by twelve months.
• The child does not say single words by the age of sixteen months and does not say two-word
phrases on his or her own by 24 months.
• The child has a loss of any language or social skills at any age.

• Typically, diagnosis unfolds in the following manner. Parents or guardians become concerned
about their child's atypical behaviors or developmental delays, and take their child to see a
pediatrician who conducts a medical exam, and notices symptoms consistent with a PDD. The
pediatrician will then often refer the family to a specialist child psychiatrist or psychologist for
further assessment.
Screening tools
Parent-Administered Tests
• Pervasive Developmental Disorders Screening Tests (I and II).
• The Ages and Stages Questionnaire.
• The Child Development Inventories.
• The Parents' Evaluation of Developmental Status.
• Social Communication Questionnaire.
Specialized Tests
• Checklist for Autism in Toddlers (CHAT) and the Childhood Autism Rating Scale (CARS).
• Checklist for Autism in Toddlers: The Checklist for Autism in Toddlers (CHAT) is a screening test that a pediatrician
may use to determine if she should send a child on to a specialist psychologist or psychiatrist for further
assessment. The CHAT is designed to be used with children who are at least eighteen months old. It is filled out by
an examiner who answers questions based on personal observation of subject children, and on parental or guardian
reports. The test addresses children's social development and also tests their ability to simultaneously focus on an
object that another person is also paying attention to (joint attention). It considers children's ability to use
imaginative play skills and their ability to point to objects on command. It measures eye contact and social
reciprocity. The examiner considers her own observations and the parents' responses to nine questions concerning
their child's behavior to determine whether the child in question appears to be at risk for a PDD like autism.

• The push for earlier and earlier autism diagnoses has resulted in the M-CHAT, a shortened version of the CHAT
designed to be filled out by parents. The questionnaire focuses on stereotyped movements, social reciprocity and
imaginative play. Parents are directed to seek professional attention if their child's answers suggest symptoms of
autism may be present. The M-CHAT is a relatively new instrument and as such is still under development and
evaluation.
The Childhood Autism Rating Scale.
• The Childhood Autism Rating Scale (CARS) consists of a list of fifteen questions
probing five diagnostic domains relevant to autism spectrum disorders. The
five domains include: relating to others, body use, adaptiveness to change,
listening response and verbal communication. The test examiner answers
these questions after observing the child subjects' behavior, reviewing reports
concerning the child's behavior, and interviewing the parents, and then
computes a CARS score which is compared to normative data that describe
how typical children and children known to have PDD diagnoses score on the
test. A child's CARS score thus helps examiners to know whether that child's
behavior is most similar to a typical child's behavior, a child with mild autism,
or a child with severe autism. CARS does not diagnose autism, but it does help
identify who acts like an autistic person.
Brigance Screens.
• The Brigance Screens address developmental milestones in twelve-
month increments. There are a series of tests that are designed to
measure an infant's or toddler's development in communication and
language skills, social interactions, motor skills and self-help skills. The
tests are segregated into four age-based categories: birth to twenty-
three months; two to two-and-a-half years; three to four years; and
kindergarten to first grade. Each age category is further subdivided into
twelve-month increments. Test results are compared against normative
data, and the results of those comparisons, which indicate degrees of
age-corrected developmental delay within measured skill domains,
indicate whether further evaluation and diagnosis might be appropriate.
Bayley Scales of Infant and Toddler
Development.
• The Bayley Scales (now in their third edition) are not simple questionnaires, but rather norm-referenced objective tests of infant and
toddler development. They require expert administration by a trained child psychologist or psychometrician and cannot be administered
or interpreted directly by parents or pediatricians. They are appropriate for use with children between one month and forty-two months
old.

• The Bayley Scales are designed to be age-sensitive. Test items are organized so as to be age appropriate for each child being tested. The
examiner determines the subject child's age, and then uses set test items previously determined to be appropriate based on three-
month developmental intervals.

• The individual tests comprising the Bayley Scales II cover three different developmental domains: behavioral, mental and motor skills.
The behavioral part of the Scales measures how well children can attend to tasks, maintain emotional control and tolerate the testing
process. The mental Scales track children's language development, problem-solving skills, memory and perception. Finally, the motor
skills portion of the Scales assess children's posturing, muscle control, gross motor skills and fine motor skills.

• Scores from the Bayley Scales are used to construct a customized infant development charts for each test subject that places the
subject's development in the context of average same-age children's development. Children who demonstrate developmental delays are
seen to be impaired in reference to test norms which were created by administering the test to thousands of normal children of varying
ages, and varying conditions such as premature birth status, illness and other variables that might account for developmental delays
Wechsler Preschool and Primary
Scale of Intelligence.
• The Wechsler Preschool and Primary Scale of Intelligence, abbreviated as WPPSI, is one of the oldest intelligence tests designed
specifically to measure the cognitive abilities of preschoolers. The test yields Intelligence Quotient (IQ) scores, as well as subtest scores
yielding additional domain-specific information. It is a revision of the original Wechlsler Scale of Intelligence, created in the late 1960's
to measure IQ for children between four and seven years of age. The modern WPPSI, now in its third edition, is appropriate for
children between the ages of two and six. Only a specially trained child psychologist or psychometrician can administer the WPPSI.

• The WPPSI has been designed to measure a child's cognitive abilities without requiring the child to be able to read or write. The
language portion of the test is oral and focuses on the child's receptive and expressive language skills. The WPPSI also measures the
child's the child's ability to imitate and reason through block design and pattern completion subtests contained in the processing
performance section. The test also measures general language skills in receptive activities and object labeling activities.

• The WPPSI yields an overall "full-scale" IQ score, as well as separate verbal and performance IQ scores, and additional subtest scores,
each norm-referenced so as to indicate relative strengths and weaknesses in relation to average test scores of normal children of the
same age.

• The IQ score is critical for assessing whether a mental retardation diagnosis is reasonable. IQ scores are set so that their average is
always 100. Some 98% of children who take the test will achieve scores within 30 points plus or minus of that average figure. Scores
below 70 can be indicative of mental retardation.
Treatment
• There is no cure for autism or PDD diagnoses. They are chronic
lifelong conditions that can only be treated and moderated with
appropriate intervention. It is crucial to intervene as early as possible
when autism or another PDD is present, because (with the exception
of Asperger's disorder) these conditions interfere with normal
language development.
Behavioral And Communication
Approaches
• Speech and Occupational Therapy
• Picture Exchange Communication System (PECS)
• Applied Behavior Analysis
• Discrete Trial
• Fluency
• Sensory Integration
• Floortime
Medication

• Antidepressants and Anti-Anxiety Medications. Antidepressant drugs, generally of the Selective Serotonin Reuptake
Inhibitor (SSRI) variety, including brands like Zoloft, Luvox and Paxil, are sometimes prescribed to help autistic patients
reduce self-stimulatory behaviors, repetitive movements and tantrums. These same drugs are prescribed for people
with depression and some anxiety disorders (including obsessive-compulsive disorder) in other context.

• Psychotropic Medications. Commonly thought of as anti-psychotics, psychotropic medications are frequently used
to treat the symptoms of autism. They help reduce aggressive behaviors and repetitive movements and they have
been found to lessen social withdrawal in some cases. Popular brands prescribed today include newer medications
like Risperdal, Seroquel and Zyprexa. In other contexts these medicines are used to treat schizophrenia, and some
forms of depression.

• Stimulant Medications. Stimulant drugs such as those used to treat ADHD have been found useful for treating some
cases of autism. Drugs like Adderall and Ritalin, which are buffered forms of methamphetamine, a stimulant drug sold
on the street as "meth" or "crystal", are known to reduce hyperactivity and impulsiveness, in turn helping ADHD and
some autistic patients to concentrate better and remain on task longer.
Diet And Vitamins

• 1) the casein and gluten-Free diet, 2) vitamins B-12, A, D and C

supplements, and 3) cod liver oil.
Complementary Approaches

• Social Stories
• Son-Rise Program
• Relationship Development Intervention
• Therapeutic Animals
• Chelation
• Facilitated Communication
• Helping Families Cope
• Respite
• Wraparound Services