Autism Spectrum Disorder

Autism is primarily a disorder of social interaction. People with autism struggle to make and keep friends. Their struggle with “social reciprocity” means they do not understand the give-and-take of social relationships. They struggle to communicate, and social interactions tend to feel awkward. Individuals with autism might not get jokes, analogies, or metaphors. When an adult says, “button your lip,” a child with autism might think, “uh, no thank you. That would hurt.” Humorous and sarcastic comments are often misunderstood. Some individuals with autism sound a little odd when they talk. For example, they might use lots of big words or sound very formal. An individual with autism might use a robotic, sing-song, or high-pitched voice. People with autism tend to have favorite topics. They might go on and on about their favorite video game or movie, sometimes inserting quotes from that movie in their everyday speech. For example, a child might say “to infinity and beyond” after every question on a test. Often, children with autism do not play the way other children do. They might struggle to take on the part of a doll or an action figure. People with autism may need to be reminded to tune in with the conversation or to come join others in a game.

Children who have significant problems in this area may have any of the following potential disability. *Note, this does not serve as a diagnosis in any way. See Where to Go for Help With Autism for professionals who can diagnose or provide a referral.

An autism spectrum disorder is a neurodevelopmental disability that is present from birth but may not be detected and diagnosed until 12 to 30 months of age. That is, people are born with their autism, but sometimes the symptoms are not evident until much later. Studies show that motor delays may be the first precursors as they have been identified in sibling studies at ages as young as 6 months old. This motor delay means that the first signs of autism might be that the child does not sit up, crawl, or walk as expected developmentally. At times, autism is not diagnosed until much older, even into adulthood. Autism is characterized by social communication deficits and restricted or repetitive interests and behaviors. People with autism struggle to form relationships with other people and tend to be hyper-focused on, even obsessed with, certain interests, ideas, or behaviors. Autism is a disability that impacts a variety of individuals over a broad spectrum of characteristics and traits, hence the term Spectrum. The old adage, “if you have met one person with autism, you have met one person with autism” highlights the wide range of symptom profiles. Some individuals with autism may have cognitive (intellectual) and language (communicative) deficits. Some individuals may be nonverbal or may have trouble communicating their wants and needs. Other individuals with autism may be extremely bright or gifted (IQ scores that fall in the top 5% of individuals). Some people with Autism may have exceptional fluid reasoning (solving new problems), visual spatial skills (seeing how objects fit together) or verbal knowledge.

The primary deficits in autism are in social communication. Social communication is a term that refers to social perspective taking, social emotional awareness, conversational speech and communication with others.

Social Reciprocity. An individual with autism may have difficulty sustaining a reciprocal back-and-forth conversation about an area that he or she finds uninteresting. When an individual with autism is interested in the topic, he or she may monologue on that topic. For example, he or she may provide lots of information in a professorial manner without allowing for a back-and-forth exchange and dialogue between two people. As individuals with autism have trouble taking others’ perspectives, they don’t always know how to engage and interact with other people in a way that is smooth and socially appropriate.

Restricted or Repetitive Behaviors and Interests. The other component of an Autism Spectrum Disorder diagnosis is the restricted and repetitive behaviors and interests. Many people think of more obvious behaviors, such as rocking, hand flapping, avoiding gaze and completing repetitive body movements. In reality, these behaviors can be much more subtle. A person with restricted interests might talk about nothing but dinosaurs, might know every type of Lego that Mattel has created or might tell you everything about World War II. A repetitive behavior could include wiggling one’s pencil or chewing on the sleeves of a shirt or flipping fingers back and forth ever so subtly. Individuals who speak very formally or use language in a manner that is stilted or isn’t appropriate to the situation also meet the criteria for autism even without some of the more obvious traits.

Sensory Sensitivities. Another characteristic of restricted and repetitive behavior relates to sensory sensitivities or differences in sensory processing, such as smelling or licking things in a way that is unusual (e.g., licking a doll or smelling Play-Doh). Sensory challenges can also refer to extreme sensitivities to sounds, textures or smells. Individuals with autism tend to have different sensory perceptive systems. When your child covers his or her ears and moves away from sound, it’s not just a dramatic reaction. This behavior may in fact be evidence of a true difference in sensory perception. These differences can make certain experiences quite uncomfortable.

Severity Levels. Autism is characterized as having three different severity levels. Severity level 1 is the mildest level. Traits are subtle and may not be obvious to those who are not trained to diagnose, but the challenges in social settings are significant enough to lead to a referral. Severity level 2 is noted for individuals who might have more challenges communicating, speaking in simple sentences, and may be more obviously impaired. Severity level 3 is for individuals who have significant deficits in language and communication, adaptive skills and social interaction.

It was mentioned earlier that children can be diagnosed with autism as young as 12 months of age. It is important to explore and consider an assessment as concerns arise. The services that diagnosed young children qualify for can enable them to make great gains and strides in developing the social reciprocity, social skills, and emotional awareness that these children will need as they get older. Many children make significant progress, and some do make a recovery, obtaining what we call “Optimal Outcomes.” This term means that after treatment the child’s skills are approximately on track with peers and that the child no longer meets criteria for the disorder. Taking all this assistance into consideration, it is important to assess children at a young age and to determine whether services are warranted.

The Autism Diagnostic Observation Schedule (ADOS-2) is a semi-structured measure that can be administered to individuals from 12 months through adulthood. Clinicians who administer the ADOS-2 train extensively on the measure, co-score the measure with other more experienced clinicians, and usually complete a 3 to 4 day workshop. Tasks and activities give the evaluator a chance to determine the child’s social interaction style, creativity, ability to pretend and ability to play when these abilities are directed in the examiner’s style. The measure assesses emotional awareness, the ability to express and explain one’s own emotions, and the ability to talk about other people’s perspectives and describe relationships with important people in the individual’s life. The ADOS-2 also provides a scoring algorithm that leads to a score that is indicative of autism or not. Importantly, your child’s score on this measure is taken in context with parent rating scales, teacher rating scales, observations during testing, and self-report to get a complete assessment of your child. It is also necessary to have a comprehensive developmental history and to conduct a clinical interview. This piece could be completed using the Autism Diagnostic Interview Schedule Revised (ADI-R) or could be obtained through a clinical interview. Rating scales from parents and teachers may include the Vineland, the BASC-3, the SRS and/or the SCQ.

Assessment. Looking across measures at various symptoms, the clinician is going to determine whether or not the symptoms are significant and what may explain the symptoms. For example, a child may have difficulty pretending or using creative play skills because of anxiety and insecurity. If this difficulty is the only symptom present, then perhaps autism is not the issue. If, however, a child can talk excessively about a topic and uses stereotyped and repetitive speech in addition to having challenges with creativity, autism may be the appropriate diagnosis. It is important to have someone with expertise in autism complete the assessment if some of your concerns revolve around sensory challenges, social skills and reciprocal interactions with others.

WHERE TO GO FOR HELP WITH AUTISM

A referral for a comprehensive neuropsychological evaluation is most appropriate when concerns are suspected about autism. This type of assessment includes an evaluation of your child’s social communication as well as his or her cognitive ability, adaptive skills, language skills, social skills and sensory processing. Other areas may be evaluated as concerns arise. Referrals may include ABA therapy, Psychotherapy, speech therapy, occupational therapy, parent consultations, an IEP or a Section 504 plan.

Applied Behavior Analysis (ABA) Therapy. ABA therapy refers to behavioral therapy that is used to increase communicative behaviors or decrease problem behaviors. A therapist often comes into your home or preschool to do this therapy and takes extensive data on your child’s progress.

Psychotherapy. Psychotherapy occurs in an office with a psychologist or therapist and is often focused on improving coping skills, social skills, developing strategies for social interaction and taking other’s perspectives. The psychotherapy modality that has the most research for treating autism is cognitive behavioral therapy (CBT). Some smaller children may benefit from a modified play therapy approach that also utilizes CBT principles.

Speech Therapy. Speech therapy may be recommended to increase pragmatic language or if Speech & Language articulation challenges or problems are present. It is great to have your speech therapist collaborate with any other therapist so that everyone is working together to meet your child’s needs.

Occupational Therapy. Occupational therapy addresses sensory issues and challenges and also any deficits in fine motor skills. Occupational therapy can be very helpful for some children with autism and a referral may be an option if your child has significant sensory deficits.

Parent Consult. Parent consultation can follow an ABA or a Family Systems model and can provide guidance to parents on strategies to use and principles of reinforcement. Consultation can also focus on the parent’s experience and emotional well-being.

School Services. School-based supports like an IEP or a Section 504 plan can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report to any of these professionals will help them to get an understanding of your child. It will be important to think about how these therapies fit together and about how different skills are being built and addressed to best support your child.

Psychiatrist. Sometimes children with autism spectrum disorders do take medication prescribed by a psychiatrist. This medication is usually prescribed to treat ancillary symptoms, such as behavior, attention, or perhaps anxiety or depression. Medications can be quite effective for these other symptoms, but they do not address the core symptoms of autism, social communication and restricted and repetitive patterns of behavior or interests.

Although autism presents a myriad of challenges to children and families, it is reasonable to have hope. Deborah Fein’s research out of the University of Connecticut finds that as many as 20% of children who are diagnosed young and provided treatment and services may no longer meet criteria for the diagnosis at a later assessment. The other 80% of children can make considerable gains, particularly if they have strengths in language and adaptive skills. Children with autism often can be educated effectively in the general education classroom, although different levels of support may be needed based on the child’s symptoms. Taken together, it is valuable to obtain a diagnosis and to engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see growth in skills, the ability to form friendships, and the potential to live a fulfilling life.

• Presence
• Parallel play
• Interacting
• Conversation
• Empathy
• Intimacy
• Repetitive behavior
• Joint attention
• Adaptive skills
• Functional communication
• Toilet training
• Hygiene
• Sleep problems
• Manners
• Disordered eating
• Motor Planning
• Coordination
• Body space awareness
• Central coherence
• Sensory sensitivity
• Sensory seeking
• Memory for faces
• Memory for names
• Flexibility
• Compulsions
• Social anxiety
• Perseverating
• Anti-social behavior
• Rigid behavior
• Bossy behavior

[1] Kroncke, Anna P., & Willard, Marcy & Huckabee, Helena (2016). Assessment of autism spectrum disorder: Critical issues in clinical forensic and school settings. Springer, San Francisco.

Springer: http://www.springer.com/us/book/9783319255026

Amazon: https://www.amazon.com/Assessment-Autism-Spectrum-Disorder-Psychological/dp/3319255029/

[2] Madrigal, Stephanie & Winner, Michelle G. (2008). Superflex. A superhero social thinking curriculum.

Amazon: https://www.amazon.com/Superflex-Superhero-Social-Thinking-Curriculum/dp/0979292247/

[3] Koegel Autism Center, University of California at Santa Barbara.

Link: education.ucsb.edu/autism 

[4] UCSB PEERS Clinic.

Link: https://www.semel.ucla.edu/peers

[5] Jed Baker behavior and social skills books.

Link: www.jedbaker.com 

[6] Koegel, Lynn Kern & LaZebnik, Claire (2010). Growing up on the spectrum: A guide to life, love and learning for teens and young adults with autism and Asperger’s.

Amazon: https://www.amazon.com/Growing-Up-Spectrum-Learning-Aspergers/dp/0143116665

[7] McMahan, Ian (2009). Adolescence.

Amazon: https://www.amazon.com/Adolescence-Ian-McMahan/dp/0205482325

[8] Newman, Barbara M. & Newman, Phillip R. (2014). Development through life: A psychosocial approach.

Amazon: https://www.amazon.com/Development-Through-Life-Psychosocial-Approach/dp/1285459962

[9] Berns, Roberta M. (2010). Child, family, school, community: Socialization and support.

Amazon: https://www.amazon.com/Child-Family-School-Community-Socialization/dp/1305088972/

[10] Ozonoff, Sally & Dawson, Geraldine & McPartland, James C. (2014). A parent’s guide to high functioning autism spectrum disorder: How to meet the challenges and help your child thrive.

Amazon: https://www.amazon.com/Parents-High-Functioning-Autism-Spectrum-Disorder/dp/1462517471/ 

[11] Trawick-Smith, Jeffrey (2013). Early childhood development: A multicultural perspective.

Amazon: https://www.amazon.com/Early-Childhood-Development-Multicultural-Perspective/dp/0132868598/ref=dp_ob_title_bk

[12] Mendler, Allen (2013). Teaching your students how to have a conversation.

Amazon: http://www.edutopia.org/blog/teaching-your-students-conversation-allen-mendler

Children’s books on social skills:

Brown, Laurie Krasny & Brown, Marc (2001). How to be a friend: A guide to making friends and keeping them (Dino life guides for families).

Amazon: https://www.amazon.com/How-Be-Friend-Friends-Families/dp/0316111538/

Cooper, Scott (2005). Speak up and get along!: Learn the mighty might, thought chop, and more tools to make friends, stop teasing, and feel good about yourself.

Amazon: https://www.amazon.com/Speak-Up-Get-Along-Yourself/dp/1575421828/

Cook, Julia (2012). Making Friends is an art!: A children’s book on making friends (Happy to be, you and me).

Amazon: https://www.amazon.com/Making-Friends-Art-Childrens-Paperback/dp/B00DCVWAJI/

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