1. Autism and Autism Spectrum Disorders
Professor Graham Martin OAM
Director Child and Adolescent Psychiatry
The University of Queensland

2. Autism
A severely disabling condition that develops in first 3 years of life
Occurs approx 1 in every births
More common in boys (4:1)
Features vary from child to child, and differ in severity from child to child
No influence from ethnic, racial, social factors, income, lifestyle or parental educational levels

3. Common Features Communication problems Limited Social Interactions
Both verbal and non-verbal, with relative lack of speech, repeated words, phrases or patterns
Limited Social Interactions
Poor eye contact and difficulty interacting
Difficulties expressing emotions
Poor perception of how others think and feel
Repetitive Behaviours
repeating words or actions
obsessively following routines

4. Causes of Autism Genetic
12 or more genes on different chromosomes may be involved
Genes may
make a person more susceptible to impact of (say) infection
directly cause specific symptoms
determine severity of symptoms

5. Likely Chromosomes and Genes
The X Chromosome
HOXA1
HOXD1
Gamma-amino-butyric acid (GABA) pathway genes
consensus that it is Polygenetic (>10)

6. Other Causes 24% of cases overlap other genetic medical disorders
Fragile X Syndrome
Tuberous Sclerosis, Phenylketonuria (PKU)
Rett Syndrome
Other possible causes
in utero rubella
encephalopathy
cytomegalovirus

7. Diagnostic Criteria
6 items; at least 2 from (1), 1 each from (2) & (3)
(1) Qualitative impairment in social interaction, as manifested by at least two of the following:
Marked impairment in the use of multiple non verbal behaviors such as eye- to- eye gaze, facial expression, body postures, and gestures to regulate social interaction.
Failure to develop peer relationships appropriate to developmental level
A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by lack of showing, bringing, or pointing out objects of interest)
Lack of social or emotional reciprocity

8. Diagnostic Criteria (2)
Qualitative impairments in communication as manifested by at least one of the following:
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)
In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.
Stereotyped and repetitive use of language or idiosyncratic language, or copying of language (Echolalia)
Lack of varied, spontaneous make- believe play or social imitative play appropriate to developmental level.

9. Diagnostic Criteria (3)
Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two of the following:
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.
Apparently inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole body movements or copying of movements (Echopraxia)
Persistent preoccupation with parts of objects.

10. Diagnostic Criteria
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age three years:
Social interaction
Language as used in social communication or
Symbolic or imaginative play
C. Not better accounted for by Rett disorder or childhood disintegrative disorder.

11. Sensory Changes
Overly sensitive to touch (may have a tactile defensiveness)
Under-responsive to pain
Senses may be affected to a lesser or greater degree
No real fear of dangers

12. Play Lack of social interaction in play - which is more solitary
Lack of spontaneous or imaginative play
Does not imitate others’ actions
Does not initiate pretend games
Sustained odd play

13. Behaviours Overactive or Passive
Temper tantrums for no apparent reason
May perseverate on a single item, idea, person
Apparent lack of common sense
May show aggression or violent behaviours
May injure themselves deliberately for no apparent reason
May spin objects, line things up, organize
Inappropriate attachment to objects
Unresponsive to normal teaching methods
Insistence on sameness; resists change in routine
Uneven gross/fine motor skills (may not can kick ball but can stack chairs)

14. Absolute Indications For ASD Assessment
No babbling, or pointing, or other gestures by 12 months
No single words by 16months
No 2-word spontaneous phrases by 24 months
any loss of any language
any loss of social skills at any age

15. Specific Screen for Autism
Full audiological assessment, lead screen if pica present
CHAT, MCHAT
Autism Screening Q
Australian Scale for Asperger’s Syndrome
then refer for intervention and autism specific assessment

16. Specific Autism evaluation Diagnostic Parental Interviews
Gilliam Autism Rating Scale (GARS)
Parent Interview for Autism
The Pervasive Developmental Disorders Screening Test ( PDDST)
Autism Diagnostic Interview- Revised (ADI-R)

17. Diagnostic Observation Instruments
The Childhood Autism Rating Scale (CARS)
The Autism Diagnostic Observation Schedule (ADOS)

18. Intervention There is no cure for autism.
Treatment and education approaches may reduce some challenges associated with the disability.
Intervention may lessen disruptive behaviours.
Education can teach self-help skills for greater independence.
Intervention needs to be tailored to the individual, and their family

19. Behaviour Therapy
Most widely used and successful method is intensive behavioural intervention (IBI)
“We believe that behavior modification carried out in systematic, highly individualized, daily programming is the best overall approach now available to persons with autism” (Graziano, )

20. Team Approach Speech therapy
Helps in developing communication skills which may include alternative forms of communication (sign language and the use of keyboards)
Occupational Therapy
Addresses specific needs for daily living

21. Team Approach
Art and music therapy can be used to increase communication skills, social interaction, and a sense of accomplishment.
Medication may be necessary to control behaviour or sleep
Dietary assessment is important - a balanced diet as far as possible but with extra vitamins and/or minerals. people with autism are more susceptible to allergies and food sensitivities than the average person. The most common food sensitivity in children with autism is to gluten and casein.

22. Autism Spectrum Disorder
May have to consider:
Autism
Asperger’s Syndrome (AS)
Tourette’s Syndrome (TS)
Landau Kleffner’s Syndrome (LKS)
Rett Syndrome
Attention Deficit/Hyperactivity Disorder (AD/HD)
Specific Learning Disabilities (SLD)
Childhood Disintegrative Disorder (CDD)
Prader Willi Syndrome
Fragile-X Syndrome
PKU
Hurler’s Syndrome
Cornelia de Lange Syndrome
William’s Syndrome

23. Asperger’s Syndrome Original report:
“Autistic Psychopathies in Childhood” (1944)
translated into English in 1980

24. Asperger’s Observations
Children
Find it difficult to ‘fit in’ socially
Have poor social use of language
Have limited ability to use and understand gestures and facial expressions
Use repetitive, stereotypical behaviors
Have abnormal fixations on certain objects/ areas of interest
Are vulnerable to teasing and bullying

25. Asperger’s Syndrome
A pervasive developmental disorder characterized by:
Impairment of two-way social interaction and general social ineptitude
Speech which is odd/pendantic, stereotyped in content, but which is not delayed
Adherence to rules, routines, rituals
Lack of social reciprocity
Limited non-verbal communication skills – little face expression or gestures
Generally equated with high functioning autism.

26. Distinctions between Asperger’s Syndrome and Autism
Children with autism exhibit a significant delay in language skills
Children with Asperger’s have only mild impairments or peculiar ways of using language

27. Diagnostic Features of Asperger’s
Social Interactions
Socially aloof, unconcerned
Inappropriate eye contact (but usually present)
Peer friendships occur, but may lack strategies to develop or maintain
Difficulty taking the perspective of another person
May often lack empathy
Blatantly honest or straight-forward even when not in their best interest
Tense and distressed when trying to cope

28. Social Communication Superficially perfect spoken language
May lack voice expression, difficulty interpreting different tones of voice
Difficulty interpreting and using non-verbal communication, body language, gestures, facial expressions
May take things in a very literal way
May fail to grasp implied meanings of language
May not easily grasp social rules or subtleties
May talk at length about topics that are of interest to only him/herself
Uses objects in an atypical fashion
Insists that others do things according to their own prescribed order and rules

29. Poor Problem Solving and Organizational Skills
Difficulties in…
Situations requiring “common sense”
organizing thoughts and abstract reasoning
Transitioning from one situation to another
Deficits in…
mental planning
Impulse control
Self monitoring
Strong desire for orderliness may delay achieving goals

30. Limited Interests and Preoccupations
May talk at length about topics that are of interest to only him/herself
Redirects conversations back to topics of interest even at risk of being ridiculed or shunned
Friends interested in similar things
Jobs in areas of interests

31. Pragmatic Disorder
Lack of understanding about the reciprocity of verbal and nonverbal communication
Decreased understanding and use of gestures
Decreased use of questions
Difficulty maintaining a conversation

32. Tests
Test of Pragmatic Language
Test of Problem Solving

33. Effective Strategies to Teach Pragmatic Language
Social Language Groups
Social Language Stories
Reciprocal Conversation with Therapist
Role Playing
Videotaping
Coaching During Social Times

34. Language Disorder Sometimes language learning is precocious
There must be words by 2 years and phrases by 3 years
Style of learning language may be like an autistic child: echolalia, difficulty learning pronouns, difficulty understanding verbal explanations

35. Tests Preschool Language Scale-4 Clinical Evaluation of Language
The Test of Language Development
Expressive One Word Vocabulary Test
Peabody Picture Vocabulary Test

36. Language Test Scores Show an Unusual Profile
Highest scores are in expressive vocabulary,
Next highest are in receptive vocabulary,
Next are in grammatical structures,
Often below average are tests of problem solving,
Lowest area is in pragmatic language skills.

37. Teach Flexibility COMPROMISING
If you compromise, you are doing the right thing.
Compromise means letting the other person have his way.
If you do this, you get a bonus point.

38. Teach Flexibility BEING BOSSY
Often turn other children off by being bossy, controlling and judgmental.
So, they lose a point (or a turn) for teasing criticizing another child.
Alternately, they get extra points for saying something nice.
If the child starts out saying several nice things, he is not teased as much.

39. Resources