What is Autism? Autism is considered a spectrum disorder in which the individual exhibits “severe and pervasive impairments” in communication, social interaction, and/or presence of stereotyped behavior, interests, or activities. Diagnostic and Statistical Manual, 4 th Ed, TR (DSM-IV-TR; 2000) Highly Impacted High Functioning
DSM – IV Criterion Social Interaction Impairment in multiple nonverbal behaviors such as eye contact, facial expression, body language, and gestures. Failure to develop developmentally appropriate peer relationships. Lack of spontaneous seeking to share enjoyment, interests, or achievements with others. Lack of social or emotional reciprocity.
DSM – IV Criterion Communication Delayed or total lack of spoken language without compensating nonverbal communication strategies (e.g. pointing, gestures, or mime). Inability to initiate or sustain a conversation for those with adequate speech. Odd or repetitive use of language. Lack of developmentally appropriate pretend play or social play.
DSM – IV Criterion Restricted, Repetitive, and Stereotyped Behavior Patterns of interest that are either excessive, overly odd, or overly narrow. Inflexible adherence to specific nonfunctional routines and rituals. Odd and repetitive hand, finger, or complex whole body movements. Preoccupations with parts of objects.
DSM – IV Criterion Other Criterion Causes clinically significant impairment in academic, occupational, social, or other important areas. Age of onset prior to 3 years with regard to social interaction, social communication, or play skills.
DSM – IV Criterion For Autistic Disorder – Must have at least one impairment in all three categories and at least 6 impairments total. For Asperger’s Disorder – Must have at least two impairments in the social interaction category and one impairment in the restricted/repetitive behavior category. Must also have appropriately developed language, cognitive abilities, and self help skills. For PDD-NOS - Must have impairment in Social Interaction and either Communication or Restricted/Repetitive behavior
DSM – V Criterion Major Changes from DSM-IV Instead of three diagnostic categories (Autistic Disorder, Asperger’s Disorder, and PDD-NOS) there will now just be one diagnosis (Autism Spectrum Disorder). The three existing domains (Social Interaction, Communication, and Restricted/Repetitive Behavior) will be combined into two (Social Communication & Restricted/Repetitive Behavior). Specifiers will be made for level of support needed and other contributing factors. Sensory Sensitivity is now part of the criterion.
DSM – V Criterion Reasons for the changes Clinicians & researchers unable to distinguish between High Functioning Autism, Asperger’s Disorder, and PDD-NOS. Social and communication functioning interrelated. Language and intellectual delays not related to ASD. Criteria for PDD-NOS too vague. Service providers, governing agencies, and insurance companies designated level of support based solely on diagnosis (not on functional ability).
DSM – V Criterion Social Communication Deficits in Social-emotional Reciprocity. Deficits in nonverbal communication used for social interaction. Deficits in developing and maintaining developmentally appropriate relationships. All three areas must be met for ASD diagnosis.
DSM – V Criterion Restricted Repetitive Behavior Stereotyped or repetitive speech, motor movements, or use of objects. Excessive adherence to routines, ritualized verbal or nonverbal behavior patterns, or excessive resistance to change. Highly restricted, fixated interests that are abnormal in intensity and focus. Hypo or hyper-reactivity to sensory input or unusual interest in sensory aspects of environment. Must have at least 2 of 4 areas for ASD.
DSM – V Criterion Levels of Support Needed (Severity) Requires very substantial support Requires substantial support Requiring support Subclinical symptoms Normal variation
DSM – V Criterion Specifiers and Modifiers Possible specifiers of etiology include medical conditions such as Rett Syndrome, Fragile X Syndrome, or Mitochondrial Disease. Possible modifiers (important other factors) may include language or learning disorders, intellectual disability, seizures, motor tics, or Irritable Bowel Syndrome
DSM – V Criterion Early History also specified Age of onset Pattern of onset – Include any delays in development, regression, or loss of previously acquired skills.
DSM – V Criterion Social Communication Disorder Impairment in pragmatic communication Difficulty in the social use of verbal and nonverbal communication in naturalistic contexts. Functional development of social relationships and communicative comprehension negatively affected. Cannot be explained by low abilities in use of word structure, grammar, or general cognitive ability.
DSM – V Criterion Implications? Greater accuracy in diagnosing Early studies indicate no change in overall rate of diagnosis, there was a change in the distribution of people being diagnosed. A clearer understanding of the level of support needed (more individualized). Social Communication Disorder to be classified as a communication disorder (may not receive as much support) People diagnosed with Asperger’s Disorder feel like they are losing their identity.
Challenges Communication Cognitive Productivity Social Emotional Navigational
Communication Challenges Initiating and maintaining conversation Asking for assistance or clarification Literal interpretation of language Overly direct/blunt Expressing feelings/needs
Cognitive Challenges Flexibility: Rigid or concrete problem-solving strategies Tendency to get “stuck” on topics or ways of doing things Perfectionism Desire for control Difficulty with transitions Preference for known procedures & established routines
More Cognitive Challenges Executive Functioning Organization & Planning: Challenges with organizing self, materials, experiences Difficulty choosing & prioritizing Delays in completing work on time, turning in assignments
Productivity Challenges Problem-Solving Difficulty seeing “whole picture” or main ideas Difficulty understanding individual steps Challenges related to integrating information, drawing inferences Difficulty learning from experiences, generalizing to new situations
More Productivity Challenges Attending Difficulty shifting attention to new tasks Overly focused on narrow details Self-Monitoring Off-task behavior Verbal impulsivity Difficulty modifying behavior to demands of environment
Social Challenges Theory of Mind: Predicting others’ behavior Reading others’ intentions & motives Explaining one’s own behavior Noticing, understanding emotions Motivation to please others Conversational & social reciprocity Sharing of attention with others Understanding “pretend” Asking for help Understanding personal boundaries
Emotional Challenges Regulating Emotion (Overly Sensitive) Coping Skills (Outside World Does Not Always Accommodate) Anxiety Depression
Navigational Difficulty breaking down larger concepts. Difficulty with organizing and planning. Difficulty with sequencing. True for thoughts/speech as well as actions. Getting stuck leads to inaction, withdrawal, or frustration.
Other Issues Affecting Success Motivational issues – What’s the point? Sensory Issues Increased interest in opposite sex/dating but lack skills to be successful (could distract or overwhelm) Depression and anxiety increase with awareness of social difference/lack of success. Anxiety surrounding new experiences (e.g. separation from home, lack of predictable routines, increased responsibility)
Strengths Visual-spatial skills and/or verbal skills Excellent knowledge & passion related to interests (e.g., computer) Good attention to areas of interest Good rote memory, memory for facts Original way of thinking Strong moral code, sense of justice Honesty, loyalty Recognizing order, following rules Independence Exceptional talents
Educational Strategies Visual Supports Technology Task Analysis Small class size, low social demand Match course work with interests
More Educational Strategies Scheduled help sessions Develop organization system/assignment calendar Develop study routines – specific study times + strategies Develop rationale/motivation for completing work Study groups? (May need facilitator).
Coping Strategies Regularly scheduled stress relieving activities Activity or club related to interest Physical Exercise Relaxation Exercises Counseling – Individual or Group More effective – Structured, Skill Based approaches like Cognitive Behavior Therapy, Biofeedback, or Social Skills Less effective – Insight oriented therapies Support Groups Schedules and clear expectations
Resources Assessment/Treatment Centers for Adults UW Autism Center – Seattle and Tacoma Can also assist with: Finding local resources (877) 408-UWAC Training/consultation for college counselors The Center for Lifespan Development – Federal Way April Walter, Psy.D.
Resources Support Groups FEAT of Washington – Seattle & South Sound South Sound Autism Partnership TACA – South Sound (Traditional and Alternative therapies) The Hub – young adult group through PAVE – Tacoma Exceptional Families Network – Pierce County Autism Society of Washington – Olympia South Sound Parent to Parent – Thurston County T.A.C.I.D. – Runs multiple support groups including Living with Asperger’s (206) 935-2479.
Resources – Information Autism Speaks www.autismspeaks.org NIH Autism Fact Sheet www.ninds.nih.gov/disorders/autism/detail_autism.htm CDC Autism Information Center www.cdc.gov/ncbddd/autism/ Autism Guidebook For Washington State http://www.doh.wa.gov/cfh/mch/Autism/guidebook.htm