Warrnambool 30th March Diagnosis of ASD

DSM5 Diagnostic Criteria for Autism

Criterion A: Persistent deficits in social communication and social interaction across contexts, manifested by all three of the following: Deficits in social-emotional reciprocity; ranging for example, from abnormal social approach and failure of normal back and forth conversation to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

Social and Emotional Reciprocity Shy, withdrawn, introverted Intrusive, intense and motivated to socialise

The Highly Skilled Profile The criteria need to acknowledge the profile of abilities and coping and camouflaging strategies of people who have attained social communication skills via intellectual analysis, eg many girls and women Observation, analysis and imitation Superficial social abilities Contrived reproduction, an act

Deficits in non-verbal communicative behaviours used for social interaction; ranging from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body- language, or deficits in understanding and use of gestures, to a total lack of facial expressions and non-verbal communication.

Theory of Mind Ability to read and interpret the cues and context that indicate someone’s feelings, thoughts, intentions and beliefs (Alien) Ability to self-reflect, to perceive and think about one’s own thoughts and to monitor, communicate and manage one’s own emotions (inner turmoil)

Deficits in developing, understanding and maintaining relationships, ranging for example, from difficulties adjusting behaviour to suit various contexts: to difficulties sharing imaginative play or in making friends; to absence of interest in peers.

Social Understanding Number, quality and duration of friendships through childhood and adolescence Need for a social guide in childhood Ability to read and adjust to social situations Degree of social-emotional reciprocity in interactions

Social Understanding Motivation for friendship Team skills Adult relationship experiences Social anxiety Wearing a ‘mask’ or using a ‘script’ Soclialising is effortful and exhausting

Social Understanding Ability to cope with social ‘chit chat’ Bullying experience Ability to reflect on others’ thoughts, feelings and intentions Physical proximity Sense of humour

Nonverbal communication Ability to read examiner’s facial expression, gesture and tone of voice Use of eye contact Range of facial expressions Their use of nodding, reciprocal smiles and complimentary sounds

Emotion Understanding Limited vocabulary for emotions Difficulty understanding expression of affection Experience and expression of anxiety and anger throughout life Rapidity of mood and intensity of emotion Timing and expression of empathy

Introspection Ability to describe own inner thoughts and feelings in the present Ability to describe self in terms of personality characteristics rather than actions and abilities Subjective sense of being different

Criterion B: Restricted, repetitive patterns of behaviour, interests, or activities as manifested by at least two of the following: Stereotyped or repetitive motor movements, use of objects or speech; (such as simple motor stereotypes, lining up toys or flipping objects, echolalia, or idiosyncratic phrases).

Criterion B: Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behaviour, or excessive resistance to change; (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route, or eat the same food every day).

Criterion B: Highly restricted, fixated interests that are abnormal in intensity or focus; (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (e.g., as apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity

Special Interests Enjoyment Thought blocker (anxiety) Energizer when exhausted or depressed Sense of identity and employment Creation and enjoyment of an alternative world

Special Interests Encyclopedic knowledge. Origin may be associated with a pleasurable occasion or to resolve a fear. Limited duration but always replaced. More than one interest at a time as the person matures. Reduces anxiety and stress.

Nature of the Interests Self-directed and self-taught. Solitary and intuitive activity. Development of a cataloguing system. Creative arts, drawing, sculpture, music and poetry. Attention to detail.

Clinician’s Perspective. Change in the person’s persona when talking about the interest. Macabre interests can be a sign of depression or bullying. When severely stressed there can be a progression from an activity for pleasure to a compulsive act (OCD).

Sensory Sensitivity Auditory (sudden or ‘sharp’ noises, pitch) Tactile Visual Aroma Proprioceptive system (position and movement of the body) Pain Mind and body connection

DSM 5 Criterion 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 later in life)   Criterion D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

Clinically Significant Impairment Social, occupational, or other important areas of current functioning Where to draw the line? Subjective Eligible for government support (USA, Health insurance)

Clinically Significant Impairment Asperger personality type (Broader Autism Phenotype) Progression beyond clinically significant impairment Clinical experience and 3 longitudinal studies, 10-15% become sub- clinical