Autism Spectrum
Disorders
Tonya A. Gscheidle, Ph.D., NCSP
January 4, 2010
Pervasive Developmental
Disorders
• A class of neurological disorders, present by age
3, that affect a child’s ability to communicate,
relate to others, understand language, and engage
in appropriate play
• No clear etiology but neurological/brain damage is
suspected to play a role
• PDD and ASD are used interchageably when
referring to Autism, PDD-NOS and Asperger’s
Syndrome
What is Autism?
• Pervasive Developmental Disorder
present by age 3 and is characterized
by disruption of:
• Reciprocal social interactions
• Language and communication
• Restricted, repetitive, and stereotyped
patterns of behaviors, interests, and
activities
IDEIA (2004) & Autism
• Affects verbal and nonverbal
communication, and social interaction
• Adversely affects educational
performance
• Repetitive activities and stereotyped
movement
• Resistance to change
• Unusual response to sensory experiences
• Also includes PDD-NOS & Asperger’s
Syndrome
Facts about Autism
• Lifelong developmental disability caused by
neurological dysfunction
• Spectrum disorder (ranges in severity)
• Affects 1 in approx. 100 children
• Boys outnumber girls 4:1
• No known single cause
• No known cure
• More common than childhood cancer, cystic
fibrosis and multiple sclerosis combined
More Facts
• Some believe that vaccines
(mercury), diet (casein and gluten), as
well as environmental factors can
contribute to ASDs but have not
been proven to do so (vaccines have
been recently ruled out as a cause of
ASDs)
“Red Flags” of Autism
• No babbling by 12 months
• No gesturing (pointing, waving good-bye)
by 12 months
• No single words by 14-16 months
• No spontaneous two-word phrases by 24
months (some echolalic phrases may be
present)
• Lack of response to name
More “Red Flags”
• Lack of gaze shifting: person-objectperson or object-person-object
• Lack of joint attention
• Restricted interests and stereotypic
behaviors
• Low levels of social orienting and social
monitoring (poor social endurance)
• Significant loss of any language or social
skills (regressive autism)
Theory of Mind
• Refers to the concept that individuals with autism
do not understand that other people have their
own plans, thoughts, and points of view; not
comprehending that others think differently than
they do.
• Children recognize that others have their own
thoughts at around the age of 4.
• Develops in phases; varying levels of
understanding
• “You know the rules!” No, he really doesn’t.
The “Triangle”
Language & Communication
Disruptions
In
Development
Social
Interactions
Restricted/repetitive
behaviors
Reciprocal Social
Interactions
• Lack of eye contact
• Inability to read the emotions of others
• Prefers to use people as a “pawn” to
obtain wants/needs rather than for
social interaction
• Not interested in/unable to carry
reciprocal conversations
Reciprocal Social
Interactions
• Neutral/flat affect or a generally
inappropriate range of affect
• Inappropriate giggling or laughing
• Prefers to be alone rather than
around others
Reciprocal Social
Interactions
• Avoid or seem oblivious to social attention
or may seek it out in unusual ways
• Does not understand subtle social rules or
cues
• Often rule-governed and routine
dependent
• Easily upset, frustrated and overwhelmed
Language &
Communication
• Usually some language
impairment is present
• Those who have language
may use it to label
rather than
communicate
• Important to consider
verbal AND nonverbal
language
• Speech can be scripted,
have a ‘sing-song’ quality,
or a pedantic tone to it
that is atypical
• Nonverbal children may
incorporate jargon,
squeals, and noises
• Some may have started
to speak and then
stopped – disruption in
communication
Language &
Communication
• Peculiar speech such as echolalia (immediate and
delayed) and pronoun reversals
• Disruptions in prosody (variations in rate,
loudness, stress, intonation and rhythm)
• Difficulty initiating requests
• Communication often not directed at another
person
• Ability to respond to receptive language demands
is inconsistent
Restricted, Repetitive, &
Stereotyped Behaviors
• Limited interests/insists
on sameness
• Spinning objects
• Toe walking, finger
posturing, body tensing,
hand flapping
• Shows frustration
during transition from
one activity to the next
• Does not play with
toys/materials
appropriately
• Explores the
environment in an usual
way using senses
Restricted, Repetitive, &
Stereotyped Behaviors
• Limited ability to self-regulate (some
use rocking or spinning to selfregulate or indicate boredom)
• Self-injurious, self-stimulatory
behaviors (picking skin, head banging)
The “Triangle”
Language & Communication
Disruptions
In
Development
Social
Interactions
Restricted/repetitive
behaviors
PDD-NOS vs. Autism
• PDD-NOS is used when the child
meets the following criteria:
Impairment in Social Interactions
AND
Impairment in Communication
OR
Restricted, repetitive, & stereotyped pattern
of behaviors, interests in activities
PDD-NOS
• PDD-NOS behaviors are
characteristic of autism spectrum
disorder, but to a lesser degree and
do not have the full classic
neurobehavioral patterns of autism.
Asperger’s Syndrome
(AS) vs. AU
• Child must have average to above
average intelligence
• No presence of a speech delay
(though will have great difficulty
with pragmatic(social) language)
• Similar sensory differences as those
with AU or PDD-NOS
AS/PDD-NOS vs. AU
• Although symptoms still must be
present by age 3, typically AS or
PDD-NOS are diagnosed later due to
milder symptoms
• High co-morbidity (approx. 70%) of
AS with an SLD in written language
• Fine motor skill deficits in AS or
PDD-NOS more pronounced
AS/PDD-NOS & Reciprocal
Social Interactions
• Initiate social interactions with others,
but have difficulty reciprocating and
sustaining conversation
• More likely to approach others
• Use of more sustained eye contact
• Use of some facial expressions
• Anxious about changes in schedule
• Difficulty with representational play; will
keep the conversation simple
AS/PDD-NOS: Reciprocal
Social Interactions
• May be rude or aggressive with adults and peers
when over-stimulated or upset
• Oblivious to most subtle social cues, even with
repeated reminders
• When bored or upset, will initiate familiar
activities for stress relief or entertainment
• Often prompt-dependent to the point of not being
able to complete familiar routines without cues
AS/PDD-NOS: Reciprocal
Social Interactions
• Play is a mixture of approaching
others and being on own
• Act out and become characters by
repeating scenes from videos,
cartoons and movies
AS/PDD-NOS: Language
& Communication
• Child will direct some language toward
listener, but usually doesn’t wait for a
response from listener
• Functional language is present
• Will not extend conversation
• Asks many questions
• Mostly initiating, not responding
• Frequent labeling and repeating
AS/PDD-NOS: Language
& Communication
• Social language development often delayed
and/or odd
• Obvious scripting from media or
memorized communication sequences
• Nonverbal language may be significantly
impaired
• Motor-planning problems may interfere
with articulation
AS/PDD-NOS: Language
Sample
• “OK. Let’s find a another match. Let’s
click and drag it. Try again. Let’s do
another one. You can do it.” (with
clicking tongue sounds)
• “Wrong answer. Try again.” (said in a
sing-song, computerized voice)
AS/PDD-NOS: Restricted,
Repetitive, & Stereotyped
Behaviors
• May engage in repetitive movement when
over-stimulated, overwhelmed or upset
(often accompanies nervous scripting)
• Difficulty with motor planning may result
in not responding or performing promptly
on demand
• High interest in technical aspects of
objects – how things “work”
AS/PDD-NOS: Restricted,
Repetitive, & Stereotyped
Behaviors
• Minimal or exaggerated use of facial
expression and body language, especially
when over-stimulated or overwhelmed
• Less flexibility with movement and
posturing, appearing stiff or viewed as
having a threatening posture by others
Differential Diagnoses:
AU vs. ID
• Difficult to tease out since research
estimates that 40-60% of children
with AU also have ID
• Look at social behaviors – if a child is
overly social (hugging, not respecting
personal boundaries) – primary
diagnoses more likely ID
AU vs. ID
• Adaptive behaviors – though children
with AU may have lower adaptive
behavior skills, they should not be
significantly lower than cognitive
level (e.g., look at ability to
independently toilet)
• Note: Severe/profound ID children
can also have significant sensory
differences
AU vs. ID
• Look at desire to want friends and
social rejection due to impairments
vs. no desire to have friends at all
and preference to play by oneself
AU vs. ED
• AU symptoms, even mild, should be
present before age 3
• In AU, kiddos tend to use sensory
behaviors to regulate emotionally; ED
kids are many times unaware of their
emotions
AU vs ED
• ED diagnoses should have an
underlying emotional event behind
them; Not true in those with AU
• Need to know difference b/w
inability to maintain interpersonal
relationships (ED) and lack of
interest in forming interpersonal
relationships (AU)
AU vs. Severe SLI
• Disruptions in
language/communication is only one
aspect in the diagnosis of AU
• Look at social behaviors and use of
nonverbal gestures
• Severe SLI kiddos typically do not
have disruptions in the sensory realm
AU vs. Sensory Integration
• Sensory Integration Disorder
(SID) now called Sensory
Processing Disorder
• Not recognized by schools, the
DSM-IV TR, or the ICD-10
• Describes the inability of the
brain to organize/process sensory
information
• Sensory difference only 1 aspect
of AU diagnosis
Autism Evaluations
• Structured, play-based assessment OR
Interview for older kiddos
• Comprehensive parent interview
• Medical form
• IQ and Achievement also assessed as part
of comprehensive evaluation
• Cognitive batteries that are less verbally loaded (e.g.,
KABC; SB5) are better suited when AU is suspected
• For nonverbal batteries, concrete (e.g., CTONI-2) is
better than using one that is more abstract (e.g.,
UNIT)
Checklists
• Checklists are designed to
complement the eval along with
observation and interview data; they
are NOT designed to make a
diagnosis
• Using checklists only (e.g., CARS,
GARS, GADS, ASDS) for an
AU/AS/PDD-NOS eval is invalid due
to bias
Suggestions for Possible
Batteries
• Initial AU Eval
– KABC-II or SB5
– Full Academic Battery
– If looking at processing, use VMI vs Bender
(less abstract)
– Play-based assessment/ADOS
– Parents/Teachers complete GARS
– Medical Form
– Parent Interview
– CARS (not needed if using ADOS)
– Notify OT and ask for Sensory Profile if
significant sensory disruptions are observed
Note about CARS
• CARS is a screening tool and not a
diagnostic instrument
• Should be completed after a play-based
evaluation by the examiner; should NOT be
done by giving it to teacher/parent to
complete or in interview format or ratings
will be artificially high
• Areas of ‘imitation’ and ‘object use’ should
be rated based on developmental rather
than age-appropriateness
Suggestions for PDDNOS/AS Batteries
•
•
•
•
•
•
•
Parent Interview
Student Interview
ASDS
GADS to parent/teacher
Observation
ADOS Module 4
Cognitive battery not as important but may
want to use a low verbal battery
• VMI
• Full Achievement battery
What To Look For?
• Does the child seek out input/interaction
from the examiners? If so, how?
• Does the child play with toys
appropriately?
• Does the child become fixated on one or
more object? Sensory issues?
• Does the child tolerate their play being
interrupted?
More of What To Look
For
• How does the child tolerate
transitions and unstructured time?
• Any spontaneous
language/communication? Fixation on
one specific topic of interest?
• Does the child talk about or interact
with peers in a meaningful way?
Possible Interventions
• Stress the need to have daily, predictable
routines; children with ASD do better with
structure
• Warn a child ahead of time of any major changes
to that schedule (e.g., if there will be an assembly
or indoor recess) so that they can anticipate the
change
• Start a learning activity with sensory stimulation
first depending on the child’s needs (e.g., if the
child is tactile, use tactile toys to introduce the
activity)
More Ideas
• For nonverbal children, encourage the
child to use pictures to help communicate
(e.g., point to what they want to make
choices)
• Pictures can also be used to teach a child a
routine (e.g., bath time, toileting)
• Speak in short sentences; too much
verbage can overwhelm a child who has
ASD
More Ideas
• Use sensory items to see what the child
prefers; this information can be used to
see how the child explores the
environment and be incorporated into his
learning
• Do not try to eliminate behaviors that
seem to be self-regulating unless a safety
hazard; these behaviors are necessary for
the child…eventually these behaviors can
be replaced with more functional behaviors
Interventions cont’d
• Use of social stories about the child and
social situations to assist in understanding
social rules and behaviors.
• Social stories can also help gain further
insight into his role in social relationships,
including friendships.
• Social skills groups to reinforce what is
learned from social stories/guided
practice.
Cautions About
Behavioral Interventions
• Keep reinforcers/consequences
simplistic and linear
• Children with AU have difficulty
understanding cause/effect of
behavior charts (if you behave 5
times….you will get___.) Instead
reinforce positive behavior
instantaneously and try to ignore
inappropriate behavior
More Cautions
• Use simple verbage that is clear and
concise; the more language used (e.g.,
‘lecturing’) the more the child will
tune out or become frustrated
Finally…
• Praise child when they engages in positive
behavior such as following directions or
staying on task. Catch child “being good”
and praise/reward him immediately when
he does what is expected of him. If child
receives overwhelming positive attention,
it may decrease his need to seek out
negative attention and improve his overall
behavior.
• Home/school collaboration VITALLY
IMPORTANT
FBA & BIP
• Specific FBA and BIP should be
written to reduce negative behavior
and increase appropriate behavior
• High interest rewards need to be
identified to help reinforce positive
behaviors
• BIP needs to be followed by all staff
and should also be followed at home.
• Keep BIPs simple and realistic
Resources
• Autism Society of America website
www.autism-society.org
• Pictures for Picture Schedules
http://www.do2learn.com/
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Discussion & Questions
• Any questions, thoughts, ideas?