Autism Spectrum Disorder

Dr Mohamed El Tahir
Consultant Psychiatrist
Introduction
 Overview
 History of Autism
 Features
 Diagnosis
 Comorbidity
 Interventions
What is Autism?
Autism is a lifelong developmental condition
that affects how a person communicates with,
and relates to other people and the world
around them. It is a spectrum condition, which
means that, while all people with autism share
certain areas of difficulty, their condition will
affect them in different ways.
(National Autistic Society)
 Background
• Autism is a lifelong disorder that has a great
impact on the child or young person and
their family or carers.

• Autism describes behavioural differences and

difficulties with reciprocal social interaction
and communication, combined with
restricted interests and rigid and repetitive
behaviours.
History
 Earl 1934: Primitive catatonic psychosis of
idiocy
 Kanner 1943: Early Infantile Autism
 Asperger 1944: Autistic psychopathy
 Mahler 1952: Symbiotic psychosis
 Weygandt; Hulse 1954: Dementia infantilis
The Label – it’s journey
 1910 ‘Autismus’ – coined by Swiss Psychiatrist Eugen
Bleuler. Defining symptoms of Schizophrenia
 1943 Leo Kanner publishes “Early Infantile Autism”
 1944 Hans Asperger publishes his doctoral thesis
“Autistic Psychopathy”
 1981 Dr Lorna Wing translates Asperger’s work
 1994 DSM IV Triad Impairments
 2008 Welsh Assembly Government ASD strategic action
plan
 2009 The Autism Act in England
 2013 DSM V
Who?
 Epidemiology

• Autism was previously thought to be an

uncommon disorder, but is now thought to
occur in at least 1% of children.
• There is wide variation in availability of
services.
• Delays in diagnosis affect access to services.
 We refer to an Autism ‘Spectrum’ because of the way in which
the condition affects individuals can vary

On the other end individuals

On one end of the spectrum
may have an average or
people with an ASD may have an
above average intellect and
additional learning disability and
may function at a higher
be more severely impaired.
level
All individuals with an ASD have impairments in the same
three areas.
This is often referred to as the ‘triad of impairments’ -

impairments in social
interaction

impairments in social impairments in social

communication imagination
Autistic spectrum
 Triad:
 Social interaction
 Communication (verbal and nonverbal)
 Imagination

 Associated with:
 Rigid, repetitive pattern of behaviour
Social impairment
 Aloof, indifferent
 Passive
 Active but odd, bizarre
 Over-formal, stilted
 Sociable with 1 person-problem with
groups
Communication impairment
 No communication

 Communicates own needs

 Repetitive, one sided

 Formal, long winded, literal

Imagination impairment
 Handle objects for simple sensation
 Handles objects for practical uses
 Copies pretend play of others
 Limited pretend play, repetitive, isolated
 Invents own imaginary world but rigid,
stereotyped
Repetitive activities
 Bodily movements
 Fascinations with sensory stimuli
 Simple, object directed
 Routines involving objects
 Routines in space or time
 Verbal routines
 Routines related to special skills
 Intellectual interests
Factors affecting clinical picture
 Triad manifestation
 Associated features
 Associated disabilities
 Overall abilities level
 Age
 Gender
 Personality and temperament
 Environment/ Education
Other features
 Untypical patterns of:
 Language use
 Response to stimuli
 Movements and posture
 Attention/ level of activity
 Eating/ drinking/ sleep
 Mood
 Behaviour
Communication Style of someone
on the Spectrum
• Delayed/normal in 25%
• Can present initially as a language disorder
• Expressive and receptive language disorders
• Intonation
• Volume-too loud/mute/soft whispers
• Content-may sound disjointed or even
delusional
• May sound paranoid-misinterpretation of
cues/language
• Prefer visual cues
 Communication cont’d
 Echolalia - where the person copies what was said, what they
have heard-may give façade of verbal competence
 Long winded and formal grammatically correct speech which
sounds rather old fashioned
 Extensive vocabulary and well developed speech, but limited
descriptive vocabulary and limited vocabulary for expression
of needs or emotion.
 Repetition - often for comfort, reassurance and checking but
also sometimes because saying the words gives sensory
enjoyment.
 Odd use of personal pronouns, e.g. referring to self as ‘he’ and
to mum as ‘his mother’-during childhood
Communication cont’d
 Learning to use spoken language depends on
acquiring an array of abilities e.g semantics (ability
to understand and create meaning) and pragmatics
(ability to use language for the purpose of
communication).

 Difficulty with pragmatics is a universal feature of

autism; everyone who has autism, no matter how
verbally skilled in other aspects, has difficulty.
E.g. ask the question “Can you shut the door?” and
the person with autism replies “yes” - but the door
remains open.
 Allow time Avoid relying
Don’t use for the Keep on gesture,
Speak slowly idioms or individual to instructions facial
and clearly metaphors process short expression or
information tone of voice
Social Interaction different quality
Active and Odd
– No turn taking in conversation – how do you know when to start
talking?
– Talking about own interests – how do you know when to stop talking?
– Might misinterpret or misunderstand interaction

One sided
– Little response to other people’s needs in an interaction
– Little response to other people’s emotions
– Reluctance to talk, despite good understanding
Social Interaction cont’d
• Inappropriate
- naïve and peculiar
- Over familiar and asking personal questions
• Difficulty expressing own feelings
• Repeated conversation and questioning
• They may stand too close
• Too honest – telling someone they are overweight,
breaking the law, they smell
• Disliking being touched, touching others
Social Interaction
Building and sustaining relationships
• May prefer solitary activities
• Avoid interaction with others
• May prefer objects/animals to people
• Use people to meet their own needs
• Little desire to share enjoyment, interests or
achievements with other people
High functioning
 Individuals who meet criteria for autistic
disorder and are intellectually normal are
considered “high functioning”
Ozonoff, Goodlin-Jones &
Solomon (2007)
 Not an official diagnostic term but is commonly
used in both clinical practice and research [to
describe] impairments in social-communication
and a preference for repetitive stereotyped
behaviors in the absence of intellectual disability
Szatmari et al.
(2009)
Asperger’s syndrome
 “High functioning autism” and “Asperger’s
syndrome” are probably two words for the
same thing
 People with “high functioning autism” are not
necessarily high functioning
 HFA is associated with a range of clinically
significant difficulties in addition to the autism
triad
 HFA is frequently missed, often with serious
consequences for the individual, their family and
the wider system
Difficulties in diagnosis
 ASD - wide spectrum of presentations,
not a uniform category
 No biological marker
 Learned compensatory superficial social
skills
 Gender differences
 Consequent family difficulties can be
perceived as the underlying issue with
parenting
Difficulties in diagnosis
 Viewing child’s difficulties through a
particular perspective/’lens’
 Different thresholds depending on the
family context
 Different thresholds depending on the
child’s overall developmental level
 Dimensional vs categorical understanding
of ASDs
Comorbidity
 Amongst children with an ASD there is
evidence for increased incidence of:
 Specific learning difficulties
 ADHD
 Social Anxiety
 Conduct problems
 Anxiety and depression
 Feeding and eating difficulties
 Tic disorders
(Simonoff et al., 2008)
Early Genetics
 Genetic factors important in causing
autism
 Genetic factors confer a risk for broader
range (spectrum) of difficulties
 Non genetic (environmental?) factors also
important
 Diagnostic concepts should be broadened
Harry
Harry is a 23 year old man who lives with his family. He
works in an office and is very interested in Star Trek.
He calls himself a “trekky”. He talks to anyone in great
detail and at great length about Star Trek, whether they
are interested or not. This is causing problems at work
as Harry’s work colleagues are complaining that they
can’t get their work done. Harry doesn’t seem to pick
up on cues that people want to talk about something
else or want to get on with their work. He sometimes
says things that upset or offend other people and
doesn’t seem to notice when people are getting
frustrated or angry with him.
Myra
Myra is a 23 yr old young lady who has been good at
getting jobs but is unable to sustain long term work. She
often forgets to turn up for work if she has been out
the night before. She also spends a lot of her money on
buying gifts for her ‘friends'. She has a car and her
friends often get her to take them out and pick them up
from a night out as she has a car. She gets into
relationships easily and often mistreated by her boy
friends. She has also taken money from home to give
money to them. As a child she seemed to get on well at
school and being pretty was popular with boys. She is
quite disorganised and often finds it hard with social
scene until she has had a few drinks. She is also
irresponsible with physical relationships and has had
treatment for STI already.
Mind reading
 Mind reading is often thought to be the
activity of psychics, but in a sense most of
us are mind readers
 The concept of theory of mind can be
difficult to grasp
 This construct does not represent a
single cognition, behaviour, or emotion.
 The mind is comprised of beliefs, desires,
emotions, perceptions, and intentions.
Theory of mind
 Theory of mind is the ability to attribute
these mental states to self and others in
order to understand and predict
behaviour.
 Involves making distinction between real
world and mental representations
 Individuals with autism spectrum disorder
tend to be less proficient “mind readers”
 Deficits can be used to explain the social
and communication impairments
Social Imagination’ Sally Ann Test

 Where will Sally look for the ball?

 Where does Ann think Sally will look for the
ball?

 If Ann has an ASD where does Ann think Sally

will look for the ball?
Social Imagination cont’d
 Difficulty in predicting other peoples’ behaviour
leading to fear and avoidance of other people.
 Difficulty in reading the intentions of others and
understanding the motives behind behaviour.
 Difficulty in making sense of and explaining their
own behaviour.
 Difficulty understanding emotions – their own
and those of others, leading to a lack of
empathy. N.B. Still have emotions.
Central Coherence Deficit
• Published work by Simon Baron Cohen
describes how people on the autism spectrum
have impaired theory of mind.

• This means that they have difficulty with the

concept that other people think, feel and know
about things in a way that is separate or
different to their own.

• They may expect you to know what they know.

• Between 80 and 90 percent of people with ASD

fail theory of mind tests
Executive functioning difficulties
 Difficulty choosing and prioritising
 Difficulty organising
 Learning things is often tied to the situation in
which it was taught. People with ASD have
problems generalising a skill across different
environments, with different people or in different
situations.
 E.g. They might learn how to get money from one cash
machine but can’t do this at another unless specifically
shown and practised
 Lack of compliance
 Prompt Dependence
Who makes a diagnosis
 Aiming for multi-disciplinary
 Need
◦ Screening info,
◦ assessment info,
◦ clinical observations,
◦ developmental history where possible.
 Management
 Early diagnosis- Most essential

 Goals of Treatment
To reduce disruptive behaviours

To promote learning ( Language, Communication and self

help skills)

To develop social skills

“goals should be updated regularly”


Interventions
 Multidisciplinary team approach:
to address problems with
communication, socialisation and
adaptive behaviour

 Early intensive interventions

very effective (significant progress in
communication and IQ )
- TEACCH (Treatment and Education of
Autistic and other Communication-
Handicapped Children)
-ABA (Applied Behaviour Analysis)
Educational approaches

 Intensive highly structured special education

 Classroom- low student to teacher ratio; less
distractive environment
 More-challenged children require individual
work stations and forceful adult intrusion
 Highly predictable, consistent routines are
necessary
 Ensure the child both begins to use the skills
spontaneously and to generalise.
 Vocational and independent living skills, social
and communication skills for older and higher
functioning children
Therapies
 Speech and Language therapy
focuses on the use of words for
meaningful communication
 Verbal and Non verbal
communication
 Sign language, PECS,
Communication boards
Behaviour Therapy

 Behaviour modification techniques-

establish desired behaviours and
eliminate problem behaviours

 Facilitate learning
Behavioural Model
 Intensive home base behavioural treatment for
children with Autism :
 Evidence for effectiveness documented
Lovaas et al 1987
Type II randomised
controlled trial
I Beneficial
Intensive interventions are effective in reducing
symptoms in Autism
Schreibman L 2000
Type V expert review
Greenspan
 DIR: Developmental Individual Relationship
based therapy: evidence for effectiveness but
limited
Greenspan 1997
Type V expert report

 II Likely to be beneficial
Psychotherapy
 Individual psychotherapy for Higher
functioning children with anxiety
and depressive symptoms

 Focused on problem solving skills

 CBT approach
Social Intervention
 Variety of interventions aimed at increasing
social engagement with others:
Demonstrated effectiveness on Autistic
children
Krantz PJ
2000
Type V
commentary
Rogers SR
2000
Type V review
II Likely to be beneficial
Biological Interventions
 Dietary Treatments
No evidence for effectiveness
V Unlikely to be beneficial
Eric Taylor et al 1990
Type V expert review

 Secretin
No evidence for effectiveness in Autism
V Unlikely to be beneficial
Sandler AD et al 1999
Type II randomised controlled
trial
Psychopharmacology

 Not curative

 Anti psychotics-Risperidone
decrease stereotyped behaviour and
agitation

 SSRIs reduce repetitive behaviours

and impulsive aggression
Psychopharmacology
 Clonidine
modest effect on activity levels
 Naltrexone
mild decrease in activity levels
 Other agents
Lithium
Psycho stimulants
Beta blockers- reduce aggressive, self
injurious and impulsive behaviours
Other Biological

 Immunological therapy
Dimethylglycine: No evidence

Jacobson 2000 expert report

Rimland 1998 expert report
Type V

V Unlikely to be beneficial
Alternative treatments

 Diet and vitamin therapy

 Dolphin therapy

 Play therapy
Music Therapy

 Music therapy
helps in promoting cognitive, social and
emotional development
Brown1994
Type V review
II Likely to be beneficial
Vitamin Therapy
 Favourable response to Vitamin B6 treatment
 But:
 Studies that showed methodological
shortcomings
Pfeiffer S J et al 1995
Type V expert review

 III Trade between beneficial and adverse effects

Conclusion
 Autism Spectrum Disorder has been well
recognised as a developmental disorder
 Literature is meagre
 Early diagnosis and interventions help
individuals and their families
 Research in Interventions remain a
challenge