autism spectrum disorders DSM IV

1. Autism
2. Rett's Sydrome or Disorder
3. Pervasive Developmental Disorder - NOS (Not Otherwise Specified)
4. Asperger's Syndrome
5. Childhood Disintegrative Disorder (CDD or Heller's Syndrome)
6 of 3 categories, onset prior to 3:
1. Impaired Social Interaction
-Marked impairment in nonverbal behaviors such as eye contact and gestures
-Failure to develop peer relationships
-Impaired expression of pleasure when others are happy
2. Impaired Communication
-Delay or lack of development of spoken language
-Impairment in ability to sustain conversation
-Repetitive or stereotyped use of language
-Lack of pretend or social imitative play (related to developmental level)
3. Restricted Repetitive and Stereotyped Behaviors
-Preoccupation with one or more patterns that is abnormal in intensity or focus
-Compulsive adherence to rituals or routines
-Repetitive motor mannerisms
-Preoccupations with parts of objects
-Maybe obsessed with parts of an object (spinning a wheel)
*You do not see anything sensory, cognitive under this classification
Stimming ? rewarding themselves internally

changes in the DSM-V in regard to diagnosis of autism

V- new name:
ASD: Autism, Asperger's disorder, childhood disintegrative disorder, and PDDNOS.
Rationale: Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category
A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation.
3 domains turn into 2:
1. Social/communication deficits
-Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities.
2. Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis.
Stereotypical Behaviors - Fixated interests and repetitive behaviors

current theories on reasons for increased prevalence of autism over the last 2 decades

Prevalence of Autism: Various state and federal reports on the prevalence of Autism highlight a significant increase in the incidence of children diagnosed with an autism spectrum disorder:
-Between 1992 and 1997 the U.S. Department of Education reported to Congress that the number of U.S. school children educationally labeled with autism increased 178.86%
-Current estimates: 1 percent of the population of children in the U.S. ages 3-17 have an autism spectrum disorder
-Prevalence is estimated at 1 in 88 births; 1 in 54 boys
-1 to 1.5 million Americans live with an autism spectrum disorder
-Fastest-growing developmental disability; 1,148% growth rate since 1992
-10 - 17 % annual growth (some say higher??)
-$60 billion annual cost (medical, medications, therapies)
-60% of costs are in adult services
-Cost of lifelong care can be reduced by 2/3 with early diagnosis and intervention
-In 10 years, the annual cost will be $200-400 billion
1. More specifically defined autism spectrum disorder characteristics in DSM-IV
2. Development of better assessments of autism and autism spectrum disorders
3. Physicians, educational psychologist, teachers, and therapists are more knowledgeable of the behaviors of autistic children
4. Development of earlier screenings and tests for Autism
� CHAT - Checklist for Autism in Toddlers
o Used by Pediatricians at 18 month old check-up (see link on PPT)
o Look at a reference point (look at that bird, ASD not able to do this)

3 areas of dysfunction in a child diagnosed with autism

1. Impaired Social Interaction
-Marked impairment in nonverbal behaviors such as eye contact and gestures
-Failure to develop peer relationships
-Impaired expression of pleasure when others are happy
-Impaired Communication
-Delay or lack of development of spoken language
-Impairment in ability to sustain conversation
-Repetitive or stereotyped use of language
-Lack of pretend or social imitative play (related to developmental level)
2. Restricted Repetitive and Stereotyped Behaviors
-Preoccupation with one or more patterns that is abnormal in intensity or focus
-Compulsive adherence to rituals or routines
-Repetitive motor mannerisms
-Preoccupations with parts of objects

current etiology and neurologic basis to autism backed by the scientific community

which causes of autism are supported by research findings and which are not

communication deficits seen in children with autism

Communication forms the basis for social and emotional connections to other people. Language is a system in which abstract and arbitrarily assigned symbols represent concepts. For communication to be effective within a child's social and cultural group, a shared language is needed. Deficits in communication seen in children with autism:
-Deficits in joint attention (cannot shift eye gaze between people and objects during play)
-The timing and reason for looking at others and making eye contact is atypical
-Child may not use the gesture of pointing
-Child does not vocalize, babble, or engage in verbal jargon
-Unusual speech tone and rhythm
-Difficulty attending to others facial expressions
-Infrequent crying, cooing, smiling
-Does not respond to own name
-Limited understanding of object labels
-Limited understanding of novel information
-Limited understanding of direction or instruction
-Pronoun confusion (speaks in the 1st person)
-Echolalia - child reproduces sounds that are identical to the model in both tone and rate of speech
-Delayed echolalia - when utterances are repeated from past experience, could be an attempt to relate a need or want. (ie. the child states, "chocolate milk is good vs. I want some milk)
-Immediate echolalia - when a child repeats what was just said. This can reflect the child's inability to comprehend what was said or to manage social demands.
-Limited use of words
-Use of unconventional means to request something (ie. biting, rocking, spinning)
-Crying not related to obvious needs or laughing not related to situation

social skill deficits seen in children with autism

Socialization includes the ability to effectively interact in social situations involving language, gestures (also eye gaze, facial expressions), cognitive, and emotional components. Socialization can occur in dyads, triads, or in groups. Children with autism spectrum disorders typically have difficulty with the range and quality of social acts:
Use of unconventional behaviors, biting or hitting oneself or others
Difficulty with transitions or anticipating future events
Difficulty being soothed by others
Difficulty understanding others reactions
Difficulty engaging in play with others
Beginning play, remaining focused on play, joint attention during play
Poor ability to use monologues during play situations
Do not respond to others who initiate play or social interactions
Respond with only rote answers during social situations as if taught the correct answer
Initiates social interaction by unconvential language and nonlanguage methods (echolalia, self-biting, head banging)
Cannon change means of communication to clarify intent

stereotypic behaviors seen in children with autism

These behaviors can reflect a sate of anxiety, or indicate the presence of an obsessive-compulsive disorder, or reflect difficulty with ideation when attempting a task, or reflect the need to self-regulate to maintain a calm/alert state. Typical stereotypical behaviors seen in children with autism spectrum disorders:
Hand flapping
Head banging
Moving objects close to and away from eyes
Moving objects within the peripheral field of others
Spinning objects or self
Putting objects in mouth
Preoccupation with own hands
Strong attachment to an object or part of an object
Creating specific routines that are difficult to modify
Need to arrange items in a specific way
Persistent review of specific parts of songs or movies
Persistent sorting of objects

cognitive and learning skill of a child with autism

Children with autism spectrum disorders can IQs ranging from profound mental retardation to genius. It is difficult to accurately access the intellectual ability of children with autism due to communication, social, and behavioral deficits. Characteristic learning styles of autistic children include;
Rigid thinking and difficulty comprehending abstract concepts
Children find it difficult to assimilate, modify, and integrate old information with new information
Children may think in "pictures" - take mental snapshots of events (ie. autistic child has a birthday party with Barney cake and decorations, opens birthday gifts. Same child goes to another child's birthday party but it is a Power Rangers party and autistic child cannot open gift because it is not "his" birthday party - child has a tantrum. Do you think the autistic child would classify the Power Rangers party as a birthday party?)
Strengths in rote memory
Preference for constructional play
Limited functional object use
Prefers solitary play
Limited in play involving ideation and problem solving
Many times play skills mirror developmental level
Decreased imitation
Hyperlexia - reflects the way the child attends to visual stimulation, noting stability and consistency in print. Child may read early by decoding words but have difficulty with reading comprehension (meaning).

General problems children have with motor skills

1. underlying hypotonia
2. poor ability to sustain motor movement or grade muscle control
3. poor pelvic control
4. may show posturing or stiffness with movement
5. poor motor planning and overall coordination (dyspraxia)
6. child may be in constant motion or fatigue easily
7. processing sensory input

Difficulties autistic children have with ideation (praxis)

-significant problem
-begins with child's difficulty interpreting cutes from the environment and forming ideas about new motor acts
-tend to think very concretely
-play is stereotypical and repetitive (limits exploration of the environment and decreases new ideas)
-usually a significant problem in autistic children
-possible preoccupation with certain objects (limits meaning interactions and use of toys in appropriate ways)
-difficulty with transitions (may not be able to visualize next activity in mind)

Ideation (praxis) Case Study

Emily started her OT session in a large room filled with objects. She moved directly to a large crate on the floor and began pulling toys out. She picked up a small ball covered with pink, yellow, and green suctions cups. The ball, when thrown against a wall with stick to the wall surface. Emily held the ball up in front of her eyes and stood in front of a window so the light would catch the colored tips. Her OT attempted to get Emily to throw the ball, but Emily turned her head and moved to another window in the treatment room. Emily resisted interaction and play with the OT in favor of the visual stimulation she received from the colored ball in the window.

Difficulties autistic children have with planning motor acts (praxis)

-difficulty forming motor plans
-rigidity, lack of flexibility, and intense desire for sameness
-favors solitary activities due to failure in group games requiring motor skills
-imitation is very difficult (esp. multi-scheme tasks) "feeding a baby doll"
-Echopraxia - imitation by an autistic child that resembles copying of motor acts but little understanding of meaning

Motor Planning (praxis) Case Study

Rachel is a 5 year old girl with autism. In preschool, Rachel engaged in play in the dress-up area. She liked to play a game based on the video Cinderella. She preferred to be alone and in control of the situation. When other children approached her, she turned away and sometimes cried. If encouraged strongly by her teacher, Rachel would spend 5-10 min. with other children. She fatigued quickly and would always return to her solitary play as Cinderella.

difficulties autistic children have with execution of motor acts (praxis)


Execution (praxis) Case Study

Zachary is a 6 year old boy diagnosed with autism. He enjoys climbing and is constantly on the go. His difficulties with body scheme and motor planning create severe safety issues though. His teacher must continually monitor his playground activity because he is unsafe. The teacher described one recess where Zachary jumped from the top of the playground jungle gym 3 times. The first time he skinned his knee. After 10min. of relatively safe play, he again jumped off the jungle gym and fell into a classmate. Still a 3rd time Zachary jumped again and almost hit another classmate. Without considering his height from the ground or the feedback he received form previous jumps or injury to fellow classmates, Zachary continued to engage in the unsafe behavior of jumping off the jungle gym.

Motor Planning Interventions

1. Provide a safe environment, allow for exploration within safe boundaries
2. Provide an optimal sensory environment and level of stimulation
3. Watch the child closely, respond to child's wants, desires, and attempts at subtle communication
4. Observe and respond appropriately to the child's comfort level with your physical play proximity
5. Be appropriately playful and animated
6. Be interested in what the child is doing, "get into his/her world"
7. Attempt to motivate the child to engage or interact at some level
8. All the child to have control in initiating and ending activity, follow the child's lead whenever possible, allow choices
9. Sing and use music, exaggerate vocalizations
10. Provide appropriate assistance to allow success, use nonverbal hand-over-hand guiding
11. Provide opportunities for turn-taking
12. Imitate the child and allow opportunities to imitate you, expand on what the child is doing (ie. if the child rips a piece of paper, you rip a piece of paper , the child repeats the action, then you rip the paper and throw it into a trash can)
13. Playfully block repetitive play to create new play (ie. add obstacles to negotiate for a child who is running walking in circles around an area or put something in the way of a child who is repetitively pushing blocks like a train).
14. Use familiar themes to begin pretending (ie. favorite movie or cartoon characters)
15. Use peer groups, "circle of friends" pairing autistic child with non-disabled peer in small group (dyads, triads - whatever the child can handle)
16. Use play to develop praxis skills, find a "hook" or a toy that holds particular interest to the child

Use of Sensory Motor Circuits for autistic children

Sequence of activities done repeatedly to allow learning to occur (daily or a few times a week depending on environment and schedule)
Completed in: self-contained classroom, preschool program, regular kindergarten or primary classroom
What is involved:
-Various sensorimotor activities are set up in centers
-The child is taught sequencing and independent work skills needed to go through the circuit
-The sensorimotor activities should include speech and language skills, sensorimotor, social, and academic areas
(ie. one center could be dress up involving 1 child fastening a zipper on a dressing vest worn by another child)
-Try using a signal to stop and start the circuit (ie. timer, lights on/off, music)
Examples in a Preschool Class:
Station 1: Push a large car along a colored-tape line
Station 2: Cut straws to prepare to make necklace (string straw pieces on yarn)
Station 3: Twirler game, use tops on table
Station 4: In half-kneel, throw beanbags into large bucket
Station 5: Climb up and go down commercially make small plastic slide
Station 6: Draw while standing on art easel, use brush or finger paints

Use of sequencing and grading of motor tasks to teach self-care skills to autistic children

-Task analysis
-Teaching proper sequence
-Teaching motor skills to a child with autism is easier if the details of the activity are distinct and the child's abilities are observed.
1. Select a task that develops a needed skill. Consider the sensory, cognitive, language, and social components needed.
2. Break the task into part. Consider which parts should be done by or for the child.
3. Identify needed adaptations.
Activities can be graded once the detailed steps and known.
1. The sequence
2. The size of shape of the tool
3. Position of the tool, furniture, or material
4. Speed, length, or repetition of a trial
5. perceptual or cognitive components
6. amount of instruction, demonstration, or assistance given
7. place where the task is performed
8. amount of choice or problem solving involved
9. cooperation or teamwork needed with other children




ABA is a set of principles and guidelines upon which educational programs (or any number of applications) are based.
7 essential elements of an ABA-based program:
The program must be applied.
The behaviors have some social significance.
The program must be behavioral.
The environment and physical events should be recorded with precision.
The program must be analytic.
There should be clear and convincing evidence, through carefully collected data, that the intervention is responsible for a change in a behavior.
The program must be technological.
The techniques that one uses should be described completely enough to allow for duplication by another individual.
The program must be conceptually systematic.
There should be relevance to established and accepted principles (for example, the principle of operant conditioning, appropriate behavior receive rewards).
The program must be effective.
The program should seek to change the targeted behavior to a meaningful degree.
The program should display some generality. A change in behavior should be seen in a wide variety of environments, or should spread to a wide variety of related or similar behaviors.
**CRITIQUES: teaches them to mimic appropriate behaviors without really understanding the meaning of the social cues they are using

Greenspan's Floortime (DIR)

-"developmental, individual-difference, relationship-based" therapy
-based on the natural development of emotion and human interaction in children
-assumes 6 milestones of typical emotional and communicative development and attempts through intensive play and interaction, to guide children through each of these stage
-about building relationships providing a meaningful context within which those skills and behaviors make sense and which allows for countless natural opportunities for practice and teaching
Approach - the DIR (Developmental, Individual-Difference, Relationship-Based/Floortime approach. The focus is on helping children master the building block of relating, communication and thinking.

TEACCH method

Structured teaching via the TEACCH method was developed by Professor Eric Schopler and many of his colleagues at the University of North Carolina at Chapel Hill. The TEACCH method is not considered an actual therapy but rather a therapeutic tool to help autistic individuals understand their surroundings and is widely used in school settings.
� Physical structure
Physical structure refers to the actual layout or surroundings of a person's environment, such as a classroom, home, or group home. The physical boundaries are clearly defined and usually include activities like: work, play, snack, music, and transitioning.
� Scheduling
A schedule or planner is set up which indicates what the person is supposed to do and when it is supposed to happen. The person's entire day, week, and possibly month, are clearly shown to the person through words, photographs, drawings, or whatever medium is easiest for the person to comprehend.
� Work system
The work system tells the person what is expected of him/her during an activity, how much is supposed to be accomplished, and what happens after the activity is completed. The goal is to teach the person to work independently. The work system is also organized in such a way that the person has little or no difficulty figuring out what to do. For example, the activity or task should be performed from top to bottom and from left to right.
� Routine
According to the TEACCH method, the most functional skill for autistic individuals is a routine which involves checking one's schedule and following the established work system. This routine can then be used throughout the person's lifetime and in multiple situations.
� Visual structure
Visual structure refers to visually-based cues regarding organization, clarification, and instructions to assist the person in understanding what is expected of him/her. For example, a visual structure may involve using colored containers to assist the person in sorting colored materials into various groups or displaying an example of a stamped envelope when the person is asked to place stamps on envelopes.

Asperger's Syndrome

First described by Hans Asperger in 1944, an Austrian psychiatrist. He described this disorder as an "abnormality of personality" that he called autistic psychopathy. Dr. Lorna Wing first used the term Asperger's Syndrome in the early 1980's when attempting to explain children who presented with classic autistic features when very young, but later developed fluent speech and a desire to socialize. Her research focused on these children's lack of empathy and inappropriate, one-sided interaction with little to no ability to form friendships.

Asperger's Syndrome vs Autism

The difference centers on the degree of the child's ability in socialization and communication, language is intact although sometimes "atypical". Cognitive ability is usually average to above average. There is some controversy over whether Asperger's should be classified separately from Autism. Some argue that Autism and Asperger's share the same core difficulties and differ only to the degree to which they are expressed in children. Some experts refer to children with Asperger's as having a "dash of Autism".

social and behavioral characteristics common in children with Asperger's Syndrome

Social impairment (extreme egocentricity)
-Inability to interact with peers
-Lack of desire to interact with peers
-Lack of appreciation of social cues
-Socially and emotionally inappropriate behavior
-Comes too close to others - "treats others like furniture"
-Approaches others only to have own needs met
-A clumsy social approach
-One-sided responses to peers
-Difficulty sensing feelings of others
-Detached from feelings of others
Narrow interests
-Exclusion of other activities (due to preoccupation in one activity/topic)
-Repetitive adherence to routines
-Excel at rote memory - learning information without meaning (don't assume a child understands information that may be "parroted" back to you)
preoccupation with part-objects or nonfunctional elements of play materials (such as their odor, the feel of their surface, or the noise/vibration that they generate); preoccupations may change over time, but not in intensity themes of transportation; trains, airplanes, dinosaurs, maps
Repetitive routines
-Unusual behaviors towards others
-Distress over changes in small, nonfunctional, details of the environment
-Speech and language peculiarities
-No clinically significant general delay in language single words used by age 2 phrases used by age 3
-Superficially perfect expressive language; overly formal; speak in a monotonous tone
-Hyperverbal - speak incessantly on a topic of interest only to themselves
-Odd prosody, peculiar voice characteristics
-Impairment of comprehension including misinterpretation of literal/implied meanings
-Often appear to talk "at" you rather than "to you"
-Repetitive patterns of speech
-Abnormalities in inflection - speak too loud
Nonverbal communication problems
-Limited use of gestures
-Clumsy/gauche body language
-Limited facial expression
-Inappropriate expression
-Peculiar, stiff eye gaze, stare

motor planning difficulties typically seen in children with Asperger's Syndrome

Motor clumsiness: dyspraxia; literature reports ~90% are poor at sports (Wing, 1981)
-Poor body scheme
-Poor somatosensory processing
-Difficulty coordinating both sides of the body
-Avoid motor challenges
-Poor sustained postural control (holding positions)
-Poor anticipation of movement in space
-Poor grading and timing of movement
-Muscular weakness, poor endurance

sensory modulation and regulation difficulties commonly seen in children with Asperger's syndrome

Children with Asperger's Syndrome typically demonstrate atypical responses to sensory input and difficulty modulating or regulating to the various sensory inputs in the environment.
� Tactile (typically poor tactile processing, hypo or hyperresponsive)
� Auditory (typically poor auditory processing, hypo or hyperresponsive)
� Visual (**typically a strength)
� Vestibular (tend to seek vestibular experiences, hyporesponsive)
� Proprioception (poor body awareness, hyporesponsive to preoprioceptive input)

treatment strategies that could be used for a child with Asperger's Syndrome

OT Treatment Goals:
� Improve attention, learning and flexibility through sensory based interventions
� Improve motor planning
� Improve social and play skills
� Improve pre-vocational skills
Keep all your speech simple - to a level they understand.
Keep instructions simple ... for complicated jobs use lists or pictures. The visual sense is usually a strength for these kids.
Try to get confirmation that they understand what you are talking about/or asking - don't rely on a stock yes or no - that they like to answer with.
Explain why they should look at you when you speak to them.... encourage them; give lots of praise for any achievement - especially when they use a social skill without prompting.
In some young children who appear not to listen - the act of 'singing' your words can have a beneficial effect.
Limit any choices to two or three items.
Limit their 'special interest' time to set amounts of time each day if you can. (Social Story)
Use turn taking activities as much as possible, not only in games but at home too.
Try to identify stress triggers - avoid them if possible -can a sensory diet be used to diffuse the issue? Anger and tantrums may become an issue, especially in school settings.
Find a way of coping with behavior problems
Teach them some strategies for coping - telling people who are teasing perhaps to 'go away' or to breathe deeply and count to 20 if they feel the urge to cry in public.
Begin early to teach the difference between private and public places and actions, so that they can develop ways of coping with more complex social rules later in life.

why the diagnosis of Asperger's Syndrome will not appear in the DSM-V

-Asperger's syndrome will be subsumed into Autism Disorder (Autism Spectrum Disorder)
-'Asperger syndrome' is used loosely with little agreement: Williams et al. (2008) survey of 466 professionals reporting on 348 relevant cases, showed 44% of children given Asperger, PDD-NOS, atypical autism, or 'other ASD' label actually fulfilled criteria for Autistic Disorder
1st View: That Asperger disorder is not substantially different from other forms of 'high functioning' autism (HFA); i.e. Asperger's is the part of the autism spectrum with good formal language skills and good (at least Verbal) IQ. Note that 'HFA' is itself a vague term, with under specification of the area of 'high functioning' (performance IQ, verbal IQ, adaptation, or symptom severity).
2nd View: That Asperger disorder is distinct from other subgroups within the autism spectrum (see Matson & Wilkins, 2008, review): e.g. Klin, et al. (2005) suggest the lack of differentiating findings reflects the need for a more stringent approach, with a more nuanced view of onset patterns and early language (e.g. one-sided verbosity, unusual circumscribed interests).
Witwer and Lecavalier's (2008) perhaps more comprehensive review concludes there is little evidence that Aspergers is distinct, and that current IQ is the main differentiating factor.
Bennett et al's (2008) follow-up study suggests that language impairment at 6-8 years might have greater prognostic value than early language milestones, and Szatmari et al (2009) argue (on the basis of later developmental trajectory) for a distinction between ASD with (autism) versus without (Aspergers) structural language impairment at 6-8 years.