Childhood: Clinical and School Psychology – Lecture 4 (UNIVERSITY OF AMSTERDAM)

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with five criteria:

1. Persistent deficits in social communication or social contact across multiple contexts
   1. Deficits in social-emotional reciprocity (i.e. visible in toddlers)
      1. Strange way of making contact.
      2. Reduced sharing of interests, pleasure, emotions or affect.
      3. Inability to initiate and respond to interactions.
      4. The child is untuned (e.g. ignoring the listener).
   2. Deficits in non-verbal communicative behaviours used for social interaction (i.e. visible in toddlers)
      
      1. Limited eye contact.
      2. Odd body language (e.g. turning away).
      3. Limited facial expressions and understanding.
      4. Few gestures and limited understanding of gestures.
   3. Deficits in developing, maintaining and understanding relationships.
      
      1. Not a lot of fantasy play.
      2. Difficulties in making friends.
      3. Limited empathy.
      4. Difficulty playing together.
      5. Not a lot of interest in peers.
2. Restricted, repetitive patterns of behaviour, interests or activities (at least two)
   
   1. Stereotyped or repetitive motor movements, use of objects or speech.
   2. Insistence on sameness, inflexible adherence to routines or ritualized patterns or verbal or non-verbal behaviour.
   3. Highly restricted, fixated interests that are abnormal in intensity or focus.
   4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment.
3. Present in early development (i.e. around two years of age)
4. Distress and reduced functioning
5. The symptoms are not better explained by another disorder

Symptoms of autism may not manifest themselves in early development if there is a mild version of the disorder. Most children with ASD will demonstrate difficulties in the key symptom clusters but the symptomatology and severity differ. The severity is based on support needed. This ranges from support to very substantial support.

In ASD, there is abnormal language development and several language difficulties are associated with ASD. The child with ASD:

• Does not babble.
• Shows delayed language development (e.g. no use of functional words at 18 months).
• Shows inappropriate use of language (e.g. difficult words at early age).
• Makes use of abnormal language (e.g. repeating words; monotonous; long-winded).
• Takes language literally.
• Mostly talks about the favourite subject.

There are several symptoms of Asperger’s syndrome:

• Social impairment and restricted behaviour.
• There is no speech delay and no cognitive delay.
• There is specialized knowledge in restricted domains.
• There are eccentricities (e.g. formal speech; stiff speech).
• There are difficulties in comprehending non-literal use of language.

While many people with Asperger’s syndrome see it as part of their identity, it was removed from the DSM-5 together with PDD-NOS (1), childhood disintegrative disorder (2) and autistic disorder (3). Asperger’s may not be severe enough to classify as part of the autistic spectrum. However, Asperger’s syndrome may be a separate category due to differences in language development. They tend to have more verbal rituals and ask odd questions.

There are three proposed underlying mechanisms of ASD:

1. Theory of mind
   A child with ASD appears to show difficulties in theory of mind (e.g. difficulties with social interactions). The child experiences different social interactions (e.g. difficulties in understanding motives and intentions). While a limited theory of mind may explain the social deficits of ASD, it may not explain the restricted and repetitive patterns of behaviour.
2. Limited executive functions
   A child with ASD appears to show difficulties in shifting (1), inhibition (2) and working memory (3). The executive function deficit does not appear to be pervasive across all settings. While this partially explains the deficits in social communication and restricted activities, it does not explain all deficits (e.g. insistence on sameness; hypersensitivity to sensory input).
3. Weak central coherence
   A child with ASD appears to show a weak central coherence. This means that more time and energy is needed to process information (1), there is a difficulty with cause-and-effect relationships (2), there is a difficulty in distinguishing between main and secondary issues (3) and the situation is not perceived as the same when a detail changes (4). While this may explain parts of the restricted and repetitive patterns of behaviour (e.g. insistence on sameness), it does not explain all symptoms and it also does not fully explain the deficits in social interaction.

The central coherence theory states that a person integrates perceived details into a meaningful whole and people make use of the given context. Evidence that children with ASD have poorer central coherence comes from autistic children performing better when needing to focus on the details compared to focusing on the whole.

It is likely that ASD is explained by a combination of all the factors, meaning that a child with ASD likely has deficits in theory of mind (1), executive functioning (2) and central coherence (3).

ASD is pervasive over developmental periods (i.e. it does not go away) but learning and compensation are possible which makes it less impairing. One thing which makes ASD very impairing is the high rate of comorbidity. There are two possible explanations for comorbidity:

1. Comorbidity due to a common cause
   This states that both ASD and the comorbid disorder may have the same underlying cause. This may be the case for ADHD (e.g. executive functioning impairment), intellectual disability or language and learning difficulties.
2. Comorbidity due to ASD symptoms (i.e. secondary issues)
   This states that some comorbid disorders may be the consequence of having to deal with the symptoms of ASD. This may be the case for separation anxiety (1), social anxiety (2), specific phobia (3) and depression (4).

Comorbidity with intellectual disability is very common. High functioning autism refers to people with ASD and an IQ of higher than 70. They typically have more atypical speech patterns (e.g. echolalia; noun reversal; atypical gestures). It is difficult to differentiate high-functioning autism and Asperger’s syndrome solely on the basis of diagnosis.

The main difference between repetitive behaviours in ASD and OCD is the function of the repetitive behaviours. Due to the heterogeneity of ASD (i.e. different symptomatology and different comorbidity per person), it is imperative to actively look for comorbidity. When assessing comorbidity, it is important to look at the function of behaviour (e.g. reason for avoiding social interactions) and make a functional analysis.

However, it is difficult to properly assess comorbidity in ASD for several reasons:

1. Children with ASD often have social deficits which make making a functional analysis more difficult (e.g. difficult to ask for a reason why a child shows behaviour).
2. Children with ASD often have cognitive deficits (e.g. intellectual disability).
3. Children with ASD often have language deficits.
4. Children with ASD often have learning deficits.
5. The symptoms of ASD often overlap with other disorders.
6. The symptoms of ASD may lead to secondary problems (e.g. anxiety).
7. The symptoms of ASD are very heterogeneous.
8. There is diagnostic overshadowing.
9. There often is a different symptom presentation in children with ASD than in children without ASD.

Diagnostic overshadowing refers to not recognizing a second disorder because the problems are attributed to the first disorder. All in all, it is difficult to disentangle causes of disorders and properly assess comorbidity in ASD.

There are several benefits of having accurate and early recognition of comorbidity:

• Early treatment has substantial effects on cognitive ability (1), adaptive behaviour (2) and psychopathology (3).
• Knowledge of comorbid disorders can inform treatment planning.
• Knowledge of comorbid disorders can focus researchers on developing specific diagnostic tools (1), treatments (2) and psychopharmacology (3).

Problems in ADHD often appear similar to core symptoms of ASD. This includes executive functioning deficits (1), learning disabilities (2), low processing speed (3), sleep disorders (4), early language delay (5), deficits in attention, motor control and perception (6), fewer social relationships than same-age peers (7), disruptive behaviour problems (8) and difficulty adapting to change (9).

It may be irrelevant to diagnose people with ADHD when they are diagnosed with ASD due to the large symptom overlap and high functioning autism has often been misdiagnosed as ADHD. This means that screening people with ADHD for ASD may be relevant.

Overlapping behaviours of ASD and OCD are excessive involvement in special interests (1), engagement in compulsive rituals (2), stereotyped and repetitive motor mannerisms (3) and insistence on sameness (4). However, individuals with ASD may not express distress associated with their rigid beliefs and do not perform rituals to alleviate anxiety.

Children with ASD are at greater risk for anxiety, especially those with high-functioning autism or Asperger syndrome. This may be due to the higher cognitive and linguistic abilities that allow for verbalizing obsessions, thoughts or beliefs. While anxiety symptom presentation is similar in people with ASD compared to those without, anxiety is also a symptom of ASD making it difficult to distinguish comorbidity.

Stimming behaviour (i.e. self-regulatory behaviour) refers to repetitive or unusual body movement or noises (e.g. flapping hands). This often helps a person with ASD regulate their emotion and behaviour.

ASD appears to be more prevalent in boys than in girls but diagnosis depends on behavioural assessment and it may just be the case that symptom presentation differs between the sexes. Screening in a non-clinical population shows that the gender gap in ASD is smaller than in clinical samples.

When it comes to females and ASD:

• Girls are often diagnosed later than boys.
• Girls with a low IQ are more likely to receive a diagnosis than girls with a high IQ.
• The rates of ASD diagnosis have been increasing and the gender gap is decreasing.

This leads to the notion that there is no difference in the prevalence between males and females when it comes to ASD but that females with ASD are often overlooked. Underdiagnosis of females may be due to the behavioural markers that are used to assess ASD as these markers are based on male cases of ASD. This means that females may have different symptom presentation than males.

One hypothesis states that the prevalence rates do differ because females are protected against ASD by having a more social brain and a different genetic make-up. This argues that ASD is an extreme version of a male brain. However, this hypothesis is very controversial and not widely supported. There is evidence that the phenotype of autism differs across sex:

1. Social communication and interactions (compared to boys).
   Females with ASD have more desire and intent to form friendships (1), have fewer social difficulties (2) but they find it more difficult to maintain long-term friendships (3).

1. Restricted, repetitive behaviours and interests
   Girls are more often obsessed with animals (1), fictional characters (2) or psychology (3) whereas boys are more often obsessed with vehicles (1), computers (2) or physics (3). The restricted interests of girls are often considered less inappropriate than those of boys.
2. Co-occurring behavioural problems
   Girls have more comorbid internalizing problems (e.g. anxiety) whereas boys have more comorbid externalizing problems (e.g. conduct problems).
3. Camouflaging
   This often takes the form of social desirable behaviour (e.g. by imitating others) and females often try to avoid standing out (e.g. keeping to the rules; being naïve and sweet; attempt to be invisible).

All of this may make it more difficult to detect ASD in females than in boys.

Camouflaging refers to the use of conscious or unconscious strategies (i.e. explicitly learned or implicitly developed) to minimise the appearance of autistic characteristics during a social setting. Camouflaging and compensating are exhausting as mood swings (1), identity issues (2) and physical exhaustion (3) are common.

Successful treatment programmes may have several characteristics:

• It targets specific deficits.
• It uses a highly structured and predictable programme with a low teacher/student ratio.
• It integrates programmes across situations.
• It engages parents as co-therapists.
• It carefully monitors the transition between programmes.

It is important to have an early and intensive intervention. Next, it is important to modify the treatment to the cognitive, social and linguistic abilities of the child with ASD.