Autism Spectrum Disorder
Dr. Petrosky has evaluated and consulted with clients Autism Spectrum Disorders (ASD) for many years. See answers to common questions about ASD as well as Asperger’s Syndrome, and PPD NOS below.
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What is Autism?
What are the symptoms of Autism?
Before describing the symptoms of Autism, it is important to know that not every child with Autism has every symptom or every symptom to the same degree. In fact, this is one of the reasons why Autism is called Autism Spectrum Disorder.
Social Communication and Social Interaction
- Trouble making and keeping friends. Sadly, the child with Autism may not get called for playdates, invited to parties, etc.
- Children with Autism may show a lack of interest in peers, preferring mainly to play by themselves. It is important to realize, however, that this is not always the case in Autism. There are children with Autism who do want friends and to have playdates.
- Trouble understanding other people or poor “theory of mind.” Theory of mind basically refers to the ability to put oneself “in somebody else’s shoes.” It reflects the ability to use context clues, facial expressions, body language, etc. to figure out what other people are thinking and feeling, including recognizing others’ unspoken intentions and motivations. This is a very important ability since we often say more with our faces than with our words.
- Poor emotional and social reciprocity. Children with Autism often have trouble taking turns or playing with others when it is not on their terms. They may talk about only what they want to talk about, have trouble with back and forth conversation, and insist on playing just what they want to play. They have trouble recognizing how another person may feel differently and then accommodating to others’ feelings (e.g. “I want to play with Legos, but you don’t like doing that so we’ll play something else so you don’t get bored.”).
- Poor eye contact. We use eye contact to regulate conversations. We look at people to get and hold their attention when we want to speak. We look at people when they are speaking so they keep talking (or to be polite). We look away to signal we are done speaking. For children with Autism, it often does not occur to them to do this.
- Poor joint attention. This is when we catch someone else’s attention to share an experience. For example, a child may notice an interesting toy and then look at his or her parents and then back at the toy as a way of sharing his or her excitement with the parent. It is a way of saying, “Do you see what I see?!” Children with Autism tend to not do this.
- Not using gestures and body language appropriately to communicate as well as not understanding others’ gestures and body language. Gestures include signaling with your hands things like, “O.K.,” “you go first,” “no, thanks,” “stop it,” etc., and using your hands descriptively, such as when we hold up our hands to show how big something is. Nonverbal communication also includes “beat” gestures, which are movements we make in tune with the rhythm of speech (beats are often what people mean when they refer to “talking with your hands”). Children with Autism may have a conspicuous lack of gestures, they may use unusual gestures, or their gestures may not match their words.
- Odd vocal intonation. Children with Autism may have a tone of voice that sounds flat, robotic, “sing-song,” or as if they are imitating someone (although they are not).
Restricted and Repetitive Behavior
All of the behaviors in this category reflect rigidity in one way or other (except for sensory processing differences which is placed in this category in the DSM-5, but does not bear as obvious a relationship to rigidity as the other behaviors in this category).
- Perseveration. This refers to getting locked into the same repetitive behavior. Perseveration reflects a person continuing a behavior past the point at which the behavior should have stopped and the person should have switched to a new behavior. For example, the child may talk about the same topic or ask the same questions over and over. The child may do the same play action over and over, such as roll a toy car down an arm of a couch, over and over, for a long time.
- Restricted interests. These refer to interests that are unusual in terms of what the child is interested in and/or how much the child is interested in it. For example, a child with Autism might play for hours with a hole puncher, pencil sharpener, a plastic bag, or garage door opener, roll a toy car down the arm of a chair over and over, or enjoy freezing objects in an ice tray or clogging and flooding a sink. A common form of restricted interests is a preoccupation with memorizing numerical facts, especially seemingly irrelevant or arbitrary facts, such as wanting to know and memorizing everyone’s license plate numbers, fax numbers, birthdays, age, or weight, the dates of previous holidays or purchases (e.g. the date you bought your laptop), the number of rooms in an office building or steps in your house, or the mph of each of the last 100 hurricanes. The child also may do things such as add the above numbers (e.g. computing the combined weight of everyone in the room).
Although it is not necessarily unusual for a given child to do some of the above, a child with Autism spends an inordinate amount of time doing these activities and tends to focus on a narrow range of these types of activities at the expense of doing other things. For example, a child without Autism might use a hole puncher while playing “office,” but would not do this exclusively for hours day in and day out.
Restricted interests also include memorizing detailed factual information about a specific topic, such as every fact about dinosaurs, sharks, or Pokémon. Again, not that it is unusual for a child to know a lot about a certain topic (e.g. it is not uncommon for 10-year-old boys to know every statistic about their favorite sport). However, for a child with Autism, such a focus is extreme, narrow, and to the exclusion a more variety of interests.
- Stereotypies. A stereotypy refers to non-functional behavior. Verbal stereotypies refer to using words and phrases in a manner that is non-functional and does not fit the context. An example would be giving a child directions to an ELA worksheet upon which the child responds, “Here we go girls – tearing the record,” a comment that does not make sense or fit the context. Whispering to oneself is another verbal stereotypy. Verbal stereotypies can sound cliché like, such as a child saying “Let’s go to the show” for no apparent reason. Children with Autism often produce verbal stereotypies perseveratively, that is, they will repeat the verbal stereotypy over and over, such as a child saying “Hi there. Hi there.” throughout an entire interaction, well past the initial introduction. Echolalia is a type of verbal stereotypy in which the child reflexively parrots back what s/he has heard either immediately after the fact or some time after. For example, an adult says, “We’re going to do a lot of activities” and the child immediately says, “We’re going to do a lot of activities.”
Echolalia often takes the form of the child repeating things s/he was told, saw on TV, heard in an announcement, etc. For example, a child with Autism might say out of nowhere, “Stand clear of the closing doors please” or “Pull over sir,” comments they heard somewhere else that they then mechanically repeat at a later time.
In a related vein, children with Autism may use neologisms, which refer to words that are made up or real words given a novel meaning by the child. For example, a child may say “yappity” to refer to being bored or call his or her parent “owl.”
Motor stereotypies refer to non-functional movements, that is movements that do not accomplish any apparent purpose. Examples include the child wiggling his or her fingers back and forth, arm flapping, standing up from a chair, walking around the chair, and sitting back down for no apparent reason, or the child moving his or her arms as one would if using a bow and arrow.
Echopraxia is a type of motor stereotypy that refers to reflexively imitating movement one has seen, either immediately or some time after. An example would be a person adjusts his tie and the child makes the same motion with his or her hand by their neck.
- Insistence on sameness and inflexible routines. For example, children with Autism may have trouble transitioning and have difficulty tolerating changes to their schedule, especially if unanticipated. The child may insist on things like sitting in the same seat, drinking out of the same cup, or wearing clothing only of a specific color. S/he may have a highly specific and scripted way of saying goodnight. The child may insist on having meals or doing other activities at the same specific time every day. S/he may insist that items be kept in the exact same spot or that the exact same route be taken when driving places.
- Sensory processing differences. Children with Autism may be hypersensitive to noise, covering their ears when other children are not, such as to the sound of an automatic hand dryer, a flushing toilet, fireworks, or crowd noise. The child may be averse to television jingles with high notes. They may be very fussy about tags and seams in their clothing as well as about certain fabrics. The child may refuse to wear jeans, leggings, or shirts with buttons. S/he may only wear sweatpants or very soft fabrics, like fleece. The child may resist having his or her hair or nails being cut or teeth being brushed or s/he may resist taking a bath because of an aversion to the sensations these activities cause. A child with Autism may be hypersensitive to smell. S/he may refuse to go in the kitchen because the child can smell traces of a cleaner or previous meal no one else can notice. S/he may be averse to the smell of a new textbook.
Children with Autism may have a very narrow diet. They may prefer relatively bland tasting foods and resist certain food textures (e.g. the child may only eat plain pasta or yogurt). Other types of rigidity also can affect the child’s food preferences. The child may only eat an exact brand of food as well as food prepared only one way. For example, the child may only eat one type of pasta or eat grilled cheese only if it is cut diagonally. Children with Autism may have a very high pain threshold. For example, the child may go to the doctor and be found to have an ear infection that no one suspected because the child never “made a peep.”
Abnormal visual responses. Children with Autism may stare at objects intensely for a long time, up close, or from odd angles (e.g. examining a shiny object or his or her reflection from the corner of his or her eye). They may stare at spinning objects (e.g. a ceiling fan) or other moving things (e.g. the end credits of a movie) or wave their hands or wiggle their fingers in front of their eyes. This is frequently referred to as “sensory seeking” behavior, based on the interpretation that the child is stimulating his or her visual senses with this behavior. This behavior also can reflect restricted interests in terms of the child becoming unduly focused on seemingly irrelevant stimuli and/or parts of objects (e.g. the ridges on a clip) and/or aspects of objects (e.g. what objects look like from different vantage points).
What is “stimming?”
“Stimming” is short for self-stimulating behavior and refers to behavior that is thought to be a way of reducing or increasing arousal. For example, a child might engage in “arm flapping” when excited as a way of discharging this extra energy or rock back and forth as a way of calming down or reducing arousal. On the other hand, the child may stare at spinning objects as a way of “feeding” the senses or creating visual input, thereby increasing arousal. Many of the stereotypies as well as abnormal visual responses discussed above would fit into this category and also be called “stimming.” It’s important to realize that the same behavior can serve different functions in different children or the same child at different times. For example, a child might rock back and forth at times to calm down and, at other times, to increase arousal because s/he is bored. It is also important to know that “stimming” is not exclusive to Autism. Most people “stim” to some extent, such as tapping fingers on the desk or shaking one’s leg up and down when sitting at a table.
What’s the difference between “Autism” and “Autism Spectrum Disorder”?
Autism Spectrum Disorder is simply the “official,” formal term, which people frequently abbreviate by saying just “Autism.”
The word “Spectrum” conveys the idea that children with Autism have a variety of symptom profiles. By definition, the symptom categories are the same – problems with social communication and social interaction and restricted and repetitive behavior. However, children with Autism vary in terms of which particular symptoms in each category they have. In addition, children vary in terms of the number of symptoms they have and how severe each symptom is. For these reasons, although children with Autism all have the same categories of symptoms, there is a lot of diversity amongst children with Autism. This is why the word “Spectrum” is used, in order to capture this diversity.
What is high functioning Autism? Asperger’s Syndrome? Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS)?
Is Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS) listed in the DSM-5?
What is Social (Pragmatic) Communication Disorder?
Social (Pragmatic) Communication Disorder can be described as the social skill deficit “half” of Autism Spectrum Disorder, without the restricted and repetitive half (both halves of which define Autism).
As implied by its name, children with Social (Pragmatic) Communication Disorder have difficulty with social communication. They have trouble following the “rules” of a conversation. This includes knowing how to start a conversation, how to listen appropriately, how to keep the conversation going, and how to end the conversation. Children with Social (Pragmatic) Communication Disorder have trouble having a back and forth conversation. They may dominate the conversation. They tend to miss nonverbal signals, such as those indicating that the other person is bothered by what they are saying or doing (e.g. joking or horsing around too much) or they may miss signals that the other person wants a turn to talk or wants to end the conversation.
Children with Social (Pragmatic) Communication Disorder have trouble adjusting their communication based on the “who and where” of the situation. As a result, they may be overly formal (e.g. talking like s/he is giving a classroom presentation when chatting with a friend) or overly informal, such as being “too familiar” with strangers or people they do not know very well. They also may say things “out of nowhere” or that do not fit the situation and thus strike others as odd.
Finally, children with Social (Pragmatic) Communication Disorder have trouble understanding nonliteral language, such as hints, innuendos, idioms, figures of speech, metaphor, or humor. As a result, they tend to interpret people literally and concretely. They may miss implicit requests, in which somebody asks for something without actually asking for it (e.g. a friend saying “I sure love chocolate” as a way of asking for some chocolate).
A tendency to miss indirect communication can cause the child with Social (Pragmatic) Communication Disorder to accidentally say insensitive things, even when s/he has no ill intentions at all. For example, imagine a girl who says she is embarrassed because she just got ketchup all over her shirt. Often when a person makes a comment like this, it is an implicit request for support. The child is essentially implicitly asking, “Can you please make me feel better about this?” and hoping for a response like, “Don’t worry. You can hardly notice it.” A child with Social (Pragmatic) Communication Disorder tends to miss the underlying intent of implicit requests and might simply respond, “Yes, I see it.”
How can I help my child with Autism?
There are many, many types and forms of help for children with Autism Spectrum Disorder, some of which include:
- Applied Behavioral Analysis (ABA). “ABA” is really a broad category that includes many families of interventions and numerous specific techniques. What ABA interventions have in common is they change behavior by managing “antecedents” or triggers of the behavior and managing consequences of the behavior. Managing triggers means altering the environment, the way a task is presented, etc. as a way of preventing a problem behavior or eliciting a target (desired) behavior. For example, showing the child a visual schedule before a transition might be used as an antecedent to facilitate transitioning. As another example, if a child tends to “stim” when it gets noisy, taking steps to control the noise level or the child’s exposure to noise would be a way of managing antecedents. Managing consequences means responding to behavior after it occurs, such as using rewards to encourage the person to keep doing the behavior, such as access to a preferred activity upon completion of work. It should be pointed out that, although ABA tends to be thought of as an “Autism intervention,” this is actually not the case at all. The principles of ABA apply to modifying any behavior. For example, any time a teacher or parent has praised a student for doing good work, he or she has used the principles of ABA.
- Social Skills Training. Individual and group social skills training can help with many areas, such as the ability to: read facial expressions, body language, and other social cues, better understand people, have conversations, play with other children, and build relationships. This training is often performed by psychologists, social workers, and speech-language pathologists.
- Speech and Language Therapy. Speech and Language Therapy can address the social skills components discussed above, many components of which fall under the heading of helping children with “pragmatic language.” Pragmatic language includes things like reading social cues, understanding non-literal language, such as hints, innuendos, and figures of speech, conversational skills, and knowing how to speak in a way that fits the context or situation (e.g. speaking to one’s friends versus one’s teacher). Speech and Language Therapy is also used to treat the receptive and expressive language challenges children with Autism also often have in general.
- Sensory Integration Training. Sensory Integration Training is generally performed by an occupational therapist who works with the child and his or her parents and teachers on ways of increasing the child’s ability to tolerate sensory input (e.g. having his or her teeth brushed or having a bath), ways of modifying the child’s environment to avoid sensory overload (e.g. exposure to excessive noise), and other ways of managing the child’s sensory needs (e.g. specially designed seating arrangements). Sensory Integration Training can include what’s called providing the child with a “sensory diet,” which refers to ways of feeding the child’s desire for sensory input and helping him or her discharge extra energy that’s causing the child to feel over-stimulated (e.g. uses of special swings, brushing the skin, and many other tools).
- Classroom and test modifications and accommodations. There are many classroom and test modifications and accommodations for children with Autism, such as use of visual schedules, pre-teaching and re-teaching of information, directions repeated, paraphrased, and clarified with extra practice problems and examples, check for understanding of directions, extra wait time to answer questions, provision of a sensory diet, organizational support, extended time on examinations, refocusing and redirection on examinations, examination directions paraphrased and clarified, and many, many others. It is important to know that modifications and accommodations are based on the individual needs of the child and of course not every child has every modification or accommodation.
- Occupational Therapy and Physical Therapy. Occupational Therapy and Physical Therapy can help improve children’s fine and gross motor skills, areas commonly affected in Autism Spectrum Disorder.
- Medication. Medication may help reduce behaviors that can sometimes be seen in Autism, such as aggression and self-injurious behavior (e.g. head banging). It also can help with behaviors such as “stimming,” rigidity, and inattention which are common in Autism. Medication does not directly target social functioning, although it may indirectly help social functioning by reducing some of the behaviors that interfere with social functioning, like reducing perseverative speech so the child is better able to have a reciprocal conversation.
- Others. There are many interventions for Autism. What is presented above is intended as a sampling, but it is by no means an exhaustive list.