L2 Autism
What does a complete diagnosis for autism require?
Systematic developmental history/ Parent Information/ behavioural observation
(working with person and doing this)/ dev/cog assessment (e.g IQ)/ done by
experienced clinician and multidisciplinary teams
What are the 3 standardised diagnostic assessments for autism (gold standard)?
- Autism Diagnostic Interview (ADI-R)- structured interview conducted with the parents or caregiver of individuals with suspected autism. 93 item semi-structured interview
- Autism Diagnostic Observation Schedule (ADOS)-usually done with ADI-R, delivered in 5 modules- one added for toddlers.it involves a series of structured activities and scenarios that you administered in a very structured way. If you're using module 1 you're working with sort of children with kind of limited speech and you're doing more sort of play based activities. Module 4- conversation based, kind of for adolescents and adults. Very conversational and flowing. So there's activities around work and activities around school, and it's really designed to elicit those kinds of social interaction and communicative behaviours for sort of adolescents and adults.
Both this and oADIR have a diagnostic algorithm which you use a point scoring system that you tick off at the end and it'll reveal if they have autism. Not good at picking up on repetitive behaviours cos its a very small snapshot in time so can’t really see this. Toddlers obvs can’t use language- so it is very play based.
- Diagnostic Interview for Social and Communication Disorders (DISCO)- - less commonly used- broader than just looking at autism specific disorders. Broader remit
than focusing on autism
What were the changes to the Autism diagnostic criteria in the DSM-5 (APA, 2013)?
- Revisions to create more accurate diagnosis and treatment (interrater reliability low for autism diagnosis in DSM-IV- Volkmar et al, 1994)
- Eliminate subgroups like Asperger and PDD-NOS diagnosis, create more dimensional approach, severity
- Under the DSM-IV criteria, a person can qualify for the diagnosis by exhibiting 6 or more of 12 behaviours; under the proposed definition, the person would have to
exhibit 3 deficits in social interaction and communication and at least 2 repetitive behaviours. More restricted/ constrained set of diagnostic criteria, despite this
restriction, 2+ ppl diagnosed on DSM-5 can be diagnosed even when presenting completely different
- Aim for DSM-5 to create more accurate diagnosis, lay groundwork for accurate supports and treatments for autistic people
- Subgroups in DSM=4 not reliable- clinicians would give diff diagnosis v unrealiable
- Whole idea of dsm-5 was to make a more dimensional approach, looking at autism and the spectrum as one thing rather than specific subgroups. More constricted/
constrained set of diagnostic criteria in DSM-5
Regarding the DSM-5 Autism criteria, what are the social communication and interaction sub-criteria?
MUST MEET 3 TO BE DIAGNOSED.
1) Social emotional reciprocity (e.g abnormal approach, failure of bath + forth convo, reduced sharing of interest or affect; failure to initiate or respond)
2) Nonverbal communicative behaviours for social interaction (e.g poorly integrated V + NV behaviour, abnormal eye contact and body language; poor understanding and use of gestures, lack of facial expressions)
3) Developing, maintaining, and understanding relationships and/or adjusting to social context (e.g difficulties in adjusting to social contexts, sharing imaginative play, making friends, absence of interest in peers)
Regarding the DSM-5 autism criteria, what are the criteria for the restricted and repetitive patterns of behaviour, interests or activities?
MUST MEET 2/4.
1) Stereotyped or repetitive motor movements, object use or speech
2) Insistence on sameness, inflexible adherence to routines, ritualised patterns of V + NV behaviour
3) Highly restricted, fixated interests that are abnormal in intensity or focus
4) Hyper/hypo reactivity to sensory input or unusual interest in sensory aspects of environment (Really significant about include sensory input criteria in DSM-V-
Really important sensory criteria)
What is the criteria regarding onset, specifiers, and co-occurence?
ONSET: Symptoms must be present in “early developmental period” but possible that “may
not become fully manifest until social demands exceed limited capacities” and/or “may be
masked by learned strategies later in life” (APA, 2013)
Specifiers included for:
- Intellectual disability/ language impairment (incl description of current lang functioning)/ known medical or genetic conditions/ other neurdev, mental or behavioural disorders
Co-occurence→ ASC may be diagnosed with other conditions such as ADHD, Language Impairments
Onset used to be v stringent but now is much more flexible- allows more adults and adult females to be diagnosed later
First time there is specifiers- before DSM-5 could not have ASD if you had a comorbid
disorder like ADHD, for the first time now you can
More dimensional approach than putting people into groups
DSM-5 diagnosis places emphasis on specific needs of affected individual than giving a name to their condition(focus on sub groups/categories which do not have practical utility)
Is autism a learning disability?
NO→ LD defined based on IQ and deviations from standard IQ. autism associated with LD
but is NOT
Signif variability and heterogeneity in autism- range of ability across community
E.g 40% of ASD have LD, compared to 1% w/out autism. 1 in 10 ppl with LD have ASD. 3 in 10 ASD ppl speak few or no words→ across community range of ability
Within individuals- uneven profile (Frith,2003). Difference between cognitive ability and adaptive functional skills, such as, socialisation and daily living skills (Klin et al 2007)
What did the SIGNS birthday party video by a Wales autism research centre try to represent?
Governments and charities recognise the problems of
delayed diagnosis, lack of educational support, and stigmatisation due to poor understanding of autism→ approach hed by Wales NAT who wanted to create training film for frontline professionals to increase understanding of autism. ‘The Birthday Party’ describes the SIGNS of autism and the varied ways they present themselves. Incorporated the 14 most discriminating items into our film, based around the acronym ‘SIGNS’--> shown in 3 diff ASD kids attending a bday party. Used research from DISCO- made a film to display the very different ways in which autism looks in different ppl- obvs does not cover everything but covers their research for what were the most prevalent signs
What are the problems with autism in adulthood?
Adult diagnosis available in 1980s- easier with DSM 5. Concerns about social relationships, mental health issues, decades of ‘feeling different’, various difficulties with relationships and employment, misdiagnosis. Difficult to get adult diagnosis – pathway, developmental history,
masking & clinicians understanding, post-diagnostic support (Pellicano et al. 2022)
What did Atherton et al (2022) discover about age of diagnosis and QoL outcomes?
mean age of diagnosis in males is 15 and for women 21. QoL lower for adults with ASD- could be due to late diagnosis
Costly, long process, clinicians do not understand what it means to be an autistic adult.
Misdiagnosis- women often misdiagnosed with various MH conditions when it is in fact autism- can happen to men too. Can be hard as a clinician to see what is masking and what is not and how to go beyond the mask. Often v poor post diagnostic support- you go through
this really challenging, lengthy, costly difficult process and there's little support at the end for you. Evidence to suggest the earlier the age of diagnosis, the better the outcomes in terms in QoL (Atherton, 2022)
According to Pellicano et al (2022) what are some long term outcomes of having autism?
Less likely to hold down a job, live independently, have friends/ rels compared to non-ASD (Pellicano et al, 2022). 2 in 10 autistic ppl in long term employment- lowest statistic on average than it is for any other disabled group. LT outcomes are poorer in general for people with ASD than for those without. Lower statistics than any other neurodev group (employment in those with ASD). MH chronic- they don’t just go away
What did Roestorf et al (2022) discover in their study regarding mental health and QoL?
2⁄3 adult sample (N=69) sig. Anxiety and depression issues: remained at 2 yr follow up. Strongly predicted QoL
What is true of friendships in autism?
Widespread misconceptions autistic people don’t want fiends→ variability abt how many
they want etc
ACYP do want friends (Bauminger, 2008)/Feel social rejection similarly to non-autistic peers (Masten et al., 2011) BUT find making friends more difficult, likely to be on periphery of social networks (Kasari et al. 2011) and experience more rejection (Underhill et al. 2019)
What was the cyber ball paradigm?
- Cyber ball paradigm- inclusion and exclusion paradigm. Throwing ball simulation- 3 friends in a group- inclusion criteria you get the ball passed to you, exclusion the other 2 play and you do not. Starts off friendly and everyone gets equal passes- inclusion criteria. Exclusion- over time you as pp are excluded and other 2 players just start passing to each other. Reliable, robust- get various types of psych physiological and self-report measures
- Found that autistic adolescents were very similar reports of how it felt to be rejected in the experimental condition
What is the autistic experience?
“Autistic burnout was defined as a highly debilitating condition characterised by exhaustion, withdrawal, EF problems and generally reduced functioning, with increased manifestation of autistic traits- and distinct from depression and non-autistic burnout”
- ASD ppl more likely to die by suicide than non ASD + more likely to burnout
What are sensory differences?
Mechanisms by which CNS receives input from senses and integrates this info to produce adaptive-behavioural response (Dunn, 1997; Robertson & Baron-Cohen, 2017).
Neurotypical-automic.
Multi-sensory processing→ integrating info across sensory modalities
For neurotypical people, you know, when you hear somebody talking, you interpret that information as speech and you respond to it by turning your head to listen. For us we do this without thinking about it-automatic- v diff for autistic people
What are the 3 types of senses?
- Proprioception- body’s ability to sense movement and action
- Vestibular- balance, spatial orientation
- Interoceptive- perception of internal bodily action
What type of sensory differences is there in autism?
Hyper- over sensitivity/ Hypo- under sensitivity/ Seeking
Across all modalities (light, pain etc)
What did Ben-Sasson et al (2019) find in their study regarding sensory differences in people with ASD?
90% of ppl with ASC experienced significant differences in how they experienced sensory differences but hyper-sensitivity best discriminator?
Hypersensitivity over responding was the best discriminator of autistic people from other groups. Ben-Sasson et al (2019) meta analysis of q’nnaires- 90% experience differences in how they experience sensory things
Common problematic types to sensory input→ e.g an autistic person may find certain background noises (which other ppl can usually block out) unbearably loud or distracting which can cause anxiety or even physical pain
How can we measure sensory differences?
Sensory profile q’naire (parents, teachers, self)/ neural responses/ self report/ psychophysiology
Observation - SAND
- Hard to measure cos it is an internal experience
- Hard to explain and understand as an ASD ind (child)
- SAND- like ADOS but just for sensory issues
What did Brown et al (2008) and Kientz and Dunn (1997) find about autistic children on the Sensory Profile Q?
Autistic children consistently different to neurotypical children
Significantly different scores from non- autistic children on 85% of the items on the Sensory Profile and this occurred in both for hypersensitivity and hyposensitivity
across all domains
What did Kern et al (2006, 2007) find in their study across the lifespan?
Looked at differences across the lifespan in 104 pps, aged 3-57yrs in low threshold auditory processing and high threshold auditory processing and found both decrease as people age.
What did Kaiser et al (2016) find about neural responses in terms of responses to non-social touch?
- fMRI scanning of primary somatosensory cortex & socio-emotional processing circuits (e.g. insula, STS, amygdala)
- 38 age/cog matched autistic/non-autistic people (5-20 years) (matched based on age and cog abilities)
- Brushed gently with watercolour brush on their arm for 6 seconds whilst undergoing MRI (Looking to see if there were any social or emotional differenes in how these two
groups responded, and in terms of how the sensory system was processing this information)
- Reduced activity – socio-emotional networks (in insula, amygdala etc)
- Heightened activity – somatosensory cortex (heightened activity in the primary sensory cortex, so shows this hypersensitivity)
- Shows an indication of how different those basic and sensory experiences are for autistic people (Uncertainty and unpredictability of sensory differences that most
impact learning cos they dk if they are gonna get bumped into etc)
- Hypo- if someone is under-responding they don’t really know themselves (Control is really important) → Sensory differences can massively contribute to burnout
What did Keith et al (2019) research and find out about physiology and heart rate in their study?
Looked at impact of classroom noise and task complexity
on autonomic arousal (HR-heart rate and SCL- skin conductance level). 25 autistic and 21 non autistic adols (12-17 yrs)
Number span task (WM) and background noise. Better on forward, better with noise on forward, worse with noise on backwards. Interactions with group not sig.
Everyone worse on noise backwards, but autistic people even more so
What they showed in terms of heart rate and echo was much more stress in the presence of noise- increased heart rate→ More stress= poorer outcome on this cognitive task
Effect on arousal diff for autistic group (HR increase)
Increased SCL associated with poorer performance on back span for ASD group only
Background noise as additional stressor during cognitively demanding task
What are the impact of sensory differences?
Difficulties in social play (Kuhaneck & Britner, 2014)/ sleep
problems (Reynolds et al, 2013), anxiety (Green et al, 2012)/ education (Jones et al, 2020) and daily life (MacClennan et al, 2021)
When looking at sensory differences (arousal) in school, what did Jones et al (2020) do and find?
Using a q'nnaire, researchers asked teachers and parents of ASD children about autistic children's sensory differences that impacted learning and school experiences.
57 parents, 70 teachers.
Parents--> 70% had children in mainstream schools and 30% had children in some specialist provision.
Teachers--> 37% taught in mainstream schools, 38% taught in mainstream schools with specialist provision, and the rest were teachers from SEN settings.
71% of teachers believed sensory diffs affected learning frequently/ all of the time.
81 % of parents believed sensory diffs affected learning frequently/ all of the time.
How do parents and teachers recognise sensory issues according to Jones et al (2020) study?
Mostly by neg reactions. Point at which its too much
Parents and teachers pick up on hypersensitivity, means probs not v good at picking up on
either seeking or under responsivity cos the focus is primarily on hypersensitivity.
Also probs means ur picking up on the stage when it becomes too much and are unaware of what is happening in the lead up to that
Not as easy to spot hyposensitivty
According to Jones et al (2020), what sensory differences most impact learning?
Really important to understand the nature of some of these sensory issues and how they
impact their function
Common factor is the uncertainty and unpredictability of these experiences that makes them
worse
- Auditory (loud unpredictable noises, pen on whiteboard, pencil on paper, noise from other kids
- Tactile (being touched by others, e.g in assembles, corridors, group work→ unpredictability of this) but diversity → some tactile seeking (hugging, tapping, touching, squeezing)
- Visual (fluorescent lights, strip lights, lots of classroom displays→ not specific to classroom but whole school) → Classroom displays, lights are too much, too overwhelming
- Olfactory and taste (indirectly impacted learning and school life→ e.g distress at lunchtime, in PE changing room, incidental smells like cleaning products or perfume)
How do these sensory differences impact learning? (Jones et al, 2020)
- Distraction (most common) → inability to tune out
- Distress and anxiety
- If kids are say more focused on what they are wearing it distracts them from the ability to focus on their work, and causes them distress and anxiety
What did Howe and Stagg (2016) discover when investigating the experiences of autistic adolescents?
16 ASD adolescents→ Auditory / tactile / olfactory /visual (hierarchy of what is most problematic). Impact on concentration, anxiety and physical discomfort. (Work with adolescents as part of Triple-A @ Durham)
“What I do, like, is not just for like attention, it’s because I actually can’t really cope if there’s
like a fly or something or something smells bad”
“I think mainly, it's worth understanding that for people like me... are our senses... and we get sensory overload much faster than NT people. I can only handle so much noise or something, other kids can cope, but being in a noisy classroom, I can’t”
=Quotes for autistic adolescents
In a study of 'In their own words' by MacLennan et al (2021), what did they find the % of participants for hyperreactivty, hyporeactivity and seeking behaviours, and what did these entail?
HYPER--> 20.5%
SEEKING--> 2%
HYPO--> 0%
HYPER + HYPO--> 4.1%
HYPER + SEEKING--> 44.9%
HYPO + SEEKING--> 0%
Hyper (bright flashing lights, loud noises, strong scents, lots of convos, clothing, food textures)/ Hypo (temperatures, pain, spicy food, strong scents)/
Seeking (music, fav foods, different textures).
Most people are hypereactive and hyperactive and seeking
Hyporeactivity really hard to measure cos how can you pick up on it cos they won’t really know themselves, unless someone has told you
Seeking- intense focus on same song(music) playing same over and over and over again
What were some other outcomes of this study? (MacLennan et al 2021)
Mental and Physical--> one quote "Bright lights.... are unbearable and make me feel very stressed", "I'm easily started by sound or touch, sounds physically hurt me"
Seeking calming sensory input as coping strategy--> "I always keep a fleecy blanket in my bag to wrap myself tightly in when in distress or just to hold and feel..."
What were the outcomes of the evidence collected by MacLennan et al (2021)? (see lec notes for the diagram)
From the quotes (evidence) they put together a model for understanding sensory differences in relation to outcomes and it takes into account all the variety of different sensory responses, hyper, hypo and seeking.
Helps us understand the way that different moderators affect the outcome that these sensory differences can have
Control is really important e.g someone struggles with noise sensitivity but the same person might seek out really loud music and that might be v comforting and enjoyable- reason they struggle with all the other types of noise is cos of the unpredictability and lack of control
Sensory diffs can massively contribute to burnout
What are some examples of positive sensory experiences?
DIY sensory box
Something that produces joy for someone neurotypical- makes someone with ASC completely ecstatic
e.g fidget toys, fave books, visua stimulus, headphones, nice textures etc (Maclennan et al, 2021; Robertson and Simmons, 2015; Jones et al, 2013)
Jones et al (2013)--> "All things are heightened for me, so what a regular person would be tickled with pleasure over, I'll be totally ecstatic"
Time for a different definition?
Pellicano et al (2022) → “a lifelong neurodev difference that influences the way a person interacts and communicates with others and experiences the world around them”