Autism Spectrum Disorder--DSM + Guidelines (2014) Flashcards
How many criteria are there for ASD
5
How many elements are there in criterion A for ASD (all of which must be present)
3
what is criterion A for ASD
persistent deficits in SOCIAL COMMUNICATION and social INTERACTION across multiple contexts, as manifested by ALL of the following, currently or historically:
- deficits in SOCIAL-EMOTIONAL RECIPROCITY
–can range, for example, from abnormal social approach and failure or normal back and forth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions - deficits in NON VERBAL COMMUNICATIVE BEHAVIOURS used for social interaction
–can range, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication - deficits in DEVELOPING, MAINTAINING, and UNDERSTANDING RELATIONSHIPS
–can range, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers
how many elements are there to consider in criterion B for ASD? how many of these do you have to have for a diagnosis to be made of ASD?
there are 4 elements, and you must have 2 present to make the diagnosis
what is criterion B for ASD
restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history:
- STEREOTYPED or REPETITIVE MOTOR MOVEMENTS, use of objects, or speech
–(i.e simple motor stereotypies, lining up toys, flipping objects, echolalia, idiosynchratic phrases) - insistence on SAMENESS, inflexible ADHERENCE TO ROUTINES or RITUALIZED PATTERNS of verbal or nonverbal behaviour
–(i.e extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day) - highly RESTRICTED, FIXATED INTERESTS that are abnormal in intensity or focus
–(i.e strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests) - HYPER- or HYPOREACTIVITY to SENSORY INPUT or unusual interest in sensory aspects of the environment
–(i.e apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)
how do you specify severity in ASD
based on (1) social communication impairments and (2) restricted, repetitive patterns of behaviour
what is criterion C for ASD
symptoms must be present in early developmental period (but may not become fully manifest until social demands exceed limited capacities; may be masked by learned strategies later in life)
what is criterion D for ASD
symptoms cause clinically significant impairment in social, occupational or other important areas of CURRENT functionign
what is criterion E for ASD
not better explained by intellectual disability or global developmental delay
ID and ASD frequently co-occur –> to make both diagnoses, social communication should be below that expected for general developmental level
which DSM IV diagnoses should now fall under the dx of ASD?
those with a WELL ESTABLISHED dsm IV dx of:
autistic disorder
aspergers disorder
pervasive developmental disorder not otherwise specified
what are the specifiers in the diagnosis of ASD?
- with or without accompanying intellectual impairment
- with or without accompanying language impairment
- associated with a known medical or genetic condition or environmental factor
- associated with another neurodevelopmental, mental, or behaviour disorder
- with catatonia
how many severity levels are there for ASD
3
what do each of the severity levels indicate with regard to need for support
level 1–requiring support
level 2–requiring substantial support
level 3–requiring very substantial support
describe the deficits in social communication associated with ASD level 3
SEVERE deficits in verbal and nonverbal social communication skills
causes severe impairments in functioning, very limited initiation of social interactions, minimal response to social overtures from others
i.e a person with few words of intelligible speech who rarely initiates interaction and, when they do, makes unusual approaches to meet needs only and response only to very direct social approaches
describe the restricted, repetitive behaviors associated with ASD level 3
inflexibility of behaviour, EXTREME difficulty coping with change or other restricted/repetitive behaviours MARKEDLY interfere with functioning in ALL spheres
great distress/difficulty changing focus or action
describe the deficits in social communication associated with ASD level 2
MARKED deficits in verbal and nonverbal communication skills
social impairments evident even with supports in place
limited initiation of social interactions and reduced or abnormal responses to social overtures from others
ie. a person who speaks simple sentences, whose interaction is limited to narrow special interests and who has markedly odd nonverbal communication
describe the restricted, repetitive behaviours associated with ASD level 2
inflexibility of behaviour, difficulty coping with change, or other restricted/repetitive behaviours appear FREQUENTLY ENOUGH to be OBVIOUS to the casual observer and interfere with functioning in a VARIETY of contexts
distress and/or difficulty changing focus or attention
describe the deficits in social communication associated with ASD level 1
without supports in place, deficits in social communication cause noticeable impairments
difficulty initiating social interaction, and clear examples of atypical or unsuccessful responses to social overtures of others
may appear to have decreased interest in social interactions
ie. a person who is able to speak in full sentence and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful
describe the restricted, repetitive behaviours associated with ASD level 1
inflexibility of behaviour causes significant interference with functioning in ONE OR MORE contexts
difficulty switching between activities
problems of organization and planning hamper independence
what might need to be recorded diagnostically along with the diagnosis of ASD
record if the ASD is associated with a known medical/genetic/enviro factor or with another neurodevelopmental/mental/ behavioural disorder
i.e ASD associated with Rhett syndrome or ASD with/without accompanying intellectual impairment
how do you record severity in the chart
record as level of support needed for each of the two psychopathological domains (social communication and restricted/repetitive behavious)
note, the severity levels can be different for the two domains and recorded as such
with regard to recording diagnosis of ASD in the medical record, what are the 5 elements to consider
- whether the ASD accompanies a known medical/genetic/enviro factor or with another neurodevelopmental/mental/ behavioural disorder
- severity
- with/without accompanying intellectual impairment
- with/without accompanying language impairment (and severity of the language impairment)
- catatonia (recorded separately as catatonia associated with ASD)
how do receptive and expressive language domains develop differently in those with ASD
receptive language abilities may lag behind expressive language development in those with ASD
thus, they should be considered separately
what are some known genetic disorders associated with ASD
Rhett syndrome
Fragile X syndrome
Down Syndrome
what is a medical disorder that has been associated with ASD
epilepsy
what are some environmental exposures that may be associated with ASD
valproate
FASD
very low birth weight
what is the nature of the impairments in communication and social interaction seen in ASD
they are PERVASIVE and SUSTAINED
describe the range of language impairments that can be seen in ASD
can range from complete lack of speech–> language delays–> poor comprehension of speech–> echoed speech–> stilted and overly literal language
even when formal language skills (i.e vocab, grammar) are intact, the use of language for reciprocal social communication is impaired in ASD
what is social-emotional reciprocity
the ability to engage with others and share thoughts and feelings
how may deficits in social-emotional reciprocity manifest in young children with ASD
may show little or no initiation of social interaction and no sharing of emotions
may also have reduced or absent imitation of others behaviour
what language exists is often one sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse
how might deficits in social-emotional reciprocity manifest in adults with ASD, even in those without intellectual disability or language delays
these deficits may be most apparent in difficulties processing and responding to COMPLEX social cues
(i.e when and how to join a conversation, what not to say)
adults who have developed COMPENSATION strategies for some social challenges still struggle in novel or unsupported situations and suffer from the effort and ANXIETY of CONSCIOUSLY CALCULATING what is socially intuitive for most people
how might deficits in non verbal communicative behaviours used for social interaction manifest in those with ASD
absent, reduced or atypical use of eye contact, gestures, facial expressions, body orientation, or speech intonation
may learn a few functional gestures, but have smaller repertoire than others; often dont use spontaneous gestures in communication
difficulty coordinating verbal and non verbal communication–> ie giving impression of ODD, WOODEN or EXAGGERATED “body language” during interactions
–> even if impairments subtle, notice it most with INTEGRATION of eye contact, gesture, body posture, prosody and facial expression for social interaction
what is an early feature of ASD (related to non verbal communicative behaviours)
impaired joint attention
(as manifested by lack pf pointing, showing, or bringing objects to share interest with others, or failure to follow someone’s pointing or someone elses gaze)
how might deficits in developing, maintaining, and understanding relationships manifest in those with ASD
*should be judged against age, gender, cultural norms
may be absent, reduced or atypical SOCIAL INTEREST (manifested by rejection of others, passivity or inappropriate approaches that seem aggressive or disruptive)
difficulties particularly evident in young children –> often a LACK of SHARED SOCIAL PLAY and IMAGINATION, and later, insistence on playing by VERY FIXED RULES
older individuals may struggle to understand what behaviour is considered appropriate in one context, but not another (i.e casual behaviour in a job interview) or the different ways language can be used
may be an apparent preference for SOLITARY activities or for interacting with MUCH YOUNGER or OLDER PEOPLE
how much friendships manifest in those with ASD
there is frequently a desire to establish friendships without a complete or realistic idea of what friendship entails (i.e one sided friendships or friendships based solely on shared special interests)
describe the range of stereotyped or repetitive behaviours that may be seen in ASD
*there is a range of manifestations possible, depending on age, ability, intervention, supports… i.e:
simple motor stereotypies (hand flapping, finger flicking)
repetitive use of objects (spinning coins, lining up toys)
repetitive speech (echolalia, parroting of hear words, use of “you” when referring to self)
can also have excessive adherence to routines and restricted patterns of behaviour
how might excessive adherence to routines and restricted patterns of behaviour manifest in ASD
resistance to change (i.e distress at apparently small changes, insistence on rules, rigidity of thinking)
ritualized patterns of verbal or nonverbal behaviour (i.e pacing a perimeter, repetitive questioning)
how might highly restricted, fixated interests manifest in ASD
tend to be abnormal in INTENSITY or FOCUS
i.e toddler strongly attached to a kitchen pan, a child preoccupied with vacuum cleaners, adult spending hours writing out timetables
how might apparent hyper or hypo-reactivity to sensory input manifest in ASD
some fascinations/routines may related to apparent hyper or hypo-reactivity to sensory input
can manifest through extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, cold, or heat
extreme reaction or rituals involving TASTE, SMELL, TEXTURE or APPEARANCE of FOOD or excessive food restrictions are common and may be PRESENTING FEATURE of ASD
can you diagnose ASD in an adult even if restricted, repetitive patterns of behaviour, interests or activities are not clearly present in adulthood?
yes–if they were clearly present in childhood or at some time in the past
what are some features often associated with ASD that may support diagnosis
- intellectual or language impairment
–even if average or high intelligence, often have large gap between intellectual and adaptive functional skills - motor deficits
- self injury
- disruptive/challenging behaviours
- anxiety, depression
- catatonic-like motor behaviour
what motor deficits may be present along with ASD
odd gait
clumsiness
other abnormal motor signs (i.e walking on tiptoes)
what self injury behaviours may be present along with ASD
head banging, biting the wrist
also, disruptive/challenging behaviours are more common in those with ASD than other disorders (including intellectual disability)
what types of catatonic-like behaviours are seen in ASD
some individuals develop catatonic-like motor behaviour like slowing, or “freezing” mid action, but these are typically not of the magnitude of a catatonic episode
however, also possible for those with ASD to experience marked deterioration in motor symptoms and display a full catatonic episode with symptoms such as mutism, posturing, grimacing, waxy flexibility
when is the risk period for comorbid catatonia highest in ASD
adolescent years
what is the prevalence of ASD
approaching 1% of the population
when are symptoms of ASD typically recognized
during the second year of life (12-24 months)
*may be seen earlier than 12 months if developmental delays are severe, or noted later then 24 months if symptoms are more subtle
how might the pattern of onset of autism be described
might include info about early developmental delays or any losses of social or language skills
*in cases where skills were lost, parents may give a history of a gradual or relatively rapid deterioration in social behaviours and language skills –> such losses are rare in other disorders and should be a red flag for autism
*would typically occur between 12-24 months of age
