Lecture 3: ASD Flashcards
voorbeelden autisme in kinderen
- Avoid stepping on cracks in the pavement?
- Always start the stairs with the same foot (left or right)?
- Want to know everything about dinosaurs / soccer players / horses / …?
- Line up your stuffed animals?
- Eat your meal in a certain order (e.g., vegetables first)?
- Collect marbles / stickers / Bratz dolls / unicorns / …?
autism spectrum disorder ASD
A. Persistent deficits in social communication or social interaction across multiple contexts
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors used for social interaction
3. Deficits in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of behaviour, interests or activities, =/> 2
1. Stereotyped or repetitive motor movements, use of objects, or speech
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment
C. Present in early development
D. Distress and reduced functioning
E. Not better explained by other disorder
- With / without intellectual disability, language impairment
- Severity: how much support is needed?
A criterion voorbeelden in de praktijk
Shortcomings in reciprocity
* Strange way of making contact
* Reduced sharing of interests, pleasure, emotions or affect
* Inability to initiate and respond to interactions
* Untuned: on its own track, ignoring the others in the room
Deviant non-verbal communication
* Limited eye contact
* Body language: turning away
* Limited facial expression (and understanding)
* Less gestures (and understanding)
Shortcomings in developing, maintaining and understanding relationships:
* Difficulty playing together
* Not much fantasy play
history of diagnosis ASD
DSM IV: Pervasive developmental disorder nog otherwise specified (PDDNOS), asperger, Childhood Disintegrative Disorder, Autistic disorder
DSM 5: Autism spectrum disorder
history of aspergers disorder
- Introduced in DSM-IV (1994), removed in DSM-5 (2013)
- Social impairment (but: presence of social skills), restricted behaviour
- NO speech delay, NO cognitive delay
- Often specialized knowledge in restricted domains
- “eccentricities”: stilted (“stiff”), formal speech
- Difficulty in comprehending non-literal use of language
are language difficulties associated with ASD?
- In DSM-5, language difficulties are not a criterion anymore
- Because some individuals with social impairments do develop fluent speech
- But: Deficits in receptive language prove to be good predictors of ASD
- And: social interactions contribute to language development
Conclusion: also assess language abilities in ASD-assessmen
history of ASD diagnosis: from childhood disorder to chronic disorder
- Learning and compensation are possible, making ASD less visible in adults
- But after diagnosis of their child, parents recognized themselves in the information provided: late diagnosis of parents
- Even less is known about ageing in ASD
underlying mechanisms of ASD
- Theory of Mind
- Executive Functions
- Central Coherence
ToM, EF, CC
Theory of Mind in autism
people with ASD fail in the ability to (meta)represent mental states in oneself and others is the cognitive cause of the characteristic autistic behavioural difficulties in social interaction and reciprocal communication. these children fail at the false belief task
prior to the ToM-hypothesis, social difficulties in autism were generally characterized as ….
a lack of sociability or interest in others
observations matching difficulties representating mental states
- difficulties in joining in with others’ fantasy play, little, fantasy, pretend play
- difficulties in understanding someone’s motives and reading someone’s intentions
which ASD symptoms does the limited ToM explain
criterion A:social commuication or social interaction
current vision on ToM and ASD
- Individuals with ASD also differ from one another in ToM task performance
- ToM task performance can change with age, also that of individuals with ASD
- There is a need to also assess social motivation, emotional empathy
-> Perhaps ASD is characterized by lack of implicit ToM (automatic, spontaneous tracking of mental states) and not explicit ToM (explicit task
does impaired EF explain ASD symptoms?
does not really explain criterion A or B, but high EF can compensate for the ASD symptoms
central coherence =
ability to integrate perceived details into a meaningful whole
central coherence testen
Block Design: arranging red-and-white blocks to match a given pattern within a time limit.
Children with ASD often perform better than typical controls.
consequences of weak central coherence
- more time and energy needed to process information
- difficulty with cause-and-effect relationships
- difficulty in distinguishing between main and secondary issues
- A situation is no longer the same when a detail changes (classroom interior, change of person’s clothes can cause confusion and anxiety)
welke symptomen legt weak central coherence uit
Restricted, repetitive patterns of behaviour, interests or activities:
1. Stereotyped or repetitive behaviour, speech, object use
2. Insistence on sameness
3. Highly restricted, fixated interests
4. Hyper- or hyporeactivity to sensory input
en dan vooral de laatste 3
hoe is de relatie tussen ToM, EF and CC
- Too much heterogeneity for “one cause”
- Researchers did not succeed (yet) in subtyping ASD
- Maybe even multiple causes in one individual: ASD as a compound condition
- Currently: no unique underlying mechanism can explain (the heterogeneity) of ASD
prevalence comorbidities in ASD
adhd: 33%
anxiety: 23%
sleep-wake: 13%
depressive: 12%
OCD: 10%
disruptive/impulse control/conduct: 10%
schizophrenia spectrum: 5%
bipolar: 5%
verschillen repetitive behaviours in OCD en ASD
- ASD loves them, positive sources of enjoument. we can redirect them if there are other things to do
- OCD usually has distress and anxiety, of which the repetive behaviours offer short term relief. it is really compulsive, and if their compulsion is not performed their day is wrecked
- but they do co-occur, difficult because they are both compulsive. a subset of people has both, which is really impairing.
stimming =
self-stimulatory behaviour, repetitions. helps self-regulation, relief, finding balance. medium of expression. important not to discourage, because it is a coping mechanism (and usually not harmful)
challenges in comorbidity in ASD
- overlapping symptoms, such as repetitive behaviour
- possible impairments in verbal and intellectual disabilities complicate assessment
- diagnostic overshadowing: one dominant diagnosis overshadows or masks the identification of additional conditions
- symptoms of ASD are heterogeneous
- disorders may manifest differently in children with ASD and children without ASD
- diagnostic tools are lacking
why is there high comorbidity in ASD
- Selection bias: individuals with mental health difficulties seek help and research on individuals with ASD symptoms “only” is limited
- ASD may cause co-occurring conditions (e.g., social exclusion or bullying may lead to anxiety)
- Underlying deficit (e.g., low EF, SES disadvantage) may make it difficult to cope with ASD symptoms, making other problems more likely
- Shared aetiology (e.g., EF is impaired in both ASD and ADHD)
- Difficulty in identifying, sharing and talking about feelings (alexithymia)
assessment of ASD often includes… (because it is very heterogeneous)
- dsm criteria, including intellectual ability and language skills
- multiple sources: parent, child
- theory of mind, executive functions, central coherence (often: intelligence test)
- actively seek for comorbidity: 1. the function of repetitive behaviour, 2. reasons for avoiding social interactions
ratio boys/girls in ASD
- 4:1 in clinical population (in the 1980s)
- 3:1 in more recent diagnoses (meta-analysis in 2017)
- 2:1 in individuals with intellectual disability
- Gender gap in autism-related behaviour is smaller in non-clinical population than in clinical samples
problem: is this boy/girl ratio correct?
- Diagnosed in girls later than in boys
- Females with low IQ are more likely to receive a diagnosis than females with high IQ
- Rates of ASD diagnosis have increased, and the gender gap decreases
Hypothesis: The numbers are incorrect because female diagnoses have been missed
explanations for gender gap in diagnoses
- No golden standard, no bio-marker: we need to trust on behavioural assessment and this is based on conception of what autism looks like -> based on male cases
- Very mixed evidence for hypothesis that females are “protected” (by more social brain, or genetic make-up)
- Evidence for a Female Autism Phenotype (FAP): The same underlying characteristics are expressed differently in females and males
1. Social communication & interaction
2. Restricted, repetitive interests and behavior
3. Co-occurring problems
4. Camouflaging
Female Autism Phenotype
- Social communication & interaction:
- Girls seem to have more desire and intent to form friendships
- Appear to have fewer social difficulties
- BUT find it harder to maintain long-term friendships (e.g., often claiming and forcing)
-> although females with ASD are ‘more social’ than males with ASDs, they have more social difficulties than typical girls
- Restricted and repetitive behaviours:
- Girls often obsessed with animals or fictional characters, boys more often obsessed with vehicles, computers or physics
- Specific interests of girls are considered less inappropriate than those of boys
- Girls are therefore less criticized for specific interests than boys (+), but ASD is easier overlooked in girls (-) - Co-occuring behavioural problems:
- Girls: internalizing (anxiety, depression, self-harming, eating restrictions). These internalizing problems may overshadow the AS symptoms, diagnosis for co-occuring condition but not AS. internalizing problems are also easier overlooked.
- Boys: externalizing, more striking for teachers and parents, therefore earlier requests to help. - Camouflaging: masking, due to the desire to belong to a group (forcing eye contact, mmorizing social scriptis, mimicking behaviours of others). conscious orunconscious, exhausting, need to coordinate everything. this can lead to mood swings (down, hyper, angry), identity issues, exhaustion (need alone time to recover). impairments are not as visible in some contexts as in the home environment!
Use of conscious or unconscious strategies (explicitly learned or implicitly developed) to minimise the appearance of autistic characteristics during a social setting
* Socially ‘desirable’ behaviour, imitating others
* Avoid standing out, often ‘ideal girl’ in class
* Keep to the rules
* Naive / sweet
* Adapt, make invicible to appear as ‘normal’ as possible
Camouflaging questionnaire
Scale 1: strongly agree, 7: strongly disagree
I have tried to improve my understanding of social skills by watching other people
I practice my facial expressions and body language to make sure they look natural
I monitor my body language or facial expressions so that I appear relaxed
When in social situations, I try to find ways to avoid interacting with others
In social situations, I feel like I’m “performing” rather than being myself
I need the support of other people in order to socialise
I have to force myself to interact with people when I am in social situations
evidence for hypothesis: Female ASD diagnoses may have been missed
- Criteria, diagnostic assessment: based on male phenotype
- A female phenotype: core underlying features of autism are expressed differently in females than in males
- Co-occurring (internalising) behavioural problems of females less visible for environment than those of males
- Females tend to camouflage
