According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), autism spectrum disorders are characterized by the presence of severe impairment in a number of areas of development including reciprocal social interaction skills, communication skills and the presence of stereotyped behaviors and interest. This category includes Autistic Disorder, a broader category of Autism Spectrum Disorder, which now encompasses Asperger’s Disorder, Rett’s Disorder, and Childhood Disintegrative Disorder and Social Communication Disorder. The disorders that we are most concerned with here are Autistic Disorder and Autism Spectrum Disorder.
A video presentation on Autism Spectrum Disorders.
In the 1970s the reported prevalence rate of autism was estimated to be approximately 1 in 2500. More recent estimates indicate a prevalence rate of 1 in 500 (Fombonne et al., 2001). This makes autism more common during childhood than cancer or Down’s Syndrome (Bristol et al., 1996). Part of the increase in the prevalence rate of autism is likely due to the heightened awareness that we have with regard to the disorder as well as the greater likelihood of having an evaluation done. However, these two factors account for only a portion of the new cases, the rest being due to as yet unknown factors.
Autism is characterized by severe impairment in social interaction and communication. In terms of social interaction, children at risk for developing autism have difficulties orienting to social stimuli, make only inconsistent eye gaze and have impairments in the ability for shared interest and motor imitation (Kabot, Masi & Segal, 2003). There is often a lack of interest or awareness of others. Most children with autism will have only a small number of friends and are more likely to gravitate toward older adults (Filipek et al., 1999). Interests also tend to be circumscribed and often appear obsessive in nature. For example, a young autistic boy that I met with was fascinated by tornados, only drawing them, so he would scribble spirals on page after page.
Communication deficits are part of the core profile of the autistic individual. Even as infants these individuals tend to be less vocal and are often described as quiet. Milestones for language development are typically delayed and depending on severity, speech can range from being absent to fluent. As children they often fail to engage in conversation, are unable to interpret emotional cues, tend to look through or away from people rather than at them, and lack the pragmatic components of communication such as gesture and intonation (NYS Department of Health, Early Intervention Program, 1999). Autistic individuals often repeat speech patterns in a manner that lacks any clear communicative relevance (echolalia). They also do not understand more complex forms of communication such as wit, sarcasm and jokes. Oftentimes, when conversing with an autistic individual it feels as if they are talking at you rather than with you and will persist on a topic of interest regardless of the interest level of the listener.
Parents of autistic children are also aware that these children are often dependent on routines, patterns and rituals, even when they do not serve any practical function. There is a strong need for sameness in the environment, schedule and even things such as meals. Changes to these patterns can lead to defiant behaviors and tantrums.
There is also a tendency for autistic children to perform non-functional motor movements, often referred to as motor stereotypies. These movements can range from wiggling one’s fingers to complex whole-body movements. Such movements tend to occur when the individual is excited (e.g., very happy or nervous). The movements can also include running in circles, rocking and spinning among others (Filipek et al., 1999).
Autism Spectrum Disorder (ASD)
Although ASD (Asperger Disorder is now included in this broader category) and Autistic Disorder are overlapping developmental disorders there are substantive differences between the two. Unlike the criteria for autistic disorder, individuals with ASD have normal or near normal language development, which gives them a significant advantage in terms of communication. They are generally able to hold intelligent conversations with others and have well developed receptive and expressive language skills. In addition, their intellectual functioning ranges from low average to superior, which means that their intellectual capacity is generally on par with their peers. Self-help skills, including hygiene and dressing (but not social skills) are also at near-normal levels.
As any parent with a child diagnosed with AS can tell you, despite adequate functioning in many respects, this disorder causes significant hardship for the individual and the family. According to the DSM-5 criteria individuals with ASD usually have pedantic and poorly modulated speech, poor nonverbal pragmatic skills and intense preoccupations with circumscribed topics. For example, an 8 year old boy came to my practice and despite the low average intelligence and poor communication skills, he had an extensive fund of knowledge about trains, including the types of cars and their function and the train lines and where they travel. An adolescent boy with ASD turned to me and stated, “I can tell you are being sarcastic,” doing so with a completely expressionless face and tone. Although often interested in developing relationships, individuals with ASD often just do not understand how to go about doing so. They tend to be awkward with their peers and tend to stand out in a way that keeps others away from them. In addition, they often lack the social skills and understanding of what is necessary to form relationships. This can breed social anxiety and isolation. As a result individuals with AS are often loners who involve themselves in solitary activities. Although they, like autistic children, may be prone to stereotyped movements, the motor deficits experienced by AS individuals tend to involve poor visuospatial reasoning and clumsiness.
Despite the many characteristics that individuals diagnosed with either autism or ASD share, many differences in terms of cognitive, emotional and interpersonal functioning exist. The purpose of the neuropsychological evaluation, in addition to providing diagnostic clarity, is to highlight the areas of strength and weakness that exist and provide the patient, parents and treatment team (including the school) with the guidance necessary to help the person function more effectively and independently.
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