Chapter 1 Overview of Autism Spectrum Disorders (1)

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Brooke Fillmore EDU 778IS January 29th, 2024 Chapter 1: Notes: - Autism, a childhood disorder, is experiencing rapid growth and is more prevalent than childhood cancer, cystic fibrosis, and multiple sclerosis combined. Teachers in public schools will likely come across students with Autism Spectrum Disorder (ASD). For those pursuing a career in special education, the chances of encountering a student with ASD are even higher than winning the lottery. Classic autism was initially described in 1943 by Kanner, but it was not officially included in the DSM-III until 1980. The DSM definition of autism has undergone four revisions to date. Children with classic autism may have limited or no verbal communication abilities. Clinically, children with ASD often exhibit a flat affect or a restricted range of facial expressions, although they may also display exaggerated emotions at times. It is a common misconception among professionals that a child cannot have ASD if they appear to be attached to their parents. - The Autism Diagnostic Interview—Revised (ADI-R; Lord et al., 1994) is an extensive interview conducted with the parent or caregiver of the individual being evaluated to assess the level of autistic symptoms in individuals aged two and above. The Autism Diagnostic Observation Schedule—Generic (ADOS-G) is a structured assessment that evaluates the three areas of impairment associated with autism, as defined in the DSM- IV-TR (Lord et al., 1999). It typically takes 30 to 45 minutes to administer and consists of four modules tailored to the cognitive and language abilities of the individual being assessed. The Social Communication Questionnaire (SCQ; Berument et al., 1999) comprises 40 items that utilize a yes/no format. It includes the algorithm items from the ADI-R and is designed to screen for Autism Spectrum Disorder (ASD). There are two versions of the SCQ: the lifetime and the current versions, which examine the child's behavior over the past three months. The Social Responsiveness Scale—Second Edition (Constantino & Gruber, 2012) is a rating scale comprising 65 items. It measures the severity of autism spectrum symptoms, encompassing social impairments, social awareness, social information processing, capacity for reciprocal social communication, social anxiety/avoidance, and autistic preoccupations and traits as they manifest in natural social settings. - The exact etiology of Autism Spectrum Disorder (ASD) remains unknown, although genetics is considered the primary suspected cause. Some theories suggest that environmental factors may also contribute to the development of autism, alongside genetic factors. These environmental factors include events before, during, and after birth, such as uterine bleeding in the second and third trimesters, Rh incompatibility, high bilirubin levels at birth, and oxygen supplementation during birth. While the extent of this relationship is yet to be determined, it is worth noting that approximately 5% of individuals with autism have a chromosomal abnormality. Faulty genes have been identified on various chromosomes, including 2, 3, 6, 7, 13, and 15 (long arm) and 1, 11, 13, 16, and 19 (short arm). Additionally, there is a higher prevalence of other psychiatric disorders, such as depression and anxiety, among family members of individuals with

ASD. Some researchers have even proposed the existence of a broader autism phenotype within families. These issues are further discussed in Box 1.2. - Individuals with limited or no speech often find alternative methods to express their wants and needs. In contrast, some children with Autism Spectrum Disorder (ASD) may experience delayed or limited speech, using single-word utterances or word approximations to convey their thoughts. Additionally, some individuals may appear to have adequate speech but struggle with aspects of language, such as pragmatics. It is crucial to understand that language deficits in children with autism are not fixed, and with appropriate instruction, including augmentative and alternative communication systems, they can develop speech. Children with ASD commonly face challenges in engaging in conversations and comprehending statements made by others. Although they may share certain characteristics, each individual with ASD is unique, and these differences can significantly influence their learning and information-processing abilities. This chapter provides an overview of the diagnosis and characteristics of autism, as well as causal theories and historical perspectives. It also delves into the assessment process for diagnosis, instructional planning through Individualized Education Programs (IEPs), and general information on program development. History: 1. Kanner (1943): - Autism, characterized by severe difficulties in social interaction and strong resistance to change, is still prevalent in individuals with the disorder. Some common features observed in individuals with autism include echolalia, pronoun reversal, and unusual prosody. Understanding communication problems, which encompasses more than just language difficulties, has been crucial to studying autism. The concept of "insistence on sameness," initially identified by Kanner in 1943, has also played a significant role in our understanding of the disorder. The DSM-III definition of "infantile autism" focused on the characteristics observed in young children, highlighting their pervasive lack of social responsiveness. However, it was recognized that individuals with autism could change over time, and a diagnostic term, "residual infantile autism," was introduced for cases that no longer met the initial criteria. Before its inclusion in the DSM, extensive research had already been conducted to identify and quantify the symptom profiles associated with autism. Currently, the Autism Diagnostic Observational Schedule, Second Edition (ADOS-2) and the Social Responsiveness Scale, Second Edition (SRS-2) are widely used to measure the severity of autism, independent of factors such as IQ. (1) 2. Asperger's (1944): - In contrast to Kanner's emphasis on autism as a developmental condition, Asperger's observations focused on behaviors that resembled a personality disorder and highlighted the presence of similar problems in the fathers of his cases. As a result, Asperger's report initiated a significant debate regarding the boundaries of autism, the concept of the "broader autism phenotype," and the concept of neurodiversity. The cases described by Asperger's, which primarily involved boys with notable social difficulties,

foreshadowed the growing recognition of the "broader autism phenotype" in recent decades. (Ingersoll and Wainer 2014; Silverman 2015). 3. DSM II (1968): - The only classification that existed to identify individuals with severe developmental disturbances in early childhood, as described by Kanner in his 1943 report, was the category of childhood schizophrenic reaction. However, this situation started to change when the research diagnostic criteria (RDC) approach was introduced by the Washington University School of Psychiatry in Saint Louis. This approach, pioneered by Spitzer et al. in 1978 and Woodruff et al. in 1974, marked a significant shift in how these individuals were diagnosed and understood. Additionally, there was a growing recognition of the importance of acknowledging the various challenges that patients, especially children, face in other domains, such as developmental and medical issues. This awareness was highlighted by Rutter et al. in 1969. 4. Rimland (1964/1968): - Rimland (1964, 1968) pioneered the initial checklist for evaluating symptoms that indicate the presence of autism. Through various research studies, it became evident that autism was a distinct condition and not simply an early indication of schizophrenia. Although Rimland's Diagnostic Checklist was primarily based on Kanner's and DSM-II's understanding of autism as a type of childhood schizophrenia, its focus on evaluating the fundamental symptoms of autism continues to be an integral part of current standard practices (Corsello, 2013). 5. Rutter (1978): - Rutter (1978) introduced a fresh perspective on autism, presenting a revised definition that encompassed delayed and atypical social and language skills beyond what is expected for typical development, alongside restricted interests and repetitive behaviors, all of which manifest early in life. This redefined understanding of autism had a significant impact on the development of the DSM-III. In a similar vein, the American National Society for Autistic Children (NSAC 1978) proposed a definition that incorporated distinctive patterns and sequences of development, which overlapped to some extent with Rutter's definition but also emphasized sensitivities to the environment, both hypo- and hyper-. Studies examining the clinical phenomenology of autism, such as the age of onset in early childhood and the absence of a family history of schizophrenia (unlike childhood schizophrenia), demonstrated that autism and childhood schizophrenia were distinct concepts (Kolvin 1971, 1972; Rutter, 1972). By the time autism was included in the DSM, extensive research had expanded our understanding of the disorder, positioning it as one of the most exemplary conditions in child psychiatry. Unlike many other childhood disorders, autism was not easily mistaken for extremes of "normalcy" (Rutter & Garmezy, 1983). 1980: Category of Autism was included in DSM III:

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- The early studies on the course and outcome of autism painted a rather pessimistic picture, indicating that only a small number of individuals with autism were able to achieve adult self-sufficiency and independence, as mentioned by Howlin in 1997. However, it is important to note that these studies primarily involved participants who were diagnosed later and did not have access to the newer and potentially more effective interventions available at the time. Despite the initial challenges, clinicians remained hopeful for the future, recognizing that advancements in diagnosis and intervention could lead to improved outcomes for individuals with autism. Autism in DSM III: - Autism was officially recognized and classified as one of the Pervasive Developmental Disorders (PDDs) in the DSM-III (APA, 1980). This marked a significant shift in understanding and categorizing the disorder. The DSM-III definition of "infantile autism" accurately reflected the characteristics observed in young children with the condition. It emphasized the pervasive lack of social responsiveness, which was consistent with the initial description of autism by Kanner. However, it was also acknowledged that individuals with autism could undergo changes over time, and not all of them continued to exhibit the classic symptoms associated with infantile autism. To account for this, the DSM-III included an additional diagnostic term, "residual infantile autism," for cases that had previously met the criteria but no longer did so. This recognition of the evolving nature of autism highlighted the need for a more comprehensive understanding of the disorder and its various manifestations. 6. Briefly describe the included characteristics and diagnostic categories under DSM III. - The criteria outlined in this passage highlight the lack of social responsiveness commonly associated with autism, as initially described by Kanner. However, it is important to note that individuals with autism can change over time and may not always exhibit the classic infantile form of the disorder. To account for this, a diagnostic term called "residual infantile autism" was introduced for cases that previously met the criteria but no longer did so. Additionally, another diagnostic category was included to describe children who experienced a period of normal development before the onset of autism- like symptoms. This category unintentionally overlapped with the older concept of Heller. Furthermore, the DSM-III also included a concept of "subthreshold" or atypical PDD for cases that did not meet strict criteria for a specific PDD but still seemed to fit within the broader class. This group presented its complexities, considering previous research on atypical personality development and the broader autism phenotype. 7. What were the limitations/problems of the diagnostic category of infantile autism under DSM III? - The absence of a developmental approach in diagnosing autism posed significant challenges, as adults with autism were not adequately represented by the term 'residual.' The justification for categorizing childhood onset PDD (COPDD) was not clearly explained, and the term Pervasive Developmental Disorders itself was burdensome. The relationship between the broader range of atypical PDD cases (Towbin, 1997) and the

more narrowly defined autism was a subject of great interest, particularly as our understanding of the genetic complexities of autism has grown (Rutter & Thapar, 2014; Yuen et al., 2019). 8. DSM III -R (1987): What changes were made in the criteria for autistic disorder? (What are the three major domains?) - DSM-III-R introduced a comprehensive set of 16 criteria for diagnosing autism, classified into three main domains of dysfunction commonly observed in individuals with autism. These domains included qualitative impairments in reciprocal social interaction, communication impairments, restricted interests/resistance to change, and repetitive movements. To receive a diagnosis of autistic disorder according to the DSM-III-R approach, individuals needed to meet a minimum of eight positive criteria, with at least two from the social domain and at least one from each of the other two categories of difficulty. This polythetic approach aimed to capture the diverse range of symptoms and behaviors associated with autism spectrum disorders. 9. 1992 -1993: The World Health Organization International Association of Diseases 10th edition had a vastly different approach. What was this? - The International Classification of Diseases, 10th edition (ICD-10) by the World Health Organization (WHO) took a unique approach by providing two diagnostic guides: clinical work and research. This decision was made to explicitly acknowledge various disorders, such as Asperger syndrome, Rett's disorder, and childhood disintegrative disorder. However, including these disorders in the ICD-10 raised concerns about potential discrepancies between the United States Diagnostic and Statistical Manual of Mental Disorders (DSM) and the international ICD-10, which could complicate research comparisons and international collaborations. Given the importance of diagnostic standards in fields like genetics and epidemiology, significant revisions were made to develop the fourth edition of DSM (DSM-IV) by the American Psychiatric Association (APA) to address these issues. Due to these differences from DSM III-R, field trials developed DSM IV. - The field trial conducted for DSM-IV aimed to address several issues related to the diagnostic criteria for autism. This extensive and year-long effort had a global reach, involving nearly 1000 cases with conditions that could potentially include autism in their differential diagnosis. Multiple raters and clinical sites were involved in the trial, ensuring diverse perspectives. The examiners had access to both historical and contemporary information, enabling them to provide detailed ratings of various diagnostic criteria. The field trial results indicated that DSM-III-R was broader than other diagnostic systems. The draft ICD-10 research definitions, which were quite detailed, proved effective. However, they could be further refined and aligned with the draft DSM-IV criteria. It is worth noting that less experienced clinicians showed improved agreement when using the draft DSM-IV criteria compared to DSM-III-R.

10. Under this, what subcategories were included within the Pervasive Developmental Disorders (PDDs) contained in the DSMIV? - The criteria outlined a widespread absence of social responsiveness aligned with Kanner's initial characterization of autism. However, it was also evident that individuals with autism could change over time, with some no longer displaying the more typical infantile form of the disorder. As a result, an additional diagnostic term, "residual infantile autism," was introduced to describe cases that had previously met the criteria but no longer did so. Another diagnostic category, along with its residual equivalent, was included to describe children who experienced an onset of autism-like symptoms after a significant period of typical development. 11. DSM V: There has been a significant shift from a multi-categorical system to a single diagnosis based on multiple dimensions. What does this mean? - The transition from various subcategories to a solitary dimension led to enhanced precision in diagnosis and a satisfactory level of sensitivity, as more than 90% of children with Pervasive Developmental Disorders (PDDs) met the criteria for Autism Spectrum Disorder (ASD) according to the DSM-5 guidelines (Huerta et al., 2012; Mandy et al., 2012). The newly introduced diagnosis of Social Communication Disorder is expected to encompass the remaining cases. This shift in diagnostic approach has proven beneficial in accurately identifying and categorizing individuals with PDDs. 12. What are the two significant domains under DSM-5? - The transition from DSM-IV and ICD-10 to DSM-5 and ICD-11 involved significantly reorganizing the symptom model. One notable change was the consolidation of the communication and social symptom categories into a single social-communication domain, resulting in a two-domain symptom model. However, the restricted and repetitive interests/behaviors (RRBs) domains remained separate. This restructuring was motivated by several factors. Firstly, various factor analytic findings provided support for a single social-communication factor. Additionally, categorizing specific behaviors as social or communicative was deemed somewhat arbitrary due to the substantial overlap between the two domains. Lastly, there was a recognition of the lack of diagnostic specificity in structural language deficits, such as vocabulary and grammar, in individuals with Autism Spectrum Disorder (ASD). These considerations prompted the revision of the symptom model to better capture the complexities and nuances of ASD. 13. History of Dimensional approaches: - The diagnosis and classification of autism have been approached from a dimensional perspective for many years. Even before autism was officially recognized as a separate disorder from schizophrenia in the DSM-III, researchers were already trying to measure and quantify the symptom profiles of individuals who exhibited the unique behavioral patterns described by Leo Kanner. Over time, as research and clinical practice in the field advanced, diagnostic measures were developed to capture the symptoms better. Interestingly, even after almost six decades since the introduction of the initial autism

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diagnostic tools, current gold-standard practices still incorporate many elements from earlier versions. Checklists used: Name of Checklist Date What was Measured ADOS-2 1/29/24 Communication skills SRS-2 1/29/24 Social ability 14. What is the change to the developmental approach to systems under both DSM-5 and ICD-II, and why is it happening? - The DSM-5, which builds upon the DSM-IV and extensive research, represents a significant shift in how autism is conceptualized. Instead of using a multi-categorical diagnostic system, the DSM-5 introduces a single diagnosis based on multiple dimensions. This change comes after numerous unsuccessful attempts to categorize the diverse nature of autism into subcategories that are defined by empirical evidence. Both the DSM-5 and ICD-11 utilize ASD as the unified classification for core symptoms, although they differ in their approaches to describing variations within the ASD group. In order to account for individual differences, the DSM-5 includes severity levels for core symptom domains, which are based on the level of support required for an individual's functioning. Additionally, the DSM-5 provides specifiers that describe common co- occurring impairments that are not specific to ASD, such as intellectual impairments, language deficits, and medical and psychiatric conditions. 15. What are some of the non-ASD symptom specifiers that are included within ASD? - The diagnostic specificity of Autism Spectrum Disorder (ASD) is enhanced by the presence of similar specifiers in both DSM-5 and ICD-11. These specifiers, such as intellectual impairment, language deficits, and co-occurring psychological and medical conditions, contribute to a more accurate diagnosis. Furthermore, this inclusion of specifiers provides clinicians with valuable clinical information for treatment planning and enables the identification of subgroups within ASD. This knowledge about subgroups can help understand developmental trajectories associated with ASD 16. What are the four factors under the sub-dimensions of social communication and restricted and repetitive behaviors (RRB)? - The initial component of the study, referred to as "basic social communication skills," encompassed various aspects such as nonverbal communication, joint attention, emotional expression, and emotion recognition. This subdimension received additional support from Bishop et al. (2007), who also identified this factor when comparing children diagnosed with Autism Spectrum Disorder (ASD) to those with different diagnoses. The second factor derived from the four-factor model proposed by Zheng et al. was labeled as "interaction quality." This factor consisted of items that assessed the quality of conversations, initiations, and responses. It aimed to capture the overall

effectiveness and proficiency of social interactions. The third factor, "peer interaction and modification of behavior," focuses on evaluating the quality of peer interactions and how individuals adapt their behaviors to engage appropriately with peers. This factor aimed to measure the ability to modify one's behavior to establish successful social interactions with peers. Lastly, the fourth factor, "social initiation and affiliation," encompassed items related to play, affiliation, and initiating social interactions with peers. This factor assessed the individual's inclination and ability to initiate social interactions and form affiliations with peers. Collectively, these factors provide a comprehensive framework for understanding and evaluating various aspects of social communication skills in individuals. (Zheng et al., 2020). 17. Factor analysis within the RRB domain has two factors unique to this domain. What are these behaviors? - Several research studies (Bishop et al., 2006, 2013; Cuccaro et al., 2003) have discovered two distinct characteristics that could potentially serve as distinct phenotypes of Restricted and Repetitive Behaviors (RRBs) in individuals with Autism Spectrum Disorder (ASD). The first characteristic is "repetitive sensory-motor behaviors," which encompasses repetitive actions or movements involving the senses and motor skills. The second characteristic is "insistence on sameness," which involves a strong preference for routines, rituals, and resistance to change. These two factors have been identified as significant components of RRBs in individuals with ASD. Under Factor 1: - Factor 1 encompasses a range of characteristics, including motor mannerisms, sensory- seeking behaviors, repetitive use of objects, and self-stimulatory behaviors. These behaviors have been identified as diagnostically significant in distinguishing individuals with Autism Spectrum Disorder (ASD) from those without ASD. The frequency and intensity of these behaviors can provide valuable information for diagnosis (Kim & Lord, 2010). Additionally, the number, severity, and persistence throughout development may be crucial in identifying different subgroups within the ASD population (Bishop et al., 2006). Under Factor 2: - Behaviors falling under factor 2, as outlined by Cuccaro et al. (2003) and Bishop et al. (2006), pertain to compulsions, rituals, and resistance to change. Unlike factor 1 behaviors, these behaviors tend to manifest at a later stage and have been observed to exhibit stability over time in individuals diagnosed with ASD (Bishop et al., 2006). 18. What are some criticisms of DSM-5 as a diagnostic tool? - Several issues arose regarding choosing to conduct the entire revision process at APA headquarters instead of involving academic institutions. Additionally, some individuals expressed concerns about the excessive reliance on previously collected data that utilized structured diagnostic instruments. Furthermore, some perceived the revision process to be excessively secretive. Despite acknowledging positive aspects such as

the long-awaited name change to Autism Spectrum Disorder, a growing worry emerged that the new criteria unintentionally led to a more limited understanding of autism compared to the DSM-III-R definition. 19. For a diagnosis of ASD, what criteria must an individual meet? - To meet the diagnostic criteria for autism spectrum disorder, an individual must satisfy three main criteria. Firstly, they must exhibit difficulties in social-emotional reciprocity, which includes challenges in social approach, engaging in back and forth conversations, sharing interests with others, and expressing and understanding emotions. Secondly, they must have difficulties in nonverbal communication used for social interaction, such as abnormal eye contact and body language, and struggles in understanding nonverbal communication, like facial expressions or gestures. Lastly, they should demonstrate deficits in developing and maintaining relationships with others, excluding caregivers, which may manifest as a lack of interest in others, difficulties in responding to different social contexts, and challenges in sharing imaginative play with peers. Additionally, the individual must display at least two of the following four restricted and repetitive behaviors, interests, or activities: stereotyped speech, repetitive motor movements, echolalia, and repetitive use of objects or abnormal phrases; rigid adherence to routines and ritualized patterns of verbal or nonverbal behaviors, along with extreme resistance to change; highly restricted interests with abnormal intensity or focus; and increased or decreased reactivity to sensory input or unusual interest in sensory aspects of the environment. 20. What are the levels of severity of ASD? - Individuals classified as "REQUIRING SUPPORT" at Level 1 of severity experience challenges in initiating social interactions and may exhibit unconventional or unsuccessful responses to social advances. They may also display a decreased interest in social interactions and have repetitive behaviors that interfere with their daily functioning. Redirecting their attention from their fixed interests can be somewhat difficult for them. - At Level 2, individuals categorized as "REQUIRING SUBSTANTIAL SUPPORT" face significant verbal and non-verbal communication delays. They have limited interest or ability to initiate social interactions and struggle to form social relationships, even with support. Their restricted interests and repetitive behaviors are easily noticeable and can hinder their functioning in various contexts. These individuals may experience high levels of distress or frustration when their interests or behaviors are interrupted. - "REQUIRING VERY SUBSTANTIAL SUPPORT" is the highest level of severity, where individuals with ASD face severe impairment in their daily functioning. They have minimal initiation of social interaction and show minimal response to social overtures from others. Verbal communication abilities are minimal for them. Their preoccupations, fixed rituals, and repetitive behaviors greatly interfere with their daily functioning and make it challenging for them to cope with change. Redirecting their attention from their fixated interests is highly challenging.

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21. Explain 2 of your significant takeaways/insights after these readings and taking notes. - One of my significant takeaways from these readings is that I did not know that there are three specific criteria that a person must meet to be diagnosed with ASD. - Another key takeaway from the readings is the four factors under the sub-dimensions of social communication and restricted and repetitive behaviors (RRB). I also was not aware of these before completing these readings. References: Boutot, A. E. (2017). Pearson eText for Autism Spectrum Disorders: Foundations, Characteristics, and Effective Strategies -- Instant Access (Pearson+) 2nd (2nd ed.). Pearson+. January 29, 2024 , https://plus.pearson.com Diagnostic criteria for autism spectrum disorder in the DSM-5 . CHOP Research Institute. (n.d.). https://research.chop.edu/car-autism-roadmap/diagnostic-criteria-for-autism-spectrum-disorder- in-the-dsm-5 Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. Journal of autism and developmental disorders , 51 (12), 4253– 4270. https://doi.org/10.1007/s10803-021-04904-1

Chapter 1 Overview of Autism Spectrum Disorders (1)

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