Autism

Spectrum Disorder
 Communication

Three broad Socialization

categories

Motor behavior
communication

Unusual speech patterns and idiosyncratic use of phrases.

They may speak too loudly or lack the prosody

They may also fail to use body language or other nonverbal behavior to communicate

Humour (the concept that the words people use can have multiple or abstract meanings, for instance).

Trouble beginning or sustaining conversation

They may talk to themselves or hold

They tend to ask questions over and again

Socialisation

• make eye contact,

• smile reciprocally, or cuddle
• away from a parent’s embrace and stare into space.
• Toddlers don’t point to objects or play with other children.
• They may not stretch out their arms to be picked
• May not show the normal anxiety at separation from parents.
• Tantrums and aggression.
• little apparent requirement for closeness
• Older children have few friends and seem not to share their joys or
sorrows with other people.
 • compulsive or ritualistic actions (called stereotypies)—
twirling, rocking, hand flapping, head banging,
• Maintaining odd body postures.
• They suck on toys or spin them rather than using them as
symbols for imaginative play.

Motor • Restricted interests

• preoccupied with parts of objects.
Behaviour • They tend to resist change, preferring to adhere rigidly to
routine.
• They may appear indifferent to pain or extremes of
temperature
• They may be preoccupied with smelling or touching things.
• head banging, skin picking, or other repetitive motions.
• Leo Kanner introduced the term early infantile autism in 1943
• Since then, the concept has expanded in scope and grown new
subdivisions (DSM-IV listed four types plus the ubiquitous not otherwise
specified)
• It has now contracted again into the unified concept presented by DSM-5.
Diagnostic Criteria
• To meet diagnostic criteria for ASD according to DSM-5 TR, a child must
have persistent deficits in each of three areas of social communication
and interaction (see A.1. through A.3. below) plus at least two of four
types of restricted, repetitive behaviours (see B.1. through B.4. below).
Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history.

• Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal
back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond
to social interactions.

• Deficits in nonverbal communicative behaviours used for social interaction, ranging, 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 understand relationships, ranging, 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.
Diagnostic Criteria
B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested
by at least two of the following, currently or by HISTORY
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behaviour (e.g., extreme distress at small changes, difficulties
with transitions, rigid thinking patterns, greeting rituals, need to take same route or
eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4. Hyper- or hyperactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g. apparent indifference to pain/temperature, adverse response to
specific sounds or textures, excessive smelling or touching of objects, visual
fascination with lights or movement).
Diagnostic Criteria

• Severity is based on social communication impairments and restricted, repetitive

patterns of behavior.
C.Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned
strategies in later life).
D.Symptoms cause clinically significant impairment in social, occupational, or other
important areas of current functioning.
E.These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected
for general developmental level.
Case History
• persistent problems in social interaction and communication
(criterion A).
• They include social and emotional reciprocity (didn’t want/need to be
hugged—A1); use of nonverbal behaviours (poor eye contact—A2);
and relationships (lacking interest in other children—A3).
Although the DSM-5 criteria are not carefully worded, there must be
deficits in each of these three areas for a person to be diagnosed as
having ASD.
Case History
• Temple’s restricted behaviour and interests included examples of all four
symptoms in the criterion B category (only two are required for diagnosis):
• stereotyped spinning of coins and other objects (she even twirled herself—B1); a
rejection of change in routine (dislike of holiday festivities—B2); fixed, restricted
interests in, for example, sliding doors and the paraphernalia of political
campaigns (B3); and hyperreactivity to sounds and fascination with smells (B4).
• Temple’s symptoms were present from early childhood (C);
• her biography and other books richly document the degree to which they
dominated and impaired her everyday functioning (D).
• However, she eventually surmounted them brilliantly, thereby disposing of the
final possible objection (E) that the symptoms must not be better accounted for by
intellectual disability.
 • An upward trend in ASD prevalence has been reported in many
developed and developing countries around the world.
• In a study conducted by the Autism and Developmental Disabilities
Monitoring Network (ADDM) reported that the estimated prevalence
of ASD increased from 0.67% in 2000 to 1.46% in 2012.
• A 2018 study using data from the National Health Interview Survey
found that the prevalence of ASD in US children aged 3 to 17 years
was 2.24% in 2014, 2.41% in 2015, and 2.76% in 20163.
• In another study conducted in U.S. communities showed an increase
Prevalence from approximately one in 150 children during 2000–2002 to one in
68 during 2010–2012; more than doubling during this period .
• India also showed an increased prevalence of autism spectrum
disorder; it is found to be, 2.25 per 1000 children in Chandigarh,
which is close to that in other Indian studies4 .
• There is a strong heritable component; studies shows that the
parents who have a child with ASD have a 2-18% chance of having a
second child with ASD
 • Immune system abnormalities throughout the
body and brain of many autistic individuals
include evidence of brain specific auto-
antibodies, altered lymphocyte responses to
antigen, altered cytokine production, and an
Immune increased incidence of allergies and other
autoimmune disorders .
system in • Recent epidemiological studies have shown
autism statistical correlations between risk for ASD and
either maternal or infantile atopic diseases,
such as asthma, eczema, food allergies and food
intolerance, and mouse models of allergic
asthma priming in the mother results in ASD like
behaviour in the offspring.
Poor child rearing practices

• Healthy brain development depend upon the care and support provided by individuals in
the community as well as in the family35 .
• The quality of mother infant interaction and the presence of age appropriate play
materials may be used as a surrogate for the evaluation of quantity and quality of
stimulation available at home. This often provides a fresh look at the home care,
stimulation and psychological environment of the child.
• In a case control study of 143 confirmed cases of 2-6 years old children with autism (CARS
score of e”30), attending autism clinic of Child Development Centre, reveled the following
risk factors as significant (i) child does not play with children of same age (OR=19.6); (ii) no
outings (OR=3.4); (iii) do not tell stories/sing songs to the child (OR=3.2); and (iv)
breastfeeding duration nil/<6 mo (OR=3.4) 36.
Advanced parental age
• It has been found that firstborn offspring of two older parents were
three times more likely to develop autism than were third- or later-born
offspring.
• This increase was found to be independent from other factors. The
association was observed for both maternal age ( [OR] of 1.3 for mothers
aged >35 years) and paternal age (OR of 1.4 for fathers aged >_40 years).
Valproate exposure

• It has been long established that valproate, an anti-epilepsy

drug, could cause foetal abnormality and the risk of ASD in
children in a population-based study the prenatal exposure
of valproate (n = 508) had a hazard ratio (HR) of 2.9 (95%
[CI]: 1.7-4.9) for ASD and an HR of 5.2 (95%CI: 2.7-10.0) for
childhood autism, especially during prenatal exposure 14.
• This changes might be due to epigenetic markers following
exposure to sodium valproate15
Genetics
• The presence of increased extra-axial CSF volume preceded the onset of
behavioural symptoms of autism and was predictive of a later diagnosis
of autism spectrum disorder. On MRI scans Autism spectrum disorder
had an average of 15.1 % more extra-axial CSF than controls after
accounting for differences in brain volume, weight, age, and sex and
high-risk children with autism spectrum disorder had nearly identical
extra-axial CSF volumes (p=0.78), and both subgroups had significantly
greater volumes than controls. Both extra-axial CSF volume (p=0.004)
and brain volume (p<0•0001) uniquely contributed to enlarged head
circumference in the autism spectrum disorder group (p=0.04).
Oxytocin
• Oxytocin (peptide: OT, gene: OXT) is a pituitary neuropeptide hormone
that can modulate a wide range of neurotransmitter and
neuromodulator activities.
• Genetic variation in the OXT gene has been found to be associated with
phenotypic features of ASD.
• A study of 108 Europeat trios and another sample of 156 trios (207
probands) demonstrated a significant association between OXT
rs6084258 and several endophenotypes of ASD.
Diagnostic tool:

• Childhood Autism Rating Scale (CARS): CARS is a behavior rating scale intended to help diagnose autism,
which is developed by Eric Schopler, Robert J. Reichier, and Barbara Rochen Renner. The childhood-
autism rating scale was designed to help differentiate children with autism from those with other
developmental delays, such as intellectual disability. CARS is frequently used as part of the diagnostic
process and considered as gold standard among rating scales in detecting autism.
• INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDTASD); INDTASD was developed for
identification and diagnosis of ASD using appropriateness criteria developed for Indian context, which
was based on DSM IV TR32. Revised AIIMS-Modified-INDT-ASD Tool is a simple and structured instrument
which has good psychometric properties, and based on DSM-5 criteria and can facilitate diagnosis of ASD
with acceptable diagnostic accuracy. The tool demonstrated a sensitivity and specificity of 98.4% (95% CI
= 94.5%-99.8%) and 91.7% (95% CI = 84.4%-96.4%), respectively. The modified tool had false positivity of
8.2%, while false negative rate was 1.55%. These properties are also supported by its correlation with
severity on CARS; with a score of ≥14 on this tool predicts severe ASD with sensitivity and specificity of
almost 80% each33.
 • Social Communication; As core deficit in the behavioural
Intervention repertoire of children with ASD, these skills should be
important early intervention targets. Social communication
Strategies skills include nonverbal gestures and language used to share
experiences with others. Most impaired are joint attention
gestures used to initiate interactions with others, such as
showing a toy to a parent, pointing to indicate something of
interest (e.g., a plane flying overhead), and alternating looks
between the parent and an object with shared positive affect.
• Applied Behaviour Analysis (ABA): ABA methods are used to
increase and maintain desirable adaptive behaviours, reduce
interfering maladaptive behaviours or narrow the conditions
under which they occur, teach new skills, and generalize
behaviours to new environments or situations.
Intervention Strategies
1. Naturalistic Developmental Behavioural Interventions; Early intervention approaches apply NDBI
approaches and emphasize changes in social communication and language skills instead of IQ.

2. Structured Teaching: The TEACCH method, emphasizes structured teaching including organization of the
physical environment, predictable sequence of activities, visual schedules, routines with flexibility,
structured work/activity systems, and visually structured activities 37. There is an emphasis on both
improving skills of individuals with ASDs and modifying the environment to accommodate their deficits.

3. Developmental Models: Design approaches to address the deficits in imitation, emotion sharing, theory of
mind, and social perception by using play, interpersonal relationships, and activities to foster symbolic
thought and teach the power of ommunication. 12
Intervention Strategies
1. Relationship-focused; Developmental, individual-difference, relationship-based (DIR) model, :The DIR
approach focuses on (1) "floor-time" play sessions and other strategies that are purported to enhance
relationships and emotional and social interactions to facilitate emotional and cognitive growth and
development and (2) therapies to remediate "biologically based processing capacities," such as auditory
processing and language, motor planning and sequencing, sensory modulation, and visual-spatial
processing40.

2. Social Skills Instruction; Joint attention training is beneficial in young especially preverbal children with
ASDs, as joint attention behaviours precede and predict social language development 41,42. A recent
randomized, controlled trial demonstrated that joint attention and symbolic play skills can be taught and that
these skills generalize to different settings and people 42.
Intervention Strategies

• Occupational Therapy and Sensory Integration Therapy: Traditional occupational therapy

promote development of self-care skills (eg, dressing, manipulating fasteners, using
utensils, personal hygiene) and academic skills (eg, cutting with scissors, writing).
• Occupational therapists also may assist in promoting development of play skills, modifying
classroom materials and routines to improve attention and organization, and providing
prevocational training. Sensory integration (SI) therapy is not to teach specific skills or
behaviours but to remediate deficits in neurologic processing and integration of sensory
information to allow the child to interact with the environment in a more adaptive fashion
Thank you