AUTISM SPECTRUM DISORDERS

( Characteristics , assessment and differential diagnosis)

One thing consistent with the children on the autism spectrum is that they are inconsistent.

Autism is a developmental disorder that originates prior to birth or in early infancy. Although
there are many reasons to believe that autism is a neurobiological disorder with a strong genetic
component, a biological marker has not yet been found. Therefore, the syndrome must be
defined on the basis of observed or described behaviors.

Autism is a pervasive developmental disorder that varies on a spectrum of mild to profound

impairment marked by disinterest in typical social interaction, severely impaired communication
skills and repetitive, stereotypical movements, combined with narrowly circumscribed, obsessive
interests” – M.N Hegde.

There are two classification systems ICD and DSM. ICD is given by WHO for classification of
diseases where as DSM is a standardized manual for diagnosing mental health disorders.

DSM 4 (APA 1994) identified ASD under the umbrella term Pervasive developmental disorders.
The diagnosis was based on 3 domains social interaction, communication and restricted and
repetitive patterns of behavior. The disorders included were Autistic disorder, Rett’s disorder,
childhood disintegrative disorder, asperger’s disorder and pervasive developmental disorder not
otherwise specified.

DSM 5 (APA- 2013) most of these disorders were grouped under the label autism spectrum
disorder. Instead of 3 now grouped into two categories of symptoms

1. Persistent deficits in social communication/interaction and

2. Restricted, repetitive patterns of behavior

The rationale behind this re organization of separate autism related disorders under one rubric
was that they all share pervasive deficits in social communication skills as well as restricted
patterns of behavior. Within this category, however there were considerable inconsistencies, it
was argued that the main differences among the disorders were ones involving severity, language
levels and levels of intellectual deficits.
Rett’s disorder was deleted and, instead the persons with this disorder and other known genetic
disorders that also have features of ASD will receive a diagnosis of ASD with genetic disorders
considered associated features.

To accommodate the range of difficulties in the two symptom clusters, DSM 5 (APA- 2013)
introduced 3 levels of severity:

Level 1: Requiring support

Level 2: Requiring substantial support

Level 3: Requiring very substantial support

Each level of support has been described qualitatively and has yet has no quantitative equivalent,
makes it difficult to assign severities when the person does not fall at extreme ends.

Category Level 1 Level 2 Level 3

Levels of severity for Without supports in Marked deficits in Severe deficits in
social communication place, deficits in verbal and nonverbal verbal and nonverbal
social communication social social communication
cause noticeable communication skills; skills cause severe
impairments. social impairments impairments in
Difficulty initiating apparent even with functioning, very
social supports in place; limited initiation of
interactions, and clear limited initiation of social interactions,
examples of atypical social interactions; and minimal
or unsuccessful and reduced or response to social
responses to social abnormal responses to overtures from others.
overtures of others. social overtures from For example,
May appear others. For example, a a person with few
to have decreased person who speaks words of intelligible
interest in social simple sentences, speech who
interactions. For whose interaction is rarely initiates
example, a person limited to narrow interaction and, when
who is able to speak special interests, he or she does,
in full sentences and who has markedly makes unusual
and engages in odd nonverbal approaches to meet
communication but communication needs only and
whose to-and-fro responds to only very
conversation with direct social
others fails, and approaches.
whose attempts to
make friends are odd
and typically
unsuccessful
Levels of severity for Inflexibility of Inflexibility of Inflexibility of
repetitive and behavior causes behavior, difficulty behavior, extreme
restrictive behaviors significant coping difficulty
interference with with change, or other coping with change,
functioning in one or restricted/ or other restricted/
more contexts. repetitive behaviors repetitive behaviors
Difficulty switching appear frequently markedly interfere
between enough to be obvious with
activities. Problems of to the casual functioning in all
organization and observer and interfere spheres. Great
planning hamper with functioning distress/
independence. in a variety of difficulty changing
contexts. Distress and/ focus or action.
or difficulty changing
focus or action.

Sensory issues as a symptom under the restricted/repetitive behavior category was added. This
includes hyper- or hypo-reactivity to stimuli (lights, sounds, tastes, touch, etc.) or unusual
interests in stimuli (staring at lights, spinning objects, etc.)

Criteria for the following were also included:

 Any known genetic causes of autism (e.g. fragile X syndrome, Rett syndrome)
 Language level
 Intellectual disability and
 The presence of autism-associated medical conditions (e.g. seizures, anxiety,
gastrointestinal disorders, disrupted sleep)

New diagnosis of social communication disorder was created, for disabilities in social
communication without repetitive, restricted behaviors.

DSM IV Classification is as follows

Diagnostic features DSM-IV ( APA 1994):

Qualitatively impairment in social interaction, as manifested by at least two of the following:

- Marked impairment in the use of multiple nonverbal behaviors such as eye to eye gaze,
facial expression, body postures, and gestures to regulate social interaction
- Failure to develop peer relationships appropriate to developmental level
- A lack of spontaneous seeking to share enjoyment, interests, or achievements with other
people ( by a lack of showing, bringing, or pointing out objects of interest to other
people)
- Lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as
manifested by at least one of the following:

Encompassing preoccupation with one or more stereotyped and restricted patterns of interest
that is abnormal either in intensity or focus

- Apparently inflexible adherence to specific, non functional routines, or rituals

- Stereotyped and repetitive motor mannerisms (hands or finger flapping)
- Persistent preoccupation with parts of objects
No clinically significant general delay in language (single words used by age two years,
communicative phrases used by age three), cognitive, social development, self help skills,
adaptive behaviors.

Rett’s Syndrome:

Definition: Rett’s syndrome is a genetically based neurological disorder that is included under
the category of PDD. It almost exclusively affects females than males.

- Apparently normal prenatal and perinatal development

- Apparently normal psychomotor development through the first five months after birth
- Normal head circumference at birth

Diagnostic features DSM-IV:

Onset of all of the following after the period of normal development:

- Deceleration of head growth between ages 5 and 48 months

- Loss of previously acquired purposeful hand skills between ages 5 and 30 months with
the subsequent development of stereotyped hand movements
- Loss of social engagement early in course( although often develops later)
- Appearance of poorly coordinated gait or trunk movements
- Severely impaired expressive and receptive language development with severe
psychomotor retardation

Childhood Disintegrative Disorder:

Definition: CDD is a PDD marked by a prolonged period of normal development before the
child begins to regress, losing social, language, self-help, and motor skills. It is distinguished
from RS because the period of normal development is longer and it affects primarily males.
Apparently normal development for at least the first 2years after birth as manifested by the
presence of age appropriate verbal and non verbal communication, social relationships, play
and adaptive behavior.

Clinically significant loss of previously acquired skills (before age 10 years) is at least two of
the following areas:

- Expressive or receptive language

- Social skills or adaptive behavior
- Bowel or bladder control
- Play
- Motor skills

Diagnostic features DSM-IV:

Abnormalities of functioning in at least two of the following areas:

- Qualitative impairments in social interaction (impairment in non verbal behaviors,

failure to develop peer relationships, lack of social or emotional reciprocity)
- Qualitative impairments in communication (delay or lack of spoken language, inability
to initiate or sustain a conversation, stereotyped and repetitive use of language, lack of
varied make believe play)
- Restricted, repetitive and stereotyped patterns of behavior, interests, and activities,
including motor stereotypes and mannerisms.

PDD- NOS:

These DSM IV TR states, this category should be used when there is a severe and pervasive
impairment in the development of reciprocal social interaction associated with impairment in
either verbal or non verbal communication skills, or with the presence of stereotyped behavior,
interest, and activities.

- Atypical or inappropriate social behavior

- Uneven skill development (motor, sensory, visual-spatial organizational, cognitive,
social, academic, behavioral)
- Poorly developed speech and language comprehension skills
- Deficits in nonverbal and/or verbal communication
- Increased or decreased sensitivities to taste, sight, sound, smell and/or touch
- Perseverative (repetitive or ritualistic) behaviors (i.e., opening and closing doors
repeatedly or switching a light on and off )
DSM V (APA- 2013) Classification

A. Persistent deficits in social communication and social interaction across multiple contexts,
as manifested by the following, currently or by history (examples are illustrative, not
exhaustive, see text):

1. 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.

2. Deficits in nonverbal communicative behaviors 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.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behavior to suit various social contexts; to difficulties in
sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity: Severity is based on social communication impairments and restricted
repetitive patterns of behavior. (See table below.)

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least

two of the following, currently or by history (examples are illustrative, not exhaustive; see
text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal

nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid
thinking patterns, greeting rituals, need to take same route or eat 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
interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests 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).

Specify current severity: Severity is based on social communication impairments and restricted,
repetitive patterns of behavior. (See table below.)
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.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s

disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social
communication, but whose symptoms do not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:
- With or without accompanying intellectual impairment
- With or without accompanying language impairment
- Associated with a known medical or genetic condition or environmental factor
(Coding note: Use additional code to identify the associated medical or genetic condition.)
- Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or
behavioral disorder[s].)
- With catatonia

Table: Severity levels for autism spectrum disorder ( already mentioned above)
ICD 10 WHO 1993 classification
 Comparison of diagnostic categories

Source: Autism spectrum disorders by V. Mark Durand

WHAT CAUSES AUTISM?

Genetic Risk Factors

It is largely agreed that ASD is the result of hereditable genetic differences and/or mutations,
although not all children can be identified as having a genetic linkage or mutation that is obvious
to family members. Findings in support of a genetic link include research results showing that
ASD is more common in boys than girls—most likely due to genetic differences associated with
the X chromosome (Chakrabarti & Fombonne, 2005)—and twin studies that show a 60% to 90%
rate of concordance for identical twins compared with a 0% to 10% rate of concordance for
fraternal twins (Bailey et al., 1995). In a study conducted by Ozonoff et al. (2011), almost 20%
of infants with an older biological sibling with ASD also developed ASD; the risk for developing
ASD was greater if there was more than one older affected sibling.
Given the current availability of rapid, precise gene-sequencing tools and the accessibility of
large numbers of DNA samples, significant progress in identifying genetic factors associated
with ASD has been made (Coe, Girirajan, & Eichler, 2012; lossifov et al., 2012; Neale et al.,
2012; O'Roak et al., 2012; Sanders et al., 2012).
 SHANK3, 22q13
 NRXN1, 2q32
 CDH8,16q21

Neurobiological Factors
Abnormalities in the genetic code may result in abnormal mechanisms for brain development,
leading in turn to structural and functional brain abnormalities, cognitive and neurobiological
abnormalities, and symptomatic behaviors (Williams, 2012).
Neurobiological differences associated with a diagnosis of ASD include

 problems with genetic code development involving multiple brain regions, including
frontal and anterior temporal lobes, caudate, and cerebellum (Abraham & Geschwind,
2010);
 structural and functional abnormalities of the brain, including
o increased gray matter in the frontal and temporal lobes (Carper & Courchesne,
2005; Hazlett, Poe, Gerig, Smith, & Piven, 2006; Palmen et al., 2005),
o decreased white matter compared with gray matter by adolescence (Volkmar,
Lord, Bailey, Schultz, & Klin, 2004),
o anatomical and functional differences in the cerebellum and in the limbic system
(Volkmar et al., 2004);
 differences in the brain's response to the environment, including
 o decreased neural sensitivity to dynamic gaze shifts in infancy (Elsabbagh et al.,
2012);
o preference for nonsocial versus social processing and hemispheric asymmetries in
event-related potentials (ERPs; McCleery, Askchoomoff, Dobkins, & Carver,
2009);
o disruptions in normative patterns of social neurodevelopment that contribute to a
diminished attention to social stimuli (Jones, Carr, & Klin, 2008).

Neurotransmitters:

 Cook 1990, Narayan et al. 1993 have reviewed the studies on neurotransmitters in
autism.
 Many of the studies have produced inconsistent results with respect to Serotonin,
Opioids Peptides - found in higher levels in children with ASD.

Environmental Factors
Given the complexity of autism risk, researchers have begun to investigate how pre- and post-
natal environmental factors (e.g., dietary factors, exposure to drugs and environmental toxicants)
might interact with genetic susceptibility to ASD. A number of environmental exposures have
been indentified for future study, including lead, polychlorinated biphenyls (PCBs), insecticides,
automotive exhaust, hydrocarbons, and flame retardants (Landrigan, Lambertini, & Birnbaum,
2012; Shelton, Hertz-Picciotto, & Pessah, 2012). However, no specific environmental triggers
have been identified at this time.
Research focused on the environmental risks involved with the development of ASD is quite
complicated, as researchers must include how the environmental factors interact with individual
genetic information.
Vaccines

Two theories link autism and vaccines.

o The first theory suggests that the MMR (Mumps-Measles-Rubella) vaccine may
cause intestinal problems leading to the development of autism.
o The second theory suggests that a mercury-based preservative called thimerosal,
used in some vaccines, could be connected to autism.

DIFFICULTIES FACED IN VARIOUS DOMAINS

Difficulties in social interaction

Individuals with ASD can have difficulty in understanding social and recognizing the
unwritten social rules which govern our daily interactions.
The ways in which we learn how to socially engage is an innate process and while it is
guided by parents, careers and other influential figures , it is something that tends to
occur naturally. Theses social rules can be affected by many other factors such as age
gender and culture, and for someone with ASD it is not applied uniformly.

1. Lack of appropriate eye contact

2. Inability to use normal patterns of eye gaze that are the beginnings of
communication. Joint attention impaired
These babies look at others as often, but do not maintain their eye contact as long
as a typically developing child. They do not appear to follow people’s
movements, nor do they engage with their eyes in the same way as other infants.
3. Inability to become involved in the mutual sharing and emotional engagement;
thus the other people are not reinforced for continuing interactions.
4. Do not show or bring things
5. Inability to persistently engage people to provide assistance. Some of them may
try to solve their problems and not know that they can engage someone to help. If
unsuccessful aimlessly wander about or resort to self abuse or tantrums simply as
a reflexive response to frustration
Example: Amy pulls a chair to reach cookis on the shelf tries a lot of times but is
unable to. Mother is standing right next to her but does not call her to guide. Gets
frustrated bangs head.
6. Inability to understand non-verbal cues and body language. Impaired
conversational repair skills.
7. Inconsistent response to name call
8. Not understanding the concept of personal space
9. Failure to develop peer relationships appropriate to the developmental level.
10. A lack of spontaneity in seeking to share enjoyment, interests and achievements
11. Inability to automatically understand the perspective of others and the self from
the perspective of self.
12. Inability to Identify and make sense of social information (gestures, facial
expressions, nuances of language etc.)
13. Inability to Generate and formulate an appropriate response to match the varies
and rapidly changing demands of different situations. Difficulty in matching form
and content to context, introduce inappropriate topics
14. Exhibit poor social judgment

15. Their talk seems to have good vocabulary & sentence structure but
communication is inappropriate to that situation(Westby & Mckellar, 2000).
The effects of these deficits include the following:

 Social rules are learned rigidly and inflexibly, with little understanding that
there is a range of acceptable behavior. If told what to do, they will do it
exactly, every time forever. This inflexibility makes it difficult to adapt to
changes and to blend smoothly into the world, no matter how hard they try.
Example: The child had to point at prepositions, teacher: show me behind.
Child: That’s not appropriate. Because learnt from mother do not show people
your behind, it is not appropriate. To this child behind had a single and very
literal meaning. Rules are easy to learn but not easy to apply or modify
flexible.
 Public behavior tends to be same as private behavior. Without an
understanding of the perspective of others in a culture, one would not feel
embarrassed or automatically learn social and cultural rules and taboos.
Example: everyday would go to store to play videogames. Grand mom hid
clothes to stop. Goes out naked.
 Have difficulty initiating interactions, entering into ongoing conversations or
interactions. They cannot read the subtle body language or cues indicating that
other s are bored or embarrassed or desire to change the subject or end an
interaction. Example: Kim pulling legs of children on monkey bars. avoid him
 They are unable to focus on relevant information when engaged in a group
activity in order to have a common experience to review and share.
Example: dad: how was the race? Child: It was nice. There were 25 chairs
and 47 flags some were red and some were blue. With his attention to detail
he will have little ability to share the race experience in a meaningful manner.
 Friendly social overtures, humor and jokes are misunderstood

3 groups can be made by seeing just the way they handle themselves in social
situations (wing and atwood ,1987) :
Group 1 (aloof ) Group 2 (passive) Group 3 (active odd)
1. Observed on the 1. Watch 1. Actively involved
edges of social interactions but in social situations
situation, either make few social and totally unaware
watching people approaches. of the effect of
socialize or 2. Willingly their behavior on
randomly exploring respond if others others.
the environment. initiate and 2. Pursue their intense
2. They are seemingly approach and can interests unaware
oblivious to the be led easily into that the other
interactions going activities. person is trying to
on around them. 3. May try to fit in extricate
 3. Aloof , cut off and by imitation but themselves from
withdrawn do not understand the one sided
4. Particularly the complexities conversation,
sensitive to noise, of the situation. recitations of facts
touch and and repeated
movement of questions.
people.
5. Some of those in
this group can
enjoy a measure of
physical contact
when they can
initiate it
themselves and end
it at will.
6. Few reliable social
or communication
skills, so they are
dependent on others
to read their limited
signals.

Social deviations from developmental perspective

Earliest sign.

Difficulty in communication

A child with autism spectrum disorder may or may not have a language delay. Some children
may also show a regression in their speech and language skills.

1. A delay in , or total lack of development of spoken language ( Not accompanied by an

attempt to compensate through alternative modes of communication such as gesture or
mime)
2. Joint attention difficulties – Dissociation between IJA, RJA and IBT seen
3. Difficulty in learning the meanings of words
 Things can have multiple labels
  A single word can label objects, feelings, ideas or actions
 Context changes the meaning of many words
 Intonation and inflection (humor and sarcasm) change meaning.
 Will learn concrete words better than abstract.
 Easy to label object than to label emotion or concepts
4. Make incorrect associations – Associate unusual or erroneous meanings to word or
phrase and under extension may also be seen
Example: As refrigerator door swung open, the bottle of salad dressing fell down. 5 year
old tony said, “Oh, pants down”. Because in school he had learnt that dressing are pants
down/up. A single meaning was associated with a word dressing.
Example: The teacher taught the colour yellow to the child and while teaching she said
yellow car, book, this that. Later the teacher asked the child to give the pencil but he sat
still after multiple requests the teacher said give me the yellow pencil, the child handed
her the pencil. Since the teacher had specifically called the pencil yellow, to Jose it was
no longer just a pencil.

5. Echolalia – Is the act repeating or echoing words or sentences that others have said.

The borrowed words are generally well articulated and repeated with same emphasis and
voice quality as used by the original speaker. 3 types of echolalia:

 Immediate echolalia
 Delayed echolalia
 Mitigated echolalia – either delayed or immediate with some difference from the
original form.
6. Some children may use metaphorical language (idiosyncratic remarks to express desire or
reaction to a certain event). These are not actual metaphors but formed due to unique
associations created by the child with autism and others that are aware of the child’s
personal experience while creating those utterances.
Example: Open’s fridge and asks if the candy is tom’s. Mother interpreted and asked if he
wanted candy. He said yes.
Example: may associate a line from a rhyme with a particular event like every time it
rains he may say old man is snoring. Some may form new words /neologisms
7. Repetitive questions and sentence forms are used when information is needed but an
effective question or statement cannot be generated. Therefore, questions or statements
that are sometimes unrelated to the real needs are repeated in the same way, over and
over.
Example: Wanted a drink got. Asked again for it but pushing glass away every time.
Finally made sign for music. Inability to switch responses..
Children with autistic disorder are often delayed in acquisition of normal morphological
& syntactic milestones.
  Omission of grammatical morphemes
 Overreliance on word order.
 Construction of sentences with superficial form, often disregarding underlying
meaning
 Asperger’s syndrome or high functioning often have sophisticated morphological
& syntactic skills.(Frith,2003)
 use pre-fabricated sentences because have difficulty in creating novel sentences.
Schuler & Fletcher,(2002)
 specific difficulty with verb endings & pronouns. (Owens,2004).
 Pronoun reversals seen
Example: If the child is hungry he may say ‘he hungry’
8. Repeating or reciting lines from movies and TV shows
9. Having a very literal or concrete use of language
10. Having a robotic or monotone voice.
11. Becoming stuck on a topic regardless of conversation occurring around them. Unable to
twist and turn in the direction of flow. If monologue interrupted some children will find it
hard to pick it up from where they stopped and start over.

12. Children with ASD have impairments in many socio-communicative domains including
gestural communication (Rapin,2006).

 Gestures plays a important role in the acquisition and development of

language and forms the link between actions and spoken words in young
children (Capirci and Volterra, 2008; Capirci et al., 2005; Iversion et al.,
1994;Thal and Bates, 1988)
 ASD did not compensate their verbal communication deficits by gestural
production (Wetherby et al., 2007).
 Children with ASD are more likely to use pointing for requests (Instrumental
pointing) than pointing to share attention (proto-declarative pointing) suggesting
that meta-representational and social skills are impaired (Baron-Cohen ,1989;
Kiln et al.,2002).

PLAY IN CHILDREN WITH AUTISM

Play is not an important diagnostic feature but has a lot of implications. Play is linked
with cognition, social competence, language development and emotional development.
Play behavior in children with autism spectrum disorder is deviant.
 1. The first phase of play development, which involves exploratory/manipulative behavior
of objects, is in children with autism characterized by a number of unusual features.
 They tend to restrict their play to a limited selection of objects (Van Berckelaer-
Onnes 2003), or even an isolated part of an object (Freeman et al. 1979).
 They prefer proximal senses of touch and taste above visual exploration (Williams 2003)
 can become intensely preoccupied for long periods of time with non-variable visual
examination of just one object (Freeman et al. 1979), or non-play (Ruff 1984), which
impairs further development of play (Van Berckelaer-Onnes 2003).

2. Although several studies reported children with autism to produce the same number of
functional acts under spontaneous as well as structured conditions (e.g. Baron-
Cohen 1987; Van Berckelaer-Onnes 1994; Charman 1997; Lewis and Boucher 1988;
Libby et al. 1998; Williams et al. 2001), it has also been found that children with autism
 spend significantly less time playing functionally than controls (Lewis and
Boucher 1988; Jarrold et al. 1996; Sigman and Ungerer 1984),
 show lower levels of appropriate object use (Freeman et al. 1984),
 less variety in their functional play (Sigman and Ungerer 1984),
 more repetition (Atlas 1990; Williams et al. 2001)
 fewer functional acts (e.g. Mundy et al. 1990; Sigman and Ungerer 1984;
Ungerer and Sigman 1981).
3. Children with autism spectrum disorders (ASD) may experience particularly difficulties
in symbolic play. When symbolic play is performed, their play behavior may be more
like ‘learned routine’ rather than spontaneous play (Williams et al. 2001). The lack of this
particular type of play in the behavioral repertoire of children with autism does however
not necessarily imply a specific impairment in their symbolic abilities. It might reflect a
more general cognitive or social deficit associated with autism impinging on the whole
range of play development

BEHAVIOURAL ASPECTS

A behavior is a logical response to a current situation and an effort to regulate conditions that do
not match needs.

Example : reflexive crying – baby hungry ; parents think why antha. In this situation reflexive
behavior signals a need, it must be interpreted by parents.

 Apparently inflexible adherence to specific non functional routines or rituals.

 Example: Every night first brush, then change his pants and then go to bathroom. Moving
furniture in the room Is bothersome.

 Stereotypical and repetitive motor mannerisms

1. Finger or hand flapping or twisting , rocking or head banging – these are
considered as “self stims”
- Visual staring at lights, repetitive blinking, moving fingers in front of the
eyes, hand-flapping
- Auditory tapping ears, snapping fingers, making vocal sounds
- Tactile rubbing the skin with one's hands or with another object, scratching
- Vestibular rocking front to back, rocking side-to-side
- Taste placing body parts or objects in one's mouth, licking objects
- Smell smelling objects, sniffing people

2. Engages in this behavior to either rev them up when under stimulated or

relieve them from over stimulation.
- Occurs more frequently when overly excited or bored or tired.
Add pic

SOME OTHER FACTORS

1. Physical affection
 Some children don’t like to be picked up or cuddled, from an early age
they become stiff and rigid when giving a hug.
 Some may accept only from the mother, some may want only when they
are ‘sensory seeking’.
 Some of the children may not realize their own strength and hug too
strongly.
 Keep in mind the inconsistency across the spectrum, one can still come
across a child who enjoys being hugged.
2. Separation anxiety
 Around 7 to 8 months, most children develop some separation anxiety
from the primary caretaker.
 This is primarily manifested by the child either crying or attempting to
crawl towards the primary caretaker.
 A child on the spectrum may not show such a response, but also if an
infant is not showing any response it is on the spectrum. It is just
something to think about.
3. Overly easy baby
  Some babies are laid back and they do not cry and not notice the
mother walking about for long hours as if they are busy doing their
own thing.
 But keep in mind all children are not same
4. Wandering
 Typically developing child will also wander but always stay at a
distance close to parents and keep looking and checking for their
reactions. If the child gets lost it will be a traumatizing experience
for both the child and the parents.
 A child on the spectrum may wander simply without any feeling or
concern of being separated. If the child gets lost the parents will
freak out but the child will be uncaring.
5. Lack of fear and stranger danger
 The child should show some healthy of fear towards strangers,
animals, heights or some danger. Children on the spectrum
often lack this.
6. Picky eating
 The children may want to eat only a specific thing and may
even go hungry if not provided with it.

RECEPTION AND PROCESSING PROBLEMS

1. The individual is unable to modulate and process or integrate sensory stimulation.

 Sensory integration is an innate neurobiological process and
refers to the integration and interpretation of sensory
stimulation from the environment by the brain.
 In contrast, sensory integrative dysfunction is a disorder in
which sensory input is not integrated or organized appropriately
in the brain and may produce varying degrees of problems in
development, information processing, and behavior

EXAMPLE :Concentrating on his school work intensely may lead him to fall off his chair. To
most people, Michael appears to be a sloppy, clumsy, and forgetful child.
Michael is a third grade student who is waiting for the school bus. He is challenged by sensory
experiences during everyday activities that most of us don't even think about. While he's still
reeling from the battle with his mom over brushing his teeth (that peppermint toothpaste tastes
like fire in his mouth) the school bus pulls up. Michael runs past the bus monitor's haze of
perfume and sits at the back of the bus. In his heightened state, he becomes even more aware of
his new school shirt with its stiff label and that awful feeling like a wire brush being poked into
the back of his neck. The sensory experiences of the movement of the bus, the sound of his excited
classmates laughing and yelling above the roar of the bus engine all contribute to his increased
agitation. By the time Michael arrives at school he is wound up and ready to unravel. There is no
time to wait for the bus monitor's direction...getting off the bus quickly becomes a matter of
survival and he resorts to pushing, shoving and finally kicking his way out. Unfortunately, there
is a price to pay for this seemingly outward aggression...he can expect another trip to the
principal's office.

 Overwhelming sensory stimulation is often painful and disorienting, leading to

withdrawal and attempts to avoid or escape the pain and confusion.
 Some children will show abnormally high amounts of pain tolerance

2. Individual has decreased ability to scan an area or environment to identify and focus
consistently on the important elements or events
 Impaired ability to control the direction of attention, striking
ability to concentrate attention in one narrow spatial location
while being unaware of sensory events going around.
 Inability to continuously, selectively and smoothly shift
attention to follow rapid flow and ebb of objects , actions,
sounds, words, gestures, facial expressions , internal feelings
and a myriad of subtle details of the environment.
Therefore disconnected fragments of information would lack
context and temporal continuity.

 May have unexpected information gaps because attention was

focused somewhere else.

Example: May focus on edges of the bulletin board and not see the information written.

3. Chunks of information that occurs simultaneously or very closely in time are quickly
associated and remembered. This kind of learning is called gestalt learning.
 Information is not automatically or independently organized or analyzes to eliminate
clutter, to elicit meaning or to determine the meaning of new information from past
experiences.
 During free time Jose sat in the teacher’s chair and echoed the total language
lesson, including the total language lesson, including the cues, prompts,
corrections. He had memorized the entire lesson but could not request for a
drink.
 Routines are learned quickly and firmly.

Because of the inability to analyze and organize information, they will have less ability to :

 Identify critical elements or meanings, but focus on details and learn the routine.
 Evaluate information for accuracy or completeness, edit or modify information, or
know when more information is needed.
 Retrieve meaningful information at the appropriate time.
 Manipulate information flexibly to generate new ideas, to pretend, imagine or
create.
 Understanding analogies, inferences and other higher order thinking skills,
solving problems, choosing/ decision making.

To learn quickly can be a strength if events and experiences are organized to highlight important
elements and relationships. Without assistance wrong lessons are learned or they may be
incomplete but firm.

4. Information is not retrieve in the correct sequence.

5. Time concept and perception of passing time are impaired.

6. Auditory information is not processed efficiently or reliably.

 Hypersensitivity
 Delays and discrepancies in analyzing and retrieving information
 Long chains of auditory information recorded without typical meaning

7. Meaning is not automatically attached to visual information

Remarkable ability to remember and manipulate the things they see and quick ability
to take in visual information, often meaning is not attached.
ARTICLE : Gaze behavior and affect at 6 months: predicting clinical outcomes and language
development in typically developing infants and infants at risk for autism Gregory S. Young,1 Noah
Merin,2 Sally J. Rogers1 and Sally Ozonoff1

COMORBID CONDITIONS

1. Intellectual disability
 Most common co occurring problem
 In kanner’s type autism almost 2/3 rd score below average in IQ tests, AUTS2,
CNTN4, CNTPaP2
 ASD associated with genetic syndromes are also likely to have mild to profound
cognitive impairments
 This can complicate the efforts to provide intervention as well as later outcomes.

There is growing evidence to support thenotion that ID, autism and other cognitive disorders
share a common molecular etiology at the single gene level – Van bokhoven (2011)

He noted that single gene variants for IL1RAPL1, SHANK2, SHANK3, NLGN3, NLGN4,
GRIN2B,TCF4, AUTS2, CNTN4,CNTPAP2and NRXN1 have been expressed in individuals
with intellectual disability , with autism and also in idv. With both .

This is indicative that ID and Autism are concurrent and not co morbid.

2. Epilepsy
 A significant number develop seizures as they grow older.
 Estimates suggest that those with ASD are approximately 10 to 30 times more
likely to have epilepsy than general population.
 Presence of this indicates poorer long term outcomes. Early identification and
treatment may improve outcomes for these individuals.
3. Anxiety Disorders
 It is estimated that approximately 50 to 80% of these individuals can be diagnosed
with one or more anxiety disorders including simplephobias , GAD , Separation
anxiety disorder, OCd and social phobia
 Repetitive behaviours exhibited by person with ASD are considered similar to
OCD by some.
 Although forms of behavior vary between the two ( OCD – checking,cleaning etc;
Asd linging up, touching), the overlap of motor component and cognitive
component ( perseverative thoughts) suggests a possible connection .
 4. ADHD
5. SLEEP DISORDERS
 Affects 50 to 80 % ( richdale and shrek , 2009)
 Insomnia with prolonged sleep latency , disruption at bedtime etc.
Partly due to overlap of neurobiological influences – Abnormalities of GABA and
Melatonin – appear both in sleep disorders as well as ASD ( K.P Johnson and
Malow ,2008)

SOME THEORIES EXPLAINING AUTISM

The Theory of Mind

Theory of mind is the ability to attribute mental states—

beliefs, intents, desires, emotions, knowledge, etc.—to oneself, and to others, and to understand
that others have beliefs, desires, intentions, and perspectives that are different from one's
own. Theory of mind is crucial for everyday human social interactions and is used when
analyzing, judging, and inferring others' behaviors.

One of the most important milestones in theory of mind development is gaining the ability to
attribute false belief: that is, to recognize that others can have beliefs about the world that are
diverging. To do this, it is suggested, one must understand how knowledge is formed, that
people's beliefs are based on their knowledge, that mental states can differ from reality, and that
people's behavior can be predicted by their mental states. Numerous versions of the false-belief
task have been developed, based on the initial task done by Wimmer and Perner (1983).
In the most common version of the false-belief task (often called the "'Sally-Anne' test" or "'Sally-
Anne' task"), children are told or shown a story involving two characters. For example, the child
is shown two dolls, Sally and Anne, who have a basket and a box, respectively. Sally also has a
marble, which she places into her basket, and then leaves the room. While she is out of the room,
Anne takes the marble from the basket and puts it into the box. Sally returns, and the child is
then asked where Sally will look for the marble. The child passes the task if she answers that
Sally will look in the basket, where Sally put the marble; the child fails the task if she answers
that Sally will look in the box, where the child knows the marble is hidden, even though Sally
cannot know this, since she did not see it hidden there. To pass the task, the child must be able to
understand that another's mental representation of the situation is different from their own, and
the child must be able to predict behavior based on that understanding.
By 5 years children pass false belief tasks.

Executive functioning theory-The cognitive processes that help us regulate, control and manage
our thoughts and actions. It includes planning, working memory, attention, problem solving,
verbal reasoning, inhibition, cognitive flexibility, initiation of actions and monitoring of actions.
Here is a list of our executive functions and their basic descriptions.

 Planning:
Planning is the ability to forward-think and chooses the necessary actions to reach a goal,
decide the right order, assign each task to the proper cognitive resources, and establish a
plan of action. Those on the spectrum can have difficulty formulating plans to get
through their days and organize tasks into completable sections.

 Problem Solving:
To problem solve, an individual must identify a problem and then formulate a strategy to
solve the problem. Problem solving uses almost all the other executive functions
including reasoning, attention, planning, initiation, working memory, and monitoring.
Depending on which of the executive functions the individual struggles with, that is
where the problem solving chain will get broken.

 Working Memory:
Individuals on the spectrum notoriously have specific memory deficits and strengths.
They can seemingly remember every Jedi name, rank and serial number in all ten Star
Wars movies, but have trouble remembering to eat, or what day it is, or what the order of
the steps are when brushing teeth. Working memory is the ability to remember specific
short term memories needed to execute a function or daily task.

 Attention:
Attention is closely tied to working memory, and again those on the spectrum can show
great strengths in some areas and severe challenges in others. Individuals with ASD often
have a keen ability to focus, but directing that focus can be challenging. If the person
with ASD has sensory issues, then it’s possible all they will be able to focus their
attention on is the sound of the lights buzzing or the smells of the other people in the
room. An individual’s ability to focus directly affects what they can keep in and recall
from their short term memory

 Reasoning:
Reasoning, or verbal reasoning, is the ability to understand, analyze and think critically
about concepts presented in words, and then relay them back or integrate them
successfully. Many of those on the spectrum struggle with verbal acuity. Verbal
reasoning can also be hindered by social meanings that are not obvious to those with
autism.

 Initiation:
Initiation is the ability to start an activity, plan, or task. For those with executive function
difficulties with initiation, they may want to play a certain game, do their homework, or
play an instrument, but unless the activity is initiated by someone else it doesn’t happen.
It has nothing to do with desire, or “want” – it is about lacking the function of “just doing
it”.

 Inhibition:
 Inhibition is impulse control; the ability to have emotional, cognitive or physical
reactions that aren’t acted upon in the moment. So when a person with ASD starts
“information downloading” all the names and songs of their favourite 500 K-pop groups,
this would be a lack of cognitive impulse control. Emotional outbursts, hand flapping, or
stimming can be emotional and physical ways that impulse control aren’t in place,
(although some stimming can be soothing and help concentration if controlled and non-
harmful). Some children with ASD simply cannot control their impulses sufficiently to
participate in structured situations.
 Cognitive Flexibility:
Cognitive flexibility in simple terms is the ability to roll with the punches. Those with
autism are well known to need structure and predictability, and change can be very
challenging. This can also lead to rigidity of thoughts and opinions, as well as schedules
and routines.
 Monitoring:
Monitoring is normally an unconscious process that kicks in when we are on auto pilot
doing normal tasks. For instance, if you are walking down the street and talking to
someone at the same time, normally only a small part of your brain is engaged in
walking. You already know how to walk, so the monitoring part of the brain takes over
and keeps you from bumping into things while you have your chat. For someone with
executive function issues, if they were tired or overloaded, they would suddenly have
problems with the “auto pilot” settings on basic activities, dropping or bumping into
things, or simply not being able to pay attention in ways that could be hazardous like
walking out onto a busy street.

Weak central coherence

n 1989, Uta Frith* proposed the Weak Central Coherence Theory of autism. “Central coherence”
was the term given to a human being’s ability to derive overall meaning from a mass of details.
A person with strong central coherence, looking at an endless expanse of trees, would see “the
forest.” A person with weak central coherence would see only a whole lot of individual trees. It
is said that children with ASD have poor central coherence.

The Social brain

The human social brain includes many specialized and shared circuits in many different brain
systems and those brain systems appear to operate as a complex super network to support social
interaction

The social brain in Autism

Neuropsychiatric and neuropsychological evaluations in Autism have revealed selective

dysfunction of ‘social cognition’, with sparing of motor, perceptual and basic cognitive skills.
Social cognition includes a range of skills and functions required for successful interpersonal
interaction, mediated by a ‘Social Brain Network’,
consisting brain regions that are dysfunctional in autism: Fusiform face area (perception of
personal identity), inferior frontal gyrus (facial expression imitation), posterior superior temporal
sulcus (perception of facial expressions and eye gaze tasks), superior frontal gyrus (theory of
mind, i.e., taking another person’s perspective) and the amygdala (emotion processing).
ToM deficits in autism have been linked to abnormal patterns of hypo activation in superior
temporal gyrus, superior temporal sulcus, and basal temporal areas and hyper activation in
Brodmann’s area 9/10, compared to healthy subjects who performed well on ToM task
The mirror neuron system
The Mirror Neuron System, which is postulated to underlie the ability to mimic, learn and
understand the actions of others has also been implicated in autism. Mirror neurons are those in
the ventral motor regions that fire when subjects observe actions performed by con-specifics,
particularly when the subject has to mimic or learn that action. Although mirror neuron
dysfunction has been proposed in autism behavioral paradigms, but has not revealed differences
between autistic and non-autistic children in imitating and understanding hand gestures. It has
been proposed that lack of empathy, or the difficulty to ‘feel what you feel’ is linked to mirror
neuron system dysfunction, but the evidence is sparse.

Assessment for Autism

Given a breath of developmental domains in which children with ASD show delay or
deviance, a very strong case can be made for having multidisciplinary teams conduct the
assessments of these children.
Siegel, Plinar, Eschler, and Elliot (1988) found that parents most often expressed their
pediatrician when their child was from 1 to 6 years of age.
An early and accurate diagnosis was most likely to be made if the pediatrician referred
the child to a multidisciplinary team than if the child was sent on serial visits to single examines.
It appears that the multidisciplinary team was better able to pull single-discipline assessment
together into a diagnosis, which may relate to their shared sense of responsibility in making a
definitive diagnosis. The assessment team consist of a:
 a speech-language specialist
 psychologists
 an appropriate physician (child psychiatrist, neurologist, pediatrician)

These evaluation are conducted at a separate time and typically with that professional
alone.
Pediatrician:
Pediatricians are the first step in the autism diagnosis process. Every child gets an assessment at
their 18- and 24-month checkups to make sure they’re on track, even if they don’t seem to have any
symptoms. At these visits, your child’s pediatrician will watch him and talk to him. She’ll ask you
questions about family history (whether anyone in the family is on the spectrum), and about your
child’s development and behavior.

Some milestones your doctor will be looking for:

 Did your baby smile by 6 months?
 Did he mimic sounds and facial expressions by 9 months?
 Was he babbling and cooing by 12 months?
Also, she’ll ask about these things:

 Are any of his behaviors unusual or repetitive?

 Does he have trouble making eye contact?
 Does he interact with people and share experiences?
 Does he respond when someone tries to get his attention?
 Is his tone of voice “flat”?
 Does he understand other people’s actions?
 Is he sensitive to light, noise, or temperature?
 Any problems with sleep or digestion?
 Does he tend to get annoyed or angry?

Your responses are very important in your child’s screening. If everything checks out and you
have no concerns, that’s the end of it. But if your child shows developmental problems or your
doctor has concerns, she will refer you to a specialist for more tests.

Psychologists:

what services can psychologists provide for children with autism?

 Psychologists complete assessments of children with autism.
 The assessment can be related to diagnosis, cognition (IQ) or the way a child with
autism thinks and sees the world.
 Intervention by a psychologist is also important for children with ASD.
 Psychologists use a range of techniques including behavioural strategies, social skills
training, and emotional regulation to help children with ASD cope better in their
everyday lives.
 If a child is anxious, and this is very common for children with ASD, then a
psychologist can provide targeted interventions to decrease their anxiety levels.
 Interventions can also be provided to families, if there is a need.
 Neurologist:

When should the parents of a child with autism spectrum disorder consider taking him or
her to a neurologist?
Child neurologists specialize in identifying and treating disorders of the nervous system and
brain. Parents may consider consulting a neurologist if they notice:
 Their child is not developing at the same rate or pace as other children the same age,
 If there are delays in motor skills, speech and language, and social and play skills,
 If they notice red flags for autism including delays in social communication and play, and
an increase in repetitive behaviors and behavioral disruption,
 If there is a loss of previously-acquired developmental milestones, like speech or eye
contact or play. Parents may say, "My child was doing very well, and all of a sudden he's
not progressing, or he's losing skills." About 30 percent of children with autism do lose
skills between 18 months and 2 years of age, and a small fraction of them have seizures
as an underlying cause.
 If there is a history of seizure-like jerking movements or staring spells indicating a
possible seizure,
 If there are concerns of hyperactivity, sleep issues, feeding problems,
 If there's a concern about hypotonia [low muscle tone] or motor abnormalities – if the
child is a very floppy baby or one side of his body is stronger than the other.
Other reasons that someone might see a neurologist are a history of prematurity, a concern that
the child has a large head or a small head, or anything that makes you think there's a medical
cause for the child's autism.

Psychiatrists:

Child and adolescent psychiatrists diagnose and treat any psychiatric problems that the child with
autism may exhibit. The child psychiatrist also continues to provide supportive care and
medication management after the initial diagnosis.

How early it can be diagnosed?

 (Rogers, 2009) majority of children could be diagnosed by age of 24 months.

 12 months of age. Because significant percentage of children showed signs of ASD even at 12
months of age. (Saint- Geogers et al.,2010)
 Diagnosed by focusing on the behaviors and screening questionnaires.(Pierce et al.,2011)

A Speech-Language Specialist:
An evaluation of the language skills of any child with ASD should begin with a detailed
parent interview and case history. It includes:

• History of these problems,

• Family history,
• Developmental milestones,
• Education,
• Abnormal behaviors of the child,
• A medical and surgical history,
• Any current treatments,

Early Screening Tools:

A screening is a brief assessment aimed at identifying those infants and/or children who
may be at risk for developmental delays due to inferences compared with standard expectations
for children of the same age range and cultural background (Losardo & Notari-Syverson, 2001).
Screening tools are typically administered widely in order to identify individuals who require
further testing.
Screening for ASD includes broadband screeners designed to detect developmental delays in
the general pediatric population and autism-specific screening tools designed for either the
general population or high-risk populations, such as children referred to the early intervention
system. Any screening tool should have strong psychometric features to support its accuracy and
be culturally and linguistically appropriate.
Screening typically includes

 norm-referenced parent and teacher report measures,

 competency-based tools, such as interviews and observations,
 hearing screening to rule out hearing loss as a contributing factor to communication and
behavior difficulties.

Screening procedures evaluate the main characteristics that differentiate ASD from other
developmental disorders, including difficulties in

 eye gaze,
 orienting to one's name,
 pointing to or showing objects of interest,
 pretend play,
 imitation,
 nonverbal communication,
 language development.

Some of the screening tools are:

1. CHAT-A Screening Tool (Baron-Cohen et al. 1992)

2. MCHAT (Modified Checklist For Autism In Toddlers) (Diana L. Robbins, Deborah Fein,
Morianne L. Barton, Janes A. Green – 2001)
3. Early Screening of Autistic Traits (ESAT) (Swinkels et al., 2006)
4. Autism Behavior Checklist (ABC), Krug et al., 1980
 5. Screening Tool for Autism in Toddlers and Young Children (STAT), Vanderbilt
Kennedy Center, 1997

1.CHAT-A Screening Tool (Baron-Cohen et al. 1992):

 The checklist for autism in Toddlers is a short questionnaire which is filled out by
parents and a primary health care worker at the 18 month developmental checkup.
 It aims to identify children who are at risk for social communication disorders.
 The key items look at behaviors which, if absent at 18 months, puts a child at risk for
a social-communication disorder.
 These behaviors are:

 Joint attention,
 Protodeclarative pointing (pointing to comment rather than to request)
 Interest in, emotional engagement with others
 Social play
 Pretend play(e.g. pretending to pour tea from a toy tea pot)

 If a child fails all 5 key items, they have a high risk of developing autism.
Any child who fails CHAT should be re-screened approximately one month later.

2. MCHAT (MODIFIED CHECKLIST FOR AUTISM IN TODDLERS)

(Diana L. Robbins, Deborah Fein, Morianne L. Barton, Janes A. Green – 2001)

 MCHAT is an expanded American version of original CHAT from UK. MCHAT has 23 yes/no
questions using the original 9 from the CHAT as its basis. Its goal is to improve the sensitivity
of CHAT. It seems for autism spectrum disorders against normally developing children.
 Scoring – A child who fails the checklist when 2 or more critical items are failed or when any 3
items are failed. Yes/no answers convert to pass/fail responses.
 MCHAT is being tested among children of 24 months of age.
 Children who fail should be evaluated in more depth by physician or referred for developmental
evaluation with a specialist.

3.Early Screening of Autistic Traits (ESAT) (Swinkels et al., 2006)

The ESAT is a 14-item questionnaire that was developed in the Netherlands for
identifying young children 16 to 48 months at risk for ASD (Swinkels et al., 2006).
Parents are asked to report yes or no items such as “Can your child play with toys in
varied ways (not just fidding, mouthing or dropping them)?, and “When your child
expresses his/her feelings, for instance, by crying or smiling, is that mostly on expected
 and appropriate moment?. The developers found that caregivers other than the parents
were more likely to give negative answers.

4.Autism Behavior Checklist (ABC), Krug et al., 1980:

 List of questions about a child's behaviors.
 The ABC is designed to be completed independently by a parent or a teacher familiar
with the child who then returns it to a trained professional for scoring and
interpretation.
 Although it is primarily designed to identify children with autism within a population
of school-age children with severe disabilities, the ABC has been used with children as
young as 3 years of age.

 The ABC has 57 questions divided into five categories:

 (1) sensory
 (2) relating
 (3) body and object use
 (4) language
 (5) social and self-help.

5.Screening Tool for Autism in Toddlers and Young Children (STAT), Vanderbilt
Kennedy Center, 1997
Candidate: 24 and 36 months
There are 12 items in the categories of imitation, play, and communicating-requesting and
communication-directing attention that are completed during observations of a play
interaction. Items are scored as either pass or fail by the number of requests of directing of
attention. The utility of the STAT in community-based settings remains to be determined
(Stone et al.,2004)

Assessment/Diagnostic tools:

Diagnostic assessments would be made following the identification from a screening

assessment, a recommendation from a pediatrician, or suggestion from a parent who has a
concerns. Best practice in assessment includes obtaining information from multiple forms of
measurement (Gotham, Bishop, & Lord, 2011; Sandall, Hemmeter, Smith, & McLean, 2005).
The diagnostic evaluation for individuals at risk for ASD typically includes

 relevant case history, including information related to the child's health, developmental
and behavioral history, and current medical status;
 a medical evaluation, including general physical and neurodevelopmental examination, as
well as hearing and vision testing;
 medical and mental health history of the family;
 a comprehensive speech and language assessment.
 Some of these respected diagnostic tools used:
1. Indian Scale for Assessment of Autism (ISAA) – NIMH, Secunderabad
2. Autism Diagnostic Observation Schedule (ADOS) Lord, Rutter,DiLavore,and Susan
Risi,(1998)
3. Differential Diagnosis Checklist ForAutism Spectrum Disorder (DDC- ASD) (Dr. K.C
Shyamala,Mrs. Vijayashree, Mrs.Sujatha,2007, AIISH)
4. 4. Autism Diagnostic Interview - Revised (ADI-R) Lord, Rutter, LeCouteur, (1994):
5. Childhood Autism Rating Scale (CARS); age not specified developed by Eric
Schopler, Robert J. Reichier, and Barbara Rochen Renner
6. Gilliam Autism Rating Scale (GARS-2) (Gilliam, 1995)
7. Asperger’s Syndrome Diagnostic Scale (ASDS): Myles, B Setal 2001

1. Indian Scale for Assessment of Autism (ISAA) – NIMH, Secunderabad:

The ISAA is a 40 item scale divided into six domains-

 Social Relationship and Reciprocity (9 questions);

 Emotional Responsiveness (5 questions);
 Speech — Language and Communication (9 questions);
 Behavior Patterns (7 questions);
 Sensory Aspects (6 questions) and
 Cognitive Component (4 questions).

The scores for the each item of ISAA range from 1-5, depending on the intensity, frequency and
duration of a particular behavior with the following anchors:

• Score 1 = Rare (up to 20%)

• Score 2 = Sometimes (21-40%),
• Score 3 = Frequently (41-60%),
• Score 4 = Mostly (61-80%), and
• Score 5 = Always (81%-100%).

o Scoring is based on information from parents and observation of the child following
guidelines from the Manual of the ISAA.
o In the speech- language and communication domain the child should be rated 5 if he/she
never developed speech or communication.
o Total ISAA scores range from 40-200.
 o The lowest score represents no symptoms or symptoms which were present only rarely,
and the maximum score indicates the most severe presentation of AD.
o The following categories are recommended;
mild AD: 70-107
moderate AD: 108-153
severe AD: 153.

2. Autism Diagnostic Observation Schedule (ADOS) Lord, Rutter,DiLavore,and Susan

Risi,(1998):

 Purpose: To evaluate almost anyone suspected of having autism

 Candidates: 2+ years of age

 Administration: 35–40 minutes per module
 The ADOS consists of four modules
 Module 1 is used with children who do not consistently use phrase speech.
 Module 2 with those who use phrase speech but are not verbally fluent.
 Module 3 with fluent children.
 Module 4 with fluent adolescents and adults.
 As you administer the ADOS, you record your observations, then code them later and
formulate a diagnosis.

3. DIFFERENTIAL DIAGNOSIS CHECKLIST FOR AUTISM SPECTRUM

DISORDERS (DDC- ASD)
(Dr. K.C Shyamala,Mrs. Vijayashree, Mrs.Sujatha,2007, AIISH)

The Characteristic features are classified under different domains;

 Age of Onset
 Behavior
 Sensory
 Social
 Speech and Language

There are two parts, PART –A (For autistic & asperger’s syndrome) & PART – B (Rett’s
syndrome& CDD).

Administration of Checklist
  The parent is interviewed and the child is also observed for the possible features. The
features in the respective domain are marked in the score sheet.
 After completion of all the domains or areas, the subgroup of ASD is identified and
shaded in the score sheet.
 The general observation of the child’s speech and language, behavior is also noted down
in the score sheet.
 Profiling is done based on the subgroups shaded in the respective domains.
 The diagnosis is then made considering age as the domain & supported by any two other
domains among social, speech and language ,sensory or behaviour.
 Diagnose the child under PDD-NOS if the distribution does not meet above said criteria.

4. Autism Diagnostic Interview - Revised (ADI-R) Lord, Rutter, LeCouteur, (1994):

 Purpose: To assess individuals suspected of having autism

 Candidates: 2+ years of age
 Administration:1.5–2.5 hours
 Useful for formal diagnosis as well as treatment and educational planning.

Composed of 93 items, the ADI-R focuses on 3 functional domains:

■ Language and Communication

■ Reciprocal Social Interactions
■ Restricted, Repetitive, and Stereotyped Behaviors and Interests

5.Childhood Autism Rating Scale (CARS); age not specified developed by Eric
Schopler, Robert J. Reichier, and Barbara Rochen Renner:

CARS is a diagnostic assessment method that rates children on a scale from one to four for
various criteria, ranging from normal to severe, and yields a composite score ranging from non-
autistic to mildly autistic, moderately autistic, or severely autistic. The scale is used to observe
and subjectively rate fifteen items.

 relationship to people
 Imitation
 emotional response
 Body
 object use
 adaptation to change
 visual response
 listening response
 taste-smell-touch response and use
 fear and nervousness
 verbal communication

- In addition, it distinguishes mild-to-moderate from severe autism.

- The CARS includes items drawn from five prominent systems for diagnosing autism.
- Each item covers a particular characteristic, ability, or behaviour:

Relationships with People, Imitation, Affect, Use of Body, Relation to Non-human Objects,
Adaptation to Environmental Change, Visual Responsiveness, Auditory Responsiveness, Near
Receptor Responsiveness, Anxiety Reaction, Verbal Communication, Nonverbal
Communication, Activity Level, Intellectual Functioning.

- The CARS can be used by professionals such as physicians, special educators, school
psychologists, speech pathologists, and audiologists.
- Brief, convenient, and suitable for use with any child over 2 years of age, the Childhood Autism
Rating Scale (CARS) makes it much easier for clinicians and educators to recognize and classify
autistic children

6. Gilliam Autism Rating Scale (GARS-2) (Gilliam, 1995):

42 item norm - referenced screening instrument used for the assessment of individuals ages 3-
22 years who have severe behavioral problems that may be indicative of autism. Its purpose is
to help professionals identify Autism Spectrum Disorders. Three subscales which address
components of the definition of Autism developed by the Autism Society of America and the
DSM-IV-TR:

 Stereotyped Behaviors
 Communication
 Social Interaction
• Stereotyped Behaviors: Items 1-14 describe stereotyped behaviors, motility disorders, and other
unique & atypical behaviors
• Communication: Items 15-28 describe verbal and non-verbal behaviors displayed by children
with Autism and Autism Spectrum Disorders
• Social Interaction: Items 29-42 evaluate a child‟s ability to relate appropriately to people, events,
and objects.

7.Asperger’s Syndrome Diagnostic Scale (ASDS): Myles, B Setal 2001

• The ASDS is a 50-item norm-referenced rating scale that requires the respondent to
indicate the presence or absence of behaviors indicative of AD.

• The ASDS takes approximately 10–15 minutes to complete.

 • The ASDS contains five subscales:

Subscales

• Language
• Social
• Maladaptive
• Cognitive
• Sensorimotor

Very likely >110

Likely 110 Asperger Syndrome Quotient (ASQ)

Possibly 89
Unlikely 70-79
Very unlikely <69

LANGUAGE TESTS

1. Comprehensive Assessment of Spoken Language (CASL)

Eric Schopler, PhD, Robert J Reichler, MD, and Barbara Rochen Renner, PhD
WPS 1988

 Administration: Time: 30 to 45 minutes for the core battery

 Scores: Scores/Interpretation: Age-based and grade-based standard scores

(M = 100, SD = 15),

 Ages / Grades: 3 through 21

 Fifteen tests measure language processing skills—comprehension, expression, and
retrieval—in four language structure categories:
 Lexical/Semantic,
 Syntactic
 Supralinguistic
 Pragmatic.
 Individual test scores; Core Composite; Processing Index (representing receptive or
expressive skills); and Category Index (reflecting skills in Lexical/Semantic, Syntactic,
 and Supralinguistic domains). Provided as age- and grade-based standard scores, grade
and test-age equivalents, percentiles, normal curve equivalents, and stanines.

2. Test of Pragmatic Language, Second Edition (TOPL-2) by Diana Phelps-Terasaki

and Trisha Phelps-Gunn
 The TOPL-2 allows you to assess the effectiveness, and appropriateness, of a student's
pragmatic language skills.
 Administered in approximately 45-60 minutes,
 it tests six core subcomponents of pragmatic language: physical setting, audience, topic,
purpose (speech acts), visual-gestural cues, and abstraction.
 Raw scores, percentiles, standard scores, and age equivalents are provided.
 The TOPL-2 also provides important information about social skills and conflict resolution.
 Individually administered, this test is appropriate for individuals aged 6-0 to 18-11.

Its four principal uses include:

• identifying individuals with pragmatic language deficits

• determining individual strengths and weaknesses
• documenting an individual’s progress
• researching pragmatic language skills.

Article

Assessing Gestures in Young Children With Autism Spectrum Disorder Allison Bean
Ellawadia and Susan Ellis Weismera

Journal of Speech, Language, and Hearing Research • Vol. 57 • 524–531 • April 2014 • A
American Speech-Language-Hearing Association524

Purpose: The purpose of this study was to determine whether scoring of the gestures point, give,
and show were correlated across measurement tools used to assess gesture production in children
with an autism spectrum disorder (ASD).

Method: Seventy-eight children with ASD between the ages of 23 and 37 months participated.
Correlational analyses were conducted to determine whether performance of 3 key gestures
related to joint attention and behavior regulation (point, give, show) were correlated across 3
different measurement tools: the Autism Diagnostic Observation Schedule, the Early Social
Communication Scale, and the MacArthur-Bates Communicative Development Inventory:
Words and Gestures. To establish whether different measures were related at different points in
development, children were subdivided into 2 groups based on their expressive language levels.

Results: The scoring of gestureperformance was notentirely consistent across assessment

methods. The score that a child received appeared to be influenced by theoretical perspective,
gesture definition, and assessmentmethodology, as well as developmental level.
 Conclusion: When assessing the gestures of children with ASD, clinicians should determine
what aspects of gesture they are interested in profiling, gather data from multiple
sources,andconsiderperformanceinlightofthemeasurement tool.

Differential Diagnosis:

ADHD VS AUTISM

ADHD

 Usually spotted in school.

 Normal IQ.

• Often pragmatic language problems.

• No stereotyped behaviors
• No pre occupation with narrow interest

Autism

• Early onset
• IQ tends to be lower
• Often fail to develop spoken language
• stereotyped behaviors
• pre occupation with narrow interest

There are several ways in which autism and ADHD can overlap.

1)The first diagnostic criterion for autism is “marked impairment in the use of multiple
nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and
gestures to regulate social interaction.” It is quite possible that a child with any of the
three types of ADHD could have problems in this area.

2) Children would not respond when their name is called. This is another factor that kids
on the spectrum and those with ADHD share. Kids on the spectrum are often thought of
as being in their own world and do not respond when people call their name. If the child
has great difficulty with attention, it is also likely that they would not respond when their
name is called.

• Pragmatics is a common area of deficit for children on the spectrum, as they often have
difficulty starting or sustaining a back-and-forth conversation with others. This can also
be seen with children who have ADHD.
 • Another overlapping area for both the autism spectrum and ADHD. However, there are
some subtle differences. Typically, when a small child on the spectrum wanders away
from their parents at the mall, the department store, or the park. However, with children
who have ADHD, they seem to realize that they are separated from their parents much
quicker and become upset over the separation, hopefully decreasing the likelihood of this
happening again in the future.
• Another interesting overlap, for both ADHD and the autism spectrum, namely, “zoning
out” during the evaluation. Once again, children on the spectrum are often reported to be
“in their own worlds,” and children and teens with ADHD, especially the inattentive and
combined types, have difficulty paying attention, which is inherent in the disorder.

ASDs versus Mental Retardation

 In the 1990s, it was felt that most children with autism were also mentally retarded.
 In 2000, the DSM-IV-TR stated, “In most cases, there is an associated diagnosis of
Mental Retardation, which can range from mild to profound. There may be abnormalities
in the development of cognitive skills.
 There really is not a great deal of diagnostic overlap between autism and mental
retardation. Looking closer at the diagnostic criteria for both, autism is a combination of
socialization, language, and behavioral problems, while mental retardation consists of
having an IQ below 70, with “concurrent deficits or impairments in present adaptive
functioning ... in at least two of the following areas: communication, self-care, home
living, social/interpersonal skills, work, leisure, health, and safety.”
 one of the main differentiating factors between a child with autism and one with mental
retardation would be the stereotyped patterns of behavior, interests, and activities found
mainly in children on the autism spectrum .

ASD and Social (Pragmatic) Communication Disorder

• Impairments in social communication without the presence of repetitive, restricted or

stereotyped behaviors may meet the criteria for Social Communication Disorder
• When those stereotyped behaviors are present, the diagnosis of ASD supersedes Social
Communication Disorder

Tools:

ADI-R, ADOS-2, SRS2, SCQ, interview, observation

ASD and Anxiety Disorders

• Comorbidity up to 70%
 • When diagnostic criteria for ASD are met, attention is given to specific criteria for
anxiety disorders that are distinct from ASD criteria including significant distress when
separating from caregivers, excessive worry about safety of caregivers, school refusal,
selective mutism, fear of peer rejection
• Indications of anxiety not consistent with ASD- social impairments do not persist with
familiar persons, age appropriate social capacity, but not utilized effectively

ASD and OCD

• Repetitive behavior is performed in order to reduce anxiety; interfering recurrent

thoughts inhibit functioning
• If social communication deficits are present, then ASD may more appropriately account
for the repetitive behavior; if not, OCD is more appropriate

ASD versus SLI Leyfer et al. (2008)

 Overall significant differences between groups: On the ADOS, Children with autism
scored significantly higher on the social and communication algorithm scores than the
children in the SLI group
 25% of the children in the SLI sample met the ADOS cut-off for ASD on the
communication domain.
 11% of the SLI sample met the autism spectrum cut-off on the reciprocal social
interaction domain

Expressive language delay vs. ASD

Even children with Autism will show a delay in language. What differentiates a child on the
spectrum from a child with expressive language delay is the functioning in other areas. A typical
child with an expressive language delay would also be more likely to rely on gestures, such as
pointing, in order to get his or her needs met, sometimes not always seen with children on the
spectrum. Another main area that differentiates the child with autism from a child who only has
an expressive language delay is the presence of any of the repetitive or stereotype behaviours.
Social behaviour in a child with ELD will be better.

ASDs versus Fragile X, Down’s Syndrome

• Approximately one-third of all children diagnosed with Fragile X syndrome also have
some degree of autism.
• Fragile X syndrome is the most common known single gene cause of autism.
• Children with Down’s syndrome tend to be very social. This is not the case for children
with autism
REFERENCES

 Donald P Gallo . Diagnosing Autism spectrum disorders

 Lynn Waterhouse. Rethinking Autism – variation and complexity
 V Mark Durand. Autism spectrum disorder- Aclinical guide for general practioners
 Janice E. Janzen . Undersatnding the nature of Autism
 Tony chan.Social and Communication Development in Autism Spectrum Disorders

 John W. Oller Jr & Stephen D. Oller. Autism- The diagnosis, treatment, etiology of the
undeniable epidemic
 M.M.hegde & C.A Maul .Language Disorders in children (2006)
 Rita Jordan. Autistic Spectrum Disorders- An introductory handbook for practitioners
(1999).
 Amy M. Wetherby & Barry M. Prizant. Autism Spectrum Disorders- A transactional
developmental perspective (2001).
 Peeters, T. (1997). Autism - From Theoretical Understanding to Educational
Intervention. San Diego, Singular Publishing Group Inc.
 Laura J. Hall- Autism Spectrum Disorders- From Theory to Practice.
 Marla R. Brassard & Ann E. Boehm- Preschool Assessment Principles and Practices.