Module 8 – Autism Spectrum Disorder

3rd edition as of August 2022

Module Overview

In Module 8, we will discuss matters related to autism spectrum disorder to include its clinical presentation, prevalence, comorbidity, etiology, assessment, and treatment options. Our discussion will include autism spectrum disorder and social (pragmatic) communication disorder. Be sure you refer to Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).

Module Outline

• 8.1. Clinical Presentation
• 8.2. Prevalence and Comorbidity
• 8.3. Etiology
• 8.4. Assessment
• 8.5. Treatment

Module Learning Outcomes

• Describe how autism spectrum disorder (ASD) presents.
• Describe the prevalence and comorbidity of ASD.
• Describe the etiology of ASD.
• Describe how ASD is assessed, diagnosed, and treated.

8.1. Clinical Presentation

Section Learning Objectives

• Outline the history of autism spectrum disorder and describe misconceptions.
• Describe the common symptoms and associated features of autism spectrum disorder.
• Describe social (pragmatic) communication disorder.

8.1.1. History of Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a newly added disorder to the DSM-5. In prior versions of the DSM,  it was split into two different disorders – Asperger’s syndrome and autistic disorder. For autistic disorder, the child had to present with developmental, cognitive, and language delays, while for Asperger’s syndrome, this was not needed. The restrictive behaviors of autistic disorder that presented as motor movements most often presented as restrictive and circumscribed interests in Asperger’s syndrome (APA, 2000).

Historically, these two disorders were differentiated by developmental history. However, research indicated that distinguishing between a child with high functioning autism and Asperger’s syndrome was difficult (Barahona-Correa & Filipe, 2015; Happe, 2011). With the publication of the DSM-5 in 2013, the disorders were combined into one spectrum disorder – autism spectrum disorder (ASD; APA, 2013; Barahona-Correa & Filipe, 2015). Individuals that were previously diagnosed with Asperger’s syndrome or autistic disorder (as well as pervasive developmental disorder not otherwise specified) were ‘grandfathered’ into the diagnosis of ASD.

8.1.2. Clinical Presentation of Autism Spectrum Disorder

The essential features of ASD are twofold and include persistent impairment in reciprocal social communication and social interaction (Criterion A) and restricted, repetitive patterns of behavior, interests, or activities (Criterion B). It is described as a spectrum because of the varying manifestations of the disorder due to severity of the autistic condition, developmental level, chronological level, and gender (APA, 2022).

     8.1.2.1. Criterion A: Social communication and social interaction. The child must present with all of the following symptoms. These include behaviors such as poor eye contact, dominating a conversation/or lacking ability to maintain conversation due to absent or limited reciprocity (i.e., “to and fro” conversation in the exchange of information), trouble with integrating verbal communication with nonverbal communication (e.g., for example using gestures, body language, or visual guiding), and struggles with maintaining friendships or relationships in general. Individuals with these difficulties have trouble understanding others’ perspectives, reading emotions, and inferring minor and subtle social cues.

     8.1.2.2. Criterion B: Restricted and repetitive behaviors, interests, or activities.  The child must present with at least two of the following. First, they engage in stereotyped movement, frequently called stereotypy, such as hand flapping, spinning, or any repetitive movement that does not have an obvious function. They might display restricted or repetitive play such as lining up toys or fixating on a part of a toy or button. Individuals may have excessive and restricted interests such as being overly interested in history, dinosaurs, robotics, etc. Their interests may be so intense that, if discussing their interests, it is difficult to get them to move on to a new topic, or it may be the only thing about which they will engage in a conversation.

Restricted behaviors might include strict adherence to routines or schedules. Individuals may become very dysregulated if there is a new routine introduced or their routine is changed in any way. Moreover, sensory concerns may be of particular relevance. Some individuals may seek out sensory stimulation (sensory seeking behavior which is often referred to as “stimming”) as a soothing method. In fact, many repetitive movements can be seen as sensory stimulating. Examples, although not an exhaustive list, of “stimming” may include rubbing hands on a rough material repetitively (tactile), putting objects on their mouth/lips (oral), grunting or making nonfunctional vocalizations (vocal), or looking at lights or visual lines in odd ways (visual). Others may avoid certain sensory input which is known as a sensory aversion. For example, being very averse to certain textures, heightened sensitivity to pitch or volume of noise, or bright lights.

     8.1.2.3. Diagnosing ASD. Individuals must exhibit both social communication concerns and restricted/repetitive behaviors/interests/activities to be diagnosed with ASD. Furthermore, these symptoms must have been present very early in development (APA, 2022).

Although language delays are common in children with ASD, they are not necessarily required. Moreover, there is often a misconception that if a child has severe ASD, they are nonverbal, meaning they do not have language. This is not accurate. Children with ASD present very differently from each other. Regarding ASD, Dr. Stephen Shore said, “If you’ve met one person with autism, you’ve met one person with autism.” In other words, one child with ASD may have symptoms that present very differently from another child with ASD, but both children have ASD.

     8.1.2.4. Specifiers for ASD. ASD is diagnosed within the context of language development and intellectual development given that these factors may indicate prognosis. As such, clinicians will assign specifiers that identify if there is any evidence of language impairment or intellectual impairment. For intellectual impairment, separate estimates of verbal and nonverbal skill are necessary. For language impairment, the clinician should consider receptive and expressive language skills separately since receptive may lag behind expressive language development in ASD.

Moreover, ASD is diagnosed in the context of current severity for both social communication impairments and restricted, repetitive patterns of behavior, interests, or activities. The clinician will assign a severity level to each of the two main criteria indicating how much support the individual needs. Level 3 indicates “Requiring very substantial support,” Level 2 means “Requiring substantial support, and Level 1 states, “Requiring support.”

     8.1.2.5. Associated features. Intellectual and/or language impairment is common in many individuals with ASD. They may have difficulty seeing the world from another person’s perspective, called a theory-of-mind deficit. Motor deficits are also present and can include odd gait, being clumsy, and walking on tiptoes. Self-injury such as banging one’s head or biting one’s wrist are also common.

     8.1.2.6. Development and course. The behavioral features of ASD first become noticeable in early childhood as some children will present with a lack of interest in social interaction during their first year of life. For children in which skills have been lost, parents and other caregivers may provide a history showing gradual or relatively rapid deterioration in social behaviors or language skills occurring between 12 and 24 months.

In terms of symptoms, the first symptoms of ASD typically involve delayed language development, often accompanied by lack of social interest or unusual social interactions, odd play patterns such as carrying a toy around but never playing with it, and unusual communication patterns such as knowing the alphabet but not responding when their name is said. During the second year, odd and repetitive behaviors, and the absence of typical play become more apparent (APA, 2022).

8.1.3. Social (Pragmatic) Communication Disorder

Social (pragmatic) communication disorder is similar to autism spectrum disorder in that social communication, whether verbal or nonverbal, is impacted. Pragmatics refers to the social use of language and communication. To receive a diagnosis, all of the following must be present: 1) problems with using communication for social purposes such as greeting or exchanging information, 2) difficulty with changing communication to match context or needs of the listener such as recognizing that one speaks softer in a classroom but louder at a football game, 3) difficultly following the rules for conversation or storytelling such as understanding that individuals engaged in a conversation take turns speaking, and 4) problems understanding what is not explicitly stated and nonliteral or ambiguous meanings of language such as idioms, humor, or metaphors.

Although, in many ways this may seem very similar to ASD, one of the biggest differences is that restricted or repetitive behaviors/interests are not present. It should be noted that, as individuals with ASD age, restricted/repetitive behaviors tend to decline. If this occurs, but the individual had a history of the restricted/repetitive behaviors, they are still diagnosed with ASD, even if those behaviors are not currently present, rather than social (pragmatic) communication disorder.

     8.1.3.1. Development and course. Social (pragmatic) communication disorder is not typically diagnosed in children under four years of age. By age 4 or 5 years, most children have obtained adequate speech and language capabilities to allow for the identification of specific deficits in social communication, though milder forms of the disorder may go undetected until early adolescence, when language and social interactions become more complex.

Note to the Reader: Social (pragmatic) communication disorder was presented in this module only so that it can be distinguished from ASD in terms of a differential diagnosis. It will not be discussed going further, and to be candid, the DSM does not really have much more to say about it either.

8.2. Prevalence and Comorbidity

Section Learning Objectives

• Describe the prevalence of ASD.
• Describe common disorders that are comorbid with ASD.

8.2.1. Prevalence of ASD

ASD has been reported in 1% to 2% of the U.S. population. Prevalence is lower among African American (1.1%) and Latinx (0.8%) children compared to Caucasian children (1.3%). In non-U.S. countries prevalence has approached 1% of the population. The male:female ratio globally is 3:1. Individuals with ASD are at greater risk for suicide death and children with ASD who had impaired social communication had a higher risk for self-harm with suicidal intent, suicidal thoughts, and suicide plans by age 16 compared to those without the impaired social communication (APA, 2022).

8.2.2. Comorbidity of ASD

Comorbid disorders are very common for children with autism. Specifically, 70% of children with autism have a comorbid diagnosis. Further, 40% of children with autism have two or more additional disorders. ASD is comorbid with intellectual developmental disorder and language disorder, specific learning difficulties, anxiety disorders, depression, ADHD, and avoidant/restrictive food intake disorder.

8.3. Etiology

Section Learning Objectives

• Describe biological bases/causes of ASD.

It is largely considered that there is a strong interaction effect of environment and biology/genetics that lead to the development of autism. These causes will be discussed below.

8.3.1. Biological Basis

     8.3.1.1. Brain structure/neurological risk. Studies have most consistently shown that children with ASD have atypical brain size/overgrowth of brain structures. Also, differences specifically related to amygdala functioning have been noted in children with ASD. Additionally, underactivity in the temporal lobe when engaging in a face perception test has been noted (Volkmar & Wiesner, 2017).

     8.3.1.2. Family/genetic risk. Twin studies are often used to help understand genetic vulnerability of disorders. It is thought that there is a very strong genetic component to autism, but the roots of that are unknown. For example, research has indicated a 56% to 95% heritability of autism in twin studies; moreover, monozygotic twins (i.e., identical twins; developed from one embryo) displayed higher correlates than dizygotic twins (i.e., fraternal twins; developed from two different embryos; Colvert, Tick, McEwen, et al., 2015). Essentially, monozygotic twins which share more DNA makeup, evidenced stronger heritability estimates indicating likely genetic predispositions. However, as much as researchers have tried, they have not pinpointed a specific genetic marker that accounts for autism or predispositions of autism.

Spontaneous gene mutations may also be related to autism. According to the DSM-5-TR (APA, 2022) as many as 15% of cases of ASD appear to be associated with a known genetic mutation. Children that have a sibling with ASD have higher risk for later being diagnosed with ASD (CDC, 2018, May).

In terms of parental factors, older parental age and complicated childbirth are associated with a higher risk for developing ASD. However, no singular parental factor could predict autism in a study by Gardener, Spielgeman, & Buka (2009). The DSM-5-TR (APA, 2022) also suggests that extreme prematurity and in utero exposure to certain drugs or teratogens such as valproic acid can be causes of ASD.

     8.3.1.3. Vaccines. For a long time, there was a large misconception that vaccines, particularly the MMR vaccine, caused ASD. Since that time, we have learned that is not true. To understand this, we must first understand the background of the misconception. The idea that vaccines caused autism began around the late 90s/early 2000s when a team of researchers, headed by Andrew Wakefield, published a study that did not causally link, but indicated a relation, between MMR vaccines and autism. Statements about the study were grossly overgeneralized and summarized, and bias in the funding of the study was also revealed. Parts of the paper were criticized as being incorrect and, overall, the study presented an ethical concern (e.g., cherry-picking data, misleading statements about the data). The study was later retracted, and Andrew Wakefield lost his license (Rao & Andrade, 2011). However, by the time this was discovered, the media and society had grown to believe that vaccines caused autism. Researchers have continued to study this extensively and continue to find that there is no relation between autism and vaccines (Dudley, et. Al, 2018; Uno, Uchiyama, Aleksic, & Ozaki, 2015; Taylor, Swerdfeger, & Eslick, 2014) to no avail. The general public still believes that vaccines cause autism (Sheikh, Swetlik, & Wilson, 2018). Although this list listed under etiology, vaccines do not cause autism, according to research, and as such are not considered an etiological pathway to autism.

8.4. Assessment

Section Learning Objectives

• Describe assessment tools commonly used to assess ASD.

When assessing for ASD, psychologists often rely heavily on observations. They also rely on parent-report, particularly for early development. Because children are often diagnosed very young, teacher-reports may not be relevant if they are not yet enrolled in preschool. Often, self-report is not used. However, if the child is older, and is higher functioning or will have a delayed diagnosis, self-report will certainly be obtained. To obtain parent and teacher reports (and when appropriate, self-report) of symptoms, a psychologist often utilizes two methods: an interview and objective measures. For behavioral observations, a psychologist will observe the child, in person, either in their office and/or at school. The observation is a bit more formal than observations of other disorders. A good assessment will include information from all three areas (i.e., observation, interview, and objective measures) to make an informed diagnostic decision.

Unfortunately, there is a serious issue in screening and diagnosing children with ASD. We have improved our ability to accurately diagnosis, but we are still far from meeting appropriate screening efforts. For example, only 17.2% of children in the state of Mississippi are regularly screened for developmental milestone achievement in a standardized way. In Oregon, the state with the best screening rate, is still only 58.8% (Hirai, Kogan, Kandasamy, Reuland, & Bethell, 2018). Because early detection of ASD is imperative given its implications for treatment prognosis, these numbers are startling.

8.4.1. Observations

One of the gold standard assessment tools to diagnose ASD is the ADOS-2 (Lord, Rutter, et al., 2012). This stands for the Autism Diagnostic Observation Schedule, Second Edition. The ADOS-2 is administered by a clinician directly with the child (or adult). It can be administered to children as young as 12 months and through adulthood. It consists of 5 modules (Toddler, Module 1, 2, 3, and 4). The age and verbal abilities of the child determines which module is to be used. The Toddler Module and Module 1 allow for a caregiver to also be in the room. Module 2 allows for a caregiver to be present, if needed. Modules 3 and 4 are ideally conducted without a caregiver in the room. The ADOS-2 is comprised of a series of activities that the examiner completes with the child or adult. The activities are designed to elicit certain interactions and behaviors and allows the clinician to assess those abilities. For example, we may want to see if the child points, or do they notice certain interactions in the room, etc. At the end of the administration, the clinician scores the interactions by utilizing a detailed scoring protocol which results in one final score. This score will classify how likely a child is to meet diagnostic criteria.

8.4.2. Interview

In general, a comprehensive clinical interview will be conducted with parents. An attempt to understand the child’s current abilities, history of development and milestone progression, and current symptoms will be obtained. Although this is often done in an unstructured interview, the Autism Diagnostic Interview, Revised ADI-R (Rutter, LeCouteur, & Lord, 2003) was designed to thoroughly assess for developmental traits and related symptoms of autism. It is a structured interview that allows the clinician to thoroughly screen all relevant areas and results in a final score to use to indicate the likelihood of autism. While this is often considered to be the second tool (with the ADOS-2 being the primary tool) to a gold-standard assessment of autism, it is often not utilized due to the extensive time it takes. To complete just the ADI-R alone, it can take approximately 90 to 150 minutes. Keep in mind, this would be on top of completing an ADOS-2 and any other objective measures and interviews a clinician requires. Because of limited resources and the extensive time the ADI-R takes, though an excellent tool, it is not as frequently utilized as the ADOS-2.

8.4.3. Objective Measures

Other standardized measures are often utilized to include the following:

• Autism Spectrum Rating Scales (Goldstein & Naglieri, 2010; ASRS).This tool includes several items that address various symptoms and behaviors related to autism such as repetitive behaviors, sensory concerns, communication skills, etc. It can be used for children as young as 2 and up to age 18 years old.
• The Social Responsiveness Scale (Constantino & Gruber, 2012; SRS) is similar to the ASRS but focuses more on the social aspects and social impacts of symptoms and behaviors.
• The Sensory Profile (Dunn, 2014; SR-2) may be included to understand in more detail various sensory experiences a child has.
• The Gilliam Autism Rating Scale: 3rd Edition (Gilliam, 2014; GARS) is commonly used to screen but should not be used exclusively to diagnose a child. This is a very helpful tool to understand how likely autism is in a child.
• The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (Robins, Fein, & Barton, 2009; M-CHAT R/F) are excellent screening tools as well. They are most helpful when used in a primary care office and are quick to administer and easy to score. This helps physicians recognize if a child should be referred to a psychologist for a more in-depth evaluation.

8.4.4. Medical Screening

Because language delay is one of the key features in children with very early signs of ASD, careful medical screening is also important. Although occasional ear infections (medically referred to as otitis media) is not particularly concerning, frequent or undetected ear infections that involve fluid buildup in their ears (medically referred to as effusion), may lead to some hearing impairments (O’Conner, Coggins, Gagnon, Rosenfeld, Shin, & Walsh, 2016). If a child is not able to fully hear properly due to muffling difficulties the fluid causes, the child may be at higher risk of experiencing a language delay or oddities in their speech development (Roberts, Hunter, & Gravel, et al., 2004; O’Conner, et al., 2016). Thus, hearing loss leading to language delays would be due to a medical explanation rather than a developmental delay related to autism. As such, it is important when assessing a child to ensure that their hearing has been screened. Hearing screenings can be done in extremely young children by specialized providers, often a pediatric ear, nose, and throat (pediatric ENT) specialist. Other related medical screenings may include assessment of neurological deficits that impaired gross or fine motor movement.

8.5 Treatment

Section Learning Objectives

• Describe treatment options for autism.

8.5.1 Behavioral Interventions and Educational Supports

     8.5.1.1. Early intervention. In recent years, the term early intervention has been used more loosely, but typically speaking, this intervention includes significant behavioral intervention (i.e., applied behavioral intervention), often conducted in the home, but may also include ancillary interventions such as parent training, speech, physical and occupational therapy, etc. Therapy often starts in the home but, as the child progresses, interventions transition to other settings, such as school, in the community, or in outpatient clinics. Interventions are intensive and include several hours a week (e.g., for some children 30-40 hours a week). Services typically start around age 3 or 4 and last for about 2 years (Reichow, 2012).

Early intensive behavioral intervention (EIBI) is one of the most effective, evidenced-based treatment options for children with ASD. Although there are some variations in this finding, an overwhelming amount of research indicates significant benefits from EIBI that is not matched by other interventions (Reichow, 2012; Eldevik, Hastings, Hughes, et al.; Makrygianni & Reed, 2010). Early intervention is considered to be potentially most beneficial because the younger our brains are, the more plasticity they have. Plasticity is the ability for our brain to modify its neural connections. As such, we are able to grow and change our brain connections and structures more easily when we are younger than when we are older. Therefore, the therapies and interventions applied in early development may most impactful.

     8.5.1.2. Applied behavioral analysis. The most critical component of any treatment for autism is often considered to be Applied Behavioral Analysis (ABA). You most often hear people reference this therapy by its acronym, ABA. ABA is a large component of EIBI. ABA can take place in a child’s home, which is common when early intervention is applied, as well as school and in outpatient clinics. Many children receive a large number of their ABA services in the outpatient clinic as well, because receiving early intervention services with in-home ABA is difficult to obtain in most states. For example, the first author of this text is a psychologist in south Mississippi and can attest to the fact that very few children get enough ABA services in early intervention programs in that area. As such, most families supplement or forgo any state-funded services and seek outpatient services for their children. With private services, children receive many more ABA hours, but unfortunately, a majority of it has to happen in the outpatient clinic setting. That is, unless families decide to self-pay when insurance will not cover in-home or in-school services (Note: In-school services are often offered by a school, but at a much lower number of hours than what a family may desire/require), these services happen in a clinic or office setting. Theoretically, ABA is applicable beyond treatment for autism; however, insurance companies will only pay for ABA (if they cover ABA at all) if the child is diagnosed with ASD. So, although ABA is not exclusive to autism, as far as receiving treatment covered through insurance, it is exclusive to autism.

So, what is ABA exactly? ABA is essentially the practice of changing behavior by understanding the function or absence of a behavior and manipulating components of the individual’s environment or motivation to change that behavior. A therapist will assess what happens before the behavior (antecedent), what the behavior actually is (behavior), and what happens after the behavior (consequence). These pieces of information help a therapist understand why a behavior occurs and what potentially maintains it. For example, many behaviors are maintained because a child wants to obtain attention, obtain a tangible good, or escape an undesired task. For example, if a child throws a tantrum every time his mother leaves a room, it may be that he is throwing a tantrum because he has been denied her attention or because he knows he will be expected to do work when she leaves and wants to escape an undesired task. The behavioral therapist’s job is to assess the function of the behavior, and then manipulate that. The therapist will likely build in rewards to help motivate a behavioral change. For example, if the function is to escape an undesired task, they could work for 10 minutes and earn a 3-minute iPad break. Or, if the function is to gain the mother’s attention, they could work for 10 minutes and then play with mom for 3 minutes. This is a basic example to illustrate ABA. A component that sets ABA apart is that nearly everything is tracked in ABA, where each behavior is monitored and noted. This results in incredible graphs and data that is used to inform treatment and planning for future goals and sessions.

Task Analysis in very generic terms is when we take a task and break it down to the smallest task possible. For example, when we discuss putting on a shirt, we might generally say you pick the shirt up and put the shirt on, but a task analysis would go into more detail. You might say Step 1 is to pick up the shirt by the bottom, Step 2 is to put your left arm in the left arm hole, Step 3 is to push your arm all the way through until you see your hand, and so on. After a therapist has identified the analysis of a task, they will use chaining. Chaining can occur from the start of a task and move through the task (forward chaining) or at the end and work backward (backward chaining). Essentially, each step of the task is achieved, and then the next step, forward or backward, is achieved until the entire task (e.g., putting on a shirt on) is accomplished independently.

Discrete trail training is also common in ABA and may also be used to help achieve chaining and task success with behaviors that are currently absent. For example, language use may be a primary goal for some children, initially. Essentially, a therapist presents a behavior (e.g., models/requests), waits for a child to display the desired behavior, then responds (typically with a reward for a successful behavioral trial), and then waits for a moment before moving on to the next trial. These happen relatively quickly, and again, each behavior is recorded (Anderson et al., 1996).

The only people qualified to fully implement ABA are BCBAs (or BCBA) or RBTs. A BCBA is a Board-Certified Behavioral Analyst that typically has at least a master’s degree or higher. A BCBA is a Board Certified Assistant Behavioral Analyst that has at least a 4-year degree. An RBT is a Registered Behavior Technician that has at least a high school diploma. Typically speaking, RBTs implement a bulk of therapy and are supervised by BCBAs. BCBAs, typically handle initial appointments with clients, create treatment plans, analyze data of clients, and supervise RBTs and the interventions they are implementing with children. Each state regulates their own process and requirements to achieve formal licensure with these titles.

Other strategies that can be helpful in ABA and for parents are the use of timers, warnings, social stories, and visual schedules. Warnings and timers help children that struggle with transitions to prepare for an upcoming transition. Social stories are pictorial representations of a series of events that will occur in a situation. For example, going to a dentist office may be a perfect opportunity to use a social story with a child. The story should include all the steps involved (from getting in the car to checking out at the desk at the end of the visit). A visual schedule is a pictorial schedule that provides expectation about upcoming transitions.

     8.5.1.3. Developmental preschools. Children with autism can access a developmental preschool. This access typically allows them to enter school prior to kindergarten and receive a variety of services. The services are not typically academic oriented, rather, they are focused on various therapies, support, and social-emotional development. Children might receive some academic instruction, occupational or physical therapy, speech/language therapy, hearing/vision services, or other necessary interventions. These services are offered through the public-school system, and children with an IEP, per the Individuals with Disabilities Education Act (IDEA), are able to access these settings.

     8.5.1.4. Speech therapy. Children with speech delays benefit from enrolling in speech therapy with a speech/language pathologist (SLP). Typically, children will attend 30-minute sessions one to two times per week. While our conversation about speech therapy will be brief, it is important to note that many children that do not develop language, or those who still struggle to develop functional language, will end up using either the PECS system or an augmented communication device, which is a fancy way of saying a tablet with particular programming that helps facilitate communication. While there are differences in the two, it is important to understand that these are alternative ways for someone to communicate. The biggest difference, in very basic terms, is that the PECS system is ‘hard copy’ in which a child takes a picture and moves it on a surface, whereas an augmented communication device implements a similar concept, except the child presses the picture on a screen. Though this is a brief explanation, the important thing to know is that when children do not develop language, they may be fitted with an alternative way to communicate that heavily relies on pictures.

     8.5.1.5. Occupational/physical therapy. Gross and fine motor delays are common in children with autism. As such, many children will work with an occupational therapist (OT) or physical therapist (PT) to improve motor skills. The individual they work with likely will depend on their deficits. For example, an OT will tend to focus more on fine motor skills (e.g., holding an eating utensil, pinching finger food) whereas a PT will focus more on gross motor skills (e.g., walking, throwing a ball). At times, children with significant sensory symptoms benefit from working with an OT to reduce sensory concerns as well.

     8.5.1.6. Social skills training. Some children benefit from social skills training in addition to their other therapies. Typically speaking, these therapies occur in group settings with children elementary school age and older. Social skills groups focus on teaching very basic social skills and then having the group members practice. At times, groups will have volunteer peers that are typically developing participate in the group. This is to allow the children that are working on social skills to practice the skills they are learning with typically developed peers.

     8.5.1.7. Psychotherapy. Older children may begin to develop insight that they are perceived differently than their peers. They may desire friendships but find it difficult to develop them due to social skill deficits, and feel frustrated by their behaviors and symptoms. As a result, internal distress may develop due to their experiences related to autism. As such, psychotherapy to address associated anxiety, depression, or general distress may be helpful. Further, research indicates empirical benefits for cognitive-behavioral therapy (in the individual or group setting; Sizoo & Kuiper, 2017 and McGillivray & Evert, 2014, respectively; CBT will be discussed further in future chapters) and well as mindfulness (process of focusing on the moment and fully appreciating it; Sizoo & Kuiper, 2017).

     8.5.1.8. Family support. Parent support groups are often beneficial for families. Additionally, parent training is often a large component of treatment to help parents employ similar concepts that are being used in ABA. Moreover, siblings of children with ABA may need some explanation about some of their siblings’ behaviors. For example, a child may ask, “Why doesn’t my sister want to talk to me?” This can be confusing to siblings, particularly young ones. Children’s books to help facilitate this can be helpful for parents. Moreover, Sesame Street also came out with an episode, “Meet Julia” that does a nice job of helping children understand autism.

     8.5.1.9. Psychopharmacological. Psychotropic medications do not “treat” autism, but some medications may help with associated features or common comorbid disorders. For example, children with autism may be likely to experience high anxiety. In this case, anti-anxiety medications may be beneficial. Moreover, stimulants to help reduce hyperactivity, either due to ASD or comorbid ADHD may also be helpful.  Additionally, antidepressants may be helpful in decreasing repetitive behaviors and may also help taper irritability and tantrums. Anti-psychotic medications may decrease irritability, hyperactivity, stereotyped behavior, and aggression (NICHD, 2017, January).

Module Recap

In this module, we learned about autism spectrum disorder. We discussed the various behaviors and symptoms of ASD and how they relate to the various presentations. Then we discussed the prevalence of ASD and frequently comorbid disorders. We also learned about the etiology of ASD. We ended on a discussion of how ASD is assessed and treated.

In our next module, we will discuss motor disorders such as Tourette’s and Stereotypic Movement Disorder.

3rd edition