ASD

Recording Procedures:
 Note the level of support needed for deficits in social communication and restricted, repetitive
behaviors.
 Specify "with accompanying intellectual impairment" or "without accompanying intellectual
impairment."
 Record language impairment specification and the current level of verbal functioning if present.
 For autism spectrum disorder:
 Specify if associated with a known genetic, medical condition, or environmental factor.
 Use "autism spectrum disorder associated with (name of condition, disorder, or factor)" if
applicable.
 If catatonia is present, record separately "catatonia associated with autism spectrum disorder."
Specifiers
1. Severity Specifiers
 Description of severity categories for social communication difficulties and restricted, repetitive
behaviors.
 Importance of not using severity categories for determining service eligibility.
2. Specifier: "With or Without Accompanying Intellectual Impairment"
 Importance of understanding the intellectual profile for interpreting diagnostic features.
 Separate estimates of verbal and nonverbal skills required.
3. Specifier: "With or Without Accompanying Language Impairment"
 Assessment of verbal functioning and specific descriptions for accompanying language
impairment.
 Consideration of separate receptive and expressive language skills.
4. Specifier: "Associated with a Known Genetic or Other Medical Condition or
Environmental Factor"
 Application of the specifier when relevant without implying causation.
 Examples of conditions or factors that may be associated with autism spectrum disorder.
5. Specifier: "Associated with a Neurodevelopmental, Mental, or Behavioral Problem"
 Indication of additional issues contributing to functional formulation or treatment focus.
 Noting other neurodevelopmental, mental, or behavioral disorders as separate diagnoses.
6. Catatonia as a Comorbid Condition
 Classic symptoms of catatonia and their potential manifestation in individuals with autism
spectrum disorder.
 Worsening of stereotypy and self-injurious behavior in the context of catatonia.

Diagnostic Features of Autism Spectrum Disorder:

 Characterized by persistent impairment in reciprocal social communication and social interaction
(Criterion A) and restricted, repetitive patterns of behavior, interests, or activities (Criterion B).
 Symptoms present from early childhood and limit or impair everyday functioning (Criteria C and
D).
 Core diagnostic features evident in the developmental period, but interventions, compensation,
and current supports may mask difficulties in some contexts.
 Manifestations vary based on severity, developmental level, chronological age, and possibly
gender.
 Encompasses disorders previously referred to as early infantile autism, childhood autism,
Kanner’s autism, high-functioning autism, atypical autism, pervasive developmental disorder not
otherwise specified, childhood disintegrative disorder, and Asperger’s disorder.
 Impairments in Social Communication (Criterion A):
 Pervasive and sustained deficits in social-emotional reciprocity.
 Verbal and nonverbal deficits in social communication with varying manifestations.
 Deficits in nonverbal communicative behaviors used for social interaction.
 Difficulties in developing, maintaining, and understanding relationships, judged against norms
for age, gender, and culture.
 Restricted, Repetitive Patterns of Behavior, Interests, or Activities (Criterion B):
 Range of manifestations according to age, ability, intervention, and current supports.
 Stereotyped or repetitive behaviors including motor stereotypies, repetitive use of objects, and
repetitive speech.
 Excessive adherence to routines and restricted patterns of behavior.
 Highly restricted, fixated interests often abnormal in intensity or focus.
 Some interests and routines may relate to apparent hyper- or hyporeactivity to sensory input.
 Extremes in reaction to or rituals involving sensory experiences, including food restrictions.
 Clinical Significance (Criteria C and D):
 Features must cause clinically significant impairment in social, occupational, or other important
areas of functioning.
 Social communication deficits exceed difficulties expected based on developmental level.
 Diagnostic Process:
 Relies on multiple sources of information, including clinician observations, caregiver history,
and self-report.
 Standardized behavioral diagnostic instruments with good psychometric properties are available
but diagnosis remains clinical, considering all available information.
Associated features
 Intellectual and Language Impairment:
 Many individuals with autism spectrum disorder also exhibit intellectual and/or language
impairments.
 Even those with average or high intelligence often have an uneven profile of abilities.
 Theory-of-mind deficits (difficulty understanding others' perspectives) are common but not
universal.
 Executive function deficits and difficulties with central coherence (overfocus on detail) are also
common.
 Motor Deficits and Self-Injury:
 Motor deficits, including odd gait and clumsiness, are often present.
 Self-injury behaviors such as head banging or wrist biting may occur.
 Disruptive/challenging behaviors are more common in children and adolescents with autism
spectrum disorder than in those with intellectual developmental disorder.
 Catatonia-like Motor Behaviors:
 Some individuals may exhibit catatonic-like motor behaviors such as slowing and freezing mid-
action.
 While not typically as severe as full catatonic episodes, individuals with autism spectrum
disorder can experience marked deterioration in motor symptoms.
Prevalence:
 Prevalence rates for autism spectrum disorder in the United States range between 1% and 2% of
the population.
 Prevalence appears to be lower among African American (1.1%) and Latinx children (0.8%)
compared to White children (1.3%), even after adjusting for socioeconomic factors.
 Globally, prevalence rates approach 1% of the population, with a median global prevalence of
0.62%.
 The male-to-female ratio in well-ascertained epidemiological samples is around 3:1, with
concerns about underrecognition of autism spectrum disorder in women and girls.
Development and Course:
 Onset and Pattern:
 Behavioral features of autism spectrum disorder typically emerge in early childhood.
 Symptoms are usually recognized between ages 12 and 24 months, with some cases showing
signs earlier or later.
 Prospective studies indicate declines in critical social and communication behaviors in the first 2
years of life, distinguishing autism spectrum disorder from other neurodevelopmental disorders.
 Rare cases involve developmental regression after at least 2 years of normal development.
 Early Symptoms:
 Delayed language development and lack of social interest are common initial symptoms.
 Odd and repetitive behaviors become more apparent during the second year of life.
 Distinguishing restricted and repetitive behaviors specific to autism spectrum disorder from
typical behaviors in preschoolers can be challenging.
 Course of Disorder:
 Symptoms are often most marked in early childhood and early school years.
 Developmental gains are typical in later childhood, with some improvement in social interaction.
 A small proportion of individuals may deteriorate behaviorally during adolescence, while most
improve.
 More individuals with superior language and intellectual abilities are finding employment
opportunities.
 Even individuals with lower levels of impairment may struggle with social naivety, organization,
and mental health issues.
 Late Diagnosis:
 Some individuals are diagnosed in adulthood, prompted by a family member's diagnosis or
breakdowns in relationships.
 Obtaining detailed developmental history may be challenging in adult diagnoses.
Risk and Prognostic Factors:
 Individual Factors:
 Presence or absence of associated intellectual developmental disorder and language impairment
are significant prognostic factors.
 Additional mental health problems, such as epilepsy, can impact prognosis.
 Environmental Factors:
 Risk factors for neurodevelopmental disorders, like advanced parental age and in utero
exposures, contribute to the risk of autism spectrum disorder.
 Genetic Factors:
 Heritability estimates for autism spectrum disorder range from 37% to over 90%.
 As many as 15% of cases are associated with a known genetic mutation, but not all individuals
with the mutation develop autism spectrum disorder.
 Risk for the majority of cases appears to be polygenic, with hundreds of genetic loci making
small contributions.

Association With Suicidal Thoughts or Behavior:

 Individuals with autism spectrum disorder face a heightened risk of suicide compared to those
without the disorder.
 Children with autism spectrum disorder, particularly those with impaired social communication,
are more prone to self-harm and suicidal thoughts.
 Adolescents and young adults with autism spectrum disorder have a higher likelihood of suicide
attempts compared to their peers, even after considering other factors.
Functional Consequences of Autism Spectrum Disorder:
 Limited social and communication skills in young children can hinder learning and daily
activities.
 Routines and sensory sensitivities often disrupt daily routines like eating and sleeping.
 Adaptive skills generally lag behind IQ levels.
 Difficulties in planning, organization, and adapting to change impact academic and adult
functioning.
 Many adults with autism spectrum disorder experience challenges in independent living and
employment.
Co-occurring Conditions and Mortality Risk:
 Co-existing intellectual developmental disorder, epilepsy, mental health issues, and chronic
medical conditions increase the risk of premature death.
 Injury, poisoning, and drowning are more prevalent causes of death among individuals with
autism spectrum disorder.
Differential Diagnosis of Autism Spectrum Disorder (ASD):
1. Attention-Deficit/Hyperactivity Disorder (ADHD):
 Differentiation: ADHD may present with attention difficulties and hyperactivity, but lacks the
characteristic restricted and repetitive behaviors seen in ASD.
2. Intellectual Developmental Disorder (IDD) without ASD:
 Differentiation: Individuals with IDD may display repetitive behaviors, but the impairment in
social communication and interaction is less pronounced compared to ASD.
3. Language Disorders and Social (Pragmatic) Communication Disorder:
 Differentiation: Language disorders may involve communication problems but typically lack
the presence of restricted and repetitive behaviors seen in ASD.
4. Selective Mutism:
 Differentiation: Selective mutism is characterized by a failure to speak in specific social
situations, without the presence of restricted and repetitive behaviors.
5. Stereotypic Movement Disorder:
 Differentiation: Stereotypic movement disorder involves repetitive movements but lacks the
impairment in social communication and interaction characteristic of ASD.
6. Rett Syndrome:
 Differentiation: Rett syndrome may present with features resembling ASD, especially during
the regressive phase, but typically improves in social communication skills over time, unlike
ASD.
7. Anxiety Disorders:
 Differentiation: Anxiety disorders may manifest with symptoms such as social withdrawal and
repetitive behaviors, but the core symptoms of ASD persist even in the absence of anxiety.
8. Obsessive-Compulsive Disorder (OCD):
 Differentiation: While OCD involves repetitive behaviors, these are usually driven by intrusive
thoughts and are perceived as efforts to relieve anxiety, unlike the characteristic pleasurable and
reinforcing nature of repetitive behaviors in ASD.
9. Schizophrenia:
 Differentiation: Schizophrenia may present with social deficits and unusual beliefs similar to
ASD, but hallucinations and delusions, defining features of schizophrenia, are absent in ASD.
10. Personality Disorders (Narcissistic, Schizotypal, Schizoid):
 Differentiation: While certain personality disorders may share some features with ASD, the
early developmental course and the presence of restricted and repetitive behaviors help
distinguish ASD from personality disorders.

Comorbid Medical Conditions Associated with Autism Spectrum Disorder (ASD):

1. Intellectual Developmental Disorder (IDD):
 Description: Intellectual developmental disorder often co-occurs with ASD, involving
challenges in intellectual functioning and adaptive behaviors.
2. Language Disorder:
 Description: Individuals with ASD may experience difficulties in language comprehension and
construction, leading to language disorder characterized by improper grammar usage.
3. Specific Learning Difficulties:
 Description: Difficulties in literacy (reading) and numeracy (mathematics) are common
comorbidities in individuals with ASD.
4. Developmental Coordination Disorder (DCD):
 Description: DCD is frequently associated with ASD, involving challenges in motor
coordination and control.
Comorbid Psychiatric Conditions Associated with ASD:
1. Anxiety Disorders:
 Description: Anxiety disorders are prevalent in individuals with ASD, contributing to
approximately 70% of cases of comorbid mental health disorders.
2. Depression:
 Description: Depression is common among individuals with ASD, often co-occurring with
anxiety disorders.
3. Attention-Deficit/Hyperactivity Disorder (ADHD):
 Description: ADHD frequently coexists with ASD, contributing to the complexity of symptoms
experienced by affected individuals.
4. Avoidant/Restrictive Food Intake Disorder (ARFID):
 Description: ARFID is a common comorbidity in ASD, characterized by extreme and narrow
food preferences that may persist over time.
Additional Considerations:
 Nonverbal or Language-Deficient Individuals: Observable signs such as changes in sleep,
eating habits, or an increase in challenging behavior should prompt evaluation for anxiety,
depression, or underlying medical and dental issues.
 Potential Pain or Discomfort: Individuals with ASD may experience undiagnosed medical or
dental problems, which can manifest as changes in behavior or routines. Regular monitoring and
evaluation are essential to address these concerns effectively.

VIRTUAL AUTISM
1. Virtual Autism Phenomenon:
 Some studies suggest a link between excessive screen exposure and autism-like symptoms,
coined as "virtual autism."
 Children, by age two, show signs resembling autism spectrum disorder (ASD) due to heavy
screen time.
 Virtual autism symptoms include difficulty in communication, narrow interests, repetitive tasks,
and social isolation.
 Children engrossed in screens may prefer the virtual environment over real-world interactions.
2. Screen Exposure and ASD Symptoms:
 Screen time, particularly TV and computer use, correlates with the emergence of ASD-like
behaviors.
 Removal of screens often leads to a reduction in symptoms.
 Studies show that prolonged screen time can exacerbate autistic-like behaviors and attention
issues.
3. Impact on Neurological Development:
 Screen exposure in children disrupts healthy neurological development due to inadequate
stimulation.
 Lack of real-world social interaction hinders language and cognitive development.
 Excessive screen time may lead to impulsive behaviors, language delays, and academic
challenges.
4. Rising Autism Diagnoses and Technology:
 The prevalence of autism diagnoses has increased significantly, possibly linked to the rise in
screen technology.
 Two French doctors warn of "virtual autism" dangers, emphasizing the impact of screens on
social development and language skills.
5. Consequences of Screen Time:
 Prolonged screen exposure increases the risk of obesity, depression, and sleep disturbances.
 Language delays, impaired fine motor skills, and difficulty with self-regulation are common
consequences.
 Early intervention is crucial in mitigating severe autistic-like behaviors.