Autism

MA in Special Education Needs
Liverpool John Moores University
Understanding Autism
Vasileios Evangelidis
23rd of January 2012

“Early infantile autism”
 Kanner (1943) described autism as extreme aloneness,
insistence on sameness, obsessiveness, followed by
stereotypies and echolalia, altogether with islets of skills.
 He named this unusual pattern of behaviour “early infantile
autism”.
 Crucial for the diagnosis were the profound lack of
emotional contact, the insistence on bizarre and elaborate
repetitive routines, muteness or marked abnormalities of
speech, fascination in manipulating objects, etc. (Wing, 2002).

“Autistic psychopathy”
 Asperger (1944) contrasted autism from schizophrenia by
emphasizing the stable and enduring nature of the social
impairments and by voicing the optimistic view that unlike
schizophrenia, his patients were able to develop relations.
 They exhibited naive, inappropriate social approaches,
intense circumscribed interest in particular subjects as
railway timetables; monotonous speech, specific learning
difficulties in one or two subjects, and a marked lack of
common sense (Wing, 2002; Klin, McPartland, Volkmar, 2005).

3 areas of deficit in Autism
1. Social Impairment: Lack of response to other person’s
voice, absence of pointing, failure to understand gesture.
Failure to greet, lack of initiative in directing visual attention.
2. Language Impairment: Children with autism exhibit
delayed and/or impaired language development and persistent
abnormalities of pragmatic language, e.g. in conversation,
understanding jokes, figurative expressions, and inferencing.
3. Restricted, repetitive behaviour and Obsessions:
Stereotypic hand and finger movements and unusual sensory
behaviour.

The “triad” of impairments
Wing (2002) has given an alternative categorization of the
core autistic features:
 Social interaction: The four main types of autistics are
categorized as the aloof group, the passive group, the
active but odd group, and the over-formal, stilted group.
 Communication: Muteness, delayed speech, echolalia,
delayed echolalia, poor understanding, odd intonation, etc.
 Imagination: Lack of pretend play. The impairment of
creative, flexible imagination leads to repetitive stereotyped
activities (finger flicking, head rolling, flapping arms, etc.).

Assessment
 A health visitor or a doctor can decide whether a detailed
assessment would be helpful. Special assessment can be
made by a paediatrician, a child clinical psychologist, a child
psychiatrist, a speech therapist for a language and
communication assessment, and a child development team.
 Symptoms of social disability become more apparent
around 12 months of age. Behaviors at this age include
responsivity to name, atypical object exploration and
repetitive behaviors, and language and nonverbal
communication (Steiner et al. 2011).

Types of Assessment
 Play based direct assessment; Parent interview; Parent
rating form; Parent, teacher and caregiver rating forms.
 Structured activities, observation, and parent/caregiver
interview. Parent questionnaire; Parent report inventory of
words and gestures (Steiner et al. 2011).
 Phonetic Test in Greek Language; CELF; Action Picture
Test; TROG; Word Finding Vocabulary Test; Bus Story Test;
Test of Pragmatic Language; Symbolic Play Test (Vogindroukas,
Sherratt, 2005). PEP; CARS (Chitoglou-Antoniadou, Kekes, Chitoglou-
Chatzi, 2000).

Early signs of ASD
 In the first 6 months, babies with ASD rarely look at their
parents faces or eyes, or do little babbling or imitating of
their parents movements or sounds.
 At 6 to 12 months, some babies with ASD do not crawl or
move about, don’t stand with support, or can’t say little
words or can’t use simple gestures (e.g. “bye bye”).
 At 18 months, some children with ASD fail to use two
words together with meaning.
 Sometimes they tend to gain and then appear to lose
language skills.

Symptoms by the age of 3 years
 In more severe cases of autism the child may be very much
in a world of his own most of the time, and may seem to
treat people as if they were objects.
 Causes for concern at 3 to 5 years (apart from poor eye
contact and little interest with other people or pretend play),
may be lonely playing, ignoring or laughing at relations,
being puzzled by the imaginative play of other children.
 Not interested in joining in group games, wandering around.
 Very little language, or repetitive or verbose language;
Repeating phrases from films, TV, etc.; Echolalia.

Symptoms by the age of 6 years
 Poor eye contact. Unlikely to use readily gestures such as
pointing, beckoning, waving or making a “shhh” gesture with
their finger to mean “be quiet”.
 Without close friends of the same age.
 Not pursuing or enjoying pretend play with other children.
 Fascinated by a topic which takes up large amounts of time
and may seem slightly unusual, e.g. counting the different
colours of the cars on the road.
 Flapping his hands or making odd movements when upset
or excited (Williams, Wright, 2004).

Symptoms in adolescence
 In most cases, problems on the autism spectrum are
detected before adolescence. ASD does not suddenly
develop at this age.
 Causes for concern at 12 to 17 years are flat or unusual
facial expressions; difficulty making and keeping friends.
 Poor eye contact, poor understanding, misjudging.
 Exhibiting socially inappropriate behaviour.
 They also have notable deficits in prosody, associated more
with pragmatic and affective processes than with deficits in
the grammatical functions of prosody.

The social aspect of autism
 Social inefficiency, reduced ability for learning,
handicapped behaviour.
 Insufficient understanding of basic social signals, e.g.
facial expressions, gestures, body positions.
 Inability for empathy. Difficulty to treat other children in
accordance with a “theory of mind”, i.e. not understanding
that all persons have different ideas, thoughts and desires.
 Many children have difficulty to pass from imitation to
action, without guidance.

The emotional aspect of autism
 The children with autism have difficulties with the meaning of
friendship. They look indifferent, frigid, aloof, remote.
 They also have difficulties in understanding notions related to
emotions. They perceive emotions misrepresented.
 ASD children differ in Affect Regulation, i.e. to the extrinsic
and intrinsic processes for monitoring, evaluating, and
modifying emotional reactions, to accomplish one’s goals.
 They are more likely to show greater impulsivity, fear,
discomfort and shyness. By contrast, they are lower in
soothability, inhibitory control, attention focusing and shifting.

The communicative aspect of autism
 The 50% or more of the children with autism do not use at
all speech. For this reason they have a basic problem in
communication, especially with understanding.
 Even children with high-functioning autism have problems in
communication because of deficiency in executive function.
 They seem to lack a sense of “self-consciousness”, of the
“self-involvement”, the acting with, and the identification
with the acting person.
 They also lack of varied, spontaneous make-believe play or
social imitative play.

Problems managing behaviour
 Aggressiveness, self-injury, damage to property, stereotyped
eruptions of anger. Severe temper tantrums (Wing, 2002).
 Inappropriate and difficult behaviour may be caused by
confusion and fear of unfamiliar situations.
 Interference with repetitive routines; failure to understand
social rules, etc. In the family home the children with autism
may be restless, destructive, noisy, aggressive if frustrated,
and given to running away.
 Some autistic persons have also epilepsy since childhood
(Danielsson et al. 2005).

The linguistic aspect of autism
 A characteristic element in the speech of many children
with autism is the echolalia, the immediate, involuntary and
stereotyped repetition of words just spoken by others.
 Children with autism produce echolalia either directly (thus
they hear something and immediately repeat it) or after a
delay (e.g. after 3-4 days they may repeat a phrase they
have heard in an advertisement).
 Some children with autistic spectrum disorders produce
echolalia by repeating songs or big texts, but they cannot
answer a single question.

Islets of savant skills
 As Scheuffgen et al. (2000) argue, autism frequently
presents savant skills, such as music, drawing,
mnemonism, calendar calculation, jigsaw construction,
memory for routes, etc.
 Kanner (1943) emphasized that the speaking children with
autism may have astounding vocabulary, excellent memory,
and recollection abilities.
 Playing musical instruments; performing lengthy numerical
calculations; reading fluently though poor comprehension;
memorizing; assembling constructional toys.

 Scientists have observed a concordance for autism of about
60% to 90% in monozygotic twins.
 They have also observed a concordance for autism of about
5% to 10% in dizygotic twins (Syriopoulou-Delli, 2011).
 Heredity or genetic factors are responsible for the 90% of
autism cases.
 Similar results, from family research, show that the
percentage of autistic siblings is about 2% to 7%, much
higher than the percentage in general population (0,5%).
Heredity

Theory of Mind
 Individuals with autism lack the capacity to have a theory of
other people’s mental states, such as beliefs, desires and
intentions.
 Their ability to take the perspective of another person - to
adequately evaluate other people’s interests, beliefs,
intentions and feelings - is typically impaired in real life
contexts.
 This fundamental deficit may explain the triad of symptoms
defining autism, namely, impairment of social and
communicative functioning and imaginative activities.

Mentalizing and predicting
 First order theory of mind refers to situations in which a
subject must attribute a mental state, such as a belief, to
another person.
 Second order theory of mind requires recursive thinking
about mental states, in which a subject must predict one
person’s thought about another person’s thoughts.
 First order tasks begin to be mastered by age 4, whereas
the ability to make second-order attributions develops at
around the age of 7 (Klin, McPartland, Volkmar, 2005).

Mindblindness
 Baron-Cohen (1997b) argued that mindblindness is caused
by impairments in shared attention and in theory of mind.
 Although autistics are able to detect intentions (e.g. “want”)
and eye-direction, they lack joint-attention behavior.
 The impairment in shared attention can be early observed by
the absence of the protodeclarative pointing gesture.
 Theory of mind is triggered by shared attention, and is
responsible for the understanding of the mental states of
knowing, believing, pretending, distinguishing appearance
from reality, etc.

Joint Attention and Smile
 The autistic children diverge much more markedly in their
decreased level of positive feeling during situations of joint
attention, where the typically developing children smile.
 There are autism-specific abnormalities in face-to-face
affective coordination, e.g. combining smiles with eye
contact, smiling in response to mother’s smile, etc.
 Smile, pointing gesture, gaze-monitoring, and showing
gestures are absent in most children with autism.
 Impaired facial mimicry of emotions in autism.

Repetitive behaviour
 The theory of mind account has been virtually silent on why
children with autism should show “repetitive behaviour”, a
strong desire for routines, and a “need for sameness”. To
date, the only cognitive account to attempt to explain this
aspects of the syndrome is the executive dysfunction theory,
assuming that it is a form of ‘frontal lobe’ perseveration or
inability to shift attention (Baron-Cohen, 1997a).
 Children with autism tend to avoid certain sorrowful events by
characteristic behaviours such as self-stimulation, echolalia
and insistence on sameness (Syriopoulou-Delli, 2011).

Executive function
 Executive function is responsible for higher level action
control, for maintaining a mentally specified goal and for
implementing that goal in the face of distracting alternatives.
 It includes inhibition, set shifting, planning, coordination and
control of action sequences (Fisher, Happé, 2005).
 Executive dysfunction occurs in both individuals with autism
and their family members, across many ages and
functioning levels. Inhibitory control and possibly working
memory are relatively spared functions in autism, while
mental flexibility is impaired (Ozonoff, South, Provencal, 2005).

Flexibility and attention
 Operations that require flexibility, such as the shifting of
attention, are impaired in individuals with autism, while
inhibitory functions appear relatively intact.
 Flexibility on attention shifting tasks is correlated with social
understanding tasks and adaptive behaviour.
 Joint attention and flexibility in autism are much more
impaired with social than nonsocial stimuli.
 Against a general executive dysfunction in autistic
individuals, is the fact that many of them have strengths in
physics, mathematics and biology (Baron-Cohen,1997a).

Possible associations between theory of mind
and executive functions theory
 Both theories often seem equally useful, e.g. comparing
performance on joint attention and false beliefs tasks.
 “Several explanations for this association have been
proposed: (1) the deficits are independent modular
cognitive operations that are parallel central impairments of
autism, (2) one ability is a prerequisite for the other, so that
deficits in one cause deficits in the other, (3) both are driven
by a third shared impairment, or (4) both share similar
neural underpinnings” (Ozonoff, South, Provencal, 2005, p. 613).

Central Coherence
 Children with autism may show good discrimination and
categorization abilities, and yet poor generalization of learning.
 They tend to be more accurate and faster in tests that
require ignoring the global configuration and focusing on parts.
 This theory attempts to explain not only impairments but
also the islets of abilities, repeatedly found in autism.
 The advantage of Central Coherence theory is that the
cognitive profile of autism is unique: Difficulty integrating
information in context, paired with superior local
processing of sensory information (López, 2008).

Alternative theories
 The assumption that superior processing for parts is the result
of impairment in the ability to integrate information (e.g. global
processing) is questioned by López (2008).
 Happé and Frith (2006) emphasized the idea of superiority
in local processing rather than deficit in global processing.
 People with autism may have enhanced discrimination of
unique features and reduced generalization of common
features (Plaisted, 2001).
 Enhanced perceptual functioning theory states that autistic
perceptual processing overrides higher-control processes
(Mottron et al. 2006).

Gestalt processing
 Children with autism use fewer Gestalt principles, thus, they
have difficulty to process the interconnections between the
different parts in order to build the whole.
 They appear to fail in utilising gestalt grouping principles
(proximity, similarity, closure) and in identifying certain
impossible figures (Brosnan et al. 2003).
 Perceptual integration difficulty in autism; in tasks where the
replacement of any element alters the perception of the
whole and where it is necessary to process simultaneously
the interconnections between all the elements.

Comparison between theories
 Theory of mind, attention shifting and handling symbols
seem as the main domains impaired in autism.
 There are other autistic symptoms (such as repetitive
behaviour, and unusual perception) that are not easily
explained by the theory of mind deficit.
 The executive hypothesis of autism is important, since it
explains the perseverative, repetitive behaviours.
 The central coherence account of autism explains the non-
holistic, fragmentary perceptual style characteristic of autism;
and the unusual cognitive profile (including the islets of ability).

Imitation, Play and Mirror Neurons
 The linkage between imitation and symbolic play is
developed by the mental representations of events that
children experience and reproduce at a later time.
 The autistic impairment in joint attention impedes the
representative ability in symbolic play and imitation.
 Difficulties in planning and executing an imitative movement
may occur because of poor body awareness (kinesthesia).
 Mirror neurons, in the superior temporal sulcus, are
responsible for understanding imitation and intentionality.

Pretend play
 Both functional and sensorimotor play are accompanied with
the sharing behaviour of joint attention, which may be viewed
as a form of early dialogue.
 Symbolic play consists of 3 important attitudes: object
substitution, pretense, and dramatization (Gena et al. 2007).
 Autistic children have difficulty with the decoupling
mechanism, i.e. the ability to dissociate between the “true”
meaning and the pretense in the context of play.
 They fail in careful observation, imitation and interpretation of
the ways in which others use and react with objects.

 “Having autism as the paradigmatic and anchoring disorder
in this diagnostic category” the Autistic Spectrum Disorders
“more generally are characterized by marked and enduring
impairments within the domains of social interaction,
communication, play and imagination, and a restricted
range of behaviors or interests” (Klin et al. 2005, p. 88).
Autistic Spectrum Disorders
 The Autistic Spectrum Disorders are often categorized in a
continuum from profound aloofness and mental retarding,
to distinctive social or empathic blindness.

Asperger Syndrome
 Asperger Syndrome is a severe and chronic developmental
disorder closely related to autistic disorder and pervasive
developmental disorder-not otherwise specified (PDD-NOS)
and together these disorders comprise a continuum referred to
as autistic spectrum disorders.
 Asperger Syndrome is distinguished from autism primarily on
the basis of a relative preservation of linguistic and positive
capacities in the first 3 years of life.
 Asperger Syndrome is autism without mental retardation,
thus AS relates to higher functioning autism.

Difficulties present in the first 2 years of life in
Asperger Syndrome
 Lack of normal interest and pleasure in other people.
 Babbling that is limited in quality and quantity.
 Reduced sharing of interests and activities.
 Absence of an intense drive to communicate both verbally
and non-verbally with others.
 Speech that is abnormal in terms of delayed acquisition or
impoverished content consisting mainly of stereotyped
utterances.
 Failure to develop a full repertoire of imaginative pretend play
(Lorna Wing, 1981).

The clinical concept of Asperger Syndrome
 Individuals with higher verbal abilities or less disabled
individuals.
 Asperger Syndrome refers to “milder” forms of autism
marked by higher cognitive and linguistic abilities.
 More socially motivated but socially vulnerable adolescents
and adults with unusual and interfering circumscribed
interests.
 Impairment in nonverbal communication. Reduction in the
quantity and the diversity of facial expressions and limitations
in the use of gesture, etc.

Pervasive Developmental Disorder
Not Otherwise Specified
 A severe deficit in social learning and reciprocity, that is
associated with impairments in either verbal or non-verbal
communication.
 Social deficits similar to autism. Possible fundamental
disturbances in communication, social behaviour, emotion
regulation, cognition, and interests.
 Impairments in understanding affect regulation, affective
modulation and patterns of attachment (Towbin, 2005).

Rett Syndrome
 Rett syndrome represents one of the most common causes
of mental retardation, second only to Down Syndrome.
 It almost exclusively affects females.
 Stereotypic hand movements, typically at midline, are one
of the most prominent symptoms.
 Hand patting, waving, involuntary movements, such as
alternate opening and closing of the fingers, twisting of the
wrists and arms, nonspecific circulating hand-mouth
movements appear to be warning signals (Van Acker et al. 2005).
 Lack of sustained interest in persons, limited contact.

Dementia infantilis
 Childhood Disintegrative Disorder, Heller’s Syndrome,
or disintegrative psychosis.
 Theodore Heller (1908) termed this regression
dementia infantilis.
 A period of several years of normal development before
a marked deterioration. Catastrophic loss of skills in at
least two of the following areas: language; play; social
skills; bowel or bladder control; motor skills (Wing, 2002).
 Progressive deterioration either gradual or abrupt.
 Behavioural and affective symptoms.

 Absence of features of gross neurological dysfunction.
 Social skills are markedly impaired.
 Total muting or marked deterioration in verbal language.
 Sparsity of communicative acts, limited expressive
vocabulary and markedly impaired pragmatic skills.
 Stereotyped behaviours, problems with transitions and
change, nonspecific overactivity.
 Deterioration in self-help skills, notably toileting.
 The CDD cases are more likely to be mute, more likely to be
in residential placement, and so forth (Volkmar et al. 2005).
Childhood Disintegrative Disorder

Other related disorders
 Tuberose sclerosis, phenylketonuria, encephalitis, etc. can
be associated with autistic behaviour.
 Other related disorders are Fragile X syndrome, Landau-
Kleffner syndrome, Williams syndrome, Cornelia de Lange
syndrome, Tourette’s syndrome (Wing, 2002).
 Many other diagnoses are related to autism: Semantic-
Pragmatic Disorder, Non-Verbal Learning Disorder,
Pathological Demand Avoidance Syndrome (Vogindroukas,
Sherratt, 2005).

Intervention
 Milieu teaching is a naturalistic approach that promotes the
acquisition of skills (e.g. social interaction) in the contexts
where they are likely to be used (Gena et al. 2007).
 Peer-mediated teaching is another naturalistic approach.
Peers do not only serve as instructors, but may also serve as
models for appropriate behaviour.
 Direct instruction or discrete-trial teaching, a very
systematic, structured, and rigorous approach.
 Reciprocal imitation training, in vivo modeling and play
scripts, video modeling. Parent training.

Therapeutical applications
 Applied Behaviour Analysis; Behaviourist learning program.
 SPELL (Structure, Positive attitudes, Empathy, Low arousal,
Links) developed in UK (NAS).
 PECS (Picture Exchange Communication System).
 TEACCH (Treatment and Education of Autistic and related
Communication Handicapped Children).
 MAKATON (combination of gestures and language).
 Speech therapy (combinable with PECS); Daily Life Therapy
(Higashi); Music Therapy; Sensory Integration Therapy; Vision
Training; Berard Auditory Integration Training; Floor Time
approach.

Teaching tasks
 Keeping eye contact and sharing attention; Empathy;
Comprehending other persons’ emotions. Adjusting and
processing the distance from others.
 Waiting for their turn in group activities and play;
Understanding other persons’ intentions and learning the
relevant rules in any activity; Listing personal interests.
 Rehabilitating the interpersonal relationships; Recognizing
facial expressions. Understanding what other people think;
Sharing interesting information; Translating body language
(Vogindroukas, Sherratt, 2005).

Learning activities
 Activities oriented toward relationships and social
conventions, e.g. role playing; Multisensory communication
through objects, symbols, photos, etc.; Especially visual
methods.
 Support in play and creativity; Relating to others for
entertainment; Playing and embedding representations;
Unifying ideas; Encouraging narration and dialogue.
 Following orders; Guiding others; Inferring and evaluating;
Enigmas, puzzles, metaphors, anecdotes; Declarative
vocabulary (Vogindroukas, Sherratt, 2005).

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