Communication • Social and Emotional Understanding and Social Interaction • Flexibility of Thinking and Behaviour

NES - Autism Learning Resource - Topic1 - Section A - Page 2 l http://www.nes.scot.nhs.uk/asd/index.htm Topic One : The Patient with an ASD A: How an ASD might impact on the individual B: Sensory differences and how they can impact on behaviour C: Understanding the meaning of behaviour This Resource is designed for any professional who is working in the health care system at the primary care level (eg General Practitioner); Allied Health Professionals (eg dieticians, occupational therapists, physiotherapists, podiatrists and speech and language therapists); Dentists, Opticians, Public Health Nurses; District Nurses; Practice Nurses; and Dental nurses). A: How an ASD might impact on the individual A heterogeneous disorder (Page 2/19) The person with an Autism Spectrum Disorder (ASD) will have major impairments in three areas of development and will show a different developmental profile from the general population. Nevertheless, there are no ‘typical’ cases in this field. People with ASD are individuals. Differences rather than similarities prevail in spite of a common triad. Some impairments can be quite subtle. ’People with autism come in as many shapes and sizes as ‘people with pneumonia’. They have different races, social circumstances, intellectual levels, personalities and associated disorders. They should not be expected to conform to a highly specific prototype or to benefit from exactly the same kind of intervention, treatment or training. First and foremost they are people. It so happens that they are affected by the same (or similar) disorder but this does not make them blueprints of each other.’ - (Peeters, & Gillberg, 1999) pp14-15 The Triad of Impairments (Page 3/19) The framework of the Triad of Impairments (Wing 1996) gives common areas of development that are affected in people with ASD and has facilitated the development of clearer diagnostic criteria. This framework has also led to growing recognition of the different ways in which an ASD affects people at different levels of cognitive ability and at different ages and stages of development. It has helped establish the distinctive nature of ASD with respect to other conditions. The Triad of Impairments: Three major areas of developmental impairments need to be evident for a diagnosis of ASD to be made. The difficulties relate to : • Communication • Social and emotional understanding and social interaction • Flexibility of thinking and behaviour The Triad of Impairments (Page 4/19) Communication difficulties Language difficulties are often associated with ASD but structural language problems are only apparent in those with classical autism; other individuals with ASD may develop spoken language at the usual age. The core difficulty lies in using language to communicate with others or understanding how others do so. It is the process of communication itself that is affected in individuals with ASD. This can take the form of: • No understanding of what communication is used for No apparent interest in communication • Facial expressions and communicative gestures can be confusing for the individual to interpret • Intonation can be heard but the individual has difficulty with understanding what the communication pattern conveys • The individual has difficulty engaging in conversations and processing verbal information • Language is interpreted literally and the individual finds it difficult to go beyond the words to understand what the speaker meant • The Triad of Impairments (Page 5/19) Social Difficulties People with ASD will have difficulty in understanding social signals or the social significance of behaviour. They will have difficulty in learning these intuitively and they are hard to teach formally as social rules change with context. Difficulties with social interaction will depend on the age of the person, his/her developmental level and the severity of the disorder, but these difficulties continue into adulthood and throughout life although in some they become less obvious. This can take the form of: • Being socially withdrawn and isolated • Having difficulty relating to adults or peers • Dependency on familiar adults and siblings but difficulty initiating social contact with others • Difficulty making and sustaining friendships • Appearing very sociable and trying to dominate contact with others yet not being able to get that interaction right • Appearing socially awkward and naive The Triad of Impairments (Page 6/19) Flexibility in thinking and behaviour Autism Spectrum Disorders are characterised by ritualistic behaviours, reliance on routines and extreme delay in, or absence of, social pretend play. This can take the form of: • Difficulty joining in with others in typical pretend play situations in childhood • Difficulty generalising learning to new situations or problem- solving outside cued rote responses • Difficulty broadening interests to other than a few, narrow, often obsessional or compulsive ones that dominate thinking and behaviour • Difficulty in managing change to familiar routines (eg routes; layout; timetables) • Difficulty inhibiting behaviour without an alternative. The Infant Or Young Child With An ASD (Page 7/19) When an infant or young child presents for an appointment, a parent might report concern and worry in relation to a number of developmental issues. It is crucial to pay close attention to parents/carers’ concerns about language, social skills and unusual behaviours. Many studies document that parental concerns about developmental delays in their children are typically well founded. It is not helpful, and potentially harmful, to tell parents not to worry or to wait and see. In an infant, observe: • Mutuality of eye contact • Social smile • Joint attention • Attention to activities in the room • Interest in people versus interest in objects • Babbling • Interest in communication • Facial expressions and gesture • Variation of expressed emotion • Crying and irritability without apparent motivation • Reaction towards sound • Body contact • Rhythm and interaction • Raising position when put on stomach • Capacity for imitation • Time span for reactions • Responding capacities • Sitting stability • Body tone • Eye-hand co-ordination • Body rotation • Keeping the head in bodyline when lifted • Symmetric movements when crawling The Infant Or Young Child With An ASD (Page 8/19) Close observation of the toddler or young child during the appointment, may point towards early signs of ASD. There are some key aspects to be alert for. During the visit, look for: • Does the child respond when you point to a toy and call the child’s name? • How does the child indicate what s/he needs? • Does the child ask verbally? • Does the child point or vocalise? • Does the child point to call attention or use eye contact? • Does the child show or share things with others? • Does the child share in the activities of others? • Does the child show any interest in what you are doing? • Try to look beyond any difficult behaviour The Infant Or Young Child With An ASD (Page 9/19) Communication Although ASD is best characterised by impairments in social interaction, parents/carers more commonly express concerns with speech delay and difficult behaviours in young children. There are some key developmental delays to be aware of in the initial stages of becoming concerned. Listed are some key alerts in relation to communication. Alerts for the practitioner: • Language delay or abnormal language use • Little attempt to communicate • Showing little interest in the speech of others • Language that consists mainly of immediate or delayed repetitions of what is heard • Spontaneous communication that is stereotyped or unusual • Loss of language or development that has slowed/stopped in relation to language skills (most commonly in the second year of life) The Infant Or Young Child With An ASD (Page 10/19) Social interaction Impaired social interaction and understanding in the young child may be subtle and may require specific questioning to elicit. It should be noted that the fact that a child may give eye contact or affection does not exclude the diagnosis of an ASD. Many children with ASD do demonstrate affection and make eye contact, but on their terms. Alerts for the practitioner: • Limited use of non-verbal communication (eye contact, facial expression, body posture and gestures) in social situations • Difficulty sharing enjoyment with others • Lack of reciprocal interaction with others • Ignoring other people or appearing relatively insensitive to their needs, thoughts or feelings. • Difficulties in interacting with same-age peers and in forming friendships The Infant Or Young Child With An ASD (Page 11/19) Flexibility of thinking and behaviour Children with ASD show a tendency to routinised behaviour, resistance to change and sometimes have unusually intense interests. Interrupting these activities and interests can lead to distress. Behaviours that are not specific to ASD, such as extreme tantrums or self-injury, can therefore often be particularly problematic when children are young. Alerts for the practitioner: • Stereotyped routines of play • Extreme food fads in relation to texture, taste and smell • Lack of non-echoic imitation • Insistence on specific non-functional routines or rituals • Becoming upset by minor environmental changes • Undue preoccupation with objects, (eg elements of play materials such as wheels or wrappings) • Stereotyped and repetitive motor mannerisms, for example hand or finger flapping or twisting, or whole body movements A

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