Information, Treatments, Current Research, Resources, and Helpful Hints
By: Lynette Louise, Autism Specialist
Lynette is doubly board certified in Neurofeedback and working on her PhD in Clinical Psychology with a specialty in Psychophysiology at Saybrook University
Autism Spectrum Disorder (Often termed “Autistic” or “Autistic disorder”) refers to one of the pervasive development disorders. Autistic individuals may present with a wide variety or spectrum of symptoms, the severity of which ranges from severe to mild. Until the new diagnostic manual came out in 2013 the main areas of challenge were divided into some combination of the following diagnostic symptoms: language delays or other communication problems, poor or limited social skills and a propensity to engage in repetitive behaviors. However, since the new DSMV was released being hyper or hypo sensitive to sensory aspects of the environment (like sounds, textures, smells etc.) has been included. These are the four areas of challenge with which you may be currently dealing and on which you will need to focus with the help of qualified, experienced, intuitive, successful professionals. Depending on the individual, one or many areas of the brain may be affected. Males are four times more likely to be autistic than females.
Your son or daughter may not have developed language and/or social skills normally in the early months of life. Even if (s)he did develop such skills, (s)he may have lost some or all of these skills. Your child may have begun using some type of repetitive body movement (e.g., hand flapping, spinning, rocking, head shaking). Perhaps your little one stares at a book, feels the shag carpet, or listens to the sound of the dryer for many, many minutes each day. Possibly, when you change things (e.g., buying a new blanket, replacing a favorite broken toy with a new one, redirecting the way a toy is used), your child pulls away, has inconsolable tantrums, or hurts himself /herself. Maybe (s)he is overly sensitive to texture, lights, sounds, smells, or tastes. (S)he may have delayed motor skills (e.g., walking, riding a tricycle, chewing). Maybe (s)he prefers to play alone or maybe (s)he just doesn’t interact with peers the way you thought (s)he would. Possibly (s)he is too busy lining things up, putting them in order repeatedly, flicking lights on and off, or opening and closing a favorite door. In addition (s)he may display unusual motor behaviors (e.g., peering at things from the corners of her eyes, walking on tip toes, walking with an unusual gait). Finally, maybe your child’s enjoyment of affection has a strange quality to it, as if love and affection were only accepted or enjoyed in an idiosyncratic manner designed by your child. As you can see, autism looks different depending upon the individual child and his/her particular “recipe” of perhaps two scoops of social, three scoops of repetitive, four scoops of language challenge, and one scoop of sensory confusion.
What are the odds that my child is on the spectrum of autism?
Once considered a rare disorder, the CDC reported that in 2014 as many as 1 in every 45 American children may be considered “on the spectrum”, nearly 80% higher from 2011-2013 to 2014. That means nearly every 5-10 minutes a new case of autism is diagnosed. Until recently the diagnosis of autism was typically not made until 3-4 years of age or later. However, due in part to improved awareness and the worldwide dissemination of early warning sign information this identified age range has improved to between 2-3 years of age. Since early warning signs of autism appear in the first year of life, it can be detected as early as 18 months of age. In many cases there is still a significant amount of lag time between the emergence of behaviors and diagnosis. Research has shown that early identification and intervention can make the critical difference for children with autism, although your child is never too old to be helped to a moderate degree.
If you suspect your child may have autism, do not wait. There are many ways to find help. Fortunately, a great deal of information about autism and pervasive developmental disorders is readily available at the library and on the web. This includes how to diagnose and where to go for help.
This information may include a lot of incongruence about treatments, therapies and prognosis. Since autism is still not completely understood, much speculation and opposing views remain in the field even as we find new and better ways to help these children optimize their skills. You, the parent, have already begun to funnel through the veritable cornucopia of treatments and beliefs about autism, ranging from traditional to alternative, holistic approaches. My advice is to relax. Though this is an important step that you want to make fairly quickly, it is not an emergency. Your child is simply, wonderfully special and not in danger of death. Take your time and make it an adventure. Otherwise, the search can be quite overwhelming. At the Brain & Body Clinic we provide information, neurofeedback (i.e., EEG biofeedback), play therapy, family support, assistance in choice making, current research information, resources and helpful tips.
What causes autism, and can it be prevented?
There may be a genetic component as autism tends to run in families. In addition, studies have shown that identical twins, who have the same DNA, are much more likely to share the diagnosis of autism than fraternal twins, whose DNA is different.
That being said, as of this writing, there is no known cause for autism. However many anatomical or physiological peculiarities have been found (e.g., cerebellar abnormalities, temporal abnormalities, oversized head, overgrowth and late pruning of neurons in the early years of development, overactive brain wave activity, deficiency of dipeptydal peptidase; abnormal levels of serotonin, dermorphin,sauvagine, opioids, secretin, free sulphate, or mercury). Scientists are working hard to make sense of all the data, and many theories have been put forth. None of these theories have proven to be universal to all autistic children or have allowed a given individual to be identified as suffering from a particular spectrum disorder with a specific cause. Nevertheless, many spectrum individuals have been helped through a variety of approaches. Autistic people are extremely complex. They have chemical imbalances, nutritional imbalances, hormonal imbalances, physical abnormalities and learning/behavioral deficits. Helping them requires a willingness to look at all the various possibilities while not becoming overwhelmed and put out of action by the multitudinous possibilities. You have just become part of the puzzle. Revel in the challenge, partner with professionals in the field and begin. There is no known way to prevent autism.
What are some general age-related ‘signals’ you as the parent can use to help identify if your child is ‘on the spectrum’?
Your child avoids eye contact, does not react by looking at you when you make social sounds such as humming or clapping, does not show as much interest in people as objects, or does not smile back when you smile at him (without being tickled or touched).
Your child does not combine eye contact with smiling, does not babble or the babble does not represent speech, does not follow your gaze to look at objects, does not try to engage other people in what (s)he is doing, does not respond when his/her name is called, does not point using the index finger, does not show caring or concern when you cry, or does not wave hi or bye.
Your child does not attempt to share her/his interests with you or others, does not imitate common activities such as driving the car, does not develop pretend or make believe play, or does not use two-word phrases in an appropriate manner.
What are the differences among the various pervasive developmental disorders?
Since a person tends to envision themselves as having the label they were originally given, and since some of those people/parents may be reading this page, I am going to include explanations of labels that (since the DSMV) are no longer given. An example of this present day label adjustment is Asperger’s Syndrome, which is now generally referred to as High Functioning Autism. The point to consider while you read this is: labels are an invention of medical science and as such not an impenetrable statement of fact.
Autism Spectrum Disorders are pervasive developmental disorders, and all individuals differ in the range and severity of their collection of symptoms. Your child may even have comorbid conditions (extra disorders outside the criteria of ASD) like epilepsy and/or fit into more than one of the sub categories previously delegated when diagnosing autism. This is because there are common elements to all these disorders, and the diagnostician relies heavily on how you, the parent, represent your child. Thus, since there actually are some subtle differences even within the different levels of ASD that become important when designing a treatment protocol, you become an integral part of your child’s healing process every step of the way. As I move forward in my description I am going to use the older model (pre DSMV) because it allows me to show the range of autism personality styles without taking the human being out by assigning level numbers. Your diagnostician will of course use the new manual, but on this page I want to help you understand your child more than your doctors checklist of symptom severity. I feel this way because one unchecked box does not an unchallenged child make. Let’s proceed with names instead of numbers and at the end I will include actual DSMV information for you.
Autism (Autistic Spectrum Disorder) a disorder of social, communicative and repetitive behaviors that are sometimes accompanied by severe fears, phobias, tantrums, overly-sensitive sensory systems, retardation, special talents (autistic savant), self-injurious behavior (e.g., head banging), an inability to creatively fill leisure time and skill sets that can be learned and then forgotten on a repeated basis.
Atypical Autism was considered different from typical autism in that it was often diagnosed as having had an onset after three years of age. It also had an increased dual diagnosis of retardation or low IQ scores. Additionally your child may have received this diagnosis if (s)he only met two of the three social, communication and repetitive diagnostic criteria of autism. Thus, since IQ deficits are easier to teach to than social, communication, and repetitive disorders, this meant that atypical autism may have been seen as easier to treat than autism.
Asperger’s Syndrome was considered a separate developmental disorder that did not meet the criteria of other pervasive developmental disorders. Features of Asperger’s were severe and sustained impairment in social interaction; the development of repetitive behavioral patterns of behavior, interests and activities, and significant impairment in social occupational and other important areas of functioning. Asperger’s was considered a form of higher-functioning autism because there were often no cognitive deficits or significant language delays (though they were often extremely anxiety ridden literal thinkers with difficulty comprehending metaphors). Interestingly, though boys were four times more likely to have autism than girls, boys were eight times more likely to have Asperger’s than girls within the pervasive developmental population.
Hyperlexia a remarkable disorder was sometimes considered a subset of Asperger’s syndrome and sometimes considered a disorder of its own. Hyperlexic children have a precocious ability to read words far above what would be expected for their chronological age or an intense fascination with letters or numbers. However, they have significant impairments in verbal comprehension, in social skills and in interacting appropriately with people. They may listen selectively, appear deaf, echo what is said to them (echolalia), or rote memorize commercials or passages from books with no apparent understanding of the meaning. They also can have difficulty using pronouns correctly and comprehending ‘What…Where…Who…Why?’ questions. Like the old model of Asperger’s individuals, hyperlexics can be very literal thinkers with difficulty comprehending metaphors. The hyperlexic child is best helped with a program of intensive speech therapy that focuses on language and comprehensions skills and uses the child’s reading skills as the primary teaching tool. This is a good example of why discerning the differences within the diagnosis level matter, and why it is so paramount that parents share with clarity when seeking a diagnosis and its accompanying therapy suggestions. Though, teaching that uses a child’s interests and already-established skill sets, and that builds on those skill sets using positive reinforcement, is the most effective way to teach any child. The expectation of success and academic goals laid out for your newly diagnosed offspring will depend greatly on where the diagnostician perceives them to be in relation to the spectrum.
Fragile X is included in this list because it is often confused with autistic spectrum disorder due to the large number of fragile X individuals that also have autism. Fragile X is a hereditary/genetic condition and one of the most common causes of genetically-inherited mental impairment. Its effects range from subtle learning disabilities with normal IQ scores to severe retardation, autism spectrum disorder and “autistic like” symptoms. It is believed that somewhere between 2%-6% of all people with autism also test positive for fragile X. One third of all fragile X individuals have autism. Since many families are completely unaware that they carry the defective chromosome, it is always a good idea to have your child tested for fragile X.
For Diagnostic Criteria from the fifth Diagnostic Manual known as the DSM V please scroll to the bottom.
Discoveries of genetic factors and chemical imbalances offer much hope for families of children with autistic spectrum disorders. There is a lot already in place and available to families. Examples are family-based behavior and cognitive therapy play programs (e.g., Son-Rise, RDI, Greenspan aka Floortime, Teacch, Miller Method, Pivito, Response Training, Discrete Trial Training, ABA, Lovaas, Growing Minds). Also available are speech therapy; sensory integration techniques; and visual, auditory, and vestibular retraining programs. Get medications to help with behaviors when needed. Examine the “alternative therapies” that have been used by many clinicians with reported success. EEG biofeedback (neurofeedback) is one of the most exciting scientific advancements that appears to be holistic and not reliant on medications. (Please see special page on EEG Biofeedback on this website for an explanation of this exceptional methodology.)
At Brain and Body, our staff specializes in several treatment modalities including individual mentoring, Neurofeedback, home based family dynamics counseling (house calls), child-driven behavior play therapy, and up-to-date information on scientific advances in the field of autism. We offer full family support and are able to individualize the child’s program depending upon the family’s needs and the needs of each client. The following therapies and treatments are combined synergistically to optimize effects:
EEG Biofeedback (Neurofeedback) uses operant conditioning to alter brain waves so that a client’s brain can achieve more flexibility and stability. In addition, it can help decrease or prevent excessive arousal or anxiety and assist the client with attention and motivation. For families choosing home visits with dynamics counseling and play therapy, Neurofeedback can be done in their home.
Play Therapy is the systematic application of scientific principles of playing in order to change behavior. It is taught in an attitude of fun and excitement. By creating an environment wherein the distractions are minimal and the child is in control, the parent is able to engage and be engaged by their child. An example of this would be spending time with your child in a quiet room wherein you have hidden a great many pieces of his/her favorite food. You are dressed as a baker; and every time (s)he uses a sound, you run with great dramatic fervor and search for another bite to give him/her. After several of these games, you ask for a specific sound such as “eeeee” for eat. You model it, encourage it, wait for it and then praise your child for trying whether (s)he does or doesn’t make the sound. Now, present the food and then play again. Laugh, smile and adore the moments as you teach, shape and love your child. We will help you learn how, and you will discover the blessing of play.
Family Dynamics Counseling assists the family in achieving a more congruent environment for the autistic child, his/her siblings, parents and relatives. Raising an autistic child requires different skills than most parents have been fortunate enough to gain.
Up-to-date information on scientific advances assists parents in choosing which therapy, program, or diet might be appropriate for their child.
Seek help from mental health and educational professionals specializing in autistic spectrum disorder.
Get a diagnosis. Regardless of where your child fits on the spectrum or even if (s)he belongs in a different category like ADHD, trust your instincts. You are wondering about your loved one for a reason. The sooner you get professional help in understanding what you’re dealing with, the sooner you can ask the question, “How do I help my child?” For example, you may seek out a licensed clinical neuropsychologist; such individuals have had extensive education and training in assessing and diagnosing neuropsychological disorders. Then seek a program run by educators and health practitioners trained in your child’s disorder. A psychiatrist should be considered if medications are needed for the child or for any other member of the family. Such medications may help with sleep, anxiety, or violent outbursts. Your primary care physician is certainly licensed to prescribe these medications, but psychiatrists have had much more training and experience in monitoring their effects and usually have the latest information about the best medications (e.g., that SSRI’s such as Prozac are considered more efficacious and safer than benzodiazepines effect.) In any case, do not procrastinate in seeking help, especially if you find yourself and other family members struggling to cope. There is a lot that can be done for you, your family and your child.
Accept that your life is different now.
You may not have dreamed of or imagined raising a child or even children with autism. This may not be the way you pictured your life as a youngster playing Barbie dolls or GI Joe. The future that has become your present may not have given you what you expected. However, it did give you a marvelous challenge that can be full of excitement and joy if you see it that way. You can lament what isn’t, or you can embrace what is.
So how would the lamenting choice look? Years and years of struggling, denying and dealing with shame and thoughts such as, “Why me?” until one day you realize that no one seems able to “fix” your child without some kind of coordinating effort by you. So you start, fifteen or twenty years later. Good for you for making the decision, if that’s who you already are. However, if you are standing in the beginning part of this story, it’s a lot easier and quicker to roll up your sleeves, fill yourself with gratitude for all you are about to learn and get at it now.
You are noticing some differences in your child. This is the way it is. The longer you fight the possibility, deny the diagnosis, or close your eyes to the evidence, the longer it will take to get help. Children typically respond better to intervention the earlier the helping begins. This is not to say that there is ever a point when the child or adult is “unteachable” but rather that it is easier to influence a child’s brain when it is young and still forming.
Be a partner.
Remember that, although you will be working with experts in mental health and education, you are the expert in your child. Choose professionals who recognize your expertise, greet you with respect and thrive when partnering with parents. Helping your child takes congruency of approach, consistency in the environment and a modeling of functional relationships. For optimal improvement, you must be part of the team. There is no mystery in what behaviorists do. Have them share their knowledge and then be excited to share yours. You will be richer as a result of the interplay between teaching your child, other professionals and yourself. Life with autism truly can be a blessing.
Diet, nutrition and exercise.
A healthy diet is always a good idea whether it is for you, your child, or your spouse. However, just what a “healthy” diet is and how to get your spouse or child to eat one are questions that become even more challenging when dealing with an autistic family member. Many autistic individuals choose colors or textures or special food groups and eat only those. Other individuals eat everything they are given but don’t know when to stop. Still others don’t know when they’re hungry. Some have difficulty chewing or swallowing and are challenged to eat at all. Experimentation, creativity, information and observation are the necessary ingredients to solve this puzzle. For example, your child only eats white food, and you read that some children are negatively affected by casein and gluten and that all children with autism should go on a gluten/casein-free diet. That’s the information piece. Now you experiment by removing these items (grains and dairy) from your little person’s diet. You already know white foods are more readily eaten. Therefore, be creative by finding white specialty breads, cut up white chicken breast, or grind up white blanched almonds to coat everything and magically make all colored food white. OK. Last step. Time to observe. If the change in diet has no effect on your child’s well-being or behavior, then this is not a necessary change for your family. However, by engaging in the experience, you will have still benefited; you will have learned about the choices your child is willing to eat. Voila! A healthier diet.
One more example; this one regards exercise. You just heard that some autistic children have too much serotonin while you also heard that serotonin increases one’s ability to sleep. Your child doesn’t sleep, and so you dismiss this idea. However, then you learn that serotonin is stimulated by movement and realize that your child often runs back and forth for hours at a time. You don’t know if there is a connection, but you do know that research has found that exercise increases deep sleep, decreases stress reactivity, increases self-esteem and increases such chemicals as BDNF (brain-derived neurotropic factor) that actually “heals” the brain. Therefore, you decide to do some experimenting. You let your child be your teacher and start taking him/her for long walks in an unpopulated area every day for a month. You make the walk fun by singing or clapping or whatever (s)he likes, and by the end of the month you discover that you feel better, though you’re not sure about your child. You try it out for another month mainly because it feels good. Then maybe you start to notice a greater bond between the two of you, an increased calmness in your child and also in you. Subsequently, you keep the walk as a part of your child’s program and smile a little smile every time you put on your one size smaller jeans.
Decrease your stress levels.
Stress makes it more difficult to think clearly, to remain calm, and to cope with anxiety and the events in life that can exacerbate anxiety. One of the most exacerbating things you can do is to view your child as a problem full of broken pieces. Every child is unique, and every child requires special handling. Yours just has a label. If you see your child’s unusual behaviors as the enemy and try to expunge them, you will always be at war with a member of your own family. Because for each behavior you train away a new one will pop up to take its place. Instead, investigate and try to see what your child finds fun in the bizarre aspect of his/her chosen activity. Join your child in play; and after a while, vary the game. This way, you will not be trying to extinguish parts of your child by hating what (s)he likes. Rather you will be building upon his/her interests to normalize that activity into something more useful for learning and socialization. Actively admiring your child removes the stress. As for those often-repeated, hard-to-take repetitious sounds, try flinging a towel on doors that are constantly slammed, padding your tables, or buying plastic spoons instead of noisy metal ones. Having fun with it makes it easier to come up with good ideas.
Finally, reach for help.
Psychotherapy, biofeedback, exercise (e.g., aerobic, yoga, Tai Chi) and meditation/prayer have been shown to be effective in decreasing stress.
If your child suffers from sleep disturbances as do many autistic children, make sure that his/her disturbances do not become yours. Inadequate sleep makes coping with life’s challenges more difficult. Of course, there are many health store and over-the-counter sleeping pills that may help. However, taking excessive over-the-counter sleep aids is not a good answer; they can make things worse. Similarly, taking benzodiazepines (e.g., Xanax®) on a chronic basis is not recommended by many experts. For one thing, your sleep may be too heavy, and that may increase your anxiety as you worry about being available to your child. In addition, medication can make your sleep worse, at least temporarily, if you stop taking it. You may become dependent on benzodiazepines; and they can impair your cognition, memory, and reaction time. A published study has shown that average doses of alprazolam (Xanax®) can impair driving, divided attention, and reaction time. These are skills that you are going to need in order to properly supervise your autistic child. Sleep medication for your child is also a complicated decision and must always be done under the strict supervision of a qualified physician.
Even if you do try medication, many spectrum children do not respond well or even at all. Conversely, some are calmed significantly by the tried-and-true “ride in the car”, lavender under the nose, or hemi-sync sleep music. However, if your child is still awake despite all your best efforts, do continue to investigate. However, investigate later; you need your sleep now. Therefore, create a safe environment in which (s)he cannot hurt her/him-self whether awake or asleep, and go to bed. The only way to prioritize your child is to prioritize you.
Don’t romanticize the disorder.
Many people see an autistic child as a child in some other zone with special talents. They use terms such as “in his own world,” “gifted,” or “indigo child”. They mystify the child’s unusual ability to focus on the minute details of colors, smells, textures, or sounds. Because they can’t understand it, they assume it to be magical. If people are telling you not to try and change your child because his/her special talents may be expunged, thank them for their concern and then walk away and get back to the business of reaching out to your child.
The fact is that all parents teach. The only difference is that you are going to be intentional and learned about it. Of course your child is special and unique. Even among the population of spectrum individuals, your child has her/his own special brand of beautiful. That is the marvelous aspect of this approach. We are not going to take away; we are going to add. We are going to help him/her and you become more, not less.
While you play, teach.
Use music. Many autistic individuals respond positively to music. Some even speak only in song. Therefore, sing. If your child calms, gets excited, comes nearer, looks at you, or joins in, you have a means to communicate. Sing your instructions, sing your praise, sing your ideas and sing your love.
Use numbers. As with music, numbers can be the delight of an autistic child. Bemoaning an obsession with numbers misses the opportunity to interact and to begin the bridge of bonding. Play with the numbers. Count how many drawers to the pajama drawer or how many steps to the toilet, subtract each tooth after adding the number of brush stokes, or lay out pictures of the family in ranges of ages and match the years in which they were born. Numbers, numbers, numbers. What a great opportunity to improve your math skills.
Use puzzles. Once again, here is an opportunity to teach and connect. Anything can be made into a puzzle: favorite Disney characters, pictures of favorite toys, or a pair of old coveralls. If (s)he won’t look at you, try puzzles of eyes or mask puzzles with the eye holes cut out, which once put together can be put on. If (s)he looks at you, say, “Thanks.”
Use tickles, squeezes and airplane rides. Many autistic kids respond to sensory and vestibular treatment modalities. They have challenges in this area. Your child may even be performing her/his own therapy by spinning or head banging. However, if you start giving rides, tickles and squeezes, you become an integral part of your child’s world while at the same time stimulating her/his proprioceptive, sensory and vestibular nuclei.
More than with any other child, be prepared to do it again and again and again and again. As (s)he asks for more, so do you: another sound, a whole word, a sentence, two sentences, etc. Then, because you appreciate her/his trying, give the ride whether (s)he says the word or not.
I’m sure this sounds like a lot more playing than you had planned. Lucky you. Your child is about to help you reorganize your adult years and stay young.
Be comfortable laying down boundaries.
Begin by explaining what you want and why. For example, “There are germs in the toilet that may make you sick. I want to keep you healthy, that’s why I won’t let you put your hands in the toilet.” Now block him/her from the toilet. Your child will only know what you want if you tell her/him. Children with autism often have attention problems and slower mental processing speed. Therefore, be prepared to tell your child repeatedly. This is not a failure in your ability to teach; this is just the way (s)he learns. Now, be okay if your child tantrums. Keep her/him safe if (s)he flings her/him-self around. However, don’t react with any emotion. If your child likes to destroy things, minimize the choices and keep nothing around that would upset you to have it broken. If (s)he simply pulls away and moves to engage in her/his repetitious behaviors, thank him/her for not putting her/his hands in the toilet and give him/her some time to process what you have said. If (s)he listens and complies, respond with gusto, celebrating and telling him/her how amazing (s)he is.
The idea here is to shape your child’s behavior in the same way that you would encourage a plant to grow towards the light. Give no emotional response to the behaviors you wish to discourage (leave them in the dark) and give lots of joyous (sunny) delight for the things you want to help grow. Your child may not be motivated by the same socially-acceptable things as you. So help your child find his/her way. Lay down the road map with very frequent positive reinforcements such as “I love it when you look at me” “What a great voice you have” and “You’re the nicest person, I’m so lucky to have you.” Your child will respond even if at first (s)he shies away. So explain everything, especially how incredible you think each of his/her accomplishments are.*
*Just because your child may not communicate normally, don’t assume (s)he doesn’t understand. Many people push and pull autistic children while working under this assumption. Perhaps many of his/her outbursts are related to just such a world of having no control.
I personally suggest reading MIRACLES ARE MADE: A Real Life Guide To Autism by Lynette Louise aka The Brain Broad! (yes that’s me:) because it includes inspiration, therapy information, brain science and case studies. PURCHASE VIA AMAZON HERE Other inspirational stories, such as A Miracle To Believe In by Barry Neil Kaufman, may be helpful.
However, please realize that there is no substitute for the hands on help of a specially trained intuitive therapist.
*Full-text of the diagnostic criteria for autism spectrum disorder (ASD) as it appears in the (DSM-5).
Autism Spectrum Disorder 299.00 (F84.0)
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 paly 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 2).
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 2).
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-estaestablished 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.
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 (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.)
Table 2 Severity levels for autism spectrum disorder
Severity level Social communication Restricted, repetitive behaviors
“Requiring very substantial support” Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.
“Requiring substantial support” Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and how has markedly odd nonverbal communication. Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.
“Requiring support” Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.