Kelly Scott Moroz, October 2010Better Understanding the Autism Spectrum
Explaining and providing an understanding of childhood psychopathologies to both parents and professionals constitutes a significant proportion of my career as a child psychologist. The hope when promoting this knowledge is that these children and teens will be less misunderstood and misinterpreted while at the same time, suggested strategies will make sense to caregivers and enhance their chances of follow through. One of the more frequent questions I receive from parents and professionals working with toddlers and young children surround what constitutes a Pervasive Developmental Disorder (PDD). Indeed, the name Pervasive Developmental Disorder sheds very little insight into the challenges faced by children and teens within this spectrum, aside from the fact that these impairments are likely to be lifelong and present differently at various ages. With an emphasis on early detection and intervention, these caregivers have become more in-tune with certain characteristics that seem to differentiate these youngsters from their same aged peers, including: lack of eye contact, lack of social reciprocity/social aloofness, hand flapping behaviours, and lining up of toys, to name a few. Over the years, I have come to recognize that several other symptoms are likely to be operating for children within this spectrum, which can lead to a diagnosis that encapsulates only part of the symptomology under this umbrella, including: inattention and zoning out behaviours, emotional liability, obsessive-compulsive tendencies, motor clumsiness, sensory dysregulation issues, finicky eating habits, and restricted but intense patterns of interest. For me, however, the most important feature (by far) when identifying any child within this spectrum surrounds social developmental issues that likely include challenges with perspective taking, reading and displaying appropriate body language, and reading between the lines of social language and interactions. These individuals misinterpret, and are often misinterpreted by others.
The website DSM-5.org discusses the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013. It would appear that the category currently referred to as Pervasive Developmental Disorders will no longer exist; rather, it is proposed to be replaced by a general category referred to as Autism Spectrum Disorders. There will likely no longer be a differentiation between the various subtypes within this spectrum; Autism, Asperger's Syndrome, and PDD-NOS. From what I can tell, these proposed changes will be more reflective of the social developmental challenges evidenced by children within this spectrum, with some provision given for those other commonly associated features. For example, the proposed criteria will likely require marked deficits in nonverbal and verbal communication used for social interaction, lack of social reciprocity, and failure to develop and maintain peer relationships appropriate to developmental level. Restricted, repetitive patterns of behaviour, interests, and activities will include two of the following three criteria: i) stereotyped motor or verbal behaviours, or unusual sensory behaviours; ii) excessive adherence to routines and ritualized patterns of behaviour; and iii) restricted, fixated interests. Symptoms will need to be present in early childhood (but may not fully manifest until social demands exceed limited capacities). In my opinion, these proposed criteria will better emphasize the main challenges evidenced by those within this spectrum. These criteria will better keep pace with objective measures most often utilized in the assessment of young children suspected of having Autism, such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R).
Recognizing the social confusion and level of mental energy required for these individuals to navigate through their social lives is a clear priority when attempting to understand the challenges experienced by these individuals. For example, it would be like suddenly being transported into Shakespearean times; though English language and various gestures would still be utilized to communicate, it would present as a magnificent challenge to actually grasp the main point, given the formal language and subtle changes in social etiquette. With the build-up of reprimands that would follow the large amount of social faux pas in this scenario, one could empathize with the mental energy required to reduce social confusion, desire to avoid multi-person interactions, and appreciate the embarrassment and anxiety that comes with inevitable social blunders. Attempting to view the world through the eyes of those with Autism Spectrum disorders is perhaps the only way to truly understand the supportive strategies that must ensue to increase their competence and lower their stress levels.
In my opinion, if you are a clinician working with families who have been touched with an Autism Spectrum Disorder, there are two areas that will require significant understanding and intervention. For one, it will be imperative to communicate the importance of reducing assumptions about the child's social know-how; so often these children are told, “You should know that by now.” The second emphasis surrounds dealing with the “whys” behind various social nuances (e.g., why eye contact is valued during communication; why it is important to view conversations as a series of questions and responses that can be elaborated upon; why it is important to maintain proper hygiene; why it is necessary to speak with varied voice inflection; why others become disenchanted with those who have challenges handling defeat; why it is important to understand that others are watching and judging you at all times, similar to how actors and actresses are judged while on stage). The final phase involves the execution of the “hows” of these nuances (e.g., how to train oneself to look into the eyes of others; how to be better prepared for the small talk that ensues when entering new venues; how to stay current with certain trends and hygiene principles; how to understand what you might look like through the eyes of others). These teachings are typically best served in a setting with a few other similarly matched children. At our office, these social skills groups run daily, and incorporate such technology as video cameras to enhance perspective taking, puppets to help rely exclusively on proper voice intonation, concrete objects to symbolize the ‘to-and-fro’ nature of reciprocal conversation, and biofeedback devices to enhance the ability to re-regulate when stressed or angered. Clearly, the emphasis of such programming aims to teach these children more intellectually what comes to their peers on a more intuitive level. When these same strategies become incorporated into daily homework assignments, the results can be astounding.
Though a diagnosis within the Autism Spectrum can be overwhelming for parents, particularly given the multitude of associated characteristics that accompany these disorders, I believe that prioritizing social nuance development this way can decrease feelings of confusion, and promote a better understanding of their child’s social predicament. Conveying to parents the importance of teaching the social “whys” and “hows” to their children at every opportunity cannot be understated.