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Chapter 6
Autism Spectrum Disorder and
Childhood-Onset Schizophrenia
Autism Spectrum Disorder (ASD)
Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterised by
abnormalities in social communication, and unusual behaviours and interests
Description and History
ASD is a DSM-5 disorder characterised by significant and persistent deficits in social interaction
and communication skills, and by restricted and repetitive patterns of interests and behaviours
Children vary widely in the form, pervasiveness, and severity of their symptoms, abilities,
associated conditions, and needed supports
The factual history of autism begins in 1943, when psychiatrist Dr Leo Kanner described 11
children who, in their early years, displayed more attention to objects than people, avoided eye
contact, lacked social awareness, had limited language, and displayed stereotyped motor
activities. They also exhibited preservation of sameness which is an obsessive insistence on the
maintenance of sameness in daily routines and activities, which no one but the child may disrupt
Around the same time, Dr Hans Asperger described a milder form of this that became known as
Asperger’s disorder
Kanner used the term early infantile autism
o He described the parents of the children he observed as highly intelligent and obsessive
people who were cold, mechanical, and detached in their rxps
o Although he clearly saw it as an inborn deficit, he also planted the seeds for the
psychoanalytic view that the precipitating factor in infantile autism is the parent’s wish
that their child should not exist
This early view that autism resulted from a child’s defensive withdrawal from an
intellectual, cold-hearted, and hostile parent is unsupported
These children have not withdrawn from reality – they have FAILED TO
ENTER IT because of serious disturbances in their development
Autism is now recognised as a strongly biologically based lifelong neurodevelopmental disorder
that is present in the first few years of life
Children with ASD behave unusually
o Although they fear many things, they are also attracted to and preoccupied with other
objects and activities – they often develop unusual attachments or reactions to odd objects
They may have extraordinary perceptual abilities
o These abilities may result in distress in response to minor changes in the env
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o They may spend hours playing in a corner of their room, engaged in stereotyped or
repetitive motor activities
o Rather than seeing the big picture, they are much more likely to fixate on a miniscule
object or event
DSM-5: Defining Features of ASD
*SEE ALSO Table 6.1 and online DSM-5
Core features of ASD are represented by 2 symptom domains:
o (1) Social communication and interaction
o (2) Restricted, repetitive patterns of behaviour, interests, or activities
To receive a diagnosis of ASD, the child must display symptoms in both domains
o The symptoms must also be persistent, occur in multiple settings, and be present in early
development
1. Social Communication and Interaction
DSM-5 lists 3 symptom types in this category, with all 3 required for an ASD diagnosis:
o (i) Deficits in social-emotional reciprocity
o (ii) Deficits in nonverbal communication behaviours used for social interaction
o (iii) Deficits in developing, maintaining, and understanding rxps
2. Restrictive and Repetitive Behaviours
4 types, with at least two types required for a diagnosis:
o (i) Stereotyped or repetitive motor movements, use of objects, or speech
o (ii) Insistence on sameness, inflexible adherence to routines, or ritualised patterns of
verbal or nonverbal behaviour
o (iii) Highly restricted, fixated interests that are abnormal in intensity or focus
o (iv) Hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of
the environment
Severity Ratings in ASD (DSM-5)
DSM-5 also specifies that a severity rating of current symptoms be made for each domain
o These ratings reflect the extent to which the symptoms interfere with the child’s
functioning
o More severe deficits are rated as requiring greater levels of support, as follows:
Requiring support (level 1)
Requiring substantial support (level 2)
Requiring very substantial support (level 3)
o These ratings help in guiding the types of programs and services needed
o These ratings are not intended for use in determining the child’s eligibility for services
Changes from DSM-IV to DSM-5
DSM-5 criteria provide a new way of looking at autism
Key changes in ASD criteria from DSM-IV to DSM-5 and why:
o DSM-5s organisation of symptoms into 2 domains represents a change, in which deficits
in social interaction and those in communication were viewed as separate domains along
the third domain of restricted and repetitive behaviour
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HOWEVER, research does not support viewing social interaction and
communication as distinct domains, and clinicians struggle with separating the
symptoms of each
o DSM-5 eliminated all previous subtypes of ASD and substituted a single overarching
category – ASD
One reason for this was to increase the consistency of diagnosing ASD. In DSM-
IV, the criteria for autism subtypes were not well conceptualised. Distinctions
between subtypes were unreliable and inconsistent and were related more to
where the diagnosis was made, the child’s level of intellectual ability, and co-
occurring conditions -- than to the child’s ASD symptoms
A second reason was a recognition that changes in developmental level can lead
to changes in symptom presentation
Thus, rather than representing a true change, these age- and skills-
related fluctuations in diagnosis are best viewed as variability within a
single disorder
The elimination of subtypes does not mean that these distinctions are
unimportant
There is a great deal of heterogeneity within ASD; what is NB is having a
classification system that can address this variability
o To do this, DSM-5 includes the use of specifiers to indicate
whether the child’s ASD is associated with a known medical or
genetic condition,
o and the use of modifiers to indicate when other NB conditions
are present and/or when ASD is associated with another
neurodevelopmental, mental, or behavioural disorder
o This provides a more detailed description of the full range,
severity, and developmental trajectory of the child’s problems,
which is NB in developing an appropriate treatment plan
There is support for the conceptual validity of using a single ASD category;
however many suggest that fewer individuals will be diagnosed, especially those
with milder symptoms and normal intellectual abilities who were previously
diagnosed with Asperger’s disorder
Therefore the use of DSM-5 could result in reduced eligibility for these
children
ASD across the Spectrum
ASD is defined as a spectrum disorder because its symptoms, abilities, and characteristics are
expressed in many different combinations and in any degree of severity
Although children with ASD vary widely, the majority of them display most of the core features of
the disorder
Despite the similarities in their core profile, they show enormous variability in the expression and
severity of their symptoms
o This variability applies widely across both their social communication and behavioural
impairments
o They may also, in varying degrees, display features not specific to ASD
Extreme social unresponsiveness is typical
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