Welcome to Issue 321 of Institute Inbrief
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Issue 321 // Institute Inbrief
Dear <<First Name>>,

Welcome to Edition 321 of Institute Inbrief. Autism Spectrum Disorder (ASD) is among the most disabling and mystifying of all childhood developmental disorders, having atypical patterns of development that affect multiple areas of functioning. In this edition's featured article, we look at the theoretical background of ASD, including characteristics, aetiology, risk factors, and symptoms.

Also in this edition:
  1. The Eclectic Therapist (Order Now)
  2. Seven Secrets for a Healthy Microbiome
  3. Men and Emotions: From Repression to Expressio
  4. Lying: Exploring Our Series on Deception
  5. Quotations, Seminar Timetables & More!

Enjoy your reading!

AIPC Team. 
Diploma of Counselling
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Our Diploma of Counselling is a journey of self-discovery, providing deep insight into why you think and behave as you do. And when you graduate, you will be extremely well prepared to pursue a career in counselling – employed or self-employed – enjoying our strong industry reputation and linkage.

As a Counsellor you will:
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Ready to start your Counselling journey, <<First Name>>?

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The Eclectic Therapist
Expand your knowledge and understanding of 7 “must have” therapeutic modalities for any practitioner or student. 

You’ve done a thorough assessment of the client’s symptoms and presenting issues, identified their goals for therapy, and determined that you can work with them. Now what? Which therapy will be most effectively in helping the client attain their goals and get their life back on track?

AIPC's 300+ page e-book - The Eclectic Therapist - explores seven popular therapeutic modalities, including:
  1. Cognitive-behavioural Therapy
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  5. Creative Therapies
  6. Acceptance and Commitment Therapy, and
  7. Mindfulness-based Cognitive Therapy.

The purpose of this e-book is to help not only practitioners, but anyone who may benefit from the concepts and techniques that have helped millions enhance their mental health, happiness and wellbeing.

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Go to www.counsellingconnection.com to purchase your copy today. 
Autism Spectrum Disorder: The Basics
This article provides an understanding of the theoretical background of Autism Spectrum Disorder (ASD), including the characteristics, aetiology, risk factors, and symptoms. 

Imagine this: you come for a visit and go to greet your four-year-old nephew, Jack, whom you know well. “How are you, Jack?” you ask. Jack’s response is to continue spinning the wheels on his toy truck; he does not seem to notice you. When you repeat, “How are you?” he responds with, “How are you?” Jack’s responses would ordinarily be disconcerting, but to you they aren’t. You helped him get assessed. Jack has autism. 

If in reality you had a family member or client like Jack, would you know how best to help him and his parents?

Autism Spectrum Disorder (ASD) refers to complex developmental disorders that typically appear in the first two years of life. These disorders are characterised by impaired social interaction and communication accompanied by restricted repetitive stereotyped interests and awkward behaviours, evident at an early stage of development (Ozgen et al., 2009; Kanne, Randolph & Farmer, 2008; Meadan, Otrosky, Zadhlawan & Yu, 2009).

ASD, classified in the DSM-IV-TR as a Pervasive Developmental Disorder, is classified in the DSM-5 as a Neurodevelopmental Disorder, and includes DSM-IV diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, infantile autism, childhood autism, Kanner’s autism, high-functioning autism, atypical autism, and pervasive developmental disorder not otherwise specified (APA, 2000; APA, 2013).

Other neurodevelopmental disorders include: ADHD (Attention-Deficit/Hyperactivity Disorder), Specific Learning Disorder, and Motor Disorders, such as Developmental Coordination Disorder, Stereotypic Movement Disorder, and Tic Disorders (APA, 2013).

ASD

Autism is a spectrum disorder, meaning that symptoms can range from mild to severe, with the level of developmental delay being unique to each individual. The symptoms are typically recognised during the second year of life (12-24 months), but may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are more subtle.

While ASD is typically characterised by significant impairment in social interactions and communication, restricted patterns of behaviour, interest, and activities are also common features. Manifestations of this disorder also vary depending on the developmental level and chronological age of the individual (APA, 2000). Because there is a range of symptom severity in autism, clinicians are urged to record the severity as the level of support needed for each of the two psychopathological domains of “social communication” and “repetitive, restrictive behaviours”. The levels of severity are classified as Level 1: “requiring support”, Level 2: “requiring substantial support,” and Level 3: “requiring very substantial support” (APA, 2013).

Characteristics of ASD

Social Interaction Impairments

The inability to relate to others is a core feature of these disorders. Social impairments range from mild difficulties such as lack of social or emotional reciprocity to extreme difficulties. The assumption is that by the age of four years, children normally have the innate ability to sense the state of mind of another (a kind of empathy, in a way); and to be able to see the world through another person's eyes, to understand another person's point of view (Oltmanns & Emery, 2010; Flusberg, 2007). Children who suffer from autism, for example, fail to appreciate that others may have a perspective that is different from their own (Oltmanns & Emery, 2010; Peterson, Garnett, Kelly & Attwood, 2009).

They experience difficulty attributing mental states to themselves and others. In this context, those who suffer from autism also lack “theory of mind” (Shamay-Tsoory, 2007). “Theory of mind” refers to the cognitive ability to understand others and interpret their minds. It involves the capacity to put oneself into another person’s shoes. The assumption is that as early as two years of age, children begin to display a clear understanding of others’ emotions and desires and begin to develop the realisation that another’s perspective can differ from their own (Berk, 2007).

Sufferers of autism spectrum disorders will most likely have difficulty developing peer relationships that are appropriate to their developmental level. Some children may have very little or no interest in establishing friendships whereas others may have the interest to build friendships but lack understanding of the principles of social interaction (APA, 2013). Individuals may have impairments in their capacity to understand nonverbal language such as eye contact, facial expressions, body gestures and posture that are necessary in regulating social interaction.

Communication Impairments

Communication impairments are among the defining features of ASD. Communication impairments can vary from moderate impairments to severe. They range from a delay in the development of expressive language and problems with initiating and sustaining conversation to excessive use of stereotyped, repetitive language (for example, repeating words or phrases regardless of meaning). The use of idiosyncratic language is also common with this disorder. Idiosyncratic language refers to language that has meaning only to those that are familiar with the individual’s communication style (APA, 2000).

Those suffering from ASD may experience difficulty in understanding simple questions and directions because language comprehension is often delayed with ASD. This is commonly demonstrated by the inability to understand congruence of words and gestures or understand humour and irony with non-literal meaning. For example, children with autism have difficulty understanding gestures and deriving meaning from such gestures.

Some of the communication problems that sufferers of autism spectrum disorders encounter include dysprosody and echolalia. Dysprosody refers to the variations in melody, intonation, pauses, stresses, intensity, vocal quality, and accents of speech. The speech of the child with autism may sound unusual even if the content of the speech is normal (Oltmanns & Emery, 2010; Sidtis & Sidtis, 2003). The person can comprehend language and vocalise what they intend to say. However, they may not be able to control the way in which the words come out of their mouth.

Echolalia refers to repeatedly uttered phrases (Oltmanns & Emery, 2010; McCann, Peppe, Gibbon, O’Hare & Rutherford, 2008). For example, when someone asks the child "how are you?" instead of the child responding to the question by saying how they are, the child repeats "how are you?" Echolalia is used as a means of processing words and storing the words or complete phrases for future use. It is believed that, through echolalia, autistic children acquire language.

Other researchers suggest that even when structural language seems intact, there may be difficulty with pragmatic language that seems to persist. This would suggest that individuals with ASD have pragmatic impairment, which refers to the disparity between language and the situation in which it is used, making the language inappropriate for the situation.

Restricted and Repetitive Behaviours

Individuals may display a restricted range of interests and they are often preoccupied. Research suggests that autistic individuals have deficits in shifting and sustaining attention (APA, 2013; Pierce, Glad & Schreibman, 1997). For example, Children with autism may become preoccupied with one part of a toy, thus restricting their play (e.g. spinning the wheel of a toy truck over and over). Stereotyped body movements such as repetitive hand clapping or finger flicking or whole body movements such as constant rocking are also common characteristics of the disorders of this spectrum. These individuals may also exhibit a preoccupation and fascination with certain objects and movements (for example, buttons, spinning wheels). Attachment to some objects such as a favourite toy and an item of clothing are also common (APA, 2013).

Aetiology

Biological Factors

Autistic Spectrum Disorders are considered complex polygenic disorders, meaning they result from interactions between multiple genes and the environment. It appears that in autistic disorder, there is abnormality in the structure of the brain, e.g. cerebellum. Low blood flow to certain parts of the brain and reduced numbers of certain brain cells also seem to appear along with autistic traits (Hammond, Forster-Gibson, Chudley et al., 2008). The amygdala has been implicated as a cause of these disorders.

As part of the limbic system that regulates emotions, the amygdala sends emotional responses to the cerebral cortex to ensure that feelings are accurately matched to the emotion-provoking event. Brain imaging studies carried out in people with ASD suggest that the connections between the cerebral cortex, the amygdala, and the limbic system have become scrambled. As a result, people with ASD may suddenly experience an extreme emotional response when seeing a trivial object or event. This may be one reason why people with ASD are fond of routines; they have found a set of behaviour patterns that do not provoke an extreme emotional response. It may also explain why individuals with ASD often become very upset if their routine is suddenly broken (Adolphs, 2006).

A shortage or excess of the neurotransmitters dopamine and serotonin has also been implicated in the causes of ASD. Irregular levels of neurotransmitters may result in an incorrect processing of information. As a consequence, such neurone dysfunction may be responsible for the difficulties children with ASD have with language, social interaction and some types of learning that are synonymous with the disorders of this spectrum (Hammond, Forster-Gibson, Chudley et al., 2008).

Recent studies have described how early development of key components of the social brain are impaired in autism. The term social brain refers to the recognition, awareness and communication of emotions by an individual. Impairments in this area may lead to a cascade of social and communication deficits that are typical of ASD (Crespi & Badcock, 2008).

The genetics of autism are complex, making it unclear which genes are responsible. Twin studies indicate a hereditary factor in the occurrence of autism (Hettinger, Liu & Holden, 2007). Parents with an ASD child have a 100 times greater chance of having another child with ASD than parents who have ‘normal’ children. And it appears that autism may run in families (Hettinger, Liu & Holden, 2007; Waterhouse, 2008). Some scientists believe in a genetic theory called “complex inheritance”, which suggests that many different factors determine whether or not a child will have ASD. While the onset of autism is dependent on certain genes, environmental factors may also contribute to its development.

Psychological Factors

Much of the research investigating the psychological factors behind ASD is based on notions of theory of mind (TOM). As we noted earlier, TOM refers to a person's ability to understand other people's mental states, i.e., to recognise that each person has their own set of desires, intentions, beliefs, emotions, perspective, likes, and dislikes. Or to put it simply, TOM is the capacity to see the world through another person's eyes. Most children without ASD have a full understanding of TOM by around age four. Children with ASD develop a limited TOM or do not develop it at all. This may be one of the root causes behind their problems with social aloofness and communication difficulties.

High-functioning individuals with ASD have been found to demonstrate striking abnormalities in social attention. Studies in eye tracking found that when observing social situations, autistic individuals focused more on the inanimate and irrelevant aspects of the scene, such as trying to gather social information from mouths. These findings suggest that individuals with autism may miss the social aspects and dimensions of the event while being more likely to notice non-social aspects of it (Flusberg, 2007).

Environmental Factors

Some researchers have argued that ASD is not primarily caused by genes. Such theorists claim that, although a person may be born with a pre-existing vulnerability to an ASD, the ASD will only develop if that person is exposed to specific environmental triggers. For example, women exposed to a rubella infection during pregnancy are estimated to have a 7% higher risk of giving birth to a child with an ASD.

It has also been found that women who smoke daily throughout early pregnancy are 40% more likely to give birth to a child with an ASD. New fathers who are above 40 are estimated to be six times more likely to father a child with an ASD than fathers under 40. This is possibly because a man's genetic material is more at risk of developing mutations as he gets older. Some suggested environmental factors include:
  1. The mother having a viral or bacterial infection during pregnancy
  2. Maternal smoking during pregnancy
  3. Paternal age 
  4. Air pollution
  5. Pesticides

Risk Factors
  1. Being male
  2. Maternal infections and illnesses during pregnancy
  3. Chemical Exposure (e.g., trihalomethanes, tetrachloroethylene)
  4. Infection (e.g., herpes encephalitis, meningitis, hydrocephalus)

Prevalence

It has been observed that abnormal patterns in social interaction and communication of ASD begin in infancy and the neurodevelopment delays, deficits and atypical social and communicative difficulties become apparent by the age of two years (Meadan, Otrosky, Zadhlawan & Yu, 2009). Males are four times more likely than females to be affected (one in 37 versus one in 151). In the United States, the prevalence rate of ASD has increased by 15% to one in 59 people, from one in 68 two years prior (Autism Speaks, 2018).

In 2018, Autism Spectrum Australia (Aspect) revised its autism prevalence rates from 1 in 100 to an estimated 1 in 70 people in Australia on the autism spectrum. That is an estimated 40% increase or around 353,880 people. Aspect CEO, Adrian Ford, said the new number reflects recent changes in diagnostic criteria and new national and international research, leading to expanded clinical recognition (Autism Spectrum Australia, 2018).

Symptoms

Autism Spectrum Disorders affect each person in a different way and symptoms can range from very mild to severe. The symptoms generally fall into the areas of social skills impairment, communication skills impairment, and/or restricted and repetitive behaviours. People who suffer from this disorder share some similar symptoms such as problems with social interaction, but there are differences in when the symptoms start, how severe they are, and their exact nature. The severity of the symptoms also determines the level of support required.

Individuals with ASD may have a range of behavioural symptoms, including hyperactivity, short attention span, impulsivity, aggressiveness, self-harming behaviours, and – particularly in young children – temper tantrums (APA, 2013). There may be evident abnormalities in eating (for example, diets limited to a few foods) and sleeping (for example, recurring night awakening). Abnormalities of mood or affect are also common with these disorders (for example, giggling or weeping for no apparent reason or an apparent absence of emotional reaction) (Maestro & Muratori, 2008). Let’s look at each category.

Social Skills Impairment

Social issues are some of the most common symptoms of ASD. This includes problems with the way individuals interact with others. For example, maintaining eye contact or even making simple gestures such as waving goodbye may be a challenging experience for those with this disorder. Some may not be interested in other people at all, while others on the ASD spectrum may want friends, but do not understand how to develop friendships. Many children with this disorder may have difficulty learning to take turns during communication or in play, causing other children to avoid playing with them. This creates social isolation for the ASD sufferer (CDC, 2010).

Others may experience problems with showing or talking about their feelings and may also have trouble understanding another person’s feelings, impacting on the way they interact with them. Some of the social symptoms include but are not limited to the following:
  1. Avoids eye contact
  2. Prefers to play alone
  3. Does not show interest in others
  4. Has flat or inappropriate facial expression
  5. Does not understand personal space boundaries
  6. Avoids or resists physical contact
  7. Does not respond to name by 12 months of age
  8. Has trouble understanding others’ feelings or talking about own feelings

Source: (Centre for Disease Control and Prevention (CDC), 2010)

Communication Skills Impairment

By the end of the first year of life, typically developing children demonstrate a variety of communicative means and functions to express intentions. Although most children are not producing words at this stage, they communicate by means of gestures, sounds, and eye gaze to express themselves (Shumway & Whetherby, 2009; Berk, 2007). Such communication can be limited in children with ASD. When communicating, each person with ASD has different communication skills depending on the severity of the disorder. Some may speak well while others may speak very little. Others may speak but not until later in childhood (CDC, 2010). Individuals with ASD who do speak may use language in unusual ways, as they may not be able to put words into sentences and may have difficulty listening to and comprehending what other people say.

Individuals on the ASD spectrum may experience difficulty using and understanding body language and gestures (for example: a child may not understand what it means to wave goodbye), or they may not pick up on the varied meanings of different tones of voice. When they do try to use body language or gestures, these may not be congruent with what they are saying.

For example, someone with ASD may smile while saying something sad. Individuals with these disorders may not have a perception of personal space and therefore might stand too close to the person they are talking to. They might stick with one topic for too long or talk about a topic of personal interest for too long without allowing a typical back and forth conversation with someone (CDC, 2010). All these forms of interactional interaction deficits often create communication difficulties with others.

Some of the symptoms related to communication issues include but are not limited to the following:
  1. Delayed speech and language skills
  2. Echolalia 
  3. Gives unrelated answers to questions
  4. Uses few or no gestures
  5. Comprehension problems
  6. Literal interpretation (Does not understand sarcasm, jokes or teasing)
  7. Monologue type conversational style
  8. Unusual rhythm and intonation in speech
  9. Does not pretend in play

Source: (Centre for Disease Control and Prevention (CDC), 2010; Maestro & Muratori, 2008)

Restricted and Repetitive Behaviours

Repetitive behaviours are common indicators of the disorders of this spectrum. This may involve a repetitive movement of one part of the body or the entire body, or even an object or toy. For example, individuals with ASD might repeatedly flap their hands or repeatedly turn the light on and off. Some people with ASD may also develop routines that may seem unusual or unnecessary to others. Because many who suffer from ASD thrive on routine, any change to normal patterns of the day may be very upsetting to an autistic child, resulting in severe frustration and the tantrum behaviours that are synonymous with ASD. 

Examples of repetitive behaviours include, but are not limited to, the following:
  1. Obsessive interests
  2. Intolerance of change
  3. Adherence to rigid routines
  4. Stereotyped and repetitive motor mannerisms, for example, hand flapping and body rocking
  5. Persistent preoccupation with parts of objects

Sensory Sensitivities

Many people with ASD experience sensory sensitivities, making them over- or under-sensitive to a range of sensory stimuli. This can include unusual responses to touch, smell, sounds, and taste. This is particularly common with autistic disorder in which, for example, a gentle touch may be interpreted as an attack or the individual may overreact or underreact to pain or loud noise. Abnormal eating habits are also common with this disorder, with some people limiting their diets. This can lead to overwhelming anxiety, frustration, and confusion for both autistic children and their caregivers.

References:
  1. American Psychiatric Association, (2000). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Text Revision. Washington, DC: American Psychiatric Association.
  2. American Psychiatric Association, (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th ed.) Washington, DC: American Psychiatric Association." Under the "American Psychiatric Association, (2000).
  3. Autism Speaks. (2018). CDC increases estimate of autism’s prevalence by 15%, to one in 59 children. Austism Speaks. Retrieved on 12 September, 2019, from: Website.
  4. Autism Spectrum Australia. (2018). Autism prevalence rate up 40% to an estimated 1 in 70 people. Autism Spectrum Australia. Retrieved on 12 September, 2019, from: Website.
  5. Centers for disease Control and Prevention (CDC), (2010). CDC. ASD Signs and Symptoms. Retrieved from on the 15th of May 2015 from: Website.
  6. Crespi, B., & Badcock, C. (2008). Psychosis and autism as diametrical disorders of the social brain. Behavioural and Brain Sciences, 31, 241-320.
  7. Flusberg, H.T. (2007). Evaluating the theory of mind hypothesis of autism. Current Directions in Psychological Sciences, 16, 311-315.
  8. Hammond, P., Forster-Gibson, C., Chudley, A.E., Allanson, J.E., Hutton, T.J., Farrell, S.A., McKenzie, J., Holden, J.J.A., & Lewis, M.E.S. (2008). Face brain asymmetry in autism spectrum disorders. Molecular Psychiatry, 13, 614-623.
  9. Hettinger, J.A., Liu, X., & Holden, J.J. A. (2008). The G22A polymorphism of the ADA gene and susceptibility to autism spectrum disorders. Journal of Autism Development Disorder, 38, 14-19.
  10. Kanne, S.M. & Randolph, J.K., & Farmer, J.E. (2008). Diagnostic and assessment findings: A bridge to academic planning for children with autism spectrum disorders. Neuropsychology Review, 18, 367-384.
  11. Maestro, S., & Muratori (2008). How young children with autism treat objects and people: some insights into autism in infancy from research on home movies. McGregor, Nunez, M., Cebula, K., & Gome