Autism Spectrum Disorder (ASD) Prevalence by Gender, Ethnicity, and Socioeconomic Status

Description and Epidemiology **Autism spectrum disorder (ASD**): it's a serious childhood disorder that affects the ability to effectively interact and communicate with others. ASD: characteristics: 1\. It's characterized by - - 2.The problem in interacting with others, communicating their...

Description and Epidemiology **Autism spectrum disorder (ASD**): it's a serious childhood disorder that affects the ability to effectively interact and communicate with others. ASD: characteristics: 1\. It's characterized by - - 2.The problem in interacting with others, communicating their thoughts and feelings, and developing relationships, greatly impair their social functioning. 3.Their tendency to engage in repetitive behaviors, their adherence to routines, their preoccupation with idiosyncratic topics, or their unusual reactivity to sights, sounds, or smells will be strange to others. Spectrum of signs and symptoms: 1.It includes complete uninterest in interactions with others; have few verbal or nonverbal communication skills; and persistently engage in stereotyped, rigid behaviors or rituals. 2.Children may showcase comorbid intellectual disability. Unique strengths and ostracism: 1.Their repetitive behaviors may lead to being ostracized by peers. 2.IQ scores may fall within normal limits. 3.Autistic children may even have special talents, skills, or abilities. There is no such thing as a "typical" child with ASD. (It\'s the spectrum so everyone will be different and there are different levels; some have higher IQ and some others don't; still a behavioral issue and social issue) [History ] Early infantile autism: 1.ASD was first described more than 70 years ago. 2.Kanner used the term *early infantile autism* to describe 11 children who showed difficulty relating to other people and adjusting to new situations. 3.The children showed two salient features: - - Autistic psychopathy: 1.Asperger used the term *autistic psychopathy* to describe the symptoms of children. 2.They had difficulty interacting with others. 3.He noticed that they had problems approaching others and engaging them in conversation, looking others in the eye while speaking, and showing emotions. 4.Asperger's patients showed good vocabularies and basic language skills and could have lengthy conversations. ASD: today: 1.ASD is defined by - - 2.These symptoms are present in early childhood and impair everyday functioning. 3.Deficits may be in verbal communication or with expressive and receptive language. 4.Children's language skills need not be impaired for the child to be diagnosed with ASD. [Deficits in social communication] [Three areas of deficits:] 1.The most salient feature of ASD is the child's persistent deficits in **social communication** and social interaction. 2.*Social--emotional reciprocity*: the normal back-and-forth of conversation and social interactions through the sharing of interests, affect, or emotions. 3.*Nonverbal communication*: the effective use of eye contact, gestures, and facial expressions. 4.*Interpersonal relationships*: showing an interest in others and the capacity to make and keep friends. In their own world: (Social- emotional reciprocity) 1.Autistic children are often "in their own world." 2.They may avoid eye contact, seem uninterested in others' activities or reactions to their behavior and may not respond to the sound of their name, hand clapping and waving or other attention seeking acts. 3.Young children with ASD may not adopt anticipatory posture before picked up and will be reluctant to let others touch them. 4.They show little emotion and don't participate in imitative games. Relationships: artificial and one sided: (Nonverbal communication) 1.They may develop greater tolerance for social interaction with parents and other family members but children with ASD rarely initiate social interactions. 2.They appear uninterested in play activities and have great difficulty in forming friendships. 3.Even if they interact with others, their communication and social relationships look artificial and one-sided. Peer rejection: (Interpersonal relationships) 1.Older children may have few friends and social interests and may be ostracized by peers. 2.They may engage in rigid, scripted play and the adolescents may develop narrow interests or become obsessed with specific hobbies like collecting trading cards or rocks. 3.Children with ASD appear awkward or insensitive to others during social interactions which may cause peer rejection and lead to anxiety and depression. [Restricted,Repetitive Behavior, Interests or activities] [Four categories of behaviors:] 1.*Stereotyped or repetitive behaviors* including speech (e.g., repeating words or phrases), movements (e.g., hand gestures), or use of objects (e.g., lining up toys). 2.*Excessive adherence to routines or resistance to change*, such as the need to dress, eat, or bathe at a certain time or in a certain manner. 3.*Restricted, fixated interests* that are abnormal in intensity or focus, such as a fascination with hobbies that are unlike those of children of the same age and gender. 4.*Unusually high or low sensitivity to sensory input*, such as a tendency to become upset by certain sounds, textures, or tastes; or an unusually high pain threshold. Echolalia: 1.Approximately 85% of children with ASD and intellectual disability show echolalia, which is repeating words that they hear others speak or overhear on television and radio. 2.These words are taken out of context or repeated at inappropriate times, so they seem nonsensical to others. Complex ritualistic behaviors: 1.It is more common among older children with ASD and among individuals with higher intellectual functioning. 2.Some children have food rituals like eating foods in a certain order based on color and texture. 3.Other children showcase ritualistic patterns of walking around the room or turning light switches on and off. 4.A common feature of many children with ASD is their strong desire for daily routines. Fascination with idiosyncrasy: 1.Many children with ASD develop a fascination with idiosyncratic topics like intense preoccupation with the batting averages of baseball players, the birth and death dates of US presidents, or the history of certain weather patterns. 2.The specialized interests are often appropriate in content, but they are always unusual in their intensity. 3.The idiosyncratic interests become problematic when they preoccupy the child's time to the extent they interfere with other activities or social relationships. 4.Restricted, repetitive behaviors or interests usually emerge after deficits in social communication and social functioning. 5.Higher-functioning youths with ASD might insist on daily rituals in order to gain a sense of control over their otherwise stressful daily lives or in response to peer rejection. 6.Many children with ASD show unusual sensitivity to sensory stimulation like hyposensitivity to light, sound, temperature and pain or oversensitivity to stimuli like intolerance to textures of clothing. [Specifying symptoms ] [Rett syndrome and ASD:] 1.Rett syndrome can cause ASD, severe intellectual disability, and serious impairment in motor control. 2.Using the DSM-5 system, a child might be diagnosed with "autism spectrum disorder associated with Rett syndrome." Language impairment: Children with language delays or deficits might also be diagnosed with a communication disorder. Co-occurring disorders: 1.There may be any co-occurring neurodevelopmental, emotional, or behavioral disorders. 2.Some older children with ASD develop problems with depression. Severity of symptoms: 1.Two broad domains of ASD: (1) social communication and (2) restricted, repetitive behavior or interests. 2.The clinician might use a rating scale to describe severity based on the level of support the child needs in each domain. [What Disorder Frequently Occur with autism? (Communication Disorder) ] [Common comorbid condition:] 1.Communication disorders are the most common comorbid condition shown by children with ASD. 2.Children with ASD also showed deficits in speech or language. 3.The severity of these language problems is usually associated with children's verbal intelligence; children with higher verbal IQs tend to show superior language skills, although they almost always display some deficits in the use of language during social interactions. **Pronoun reversal**: 1.Although most children with ASD develop language, their use of language is often odd, rigid, or peculiar. 2.Many children with ASD show pronoun reversal. **Prosody**: 1.Children with ASD show abnormal prosody, their tone or manner of speech is atypical or awkward. 2.Some children with ASD speak mechanically. 3.Other children speak with an unusual rhythm or intonation, using a singsong voice. **Pragmatics**: 1.Almost all children with ASD who are able to speak show problems with pragmatic language. 2.Pragmatics refers to the use of language in specific social contexts, especially the natural give-and-take that occurs during conversation and the ability to tell coherent stories with appropriate background information. 3.The verbal communication of many children with ASD is often one-sided. 4.Some children show problems using language in social situations, but they do not engage in restricted, repetitive behaviors. 5.These youths are diagnosed with social (pragmatic) communication disorder, a disorder characterized by persistent problems with verbal and nonverbal communication in everyday situations. [What Disorders Frequently Occur with Autism?] [Behavioral and emotional disorders.] Common co-occurring disorders: The most common co-occurring disorders are ADHD (40% to 50%), an anxiety disorder (30% to 40%), and obsessive--compulsive disorder (OCD; 15% to 20%). [Difficulty in differentiation of autism and other disorders: ] 1.It is difficult to differentiate the symptoms of ASD and the symptoms of these other disorders. 2.Children with ASD or social anxiety disorder tend to experience distress when placed in social situations but children with ASD usually do not show anticipatory anxiety about social situations, as do youths with social anxiety disorder. 3.Both ASD and OCD are characterized by repetitive thoughts and actions. [Cognitive and language impairments:] The cognitive and language impairments shown by many children with ASD can also limit their ability to describe their symptoms accurately to clinicians. Medical problems: [Gastrointestinal problems:] Approximately 70% of children with ASD experience gastrointestinal problems like acid reflux, constipation, nausea and vomiting. [Sleep difficulties:] Sleep difficulties are also more likely among youths with ASD (44% to 86%) than youths without ASD (20% to 30%). [Seizures:] 1.A common, but serious medical problem associated with ASD is epilepsy. 2.Seizures are much more likely among children with ASD and intellectual disability (21.5%) than among children with ASD alone (8%). [What is the prevalence of Autism: Overall Prevalence] [Autism and Developmental Disabilities Monitoring (ADDM) Network:] 1.The Centers for Disease Control and Prevention established the Autism and Developmental Disabilities Monitoring (ADDM) Network to collect data regarding the prevalence of ASD at various locations in the United States. 2.The network reviews records in pediatric health clinics and hospitals, specialized programs for children with developmental disabilities (e.g., early intervention preschools), and special education programs in public schools. 3.It gathers data from only 11 geographic locations. National Health Interview Survey (NHIS): 1.It assesses ASD by randomly sampling 12,000 parents from across the United States, asking them if their child was ever diagnosed with ASD or another developmental disability. 2.Results showed that 20.8 per 1,000 children (approximately 1 in 48) have been diagnosed with ASD. 3.NHIS data are based exclusively on parental reports rather than official medical or educational records. Epidemiological data: 1.Epidemiological data from other countries also show a high prevalence of ASD, ranging from approximately 1% to 2% of children in the general population. 2.Prevalence estimates from Southeast Asia, Australia, Western Europe, and the Middle East are similar to those obtained in the United States. 3.The first epidemiological data, collected in 1978, suggested that ASD was a rare disorder, occurring in approximately 4 per 10,000 children. 4.Only 2 years ago, the prevalence estimate was 1 in 68. Increased prevalence of ASD: 1.Some experts have posited that the United States is experiencing an ASD "epidemic." 2.Some researchers attribute the recent increase in ASD, food allergies, metabolic disorders, and subtle neurological problems to unidentified environmental factors like foods additives, environmental toxins, or other teratogens or changes in lifestyle like delaying pregnancy until later in life. 3.It may also be explained by a greater number of children being diagnosed with the disorder, rather than an actual increase in the disorder itself. [Socioeconomic status, and ethnicity ] [Gender manifestations:] 1.ASD is much more common in boys than in girls. 2.Data indicates that the gender gap in ASD is narrowing. 3.Boys and girls with ASD show only minor differences in their cognition and behavior. 4.Girls earn lower average IQ scores than boys and are more likely to have severe or profound deficits in intellectual functioning. 5.Girls show greater problems with social communication than boys, whereas boys display greater severity of restricted, repetitive, and stereotyped behavior than girls. 6.Young girls are also more likely than boys to experience sleep and mood problems. Social and linguistic functioning: 1.Girls have an advantage in social and linguistic functioning compared to boys. 2.So, girls with ASD would need to show greater levels of impairment before they would be diagnosed. 3.Girls display superior social and communicative functioning at various times in development. 4.Girls show greater tendency to use language to convey emotions and share feelings than do boys. Level of hormones: 1.Male hormones lead to the development of ASD disproportionately in boys. 2.High levels of male hormones during gestation can affect the developing brain. 3.Prenatal hormones have been shown to affect the limbic system and frontal cortex. 4.Another explanation for gender differences in the prevalence of ASD is genetics. 5.Certain mutations on the X chromosome are associated with the emergence of ASD. [High income vs low income family:] 1.The prevalence of ASD also varies as a function of socioeconomic status (SES). 2.Mothers who complete college or who live in households with higher incomes are 1.4 to 2 times more likely to have a child diagnosed with ASD than mothers who do not complete high school or who live in poverty. 3\. The increased prevalence of ASD among higher-SES families may be partially attributable to higher-SES families' ability to obtain medical, educational, and behavioral services for their children and early diagnosis. 4.The prevalence of ASD varies across ethnicities: data indicate that non-Latino White children are 1.2 times more likely to be diagnosed with ASD than African American children and 1.5 times more likely to be diagnosed than Latino children. [Causes] [Earliest explanations:] 1.The earliest explanations for ASD placed considerable blame on families. 2.People believed that the parents of the patients were emotionally distant. 3.Parents were accused of showing little interest in their children's behavior, as socially aloof, and as overly intellectual. Refrigerator mothers: 1.A philosopher and writer suggested that cold and rejecting parents caused their children to develop autism. 2.In his book, he blamed cold, emotionally distant "refrigerator mothers" who caused their children to retreat into themselves in response to their dismissive parenting practices. 3.They asked parents to become warmer and more accepting of their children. Challenge: etiology of autism: 1.Researchers began challenging the old theories regarding the etiology of ASD. 2.In 1964, it was first suggested that ASD might have a neurological cause. 3.Parents of children with ASD were extremely involved in their children's development and care but assumed that they were somehow responsible for having a child with ASD. New theories: 1.New theories, which implicated genetics and neurodevelopment, slowly alleviated some of this guilt. 2.Even if we don't know what exactly causes ASD, most of the evidence points to a combination of genetic, neurobiological, and early environmental factors. [Is Autism Disorder Heritable? (genetics)] [Heritability of autism spectrum disorder:] 1.ASD has a strong genetic component and runs in families. 2.Twin studies confirm the heritability of ASD. 3.Concordance for monozygotic (MZ) twins ranges from 85% to 90%; in contrast, concordance for dizygotic (DZ) twins falls between 15% and 20%. Drop in concordance between MZ and DZ twins suggests that genes play an important role in ASD. Environmental factors: 50% of the variance in children's ASD symptoms could be attributed to environmental factors, such as their physical health, nutrition, and early home environment. **Autism genome project**: 1.Researchers believe that no single gene causes ASD. 2.Instead, multiple genes predispose individuals to a wide range of autism spectrum behaviors. 3.In the largest study so far, the Autism Genome Project, researchers in 19 countries studied approximately 1,200 families in which two or more members had ASD. 4.By looking at family members' DNA, researchers have been able to identify underlying genetic abnormalities associated with ASD. 5.It is caused by a genetic abnormality or mutation on a single portion of one gene. Project to scan genomes: 1.MSSNG is a project to scan the genomes of 10,000 individuals with ASD. 2.It is unique for two reasons: the study involves the largest number of participants with ASD to have their DNA mapped and the data will be shared by researchers worldwide so that scientists can work together to find the genetic underpinnings of the disorder. [Epigenetics] [Advanced parental age:] 1.Advanced maternal age is associated with ASD. 2.Older fathers are more likely to have children with ASD than younger men. Grandparental age: 1.Grandparental age (on both sides of the family) also increases children's risk for ASD. 2.If your father or your partner's father was older when you were born, your offspring may be at elevated risk for ASD. The association: paternal age and ASD: 1.Older men are more likely to experience genetic mutations to the DNA in their sperm cells than younger men. 2.It may be spontaneous or the result of accumulated exposure to environmental toxins over their lifespan. 3.Environmental stressors over the man's life span could lead to epigenetic changes that are passed down from one generation to the next, who might be at increased risk for ASD. [What Brain Differences Are Associated with Autism? ] [Abnormalities in structure and functioning: ] 1.Youths with ASD often have abnormalities in the structure and functioning of certain brain regions. 2.Children with ASD show a pattern of rapid brain growth and synaptic density in infancy and early childhood, followed by a period of deterioration and a loss of neural connectivity in later childhood and adolescence. Three brain regions implicated in ASD: 1.Three brain regions are specifically implicated in ASD: the amygdala, the fusiform gyrus, and portions of the prefrontal cortex. 2.These areas play important roles in the way children perceive, process, and respond to social information. **Social brain**: 1.There is also a neural pathway connecting these brain regions: the amygdala, the fusiform gyrus, and portions of the prefrontal cortex. 2.Collectively, this pathway is called the social brain. [What Brain Differences Are Associated With Autism? (Synaptic Density and Neural Connections)] [Head circumference:] 1.Studies indicated that infants later diagnosed with ASD show an unusual pattern of head growth. 2.At birth, their head circumference is similar to typically developing neonates. 3.Beginning at age 4 months, children later diagnosed with ASD tend to show a rapid increase in head circumference. 4.By age 12 months, the average head circumference of these children is typically one standard deviation larger than their peers. 5.Then, head growth tends to decelerate, such that the circumferences of children with and without ASD are again similar by late childhood. Brain density and volume: 1.The unusual pattern of head growth corresponds to abnormalities in brain density and volume. 2.ASD showed increased brain volume, surface area, and cortical thickness in early childhood but normal structure in later childhood. **Growth dysregulation hypothesis:** 1.According to this hypothesis, infants and young children later diagnosed with ASD show unusual maturation of the cortex, characterized by large head circumference, brain volume, and synaptic density. 2.Typically developing infants experience a period of rapid brain growth followed by synaptic pruning, while infants later diagnosed with ASD show only rapid growth. 3.By late adolescence or early adulthood, however, many of these individuals show an abnormal decline and possible deterioration in neural connections. Neuroimaging studies: 1.Scientists can use diffusion tensor imaging (DTI) to study connections between brain regions. 2.DTI is similar to magnetic resonance imaging (MRI), but it measures the diffusion of water molecules in brain tissue. 3.DTI is especially good at generating images of the brain's white matter which is the myelinated axons that form the connections between neurons. 4.By measuring the structural integrity of white matter, scientists can estimate the strength of connections between brain regions. 5.Children with ASD often show weakened connections between brain regions responsible for social communication, language, and movement. 6.DTI was used to study the brains of the younger siblings of children with ASD and found that these siblings often showed abnormalities in brain connectivity 6 months before they began developing ASD symptoms. [The Limbic System] [Difference in amygdala:] 1.A second brain area that sometimes differs in individuals with and without ASD is the amygdala. 2.It is located deep in the brain in a region known as the limbic system, an area important to our social and emotional functioning. 3.It becomes highly active when we watch other people's social behaviors and attempt to understand the motives for their actions or emotional displays. 4.Abnormalities in the structure or functioning of the amygdala might underlie some of the deficits shown by youths with ASD. 5.Compared to typically developing individuals, people with ASD showed significant reductions in amygdala activity. Structural studies of the brain: Studies of the brains of individuals with ASD show reduced amygdala volume or neural density relative to healthy controls. [Deficit in social understanding:] 1.Amygdala plays a role in the etiology of ASD, the evidence comes from studies of humans and animals with damage to this brain region. 2.Humans with damage to the amygdala often show deficits in social understanding that resemble those deficits displayed by high-functioning individuals with ASD. 3.They have problems recognizing and responding to others' facial expressions, detecting social faux pas, and understanding other people's intentions based on their overt behavior. [The Right Function Gyrus ] [Brain region important in autism:] 1.Another brain region that may be important to the development of ASD is the **right fusiform gyrus.** 2.This brain region is located on the underside of the temporal lobe, near the occipital lobe. 3.When healthy adults are asked to view images of human faces, especially faces displaying emotions, they show strong activation of their right fusiform gyrus. 4.Children and adolescents with ASD who are asked to process facial expressions do not show increased activation in this brain region. [Use of inferior temporal gyri:] 1.People with ASD use a different brain area, the inferior temporal gyri, to process facial information. 2.The inferior temporal gyri are usually used to process information about objects, not people. 3.This abnormality in processing may help explain the difficulty that people with ASD have understanding others' emotions and social behavior. Underactivity of the right fusiform gyrus: 1.Underactivity of this brain region in people with ASD might impair their understanding of social situations and contribute to their social deficits. 2.Underactivity is partially due to a lack of attention, motivation, or interest in faces and social interactions. 3.The right fusiform gyrus can function in children with ASD, but its performance depends on other factors like the child's motivation to engage in social stimuli. [The Prefrontal Cortex] [Brain area: cognition:] 1.Prefrontal cortex play a role in ASD. 2.This brain region is responsible for higher order cognitive activities, such as regulating attention, extracting information from the environment, organizing information, and using information to solve problems. 3.The prefrontal cortex acts like the chief executive officer of the brain: directing, organizing, and planning mental activity and behavior. 4.Children with ASD often show deficits in executive functioning. Attention to environment: Although their short-term memory is intact and sometimes exceptional, children with ASD often have difficulty paying attention to important aspects of their environment. [Deficits in organization and planning:] 1.Their lack of attention to salient social information could interfere with their ability to correctly perceive and respond to social situations. 2.Even high-functioning children with ASD show deficits in organization and planning. 3.They have difficulty processing information in flexible ways and solving problems on the spot. Repetitive, stereotyped behaviors: 1.Rigid cognitive style might explain their strong desire for sameness and repetitive, stereotyped behaviors. 2.People with damage to their prefrontal cortex show a desire for sameness and a propensity for stereotyped behaviors like individuals with ASD. [What Delays in social Cognition Are Associated with Autism?] [Lack of joint attention:] **Joint attention**: 1.It refers to the infant's ability to share attention with his caregiver on a single object or event. 2.In typically developing infants, joint attention gradually emerges between 6 and 18 months of age. 3.*Responding joint attention* and *initiating joint attention:* infant initiates a social interaction with her mother. Opportunities to learn: 1.Through joint attention, infants learn about the world around them. 2.Without joint attention, the child would miss out on countless learning opportunities. Joint attention deficit: three ways: 1.Children with ASD often show marked problems with joint attention. 2.Psychologists have documented these early deficits in three ways. Problems with social orientation: [Social orientation:] 1.It is the ability to attend to, and interact with, important aspects of their social environment. 2.Developing infants show well-developed capacities for social orientation. Effective communication: 1.Early parent--child exchanges teach children about social interactions. 2.Effective communication involves eye contact and emotional expression. 3\. Young children who are eventually diagnosed with ASD show problems with social orientation. 4.These children often do not respond when family members call their names, clap their hands, or otherwise try to attract their attention. 5.Instead, these children may appear distant or aloof. 6.A lack of responsiveness causes these children to miss out on important social information. Facial cues: 1.The eyes provide a rich source of information regarding the emotional quality and intent of others. 2.The mouth conveys less important information about social interactions. 3.Children with ASD may miss facial cues important to understanding social situations. [Delays in symbolic play.] [**Symbolic play**:] it refers to the child's ability to allow one object to represent (i.e., symbolize) another object. [Symbolic play: two ways:] 1.First, they can pretend that one object represents another object. 2.Second, children can pretend that an inanimate object represents a living thing. 3.Children diagnosed with ASD show delays in symbolic play. 4.When children with ASD begin to show symbolic play, it is usually simplistic and mechanical. Deficits in pretend play: 1.The pretend play of children with ASD tends to be more repetitive and without flexible, elaborative themes. 2.Lack of pretend play by 24 months of age can be an early sign of ASD. 3.Pretend play is a precursor to language acquisition. 4.Delays in the development of symbolic play, may be associated with the delays in language shown by many people with ASD. [Deficits in theory of mind and empathy.] [**Empathy**:] 1.It is the ability to take the perspective of another person in order to understand her thoughts, intentions, and feelings. 2.Ability to react in an empathic manner depends on two social skills; first, we need to understand that the person's mental state. 3.Second, we need to have an appropriate emotional reaction. **Theory of mind**: 1.During the preschool years, most children develop theory of mind, the notion that other people have mental states that motivate their behavior. 2.The mental states of others can be different from our own. 3.Theory of mind allows children to interpret social situations accurately and act with empathy. 4.Theory of mind emerges between 3 and 5 years of age. Children with ASD show marked deficits in theory of mind. 5.A well-developed theory of mind is necessary for most complex social interactions. [**False belief task**:] Psychologists measure theory of mind using a false belief task. ["Mind blindness":] 1.Children with ASD display "mind-blindness." 2.They are often unable to appreciate that other people have mental states that motivate and direct their actions. [How is Autism Spectrum Disorder Identified and Diagnosed?] Identification, Prevention, and Treatment [Early signs of ASD:] 1.Subtle and easily overlooked: earliest signs between 6 and 12 months of age show delays in social skills, communication and behavior. 2.Parents first become concerned when their children show delays in language acquisition between 12 and 18 months and an absence of creative, pretend play. 3.During this same time period, children with ASD may begin to show repetitive behaviors and a general preference for objects over interactions with people. 4.Clinicians can use these signs as "red flags" that might indicate the need for more thorough assessment. 5.The American Academy of Pediatrics recommends that physicians routinely screen all infants for ASD between 18 and 24 months. Gold Standard: diagnosis: 1.Autism Diagnostic Observation Schedule, Second Edition, ADOS-2, is the gold standard for diagnosing ASD in young children. 2.The ADOS-2 is a semistructured play-and interaction-based evaluation procedure that takes about 45 minutes. 3.The clinician delivers prompts or age-appropriate social cues to the child and notes how he responds. 4.The ADOS-2 assesses several domains of ASD including social interaction, communication, play, and stereotyped/restricted behaviors. 5.The ADOS-2 is supplemented with information from the Autism Diagnostic Interview, Revised ; assesses children's reciprocal social interactions, language/communication, and restricted or repetitive behaviors and interests. 6.ADOS-2 and ADI-R require extensive training, experience, and time to administer. 7.These instruments provide the most reliable and valid way of diagnosing ASD in young children. Modal age: first diagnosis: 1.Only 42% of children receive a formal ASD evaluation prior to age 3 and only one-third receive a formal ASD diagnosis prior to age 3. 2.The modal age of first diagnosis is 52 months. 3.This late age of diagnosis is unfortunate given that early treatment is most effective. [How Can We Use Applied Behavior Analysis to Treat Autism? (Applied Behavior Analysis) ] [An evidence-based approach:] 1.ABA is an evidence-based approach to improve the social communication and behavioral functioning of children with autism. 2.The therapist tries to identify and alter antecedents that lead up to a behavior and the consequences that maintain the behavior over time. ABA : principles of learning theory: 1.ABA relies on principles of learning theory, especially operant conditioning. 2.An ABA therapist might perform a functional analysis of the behavior of a child with autism. 3.The therapist would try to reduce the child's noncompliance and hand flapping by identifying the purpose of these actions. 4.Therapist might intervene by helping the mother change the way she responds to her son's noncompliance or stereotypies. 5.An alternative strategy would be to identify and alter the antecedents leading up to the child's defiance and hand flapping. [Early Intensive Behavioral Intervention] [A behavioral treatment:] 1.**Early intensive behavioral intervention (EIBI)** is a well-established, evidence-based treatment for young children with ASD. 2.EIBI is a behavioral treatment in which children are taught skills on a one-on-one basis, using principles of applied behavior analysis, especially operant conditioning and observational learning. [Common features of different EIBI programs:] 1.First: The focus of EIBI is on children's *overt behavior.* 2.Second: Behavior therapists rely on *learning theory* to guide their interventions and use modeling, prompting, and positive reinforcement to teach children new skills and to shape appropriate behavior. 3.Third: Behavior therapists *structure the child's environment* to maximize learning. 4.There is a mismatch between the abilities of the child with ASD and his environment and to compensate, learning experiences are structured so that there is a high probability that children will succeed at learning, rather than fail. **Discrete trial training**: 1.It is used to simplify the learning experience and increase the probability of skill acquisition. 2.Skills are taught systematically and behaviors designed to build upon one another to gradually improve the child's functioning. 3.Behaviors: learn to sit and maintain eye contact. 4.In a distraction-free setting the therapist gets the child's attention, usually with a verbal prompt, a clear and succinct verbal command in a structured environment including physical prompt and positive reinforcement once the child complies. 5.Reinforcers include touching/hugging, verbal praise/smiling, or food/drink. 6.Parents are then asked to practice the behavior at home. **UCLA Young Autism Project**: 1.The program accepts children under 4 years of age who have ASD and intensive behavioral training, approximately 40 hours per week, for about 3 years. 2.Six stages of EIBI program: - - - - - - 3.Effectiveness of EIBI: children who receive EIBI show large improvements in their motor skills, cognitive development, and social functioning and moderate to large improvements in adaptive behavior compared to controls. [Pivotal Response Treatment] [Limitations of discrete trial training:] 1.One limitation is that discrete trial training may not increase children's spontaneous social or linguistic behavior. 2.Second limitation of discrete trial training is that the skills that children acquire using this method do not automatically generalize to new situations or people. Address motivation and self-regulation: 1.**Pivotal response treatment** is designed to increase the motivation and self-regulation skills of children with ASD. 2.Parents are taught behavioral techniques to improve children's motivation to initiate social interactions and engage in self-directed play. 3.Parent-guided treatment leads to improvement in children's functioning and the generalization of skills outside the therapy setting. 4.Pivotal response treatment differs from discrete trial training in several ways; - - - - [Increases motivation and self-direction:] 1.Pivotal response treatment can also be used to increase children's motivation to verbally engage others. 2.Parents teach children simple questions; parents model, prompt, and reinforce children's use of the questions in naturalistic settings. 3.Parents use a similar procedure to increase children's self-direction. Support from data: 1.Data supporting the use of pivotal response treatment comes from both randomized controlled trials and single-subject studies. 2.Studies show improvements in children's social communication, play, and language skills. 3.These benefits persist after treatment. 4.Pivotal response treatment can be effectively applied in community settings and, when administered correctly, can be as effective as traditional EIBI. [TEACCH] [A comprehensive program for youth:] 1.**Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)** is a comprehensive program for youths with ASD that can be used at school. 2.It stressed understanding and compassion for children and their families. Principles: operant conditioning and observational learning: 1.TEACCH relies heavily on principles of operant conditioning and observational learning. 2.The focus of treatment is to help children with ASD fit comfortably and effectively in the classroom which is accomplished in two ways. 3.First, therapists try to expand children's behavioral repertoire by teaching them new social, communicative, and daily living skills. 4.Second, therapists attempt to structure the child's classroom environment to increase the likelihood that the child can complete activities successfully and independently. **Structured teaching**: 1.It involves a variety of structures and supports to help children understand and master the classroom environment. 2.The technique capitalizes on the developmental principle of **scaffolding**. 3.A behavioral scaffold guides and supports the developing child as he learns new skills through interactions with his environment. 4.Scaffolding can be seen in the classroom setting: organized and predictable. 5.Activity stations are clearly partitioned, color-coded, and labeled so that children can understand what behavior is to be performed in each location. 6.It is structured to minimize distractions. 7.Within each station, therapists use colors, pictures, shapes, and other prompts so that children can complete activities successfully. 8.Scaffolding of daily activities can also be seen in the use of **visual schedules;** therapists rely heavily on pictures to organize and direct children's behavior. 9.Children can also monitor their progress in daily activities by checking off tasks as they complete them. 10.Scaffolding is also used to help children perform individual activities. 11.**Hand-over-hand assistance**: 1.Scaffolding is also used to improve communication. 2.First, the therapist teaches the child to associate single objects with specific activities. 3.Later, physical objects are gradually replaced by more abstract representations for these activities. 4.Techniques are taught to parents, so that skills can generalize to the home. 5.Two therapists are assigned to a family: one works primarily with the child while the other serves chiefly as a "parent consultant." 6.Children who participate in TEACCH show large improvements in social communication and reductions in problem behavior. [How Can We Use the Developmental Social Pragmatic Model To Treat Autism? (The Developmental Social Pragmatic Model)] [Evidence-based approach to treat youths:] 1.A second evidence-based approach to treating youths with autism is based on the **developmental social--pragmatic (DSP)** model. 2.It focuses on the development of positive social interactions between very young children with autism and their caregivers. Focus on social communication skills: 1.The therapist teaches basic social communication skills that are typically delayed in children at risk for developing ASD. 2.Skills include children's capacity for joint attention, social imitation, and pretend play. 3.Therapists try to strengthen these social communication skills in infants, toddlers, and very young children with the goal of helping them catch up to their peers. 4.Children are able to master these building blocks of social communication and develop greater competency in their interactions with others. 5.Basic social communication skills are taught in naturalistic settings by clinicians, parents, or specially trained teachers and tailored to the developmental needs of the child. 6.The DSP approach teaches imitation, modeling, and pretend play during the natural flow of caregiver--child interactions and reinforce these interactions by imitating the child's behavior, modeling appropriate use of language, and encouraging the child to sustain their attention on shared activities for increasingly longer periods of time. [Reciprocal limitation and Joint Attention Training] [A naturalistic intervention:] 1.**Reciprocal imitation training (RIT)**, a naturalistic intervention that is based on the DSP model designed to improve imitation skills in toddlers and preschoolers with autism and administered by a therapist in a clinic playroom. 2.Here as children play, the therapist imitates the child's action with a duplicate toy. 3.During play, the therapist teaches the child to imitate gestures by modeling actions associated with his or her play activities. Improves social communication skills: 1.It supports the efficacy of RIT in improving the social communication skills of very young children with autism. 2.The hope is that RIT will allow children with autism to engage in more spontaneous imitation and improve their social communication skills over time. **Joint attention symbolic play engagement and regulation**: 1.A second naturalistic intervention for young children is joint attention symbolic play engagement and regulation (JASPER). 2.It is designed to improve the joint attention and symbolic play abilities of 3- and 4-year-olds with ASD. 3.Therapists use principles of applied behavior analysis to prompt, model, and reinforce a desired behavior and follow the child's play activities, imitate the child's actions, and look for opportunities to model, prompt, and reinforce joint attention and symbolic play. 4.JASPER has been developed so that it can be administered by parents and teachers. 5.JASPER has also demonstrated efficacy in improving social communication skills in nonverbal preschoolers with ASD. [The Early Start Denver Model] [Combine two approaches]: The **Early Start Denver Model (ESDM)** is a way of combining the naturalistic style of the developmental social--pragmatic approach to treatment and the behavioral focus of applied behavior analysis. [Views autism as developmental disorder:] 1.ESDM views autism as a developmental disorder that adversely affects many aspects of children's functioning. 2.They assume that children with autism progress through the same developmental sequence as children without the disorder, albeit at a slower pace. 3.Most children begin showing pretend play between 18 and 24 months, and theory of mind between 36 and 48 months, while children with autism usually do not develop these skills until later. [Curriculum, skills, session of the model:] 1.It provides a developmentally sequenced curriculum in which children are taught and allowed to practice the skills they need. 2.The therapist uses the "zone of proximal development" to select the skills for treatment. 3.This "zone" assumes that children learn best when skills are just slightly beyond their developmental level, the skills are neither too easy nor too hard. 4.Careful assessment of the child's cognitive, language, social communication, and play skills and also teaches new skills that are just beyond their current developmental level. 5.Focus on four skills : imitation, social orientation, joint attention, and positive emotion communication. 6.By helping children develop these skills as toddlers and preschoolers, ESDM therapists hope to prevent the emergence of long-term social, cognitive, and behavioral problems shown by many children with the disorder. 7.Sessions are structured around social activities that encourage joint attention and shared positive emotions where activities are designed to engage children and motivate them to interact with others and share positive feelings. 8.Activities include coloring or painting, dancing, making music, looking at picture books, building with blocks or Legos, blowing bubbles, or playing with water. 9.During these activities, therapists encourage children to practice age-appropriate eye contact, joint attention, turn-taking, social communication, and elaboration on the activity according to the child's interests. [Efficacy of ESDM:] 1.It is a way of improving the cognitive and social skills of young children with autism. 2.It can improve the objective behavioral and neurological functioning of youths. 3.It can be administered effectively In a wide range of settings. [How Can We Improve The Communication Skills Of Children With Autism? (Augmentative and Alternative Communication)] [Compensate for language deficits:] 1.**Augmentative and alternative communication (AAC) systems** compensate for the language deficits shown by some children with autism and facilitate their communication skills. 2.AAC systems can be used to temporarily augment or as a permanent means to compensate for language deficits and they are meant to complement, not replace, children's verbal language. [Four components of the system:] 1.*Symbols* are the representations of objects or actions that the child uses to communicate. 2.*Aids* are the devices that children use to send or receive messages. 3.*Strategies* refer to the way in which symbols and aids are organized. 4.*Techniques* refers to the methods that the child uses to communicate. [Choice of components:] Selection depends mostly on the needs of the child and preferences of the family. [Picture Exchange Communication System (PECS)] [To improve communicative function:] 1.The **Picture Exchange Communication System (PECS)** is one of the most widely used methods to improve the communicative functioning of children with language deficits. 2.It is a low-tech AAC system that consists of a series of line drawings or simple pictures printed on cards. 3.These symbols represent common objects or actions that children can present to caregivers to communicate their needs. [Positive reinforcement:] 1.Clinicians who use PECS use positive reinforcement to associate picture symbols with objects or activities in the environment. 2.To accomplish this task, therapists teach children to exchange a picture--symbol of an object or activity for a desired item or action. Six phases of training: Phase 1: The child learns to exchange pictures of commonly used objects in his environment for primary reinforcers, like a favorite food or drink. Phase 2: the child is taught to initiate social interactions by getting the attention of adults and handing them a picture card. Phase 3: the child learns to discriminate among many pictures in an array. Phases 4 and 5: children learn to form sentences and answer questions using the pictures. Phase 6: children expand on previously mastered skills to express more complex needs and desires using the picture symbols. This is often helpful in reducing challenging behavior by allowing youths to convey their thoughts and feelings rather than act out. [Speech-Generating Devices] [New options for communication:] 1.Tablets, smartphones, and other mobile touchscreen devices have given youths with autism and their families new options for communication. 2.Many youths with limited verbal skills rely on applications that allow them to press icons on their device to convey their needs or share their feelings. 3.Speech-generating apps include Pic a Word, PixTalk, and Proloquo2Go. 4.Users can customize the app to include frequently used objects and places, favorite foods, and customized pictures of family members and friends. 5.Children can also learn to combine icons to convey more complex thoughts. [**Visual scene display**:] 1.Youths augment their communication using a visual scene display (VSD). 2.VSDs organize them schematically in the context of a picture. 3.Photos of common scenes in the child's life are taken labeled as "hot spots" that the child can select by pressing on that region. [Effects of these devices:] 1.VSDs have been shown to increase the receptive and expressive vocabulary and functional communication skills for children with ASD. 2.They are useful with toddlers who have trouble using more complex pictures or symbols. 3.They are useful in helping children avoid feelings of frustration and displays of disruptive behavior that might arise because of limited spoken language. [Is Medication Effective for Children with Autism?] [Prescription medication:] 1.Physicians prescribe to reduce other behavior problems that might interfere with psychosocial treatment. 2.The goal of pharmacotherapy is to remove barriers to treatment so that parents, teachers, and therapists can implement behavioral interventions more effectively. As a supplement: Medication can be used to supplement behavior therapy and reduce the frequency or severity of challenging behaviors. [FDA approved medicine:] 1.Antipsychotics aripiprazole and risperidone are used for children with autism who exhibit challenging behaviors, which block dopamine receptors in the brain. 2.Antipsychotics can also cause a rare condition called metabolic syndrome, characterized by changes in blood pressure, lipid levels, and glucose metabolism. 3.Stimulant medication methylphenidate reduces hyperactivity and inattention at home and school for youths with autism and nonstimulant medication atomoxetine is found to be effective. 4.Side effects include insomnia and appetite suppression and gastrointestinal problems. [Medicine and sleep problems:] 1.Sleep problems may be caused by children's heightened sensitivity to stimuli, comorbid ADHD, or the effects of medication. 2.No medications are approved for treating sleep problems in children with autism, behavioral interventions are the first-line treatment. 3.To alleviate insomnia, a synthetic version of melatonin (a naturally occurring hormone that regulates the body's sleep--wake cycle), can be taken as a dietary supplement and has been shown to help children with autism fall asleep faster and stay asleep longer. [What Interventions Have Limited Scientific Support?] [Treatments: lack empirical support:] 1.Treatments that lack empirical support that experts have called ASD a "21st century fad magnet." 2.These treatments include interventions designed to increase children's social skills :"holding therapy" and "pet therapy"; communication skills: "facilitated communication"; emotional and behavioral functioning: "art/music therapy"; and sensorimotor functioning: "Irlen lenses." [Harmful treatments:] 1.These treatments include breathing concentrated oxygen in a pressurized chamber (hyperbaric oxygen therapy), injections of pig hormones (secretin therapy), chemical removal of mercury from the bloodstream (chelation therapy), and special diets (gluten- or casein-free foods). 2.These so-called treatments place children at risk for seizures, infection, liver and kidney damage, and nutritional deficiencies. [Three reasons for selection:] 1.Many parents are not aware of the scientific data regarding treatments for ASD, do not have access to reputable journals and professional newsletters which are often difficult to read and evaluate. 2.So they rely on advice from paraprofessionals or friends. 3.The inability to deliver the intensive, highly structured services that yield the best outcomes for children, as many practitioners do not rely on evidence-based treatments, such as EIBI or ESDM. 4.So parents who try these less-than-optimal interventions and have limited success may turn to other, less-supported therapies in the hope that these treatments might help their children. 5.Pseudoscientific "treatments" have seductive appeal. Components of evidence-based treatment: National Professional Development Center on Autism Spectrum Disorders (2020) has identified six components of evidence-based treatment for ASD: 1.Effective treatment involves *early identification and intervention*. 2.Treatment must be *intensive*. 3.Treatment must involve *repeated, planned, and structured learning opportunities*. 4.Treatment programs should have *low student-to-teacher ratios*. 5.*Parents must be active* in their children's treatment. 6.Programs must *monitor children's progress* in treatment and alter intervention strategies to meet children's needs and developing skills.