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Introduction of Autism - Y2 - Coggle Diagram
Introduction of Autism - Y2
Termiology, history, characteristics and prevalence of autism
Terminology and history
Medical model of autism - Bottema-Beutel et al, 2021:
Dichotimizes people as typical or atypical, or non-disabled v disabled - shift from this towards more inclusive models by not treating it as a disease
Differences associated with autism to be evidence of deficits
Assumption that disability is inherently inferior to non-disability
-> Advocates for curing these deficits via intervention
Social model of autism - Bottema-Beutel et al, 2021:
Socially valued differences in functioning or appearance, and disabilities
-> Environmentally mediated - emphasises the loss of opportunities to participate in society
Autism is disabling in societies that do not make efforts to remove barriers to participation that autistic people face
-> Acknowledge that social barriers do not explain all aspects of disability and recognise individual contributions in the context of a disabling society
-> Autism itself can be celebrated while still recognizing impairments and support needs
-> This model prompted the change in language and understanding of autism in society
Leo Kanner (1943) - Historical concept:
Infantile autism -
-> Autistic aloneness
-> Insistence on sameness
-> Islets of ability
Hans Asperger (1944) - Historical concept:
Autistic psychopathy
-> Difficulties in social integration
-> Originally of thought and exceptional achievements
Triad of impairments - Wing & Gould, 1979:
Identified a large group of children (around 15 per 10,000) who showed difficulties in social interaction, communication and imagination (referred to as the triad of impairments)
Alongside the presence of repetitive and stereotyped behaviour
Wing & Gould described these children as being on the broader 'autism spectrum'
Characteristics, classification and prevalence - DSM-V: 2013 -
Social communication skills -
-> Building friendships
-> Reciprocity
-> Initiating and maintaining
-> Emotions
-> Poorly integrated verbal and nonverbal communication
-> Eye contact
-> Gestures
-> Facial expressions
Repetitive behaviour & restricted interests
-> Repetitive motor movements (body, hand, object)
-> Insistence on sameness e.g. adherence to routines
-> Restrictive interests
-> Repetitive speech
-> Compulsive behaviours e.g. lining up objects
Pervasive
Present from childhood (although not always diagnosed in childhood)
Impacts on quality of life
Cannot be better explained by the presence of intellectual disability
Behavioural diversity - Baron-Cohen et al, 2014
-> ASC individuals score much higher in both genders on the AQ scale than controls
Diagnostic assessment - multidisciplinary input
Screening instruments - SCQ (Berument et al, 1999)
-> 40 item informant report questionnaire, binary (yes/no) responses
-> Lifetime version focuses on age 4-5
-> Score of 15 or more indicative
In-person assessments - e.g. ADOS-2 (Lord et al, 2012)
-> Gold standard semi-structured play and / or conversation focused assessment
-> 5 possible modules, depending on ability or age
-> ASD classification - calibrated severity score
Prevalence - 1.1% prevalence per 1000 people - 25 fold increase since 1966-2006:
Mixture of prevalence between ASD and other autism
Why has there been an apparent increase in prevalence -
-> Diagnostic criteria
-> Development of assessment tools
-> Public awareness
-> Research funding
-> Understanding of compensation / camoflauging
Male to female ratio in autism - 4:1 (Frith, 2008; Loomes et al, 2017) - possibly 3:1 or more common still - shows gender bias is changing
Autistic women and girls - Thompson et al, 2003:
-> Delayed diagnosis
-> Different profile of autistic characteristics - assessment tools were designed with male characteristics in mind, and so may not be able to identify autistic females who present more subtly due to masking and camouflaging
-> Focus on males in research - Rynkiewicz & Lucka (2015)
--> Measures are predominantly developed based on male samples
--> Sensitivity and specificity issues
Biological basis of autism
Strong genetic component
Twin studies provide the best evidence of genetic influence
Folstein & Rutter, 1977 -
-> Concordance for autism in MZ twins - 36% (0% in DZ) - only just a non-significant difference
-> Concordance for cognitive disorder (including autism) - 82 (10 in DZ) - difference significant
Rare genetic variations account for 10-20% of cases:
High sibling likelihood (19%; Ozonoff et al, 2011)
Broader autism phenotype
-> But, there are not yet any clear biological markers
Heterogeneity - Morton, 2004 - core deficit hypothesis
Genes -> biology -> cognition (greatest convergence of symptoms, and may be crucial to understanding autism characteristics) -> behaviour
-> More recent research has criticised this hypothesis
Cognitive theories of autism
(1) - Theory of mind account
Allows us to predict behaviour on the basis of mental states (wishes, beliefs and feelings)
Makes us better at understanding what other people are doing
Enables us to monitor the intentions of others / why they are doing something - automatic responses in social situations as a result
It is not mindreading
Mentalising in autism -
Differences in representing / interpreting another's mental state
-> Putting yourself in someone else's shoes
-> Understanding what another person thinks or feels
-> Difficulty communicating - not recognizing jokes or sarcasm etc
Theory of mind and autism - Baron-Cohen, Leslie & Frith, 1985:
False belief / Sally-Anne task - requires prediction of action on basis of attribution of false belief to other people (not on basis of own belief or reality)
Happe (1995) - autistic children have delayed development of skills - some never acquire language skills, and 50% pass by age 9 rather than age 4
-> Lower verbal mental age, and thus using language to assess theory of mind may not be valid / is confounded
Some autistic children and adults perform well on certain tests of theory of mind
-> Did they ever actually have ToM difficulty?
-> Can ToM be acquired, with long delay?
-> Are differences subtle?
-> Are different strategies being used?
Reading the mind in the eyes task - Baron-Cohen et al, 2001; harder ToM task
Implicit v explicit theory of mind - Senju et al, 2009:
Can we understand more about theory of mind abilities if we use tasks that have fewer cognitive and verbal demands?
Might there be a difference in the automaticity of theory of mind abilities rather than in the development of this skill?
Implicit task - Senju et al, 2009 - anticipatory looking paradigm
-> NTs perform significantly better than AS in this task, looking at the correct window more often
-> Could be that AS individuals develop ToM differently
Explicit and implicit mentalising tasks - Ellis et al, in prep:
Explicit mentalising tasks - performance better in NTs
Implicit mentalising tasks - autistic individuals perform worse; however, in comparison, Cornelia de Lange syndrome and Fragile X are able to perform in line with NTs whereas they do not perform on explicit tasks
-> As a result, implicit tasks may be better as assessments - reducing cognitive load can change the efficacy of assessment
Criticisms of this account
Universal - not all autistic individuals perform badly on all ToM tasks; implicit tasks show a more universal characteristic, but it is not a universal difference
Unique - others with neurodevelopmental deficits fail mentalising tasks for different reasons, but there are other indicators that these individuals and autistic individuals can understand others
-> Social impairment also emerges before mentalising emerges - counter argument of intuitive mentalising aged 2 in NTs
-> Tasks do not measure this well
-> Does not explain repetitive behaviours / fixations
Unitary - disregards emotional aspects of social communication
What about developmental progression - theory of mind changes with age, and does the process of ToM development in autism follow a different pathway e.g. neurotypicals have different results
Double Empathy problem (Milton, 2012) -
-> Recognises that autistic people have difficulty connecting with others
-> Autistic social differences are better conceptualised as operating bi-directionally for autistic and non-autistic people
-> A breakdown in reciprocity and mutual understanding that can happen between people with very differing ways of experiencing the world
-> Crompton et al, 2020 - similar story recollection in the non-autistic group, and worse performance in the mixed condition in a diffusion chain technique
--> Suggests communication deficit between non-autistic and autistic individuals, but not when autistic individuals communicate with similar others
--> In-group and out-group effect - ability to understand similar others or those that share an interaction style
--> Problems come from these interactions styles mixing
(2) Local processing bias theory
Drive for central coherence to understand the general theme - need to understand meaning:
Weak central coherence in autism leads to no attention to context and simply to local detail
It is an information processing style, not a deficit or inability
Tendency to process local details well at the expense of global meaning / context
Creates advantages when analytical skills are required
In many contexts, this is perceived as an area of strength rather than the presence of a deficit
Differences - Frith & Snowling, 1983:
Verbal tests - homographs
-> Two words spelled the same but with different pronounciations and meanings
-> Autistic individuals are more likely to read word by word instead of for sentence meaning
Verbal tests - text comprehension -
-> Difficulties integrating information across sentences
-> Tendency for lower scores on tests of verbal comprehension (uneven IQ profiles)
Strengths - White & Saldana, 2011: AS individuals perform better than NTs in these
Visuo-spatial tests - embedded figures
Visual perceptual tests - visual illusions
Cognitive strengths -
Islets of ability - about 1 in 10 have an identified skill; maths, music, art and perfect pitch
Evaluation - Drake et al, 2010; Pring et al, 1995; White & Saldana, 2011:
Universal - more appreciate of individual differences
-> However, only evidence in some but not all
-> Embedded figures task is not always replicated
Unitary - provides a complex explanation
-> But cannot explain all aspects of autistic characteristics; fixations and repetitive movements yes, but not social-communicative differences
Unique - focus on strengths over deficits only
-> But, NTs can also show local processing and islets of ability so it is not unique to autism
(3) Social motivation theory
Batki et al, 2000 - tendency to avoid eye contact, turning away in hugs, do not hug back and stiffen when picked up
Deficits in social motivation - diminished innate drive to seek acceptance and avoid rejection (Chevalier et al, 2012)
Lack of social orienting, social reward (taking pleasure in interaction) and social maintaining of social bonds - improve fitness in collaborative environments
Behavioural manifestations of human social interest - objects with social importance, rewarding social interaction and interpersonal behaviours aimed at trying to maintain and enhance relationships
Attention to social information is much lower in autistic individuals (Klin et al, 2002; Klin et al, 2008; Riby et al, 2008):
Lack of attention towards eye region - lack of attention in social orienting is robust predictor of ASD - no preference for socially salient sounds and attention deficit for speech sounds
Lack of innate prosocial behaviour which may indicate lack of social interaction interest - social anhedonia; impaired in initiating, responding to joint attention bids and less responsive to social rewards
Lack of maintenance in relationships - less influenced by considerations of impression management - no audience effect on charitable donations
Decreased attentional weight to social information, including cascading effects on the development of mature cognitive skills
Linked to orbito-frontal-striatal-amygdala circuitry and dysregulation of certain neuropeptides and neurotransmitters (oxytocin - disruption of receptor gene, deficits in glutamatergic synaptic structures in reward pathways
ASD is an extreme case of early onset diminished social motivation and provides a model for understanding humans' intrinsic drive to seek acceptance and avoid rejection
Joint attention - joint attention behaviours involve the social coordination of one's own attention with that of another person to better adopt a common point of reference and share information (Mundy, 2016)
Emerge in first 6 months of life
Critical for development of social-communication and language skills
Innate social drive -> preference for social information -> exposure to social information -> exposure to joint attention -> understanding of language and the social world -> innate social drive
Crtiicisms of social motivation theory
Unique - might not only be unique to autism - some neurodevelopmental disorders are more socially motivated, some are not, but it does provide a unique insight into the social-communicative aspect of autism
Universal - common symptom
Unitary - innate; average diagnosis of autism is after 3 years - if it was an issue with social cirucitry, this should be diagnosable in first year of life, but instead other evidence is needed
(4) - Mirror neuron theory
Suggests that deficits in the mirror neuron system prevent understanding of others intentions and feelings as exposure to a similar mechanism does not increase understanding of intentions
-> Could explain lack of empathy - unable to unconsciously copy the emotions and actions of other people, and as a result lack of social reciprocity could be explained by this
Little evidence for this, and mixed evidence also -
-> The prediction that autistic children would show less good understanding of other people's goals and goal-directed actions, and imitations of actions should be poorer - Brindley & Frith, 2007 found this does not hold up
--> They pay attention to the hand as it is related to the goal in this study, and perform similarly to NTs
Emotional resonance -
Finding that autism goes together with poor sharing of affect in social situations has not been replicated
Better to look at emotional understanding; able to understand abstract need but not localised emotions
-> Apparent indifference to other's feelings - this issue with localised emotion suggests a mirror neuron issue
-> Autistic children showed far less contagion than normally developing children - needs replicating with adults (Senju et al, 2007)
Evidence for -
-> This evidence above represents imitation to order, and thus not spontaneous imitation in a typical social context
-> Although they understand goals, they do not understand complex motivations
-> They cannot inhibit imitation, shown in echolalia, and a deeper reason for this could be lack of ToM
--> Autistic children have difficulty understanding signals that invite or prohibit imitation in particular communicative contexts
Language and communication -
Communication is reciprocal, and lack of mindfulness prevents this - it also means a lack of understanding of sarcasm, banter, tone and attitudes; inability to not take things literally
Communication struggles due to a lack of social motivation, which can also link to broken mirror theory
Criticisms -
New theory - needs to be refined to explain which social interactions go wrong in autism
Cannot explain the impoverished social life of autism
However, helps us to understand the emotional responsiveness issues in autism, and can possibly define a cognitive phenotype to be matched to a genotype
Applicable to a spectrum model, and to a model in which mentalising failure, lack of social drive and mirror system failure can be implicated as the developmental issues in autism
(5) Executive dysfunction
Lack of control - behaviour becomes less restricted:
Leads to feelings of getting stuck
Captured by incidentals
Unable to inhibit certain actions when they triggered accidentally by something that has triggered them before
Act on impulse rather than showing foresight and planning
-> Lack of inhibition - not showing some behaviours when it is not socially appropriate
Disaster zones - situations which demand flexibility are highly stressful
Can explain issues with coping with stress
Show similar deficits to those with frontal lobe damage, where executive functions are localised
Criticisms -
-> No actual anatomical abnormalities - poor functioning could be due to faults elsewhere, faults in connectivity
-> This is a widely accepted theory - however, it is not unique to autism
(6) Beyond the core deficit hypothesis
Core deficit hypothesis states that a single impairment explains multiple cognitive, behavioural and neurobiological phenomena and all profiles within a diagnostic category
Criticisms - Pearson et al, 2021 -
-> Medical model / deficit model - negative assumptions of autism
-> Cognition as a central cause - if this was the case, cognitive treatment would be highly effective
-> Failure to address other areas of need
-> Translation to functional differences is low
Study designs do not capture heterogeneity and diversity (Pearson et al, 2021; Astle & Fletcher-Watson, 2020; Jenner & Moss, 2024)
-> Highly selective samples - e.g. exclusion of participants with co-occuring conditions
-> Group-level statistics evaluating group differences as evidence of presence/absence of deficit
-> Variability in performance is rarely evaluated
-> Heterogeneity is seen as 'noise' in the data set
Moving beyond the core deficit hypothesis -
-> Unlikely that there will be single explanation that helps us to understand the development of autism
-> Focusing on core deficits results in less focus on key areas of need
Diversity and diagnosis -
Department of Education, 2018; National Center for Education Statistics, 2020:
Diversity / heterogeneity as a barrier to clinical diagnosis and support
14-30% of children experience barriers to learning, diagnosis and support worldwide
Other theories
May be interesting to consider that autism may be a result of differing perception - NTs process top-down, and autistic individuals process bottom-down
This differing in process could explain dysfunction, and alongside other systems of social misunderstanding could contribute to the characteristics seen in autistic individuals
Lack of top-down modulation can manifest in heterogenous condition presentation
Could the sense of self capture the autistic-characteristic mismatch between top-down control and bottom-up delivery
Behavioural observation
What is behavioural observation:
When behaviour is systematically described, monitored, classified and analysed
Why do we observe behaviour:
Psychology is the study of behaviour, and cognitive psychology is the study of mental processes underlying this behaviour
Clinically -
-> Diagnostic categories are behaviourally defined
-> Used to measure symptoms before and after treatment
-> Used to measure symptoms to relate them to other behaviours, cognitive processes or neural function
-> Used to identify risk markers which help predict future outcomes
Methods for observing behaviour -
Environment -
Naturalistic
-> More representative and ecologically valid
-> Exploratory and no control of the environment - causal only in that specific context
Controlled -
-> Structured, semi-structured or unstructured
-> Easier to replicate, more likely to know why a behaviour occurs and to get the same behaviour from multiple participants
-> Hypothesis driven
Methods of recording behaviour -
Description
Simple checklist
Temporal checklist
Real time coding - frequency / duration
Severity checklist
Rating scale / Summation
Natural observation - involves groups, play and transition
-> Being able to identify behaviours and the context of them to provide intervention for this
Structured observation - Moss et al, 2013:
Responsive interaction - low social demand, adult available, toys present
No interaction - low social demand, adult not available, toys present
High interaction - high social demand, adult available and toys present
No interaction control - low social demand, adult not available and no toys present
-> Attempting to observe what non-verbal communication strategies might look like in various children with varying abilities
Autism Diagnostic Observation Schedule (Lord et al, 1994) - ADOS:
Semi-structured assessment of social and communication behaviours
Different modules for different ages and level of verbal ability
Involves standardised activities - standardised rating codes which are used to categorise the observations
Includes planned social presses
Not used on its own for diagnosis
‘Gold standard’
Real time coding -
Clear definitions of the behaviour being coded before it is coded - very specific to the point that it is objective
Rating scale example - child sociability rating scale - (not as clearly defined, but according to the level of detail you need this would impact the scale you choose):
Positive emotional affect - positive facial expressions, vocalisations, manner, smiling, laughing and clapping hands
-> 0 - no examples of positive affect at any stage
-> 1 - some examples of positive affect but only tentative or occasional
-> 2 - affect positive about half of the time, may consist of brief expressions of positive affect in response to particular activities - not sustained
-> 3 - affect positive most of the time - brief expressions of positive affect in response to particular activities, but also sometimes sustained between these instances
-> 4 - affect generally positive throughout and often sustained between expressions of positive affect in response to particular activities
Negative emotional affect - negative facial expressions, vocalisations, and manner such as crying, frowning, participant may appear distressed or angry
-> 0 - no examples
-> 1 - some examples of negative affect
-> 2 - affect negative half of the time
-> 3 - negative affect most of the time
-> 4 - negative affect generally and sustained negative affect
Advantages of observation over other self or informant report measures -
Good interrater reliability
Less prescriptive
More likely to understand why the behaviour happened
More representative
Disadvantages of behaviour -
Time, money, resource intensive
Training required for ADOS
Discrete time period
Single environment
Presence of observer can alter a behaviour
Other rating scales - used for observing behaviour quickly as a replacement for self or informant report:
The Adolescent Empathy Spectrum Quotient
Autism Spectrum Quotient
Social Anxiety and Motivation rating scales
Sociability Questionnaire for People with Intellectual Disabilities (SQID)