What is ASD?
ASD is a life-long neurodevelopmental disability that affects one or two in every hundred people. While every person with ASD is unique, in general, the condition affects the way people communicate and how they interact with and understand the social world. Each child or adult with ASD will have their own strengths and weaknesses, but there are key defining features which may indicate diagnosis when they are pervasive; that is, they occur in every environment. It is nonetheless accepted that some individuals ‘mask’ some of their difficulties in certain circumstances or situations, and we are very used to seeing those who do this.
Children and adults with ASD will present with difficulties in:
Social Interactions
Those with ASD often struggle to imagine what other people are thinking or feeling or to ‘read’ them based on their body language, facial expressions, the things they say, and the manner in which they say them. Difficulties in imagining that someone else might have a different perspective are described as deficits in theory of mind; that is, the knowledge that others may have very different beliefs, thoughts, motivations and desires to oneself. Individuals with ASD may also have challenges in expressing their own emotions, or even in being able to identify them. These combined issues can make the social world seem very confusing and frightening.
Individuals with ASD can present very differently in their social interactions. Many find social interaction daunting and exhausting and need to withdraw frequently. They might need more alone time, and do not appear to seek out the company of others in the typical way. Alternatively, some autistic people are keen to be with people. However, they struggle to grade their interactions and behaviour appropriately and are therefore perceived as ‘too much’ and too intense, resulting in others withdrawing from them. This can be very confusing for the autistic person, who may not understand why it is happening. Both these examples, although seemingly completely different, share similar underlying deficits in knowing how to interact with people in a ‘typical’ manner, in being able to perceive how others are responding to them, and to adjust their behaviour accordingly. Both ways of relating may be deemed socially inappropriate, and therefore making and maintaining friendships can be very difficult.
Social Communication
Individuals with ASD struggle to interpret the non-verbal communication of those around them, such as their gestures, facial expressions and body language, in addition to not ‘reading between the lines’ in the things people say.
Those with ASD might have differences in the way they speak, such as using an unusual pitch, tone, or prosody. They may struggle to turn-take in conversation and might talk excessively about their own interests without appreciating the need for reciprocity in typical social exchange.
Some individuals with ASD have little or no speech, while others have good speech and language skills, although their use of language is atypical. Sometimes echolalia is present, which is the echoing of language they hear others use, or even phrases from the TV. Those with ASD may struggle to understand humour and sarcasm. Abstract language is often hard for autistic individuals to understand, and there is a tendency to interpret what people say very literally.
Repetitive and Restrictive Behaviour
Individuals with ASD often need life to run according to a predictable routine. They can be described as self-directed or on their own agenda, which pertains to the need for things to be a certain way, that does not consider anyone else’s perspective or needs. Examples might be needing to have a shower at exactly the same time every day, or eating the same thing for dinner every day, served on the same plate. It may also include having to engage in repetitive rituals such as turning a light on and off three times or opening and closing a door in a certain way. Changes in routine or rituals can be highly distressing for those with ASD.
Autistic people can additionally engage in repetitive movements, which are sometimes called motor stereotypies. This might include hand-flapping, going rigid, spinning, or rocking. These movements are often enjoyable for people with ASD. They may also occur when they are excited, anxious or agitated as a means of trying to calm or regulate themselves.
Highly Focused Interests
Individuals with ASD often have very limited interests or hobbies, but those they are interested in can become all-consuming. This is observable from a young age. Sometimes their interests can be quite unusual and out of keeping with peers, for example, lanyards, war memorials, or bus timetables. Autistic people might be able to provide lots of facts and figures about a high interest topic, which they may enjoy sharing with others. They can, however, struggle to perceive when their listener is bored, or when it is not appropriate to talk about their interest.
The ability to be hyper-focused on specific topics means some autistic adults become experts in certain areas that those without autism might struggle to be. This means autistic adults are invaluable in some highly specialist careers.
Sensory Processing Differences
People with ASD may be overly sensitive to some sensory input, and under-sensitive to others. This might be touch, smell, sound, taste, vision, and pain. Examples include environmental noise that others barely notice because they can block it out, which is highly distracting or distressing for someone with ASD. Another example could be that a particular smell is unbearable for an individual with ASD, while minimally unpleasant or neutral for someone else.
Issues with sensory integration can have a significant impact on the daily lives of those with ASD, including making it near impossible for them to be in certain environments without adjustments in place.
Anxiety
The culmination of the above difficulties means many children and adults with ASD suffer from considerable anxiety, particularly in certain situations or when routines are disrupted. There might also be difficulties in regulating emotional responses to anxiety, leading to ‘meltdowns’ when a person’s behaviour becomes dysregulated due to feeling overwhelmed. Other autistic people ‘shut down’ rather than meltdown, which is a way of blocking out all sensory information to cope with a situation.
How is ASD Diagnosed?
The diagnostic manuals set out the criteria that need to be met to confirm a diagnosis. Many standardised diagnostic tools used in ASD assessment are created with these criteria in mind.
Diagnostic assessments at PCEA comply with NICE Guidelines (National Institute for Health and Care Excellence), which recommends that multi-disciplinary assessments be completed, such as a clinical psychologist and a speech and language therapist with appropriate expertise and neurodevelopmental conditions including ASD.
Assessments are broken down into different sections with a view to gaining a full understanding of how a child or adult is functioning in all environments. They are assessed against the diagnostic criteria set out in the DSM-5 and ICD-10.
This may include some or all of the following (with some slight differences depending on the age of the child, or if an adult is being assessed):
- Developmental history taken from family members, usually parents or carers (usually conducted via video consultation).
- Seeking triangulated views, for example, consulting a child’s school, family members, or others who know them well.
- Face-to-face Cognitive assessment.
- Face-to-face standardised assessment of social communication and interaction (such as an ADOS-2).
- Face-to-face Pragmatic speech, language and communication assessment.
Most assessments are completed on the same day, but in some circumstances, they are conducted over two days. At least two clinicians will assess the child or adult.
Does ASD look different in males and females?
While every individual with ASD will have different strengths and weaknesses, it is increasingly understood that girls and women can present differently to boys and men. In the broadest sense, girls often seem more able to mask their difficulties and to ‘fit in’ socially compared to males. Their high interest topics may also appear more in line with their peers, although they might be more intense. Consequently, girls are often diagnosed much later than boys. Boys often present with more ‘externalising’ or acting out behaviours than girls, who may be more likely to internalise their anxiety and other difficulties. The Girl with the Curly Hair Project provides very detailed information about how males and females can present differently.
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