Autism-Spectrum-Disorders

What are autism spectrum disorders?

There is not the one autism, because every autistic person is different. Historically, two authors in particular are associated with the development: In 1944, the American child and adolescent psychiatrist Leo Kanner (1896 – 1981), based on his own observations of a group of younger children, described the disorder that is known today as early childhood autism or Kanner syndrome. His observations included, above all, the early onset of symptoms, severely restricted speech development, motor impairments and a frequently associated reduction in intelligence. At about the same time, but independently, Hans Asperger came to his own research findings in Vienna. He observed a group of older children in whom deficits in social interaction and special interests developed from the third to the fifth year of life, while language development was essentially age-appropriate and a normal distribution of intelligence was evident. The phenomenon he described is known today as Asperger syndrome.

The categories of Kanner and Asperger, which have found their way into the ICD-10 essentially as described by the authors, do not, however, cover all affected persons. In addition to the images mentioned, other forms of the disorder, such as “atypical autism” are described in the ICD-10.

However, the different manifestations of autism and the range of symptoms cannot be satisfactorily covered by the categories of the ICD-10. There is more to be said for the assumption of a “spectrum” than for the assumption of clearly definable “types” of autism. Therefore, in recent years, the term autism spectrum disorder (ASD) has become increasingly accepted to better capture the broad variability and has now also found its way into DSM-V and ICD-11 (Röttgers & Rentmeister, 2020).

Appearance/Symptoms

From a parental and therapeutic point of view, the most important symptoms of ASD in childhood are abnormalities in the areas of attention, information processing, emotional development, interaction and learning.

Autistic children find it difficult to consciously focus their attention on one stimulus and to select it among many. They are overwhelmed with the high parallel stimulus presentation in our environment. In addition, it is difficult to combine incoming individual pieces of information into an overall picture at the same time. Therefore, especially the processing of complex stimuli, for example received via different sensory modalities, is disturbed.

The emotional development of children with ASD is regularly impaired. For example, some children on the autistic spectrum often have very limited ability to recognize and interpret their own feelings and the feelings of others, and to respond in socially appropriate ways. They have difficulty empathizing with others and their emotional state, sharing attention and interests with others, and understanding the intentions and actions of those around them. The ability to understand, interpret, and predict one’s own emotional feelings, thoughts, and intentions as well as the emotional feelings, thoughts, and intentions of others is called Theory of Mind (ToM). Impairments in ToM are therefore considered an important neuropsychological characteristic of people with ASD.

Autistic people also have difficulty interpreting and responding to social cues and situations. Many signals, especially implicit signals, which are necessary for appropriate and functioning social interaction and communication, are overlooked or not understood by people from the autistic spectrum (e.g. nonverbal communication signals such as gestures, facial expressions, body posture, etc.). Accordingly, interaction with other people may be severely impaired. Persons with ASD and more severe symptoms often have a severely limited motivation to relate to other people and, at first glance, a reduced need for exchange and closeness. It is open whether this was preceded by futile, unsuccessful attempts at communication and these were abandoned at some point or whether there are actually fewer needs; both variants are probably conceivable. In both cases this leads to the fact that autistic children find learning (in social situations) difficult. The possibility to learn by imitation is largely missing, because unlike non-autistic children they do not continuously observe their fellow human beings spontaneously in order to imitate their behavior and to learn by repeating what they observe. Especially in the social area, the acquisition of new skills is limited, since many severely impaired children with ASD hardly react spontaneously to social reinforcers. Due to this lack of stimuli and learning opportunities, autistic children often fall into stereotypies and isolated actions and seem to lose themselves in them. Due to a lower central coherence (ability to recognize details as belonging together), people from the autistic spectrum often pay close attention to details, but fail to recognize the big picture (e.g., they do not recognize people by their faces as a whole, but exclusively by a specific feature in the face). Executive functions are also often impaired within behavioral regulation (inhibition, switching, emotional control) and within cognitive regulation (initiative, working memory, planning & structuring, ordering & organizing, checking). These impairments regularly lead to limitations with regard to everyday activities (e.g. brushing teeth or setting the table), limited everyday skills and a limited ability to transfer (generalization).

Characteristic for ASD is the following symptom triad:

Table: Symptom triad (Freitag, et al. 2017)

Qualitative conspicuousness of reciprocal interaction

Qualitative conspicuousness of communication

Limited, repetitive and stereotyped behavior patterns

Inappropriate assessment of social and emotional cues
Potential lack of response or feelings from the counterpart
Lack of behavioral modulations in different situational contexts
Reduced or absent use of social cues (e.g., eye contact), facial expressions, gestures to initiate, maintain, or terminate social contact
No sharing of interests, hobbies, or feelings with peers
No social-emotional reciprocity → more difficulties to establish relationships

Lack of social and pragmatic use of often reduced existing linguistic skills
Retarded speech development (lack of attempt to compensate with gestures or facial expressions)
Lack of or insufficient reciprocity in conversations
Monotonous speech melody
Gestures accompanying the conversation are often missing (e.g. pointing at something with a finger)
Impairment within the initiation or maintenance of reciprocal verbal exchanges
Stereotypical, repetitive and idiosyncratic use of language
Echolalia
Swapping personal pronouns
Pedantic, elaborated linguistic expression
Difficulties in metaphorical language comprehension
Lack of understanding of irony/ sarcasm
Deficiency in social imitating and “do-as-if- play”
Lack of or minor creativity and imagination

Occupation with stereotyped and limited interests and activities
Unusual interests (e.g. bells, traffic light systems, washing machines)
Intensive exercise of age-typical interests (e.g. Pokèmon)
Rigid, routine, compulsive and ritualistic execution of daily routines
Disruption of routines can lead to challenging behaviors
Specific attachment to unusual objects (especially in early childhood)
Repetitive, unusual, motor movements (e.g., hand flapping, hand & finger mannerisms)
Conspicious interest in non-functional partial elements of an object (e.g. taste, smell)

In ICD-11, the symptom domains “communication” and “social interaction” are combined, repetitive and stereotyped behaviors remain the second characterizing symptom group. When this version of the platform went to press, the ICD-11 had already been published, but had not yet been introduced in Germany; legal decisions in particular are therefore currently still linked to the ICD-10.

Emergence

Approximately 1 million people with autism spectrum disorders (ASD) live in Germany, and the number of ASD diagnoses has increased significantly in recent years (Fombonne, 2009; Kim et al 2011). The disorder is caused by a variety of genetic causes, according to consistent research findings. Four to ten hereditary traits are currently known to be involved in the development of autistic disorders. Changes in specific genomic regions and genes appear to be responsible for altered brain development that begins before birth. This leads to a reduced connection of the nerve cells and to a poorer communication of the cells with each other. Due to these changes, there is less synchronization of the individual brain areas in the processing of information in the brains of autistic people. The fact that identical twins usually both suffer from autism also confirms the genetic cause of autism. Likewise, the risk of having a child with an autistic disorder is greatly increased in a parent affected by autism. However, how exactly the neurophysiological and neuropsychological processes and mechanisms differ from normal development is not yet clearly understood. It can be assumed that there is a complex interaction, which explains the different expressions within the spectrum. Autism is therefore a result of innate neurophysiological changes and is by no means due to “wrong” educational behavior of the parents or even to emotional “refrigerator mothers”. The widespread assumption that toxic substances in vaccines lead to the disorder could also not be proven. In autistic people, certain regions in the brain (especially those important for language development and social behavior) seem to be formed differently than in neurotypically developed people. Recent findings show that autistic people do not lack the so-called mirror neurons, but they are less activated. This neurological structure literally evokes the feelings, body states or movements in us that we observe in others. Mirror neurons make it clear to us what our counterpart is feeling and allow us to empathize with the sensation or help us to imitate actions and movements. Thus, they are the neurobiological basis for our empathy ability and thus the “Theory of Mind”, i.e. the intuitive knowledge and understanding of what other people feel and the basis for learning by imitation (Röttgers & Rentmeister, 2020).

Course and prognosis

Autism is not “curable”. The disorder becomes apparent in early childhood and persists throughout life. Living with an autistic child often poses great challenges for families, as the children require a high degree of attention and are not very flexible in everyday life.

However, through learning psychology-based support programs based on autism-specific behavior therapy (AVT; Bernard-Opitz, 2014), significant improvements in all areas of disturbance as well as independence can be achieved. In an appropriate framework for autistic children, many developmental advances can be achieved and further delays can be counteracted. Learning and support measures in different areas can have a lasting effect on brain development and help the child to acquire many skills. A special therapy and support situation geared to the needs and possibilities of the child creates the basis for learning and enables the autistic child to better understand the world around him and to act appropriately in it. The early start of these autism-specific learning programs is of particular importance in order to be able to make optimal use of the developmental potential and to achieve the best possible therapeutic success (AWMF 2016, 2021). Language skills (Lord & Paul, 1997) and intelligence level (Eikeseth et al, 2002) are also important factors for therapeutic success.

Without treatment, however, the prognosis looks quite depressing. Only a small percentage of affected individuals live and work independently as adults. In one third of cases, a partially independent lifestyle is possible. The vast majority remain dependent on permanent support in adulthood (Röttgers & Rentmeister, 2020).

Introduction to autism spectrum disorder (ASD)

Watch this video on YouTube