Autism Spectrum Disorder (ASD): A brief explanation to enhance understanding

Understanding ASD
ASD manifests in an individual in three ways:

  1. Biologically
    There are multiple possible biological causes for ASD e.g. an infection in utero, genetic predisposition etc. This suggests that some treatments may be effective e.g. diet, medication, but they will only be effective in terms of assisting with education, care or management rather than ‘healing’. ASD is not a condition that can be ‘fixed’ so to speak.
  2. Behaviourally
    ASD is defined and diagnosed according to characteristic patterns of behaviour; however, no behaviours will in themselves unequivocally indicate ASD. Behaviour is essential in the recognition of ASD but by itself does not help us understand the condition nor how to approach it.
  3. Psychologically
    At this level biological factors are translated into overt behaviours as well as ways of thinking and feeling and seeing the world. An understanding on this level helps us make sense of the behaviours that characterise ASD.

The nature of ASD
Three areas of development provide diagnostic criteria for ASD:

  1. Social
    Impaired, deviant and/or extremely delayed social development- especially interpersonal development.
  2. Language and communication
    Impaired and deviant language and communication, both verbal and non-verbal.
  3. Thoughts and behaviour
    Rigidity of thought and behaviour and poor social imagination e.g. ritualistic behaviour, reliance on routines or absence of pretend play.

Features evident in ASD
Any disorder has core features which a person must show in order to receive the diagnosis, but there are also non-essential factors that a person may or may not display. Since ASD commonly occurs with associated disorders, such as general learning or specific language disorders, it is necessary to separate the difficulties that are from ASD alone from those that are common to other disorders. However, these associated difficulties cannot be ignored.
The notion of an autistic spectrum covers the idea that there is not one, ‘pure’ syndrome or separate syndromes. All ASD disorders may present differently among individuals but still be considered to fall on the autism spectrum. The clinical picture of ASD varies between and even within individuals according to age and intellectual ability.

A definition for practical purposes
When considering the special needs of an individual we need to consider all of those who fall within the spectrum, from those who have additional profound and multiple learning difficulties through to those within the normal range of intelligence, and up to ‘gifted’. The range of difficulties in the triad of impairments would then be:

  1. Difficulties in interacting with parents, teachers, carers and peers. This will include the classically ‘aloof’ individual, but also those who respond to social interaction (although they may be unable to initiate it) through to the ‘active but odd’ individual who seeks social interaction but who is socially naive and doesn’t seem to be able to quite get it right.
  2. Difficulties in all aspects of communication. The autistic problem concerns communication rather than language per se. There will be difficulties in holding conversations, with the individual talking ‘at’ rather than ‘to’ or ‘with’ people. There will also be difficulties in understanding and using facial expressions, body postures and communicative gestures. At the more extreme end of the spectrum an individual may have the same difficulties with understanding communication but will have no speech and will not easily compensate with signs or communicative gestures. Communication is typically directed at having needs met rather than sharing information.
  3. Difficulties in flexible thinking and behaviour. This is shown in repetitive and stereotyped behaviour and, in some individuals, an extreme reaction to change in expected situations or routine. Play is not socially creative or symbolic and tends to be isolated. The more able show these difficulties in their development of obsessive interests or ‘hobbies’ that are pursued at the expense of everything else. Understanding of fiction is minimal. Learning is by rote.

The special needs of any individual will, of course, not be determined solely by developmental difficulties but will be the result of interactions between abilities and disabilities and the learning environment. As the child grows to adulthood, the effect of education and the kind of experiences he has had will have an increasing role in determining his current behaviour and ways of thinking.
Again, there are no behaviours that by their presence or absence indicate ASD; it is the overall pattern and the underlying difficulties that define ASD.

ASD and Behaviour

Behavioural criteria for diagnosis
As has been mentioned, ASD is defined on the basis of behaviour. This is essential in a condition where there is no (at least as yet) identifiable biological marker for the condition. This does not mean, however, that there are certain behaviours that are in themselves ‘autistic’. It is important to note that one cannot look at any single behaviour or any single lack of behaviour and use this to decide whether someone does or does not fit a diagnosis of ASD e.g. one cannot say “he does not look at people therefore he has autism” or conversely, “he makes good eye contact therefore he does not have autism”. What one is looking for is a specific pattern of abilities and disabilities. The safest thing to do when faced with an autistic-like pattern is to assume that the individual falls somewhere within the autistic spectrum. To treat someone without ASD as though they had it is likely to be less damaging in most cases than to ignore someone’s very real difficulties because the diagnosis is not secure.

Differences in behaviour between individuals with ASD
Problems of socialisation, communication and rigidity are sufficient and necessary to describe much of the behaviour found to be specific and universal to ASD, provided they all occur together. However, the way each area of impairment manifests itself in any individual will differ both between individuals in the spectrum and in the same individual over the course of time (or even in different contexts). For example, when considering the way in which the communication handicap may manifest, the actual amount and structural quality of the language used is a poor guide to the difficulties experienced, and ASD is often a situation where speech may be greater than understanding. Similarly, an underlying impairment in spontaneous or flexible thinking and behaviour can manifest differently between children with ASD but also within the same individual from childhood to adulthood. In addition to this, the difficulties in interpersonal engagement will always be present in ASD but will be manifest in different ways. A person on the autism spectrum may run away from social approaches, may cause others to leave them alone through apparently ‘antisocial’ behaviour, or may in effect avoid quality conversation by appearing to be very talkative (although in a repetitive, habitualistic or obsessive manner). They may pester people, even strangers, with questions or monologues and approach people too closely, making no distinction for different levels of intimacy. These individuals may be desperate to have friends and may thus make themselves vulnerable to abuse in their attempt to have a friend at any cost.
It is the behaviour of people with ASD which leads to their diagnosis and it is only their behaviour which can be observed and needs to be coped with directly. However, we cannot really deal effectively with ASD by simply reacting to the behaviours shown, we need to understand the way the individual is thinking and feeling if we are to work out what those behaviours mean- we cannot assume they have the same root or the same meaning as similar behaviours seen in normal development.

How early can ASD be diagnosed?
It is a generally accepted view that autism can only be diagnosed from the age of about 3 or 4 years as the types of behaviours that are impaired in ASD typically emerge from this age. However, some of the precursors to these behavioural deviations can be seen in earlier developmental steps. The difficulty with ASD is that there are no biological markers at birth. Differences in the child’s behaviour are also often only noticed at a later age and brought to the attention of professionals as parents have different degrees of knowledge of normal development, different expectations of how babies should behave and differing degrees of tolerance for deviation from this norm. It has been argued that there are some reliable indicators of autism from age 18 months, however, some children who display these indicators have been known to ‘grow out of them’ in some way and in some cases develop other indicators.

The Importance of Diagnosis in Education and Care

The assumption is made that all those who work with individuals with ASD are in effect ‘teachers’ and are engaged in ‘education’ whether this takes place in a school, in the home, or in the community. Responding at the level of behaviour only may lead to unhelpful or even damaging misinterpretations of the individual’s behaviour and a consequent failure to identify and respond to true needs. This is why it becomes necessary to explore the psychology behind ASD to provide an explanation of said behaviour. It is often the case with an individual with ASD that not only does he not understand what another person is thinking or feeling, but he doesn’t understand that people are thinking and feeling. In the case of more able individuals with ASD it is possible that he may come to understand this, albeit at a much later stage than is developmentally typical. In addition to this, the route by which they reach this understanding may be different to the normal developmental route and the development may stop short of the next level of understanding (that people can have thoughts and feelings about their and others thoughts and feelings).
Put simply, looking beyond behaviour to psychological functioning is a more reliable guide to the nature of ASD and to its treatment. A fundamental difficulty in understanding thoughts and feelings would lead to:

  • Difficulty in predicting behaviour → finding people aversive
  • Difficulty understanding emotions → lack of empathy, poor emotional expression
  • No understanding of what others can be expected to know → language pedantic or ambiguous
  • No idea that one can affect the way others think or feel → no conscience, no motivation to please, no communicative intent
  • No sharing of attention → idiosyncratic reference
  • Lack of understanding of social conventions including conversational strategies → no signalling with eyes, poor interaction, poor turn-taking, poor topic maintenance

The central role of education
Biological research is a long way from offering a ‘cure’ for ASD and education remains the one treatment approach with the best track record for dealing with the difficulties associated with this disorder. Access to the right kind of education can have a central role in remediating the effects of ASD (not curing it) and improving the quality of life for individuals. A compensatory approach in conjunction with a remedial approach will be more effective in impacting on the way an individual thinks and behaves. A remedial approach is one that helps the individual learn and think more effectively and does not just teach compensatory skills. The aim is not to remediate in a biological sense (to ‘cure’) but to provide compensatory routes to learning at a psychological rather than behavioural level. What is fundamental to either a remedial or compensatory approach is an understanding of the way an autistic learner learns and understands the world.
There should not be confusion between education and schooling. Services for children carry the label ‘education’ and those for adults carry the label ‘care’ – both of which should be aspects of all services for ASD throughout life. Individuals with ASD continue to learn and make cognitive gains throughout life.

A Closer Look at the Individual with ASD
As we know, the manifestations of ASD vary between individuals and within one individual over time while retaining aspects of the triad of impairments from which ASD is defined. Rather than categorising ASD or the individual into symptoms, carers should look for the areas of vulnerability and provide appropriate support. This is a group of individuals who will always need people to care for them so it is imperative that they have their ASD acknowledged and addressed.

Problems in education and management
It is helpful to have someone to guide and assist learning for most people but for individuals with ASD the very presence of another person may be stressful and counterproductive to learning. An individual with ASD may learn faster when able to learn by him/herself, perhaps with computer assisted learning. Learning interactional skills would need to be taught separately. When placing an individual with ASD into a mainstream location, that individual needs to be taught how to interact if he/she is to gain anything from interactions. The ‘receiving group’ will also need guidance on how to interact with the individual with ASD and be provided with an explanation of possible behaviour.

Particular social difficulties
What is striking in individuals with ASD is the lack of understanding of the two-way nature of a relationship. They may display attachment behaviour to another person but it is often of the same quality, or serves the same purpose, as an attachment to a familiar or obsessional object. This is not meant to demean the feelings of those with ASD but rather to highlight that behavioural observations can be misleading. The observed behaviour has to be interpreted within the developmental context. It also needs to be recognised that the same apparent behaviour could arise in different ways and serve different purposes for the individual. Also important to note is that it is the quality of social interaction which is different- not the quantity. Thus the individual may show great willingness to interact socially; however, the interaction may be superficial or meaningless to others. In addition to this, their ‘knowing’ about themselves may be at the level of knowing about themselves and not extend to a sense of themselves. When it comes to emotional awareness, children with ASD may not have difficulty labelling pictures of emotions but are likely to struggle with coordinating verbal and non-verbal behaviours involved in real life situations.

Cognitive Impairments
Research has found that IQ is stable over time and that attention, associative memory and rule-learned abstractions may be strong or average. It is abstractions involving cognitive flexibility, verbal reasoning, complex memory and complex language (among others) which are the areas usually found with deficits. It is, however, unclear if repetitive stereotyped behaviour is due to a cognitive difficulty in expressing spontaneous and independent behaviour or whether it is a type of substitute behavioural response to overwhelming social, emotional or cognitive cues. Difficulties have also been found to lie in cognitive processing and storing knowledge, primarily in the verbal domain. An inability to reflect on one’s own thinking as well as failure to appreciate the thinking of others may mean that it becomes difficult to learn principles and strategies for problem solving cannot be reflected upon or modified. Learning thus becomes very context-bound and there is difficulty generalising to other contexts. Shifting attention between modalities and spatial attention as well as executive function (higher order) tasks have also been found to be largely impaired. Cognitive impairments lead to further difficulties in extracting meaning from experiences (especially social or cultural meaning). Because individuals with ASD struggle to perceive wider social or cognitive meanings they tend to have low tolerance for changes in behaviour or routine and are likely to seek to make their lives predictable and rely on routine. Wild outbursts may be common and are characteristic of individuals with ASD, as are compulsive routines and rituals. These behaviours are not abnormal if we view them as manifestations of someone under stress with very few alternative ways of expressing it or limited problem solving skills to explore the available options.
Education and care needs to involve a structured learning environment that reduces stress and enables learning. This conflicts with the need to teach in the context of real situations and these two needs must be carefully balanced. Skill learning can be done through teaching in graded steps and a positive and direct teaching approach can be beneficial and should be aimed at preventing the individual from retreating into autistic-like behaviour or acting out feelings. In those with additional learning difficulties, play may serve the sole function of sensory stimulation rather than a mode of learning. An apparently bizarre focus of attention may also seem evident, for example, focusing on some minor and seemingly irrelevant feature of a picture or object rather than responding to the salient and overall meaning. When educating the individual with ASD, in order to assist the individual to improve the chances of generalisation or focusing on the salient point, it may be helpful to reduce or cut out irrelevant or excessive stimuli.
Adaptive behaviour such as self-help skills can be better than age matched individuals with learning difficulties in some instances, however communication difficulties may have a negative impact. What is most disruptive to adaptive behaviours is the extreme inflexibility of learning and that there is no ‘common sense’ or generalisability applied to everyday life. Thus all behaviour is learned behaviour and is performed in the same way and in response to the same cues- hence the difficulty with tolerating changes in routine unless well prepared, or knowing how to behave around new people or in a new situation. A reliance on routine and a lack of understanding others means that everyday life is stressful, confusing and difficult for an individual with ASD. Unacceptable behavioural responses may arise from a variety of causes, but chief among these may be reactions to this stress. Environments that are successful in reducing stress will allow the individual to see what they are supposed to be doing, where, when, how etc. Such environments alone do not help people with ASD overcome or deal with their particular difficulties but will give them the space and freedom to learn.

Communication
The range of communicative ability in the autistic spectrum is striking. On the one end of the extreme lies an entirely mute individual who does not even gesture in order to communicate. On the other extreme is a fluently speaking but pragmatically bizarre individual. ASD alone, however, does not lead to an individual failing to speak. Difficulties with language are more likely to be due to associated specific language impairments or additional learning difficulties. ASD increases these difficulties in acquiring language by robbing it of its communicative framework- it robs the child of the ability to learn language as part of the process of communicating. Communication difficulties in ASD can be difficult to detect as they are sometimes masked by adequate or even good language ability. A good use of language doesn’t mean that the individual understands how to use the language in communication or that it is understood in communicative situations. Language will be best understood when it is explicit such as when written. This creates difficulties for education as practitioners will need to find more creative, perhaps visual, ways of getting the same point across.
An additional complication of these language difficulties is that people with ASD are likely to be misinterpreted as being rude or disinterested when they simply don’t understand how to have a conversation or to attend to the contributions of others.

Needs arising from the biology of ASD
Since ASD is often associated with a range of other disorders, these children may be found to have medical needs to directly related to their ASD. For example, epilepsy is common. A full neurological examination can be very valuable in all cases of ASD.

ASD as a developmental disorder
ASD is a developmental disorder and lasts throughout life. As the individual gets older, carers and teachers have to assist with issues such as sexuality, independent living, and employment. In some cases secondary psychiatric problems such as depression may arise.
On a more optimistic note, adults with ASD often settle into a more productive and peaceful existence once the traumas of adolescence have passed. All ASD individuals are capable of acquiring new skills and reaching new understanding well into adulthood. Thus, adult provision should always involve education and not just care.

Frequently asked questions:
Can parents cause ASD?
This is a question asked by many parents, and unless one is talking about genetics, the answer is no.

Can one ‘grow out of’ ASD?
ASD is a life-long condition; however, it is possible for there to be improvement over time with appropriate education and management. More able individuals are sometimes able to learn how to function in ways that are indistinguishable from the norm.

Is ASD always characterised by special, or ‘savant’ skills?
No. Some may have savant-like abilities, for example in music, art or calculation, but they are in the minority. Others may pursue very narrow interests to the extent that they develop enormous expertise in that field. Special skills may appear to arise but this could be largely due to the unique way the individual processes information and is of limited value as it is unlikely the individual is able to exercise conscious control over or adapt the skill to various contexts. ASD is found at all IQ levels but is often accompanied by general learning difficulties (such as ADHD or Dyslexia). Interestingly, the more profound the learning difficulties the more likely it is that the individual also has ASD.

Is ASD just a ‘shell’ within which a ‘normal’ person is waiting to get out?
One may get this feeling when interacting with an individual who has ASD, but the truth is that this is a disorder of communication, socialisation and flexibility in thinking and behaviour. This means these individuals have a different way of processing information and seeing the world. People with ASD do sometimes take great strides in seeing the world the way others do, but it is an effort and often they do not see why they should make the effort. Sometimes, they don’t even think it is better to be ‘non-autistic’.