Disorders in the autism spectrum

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You’ve probably heard of it before, but what exactly is it; ‘autism’? In addition, the DSM IV (Diagnostic and Statistical Manual of Mental Disorders), a widely used classification system for diagnosing psychiatric disorders, mentions various forms of disorders in the autism spectrum. Time to further explain the autism spectrum and disorders that occur within it.

Autism: what is it?

Disorders on the autism spectrum fall under the heading ‘pervasive developmental disorders’. Pervasive means that the disorder is deeply pervasive and causes problems in several important areas. An autism spectrum disorder affects various areas of development. However, this does not mean that there is always an intellectual disability. We often see uneven development, with people developing significantly faster or less quickly in one area than in another. For example, cognitive development can be above average, while social-emotional development lags behind. Someone with an autism spectrum disorder has, among other things, a different processing of stimuli. People have difficulty seeing the context, the whole, and process each stimulus as a separate element, as it were. This is also described as ‘weak central coherence’. When talking about the problem areas of autism spectrum disorders, three core problem areas are often mentioned: communication, social functioning, flexibility and imagination. These are also called the triad.

Problem areas of autism spectrum disorders

Communication

People with autism spectrum disorder and normal intelligence usually acquire an extensive vocabulary and correct grammar. In contrast to people who, in addition to a disorder in the autism spectrum, also have an intellectual disability, their language development is not so much disturbed. What they have more difficulty with is the pragmatic aspect of communication. This has to do with the social use of language, such as exchanging roles as sender and receiver.

For someone with an autism spectrum disorder, the role of listener is difficult. They are not always aware that a message is addressed to them. As a result, they may not respond or may respond late. In addition, they experience difficulties with the non-verbal aspects of communication. This also contributes to a possible later response than expected by the sender of the message.

People with a form of autism often find it difficult to adapt the information they give to the recipient and the information they already have. This has to do, among other things, with the development of ‘Theory of mind’. I will come back to this later in this article.

In addition to the difficulties that often arise in the area of pragmatics for someone with a disorder in the autism spectrum, the urge to communicate is often also limited. It should be noted that people with a form of autism and normal intelligence often talk more than communicate. A distinction can therefore be made between the urge to speak and the urge to communicate.

People with an autism spectrum disorder generally do not adapt their communication style sufficiently to others. They often even steer the conversation in the direction of their topic of conversation or the theme they want. They have difficulty adapting their communication style to the context. For example, some have a limited range of communication styles and show the same style in almost all situations, whether it is a job interview or a conversation with the local shopkeeper. Others show different communication styles, but do this by imitating others. The other person’s behavior is then copied.

As mentioned earlier, people with a form of autism have difficulty seeing the context, the whole. This is also reflected in the field of communication. For example, depending on the context, a message can have a different meaning. Also consider puns, sarcasm and figurative language. These are often taken literally.

Finally, in the area of communication, people with normal intelligence and autism spectrum disorder may experience difficulties with the organizational aspects of communication and the non-verbal aspects of language. They do not always find it easy to check interruptions in a (group) conversation, which makes it difficult to get involved in a (group) conversation. In addition, they are more focused on the accuracy of the facts they want to tell than on the way in which they convey them.

Social functioning

People with autism have problems developing a theory of mind. This means that they have difficulty putting themselves in the other person’s shoes and assessing what their ideas, thoughts and feelings are. In test situations they can often give perfect answers in areas such as empathy, but they lack the intuition to apply this in real life. In addition, people with autism spectrum disorder experience difficulties in social finesse. They do not sense intuitively what is appropriate and what is not in certain social situations. Some use learned and self-constructed rules based on imitation to judge social situations instead of intuition. They judge social situations normatively rather than intuitively. Normally gifted people with a form of autism usually have a clear desire to participate in social life. However, the skills and knowledge to understand the subtle rules of social interplay between people are not sufficiently available. As a result, they often remain outsiders.

Flexibility and imagination

Because people with a form of autism have difficulty seeing the whole, the context, the world can sometimes seem very threatening to them. After all, how do you bring order to the chaos of separate elements and stimuli? Most people with a form of autism have an enormous urge to keep everything the same and are afraid of change. When something changes in their routine, fixed way of doing things, they lose the overview. This causes anxiety or even panic reactions. By always doing everything the same way according to the same working method or routine, they create an overview and therefore safety in life.

Many people with an autism spectrum disorder have difficulty generalizing what they have learned. For example, they may have learned something in store A, but do not apply it when they go to store B.

In addition, people with autism have difficulty planning and stereotypical and repetitive body movements occur. This may include flapping the arms or rocking the body back and forth.

Disorders in the autism spectrum

Classic autism

Characteristics of the autistic disorder, as described in DSM-IV; exclusion criteria not included:

A total of six (or more) items of 1, 2 and 3 with at least two of 1, and one each of 2 and 3:

  1. Qualitative impairment in social interactions as evidenced by at least two of the following:
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    • marked impairment in the use of various forms of nonverbal behavior, such as eye contact, facial expression, body postures, and gestures to determine social interaction
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    • failure to establish relationships with peers that are appropriate to the developmental level
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    • deficit in spontaneously trying to share pleasure, activities or achievements with others (e.g. not showing, bringing or pointing out objects of significance)
    •  
    • absence of social or emotional reciprocity
  2. Qualitative limitations in communication as evidenced by at least one of the following:
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    • delay or complete absence of spoken language development (not accompanied by an attempt to compensate for this with alternative means of communication such as gestures or facial expressions)
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    • in individuals with sufficient speech, marked limitations in the ability to initiate or maintain conversation with others
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    • stereotypical and repetitive language or peculiar use of words
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    • absence of varied spontaneous fantasy play (‘pretend games’) or socially imitative play (‘imitation’ games) appropriate to the developmental level
  3. Restricted, repetitive stereotypical patterns of behavior, interests, and activities as evidenced by at least one of the following:
    •  
    • strong preoccupation with one or more stereotypical and limited patterns of interest that is abnormal either in intensity or direction
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    • clearly rigid adherence to specific non-functional routines or rituals
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    • stereotypical and repetitive motor mannerisms (e.g. flapping or twisting with the hand or fingers or complex movements with the whole body)
    •  
    • persistent preoccupation with parts of objects


Delay in or abnormal functioning in at least one of the following areas with onset before age 3: social interactions, language as used in social communication, or symbolic or fantasy play. (Rigter, 2010)

Although a lot is written about it, classical autism is very rare. Classic autism has a prevalence of 0.04 to 0.05%. This means that the disorder occurs in approximately four to five in ten thousand children. Classic autism often occurs together with an intellectual disability.

Aspergers

Characteristics of Asperger’s described in DSM-IV:

Qualitative impairment in social interaction, as evidenced by at least two of the following:

  • marked impairment in the use of multiple nonverbal behaviors such as eye contact, facial expression, body postures, and gestures to determine social interaction
  • failure to establish developmentally appropriate relationships with peers
  • deficit in spontaneously trying to share pleasure, activities or achievements with others (e.g. not showing, bringing or pointing out objects of significance)
  • absence of social or emotional reciprocity


Restricted , repetitive, and stereotypical patterns of behavior, interests, and activities, as evidenced by at least one of the following:

  • strong preoccupation with one or more stereotypical and limited patterns of interest that is abnormal in either intensity or focus
  • clearly rigid adherence to specific non-functional routines or rituals
  • stereotypical and repetitive motor mannerisms (e.g. flapping or twisting of the hand or fingers or complex whole body movements)
  • persistent preoccupation with parts of objects

 

  • The disorder causes significant limitations in social or occupational functioning or functioning in other important areas.
  • There is no significant general delay in language development (e.g. the use of single words at the age of two years, communicative sentences at the age of three years).
  • There is no significant delay in cognitive development or in the development of age-appropriate skills for self-help, behavioral adjustment (other than within social interactions), and curiosity about the environment.
  • The criteria for another specific pervasive developmental disorder or schizophrenia are not met.

(AutSider, 2001)

Asperger’s syndrome was not yet described in the predecessor to the DSM-IV. Due to renewed interest in the disorder and increasing recognition that Asperger’s syndrome is a separate disorder, it is described in the DSM-IV. Little research has been done into the prevalence of Asperger’s syndrome. Reference is often made to Swedish research. This showed a prevalence between 0.1 and 0.3% in school-age children. This would mean that Asperger’s syndrome occurs in approximately one to three in a thousand school-age children. This figure is probably too high. However, research in other countries into the prevalence of Asperger’s syndrome is lacking.

PDD-NOS

Criteria for PDD-NOS:

  • PPD-NOS is the abbreviation for: Pervasive Developmental Disorder Not Otherwise Specified. Translated into Dutch it is called: Pervasive Developmental Disorder Not Otherwise Specified.
  • PDD-NOS is, as it were, a residual category in the field of autism spectrum disorders. PDD-NOS occurs when sufficient criteria for a specific pervasive developmental disorder are not met and there is no schizophrenia, schizotypal personality disorder or avoidant personality disorder, but a pervasive developmental disorder is indeed present.

PDD-NOS has a prevalence of 0.15 to 0.2%. This means that the disorder occurs in approximately fifteen to twenty out of every ten thousand children. However, the criteria for PDD-NOS are not entirely clear. Only a ‘severe and pervasive disability’ is written about, while the criteria for a specific pervasive developmental disorder, schizophrenia, schizotypal personality disorder or avoidant personality disorder are not met. However, it is not described which minimum criteria must be met for PDD-NOS to exist. In short: no lower limit is set. As a result, the interpretation of the scientist who makes the diagnosis plays a major role.

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