What is Autism? Understanding ASD to better serve your clients

As professionals working with individuals with autism, we get plenty of training on how to use Applied Behavior Analysis to understand their motivations, but we get little or no training on how our clients perceive the world. Here we go back to the basics to understand autism so we can support our clients with compassion and understanding.

Autism, also referred to as Autism Spectrum Disorder (ASD) refers to a broad range of neurologically diverse characteristics. The condition impacts different people in different ways making it difficult to describe the condition in one cohesive definition. Many individuals with autism experience difficulty with social interactions, struggle with communication and engage in behaviors that are problematic in some contexts. There are currently 2 diagnostic criteria for autism: impaired social interaction and restricted or repetitive interests but how individuals experience these symptoms can be very different.

Please keep in mind while reading this that autism is not a life sentence nor am I implying that autism is something bad. Individuals with autism learn and view the world differently than their peers. Identifying autism early in life can help parents and caregivers learn what they need to know to help their child thrive.

Our society has benefited greatly from contributions made by individuals with autism. Creative individuals like Jerry Seinfeld, Daryl Hannah, Emily Dickinson and Michelangelo are among those with autism. Important inventors and business leaders also qualify for a diagnosis of ASD. Among these leaders are Charles Darwin, Steve Jobs, Albert Einstein, and Bill Gates. Where would the world be today without their unique vision and perspective?

Watch this video for an overview of autism diagnostic criteria and how autism affects the individuals with this diagnosis. Then read below to find even more information.

Contents

Prevalence of Autism What Causes Autism? Early Signs of Autism Diagnosis of Autism What is High Functioning Autism? Changing Needs Symptoms of Autism Behavior and ASD Treatment for Autism

Prevalence of Autism

According to the CDC, autism rates are increasing dramatically. In 2004 only 1 in 125 children were diagnosed with autism. However, in 2014 that number jumped to 1 in 59.

Surveillance YearBirth YearNumber of
ADDM Sites
Reporting
Combined
Prevalence per
1,000 Children
(Range Across
ADDM Sites)
This is about
1 in X children
2004199688.0 (4.6-9.8)1 in 125
20061998119.0 (4.2-12.1)1 in 110
200820001411.3 (4.8-21.2) 1 in 88
201020021114.7 (5.7-21.9) 1 in 68
201220041114.5 (8.2-24.6) 1 in 69
201420061116.8 (13.1-29.31 in 59

It’s no wonder parents are so concerned. This is a big leap. But what caused it? Are there really more individuals with autism?

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What Causes Autism?

Although no one knows the exact cause(s) of autism, it is widely accepted that a variety of genetic and environmental factors are to blame. Among these are:

  • The age of the parents at conception
  • Family history of autism
  • Genetic mutations (Yu, Timothy W., 2013)
  • A mother’s exposure to certain drugs or chemicals while pregnant, including the use of alcohol (What causes autism? by WebMD)
  • Maternal metabolic conditions such as diabetes and obesity, and the use of antiseizure drugs during pregnancy. (What causes autism? by WebMD)

The video Autism — what we know (and what we don’t know yet) | Wendy Chung by TED provides more information:

What we do know is that vaccines do not cause autism. WebMD‘s article Do Vaccines Cause Autism? explains that the study that originally concluded that vaccines cause autism was conducted with only 12 children. Subsequent studies did not confirm this finding. Many parents become attached to this as a cause because it’s something they can control. Unfortunately, not vaccinating their children not only doesn’t help prevent autism, it puts their children at risk for contracting life-threatening diseases.

Is There an Autism Epidemic?

No one knows the full answer to whether there is an epidemic of autism. There are a lot of contributing factors that complicate the answer to this question.  We can’t control the variables to be able to determine if the increase is specifically linked to any one of these factors because they occur simultaneously.  Therefore it is difficult, if not impossible to determine which factor(s) cause the greatest increase in the diagnoses. Among the largest contributors for the increase in diagnoses are changes in: 

  • Diagnostic criteria from the DSM-IV to the DSM 5
  • Who was providing a diagnosis
  • Increased awareness that caused parents to seek a diagnosis or teachers to make a referral for a diagnosis
  • Criteria required in order to access services
  • Environmental factors
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Early Signs of Autism

While every individual with autism expresses symptoms differently, early identification of the condition leads to significantly improved outcomes for children who experience serious deficits. Many children can be diagnosed as early as 18 months; however, a diagnosis around the age of 3 is more common.

Anyone who has concerns about the presence of autism symptoms can make a referral for evaluation. It can be difficult for parents to recognize missed developmental milestones, especially in their first child. Often teachers identify that the child is off-track developmentally once the child enters school.

A lack of joint attention may be one of the earliest signs of autism. Joint attention occurs when 2 or more people pay attention to the same item or action at the same time. Young children with autism often fail to achieve this milestone.

Other early signs include repetitive behaviors such as lining up toys, rigidity around routines, a delay in speech development and/or a disinterest in peers. Young children with ASD often retreat from social situations, yet not all do. Some children may display distress when exposed to too much sensory input and others will seek additional sensory stimulation. Frequent reactions that are out of alignment with the situation may indicate that a child is experiencing these situations in a way that is different from his peers.

If you’re a parent, talk to your child’s pediatrician if you feel your child displays these signs. One or even all of these early signs does not equal a diagnosis. Many different factors contribute to a diagnosis; however, take these early warning signs seriously enough to ask for an assessment.

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Diagnosis of Autism

There are many different ways in which autism is diagnosed. The best method depends significantly on the reasons for seeking a diagnosis. Many professionals offer diagnoses based on varying assessment methods ranging from a simple interview to identify symptoms required by the DSM 5 to comprehensive evaluations such as the Autism Diagnostic Observation Schedule (ADOS).

The method of diagnosis greatly impacts a family’s ability to seek out services. For example, in some states, Medicaid requires a comprehensive diagnostic assessment using a standardized tool such as the ADOS or the Childhood Autism Rating Scale (CARS) in order to access ABA services. In addition, the insurance company may require that a neuropsychologist or other high level expert conduct the assessment. Often parents must wait on long waitlists for these professional assessments.

The challenge remains that parents won’t know what type of services they need until the diagnosis is confirmed. Ultimately, if you or someone you know is concerned about a child’s development, it may be best to plan for a series of appointments to confirm a diagnosis. Consider seeing a developmental pediatrician as a first step towards understanding the child’s needs. From there, the pediatrician can help you determine if you should pursue a more comprehensive diagnostic assessment.

Changing Diagnoses: Autism DSM IV vs DSM 5 Criteria

Diagnostic and Statistical Manual of Mental Disorders lists the requirements for diagnosis of autism. This publication changes periodically as understanding of disorders evolve and as society becomes more accepting of individual differences (many no longer consider autism as a disorder but rather a different way of being). As the publication changes, so does the population of children eligible for services. Understanding the diagnosis, as well as changes in the diagnostic criteria can help you know your clients in a new way, and also keep you aware of changes in the way autism is understood.

DSM IV Criteria

Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), diagnosticians relied on criteria listed in the Fourth Edition (DSM IV). In this edition, the individual must have met criteria in 3 different areas to qualify for an autism diagnosis:

  • Restricted and repetitive interests and/or movements
  • Social deficits
  • Communication deficits

Depending on where the individual’s deficits fell along the spectrum, they qualified for a variety of different diagnoses such as autism, Aspergers, or PDD. The DSM IV included different names for different manifestations of the disorder. This is no longer the case when diagnosed with autism spectrum disorder with the DSM 5 criteria.

DSM 5 Criteria

The publication of the DSM 5 (available from Amazon) sparked a sharp change in the way clinicians diagnosed autism. Rather than needing all 3 of the criteria required for a diagnosis in DSM IV, individuals only needed 2:

  • Restricted and repetitive interests and/or movements
  • Social deficits

The DSM 5 included a separate diagnosis for those children presenting with communication deficits. Individuals no longer needed significant impairments in communication to qualify for an autism diagnosis. This resulted in an autism diagnosis for many individuals who experienced serious social deficits with restricted interests but not the accompanying communication challenges.

With the publication of the DSM 5, individuals who have an intact communicative repertoire but struggle socially and engage in repetitive behaviors began to receive an autism diagnosis. The increase in children diagnosed with autism also gave these children access to much needed services they may not have been able to receive otherwise. 

Six years after the publication of this manual, we still feel the effects of these critical distinctions in the prevalence of autism.

Levels of Severity

The release of the communication deficit criteria wasn’t the only important change with the DSM 5 criteria. This change also eliminated the different names associated with the degree of impairment (Aspergers, PDD, etc.) and introduced Levels of Severity.

Level 1 “requiring support” is the lowest level of the autism spectrum disorder (ASD) diagnosis. For these individuals, their social deficits and restrictive behavior don’t significantly interfere with daily functioning. The DSM 5 specifies that this interference is without support. Many individuals who previously had an Aspergers diagnosis would fit into this level of need; however, diagnostics isn’t as linear (or as simple) as that.

Level 2 “requiring substantial support” is the median level of impairment. These individuals experience significant challenges daily. The DSM 5 incorporates deficits in social communication skills. Even though individuals may be able to communicate verbally, they may struggle with engaging in appropriate conversations with others, without support. These individuals struggle significantly with inflexibility and change.

Level 3 “requiring very substantial support” is the highest level of need for individuals with autism. These individuals often appear to be nearly entirely withdrawn. They don’t initiate social interactions and experience extreme difficulty in coping with change.

Autism Spectrum disorder is a broad diagnosis that encompasses individuals with varying abilities. Although there is no diagnosis of “high functioning autism” many use this phrase as a way to group certain people with autism whose autistic symptoms don’t prevent independent living.

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What is High Functioning Autism?

In the past the term Asperger’s was used to describe individuals whose daily lives were less impacted by their autistic traits. However this was officially removed as a separate diagnosis in the DSM 5 update and was replaced by the levels of severity. These levels may be harder for individuals outside the field to relate to, and therefore the terms Asperger’s and high functioning autism are still commonly used.

Many people who are identified as having autism in DSM 5 do not need a significant amount of support. For these individuals, their family, friends, teachers and other individuals who understand what they need may be sufficient to help them overcome challenges. In general, many would consider these individuals to have “high functioning autism.” Typically they would fall under DSM 5 level 1.

Level 1 “requiring support” is the lowest level of the autism spectrum disorder (ASD) diagnosis. For these individuals, their social deficits and restrictive behavior don’t significantly interfere with daily functioning. The DSM 5 specifies that this interference is without support. Many individuals who previously had an Aspergers diagnosis would fit into this level of need; however, diagnostics isn’t as linear (or as simple) as that.

Low Functioning vs High Functioning Autism

In contrast, the phrase “low functioning” is often used to describe someone who has significant challenges that may prevent them from participating in “normal” activities such as going to school or work. These individuals are often non-verbal and may engage in a variety of behaviors others find strange. When an individual is labeled “low functioning” assumptions may be made about what that person is capable of achieving, or even how aware they may be of what is going on around them.

Individuals with Autism Speak about High Functioning Autism

The difference between high-functioning and low-functioning is that high-functioning means your deficits are ignored and low-functioning means your assets are ignored.

Laura Tisoncik

In general, if you’ve heard the term “high functioning” in relationship to autism you probably didn’t hear it from someone who has an autism diagnosis. While some people on the spectrum don’t mind this phrase, often individuals with autism find this term to be offensive and it can lead to a misunderstanding of that person’s needs.

To understand the perspective of someone who has autism, watch as Mary Talks About Different Levels of Functioning:

As Mary points out, the term “high functioning” focuses more on how the individual’s challenges relate to what other’s consider “normal” functioning or the impact on those around them, rather than the impact on the person with the diagnosis. Mary’s view is to focus on the impact autism has on the individual’s daily life.

To further understand how level 1 or “high functioning” autism affects the individual, watch as Michael McCreary speaks about his experience with Asperger’s in Does This Make My Asperger’s Look Big?

To align with the current DSM diagnosis, we will for the remainder of this post use the term “level 1 autism” which may be considered in this context synonymous with “high functioning” autism and Asperger’s, although the true definitions may vary slightly.

Level 1 Autism and Families

Raising children can be expensive and challenging in the best of circumstances. When a child has autism the burden on families can be even greater. Social challenges, behavior problems and medical issues can be costly and stressful, even for children with level 1 autism.

The CDC estimates that children with autism incur an additional $4,110–$6,200 per year in medical expenses (4.1–6.2 times that of other children). This doesn’t include costs for behavioral interventions such as ABA.

Not surprisingly, studies show increased levels of stress in families with children with level 1 autism. (Rao and Beidel, 2009) This stress can reduce the success of interventions if families are unable to get the support they need.

Level 1 Autism and Problem Behavior

All children experience challenging behavior from time to time, including children with level 1 autism. Because children with autism tend to perceive the world differently, traditional techniques to address problem behavior are often ineffective, and can even make it worse. Applied Behavior Analysis has proven to be the most effective way to address the behavior of children with autism because it uses objective data to understand what is truly driving the behavior.

For children with level 1 autism, these strategies, known as intervention,s may need to include a plan for enhancing skills such as co-operation, assertiveness, and self-control. (Macintosh and Dissanayake, 2006)

Challenges for Individuals with Level 1 Autism

Some of the biggest challenges for individuals with level 1 autism is the expectation that they be the same as everyone else. While those with a level 2 or 3 diagnosis may receive accommodations, individuals with level 1 autism are often expected to conform to social norms. Many assume that because they may be intelligent and able to communicate, that they don’t have the same challenges as others on the spectrum.

People with level 1 autism may be very aware of their own difficulties and the negative reactions of others. Yet they are unable to control the fact that they have sensory issues, lack social awareness or experience anxiety and depression. Like others on the spectrum they may experience difficulty with transitions or change, and may struggle to maintain effective social communication.

Treatment for Level 1 Autism

While it’s true that those with level 1 autism need less support than others on the autism spectrum, they still need support to reach their full potential and help them overcome challenges that they face. These interventions might include:

  • Occupational Therapy
  • Speech Therapy
  • ABA Therapy
  • Social Skills Strategies
  • Psychotherapy
  • And more

The video What is High Functioning Autism? by Kati Morton discusses the challenges faced by these individuals and treatment options.

Living with Level 1 Autism

Do you want to understand more what it’s like to live with level 1 autism? Watch Living with High-Functioning Autism:

In A Higher Functioning Form Of Autism Cuan Weijer shares his experience:

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Changing Needs

The DSM 5 provides some strict guidelines for diagnosis. However, some individuals may move between levels of need throughout their lifetime. Perhaps when the individual has access to consistent services and a structured routine, that individual presents as Level 1 severity, but during times of turmoil (such as following the death of a parent) that individual presents as Level 2 severity.

This fluid view of the levels of severity can assist clinicians providing services to understand what the individual’s current needs are. At different points in a person’s life, their needs may be dramatically different. Services should be available to support the individual wherever they currently are.

Dr. Martin Lubetsky, MD describes more of the important changes brought about with the DSM 5.

Huerta and Lord (2012) describe a step-wise approach to ADS diagnosis which includes screening for symptoms during well-baby visits with the pediatrician and subsequent referral for a more comprehensive diagnostic assessment when concerns are noted. This multi-step approach allows parents to gather a variety of foundational information from different professionals.

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Symptoms of Autism

Autism is considered a “spectrum” meaning that the symptoms vary widely from individual to individual. ASD is often stereotyped as “Rainman” or more recently Temple Grandin.

While there is no singular presentation or “look” of autism, individuals with the condition share some common characteristics, although the intensity of these characteristics exist on a continuum from mild to a very high magnitude. All individuals with ASD have:

  • “Restricted and repetitive interests and/or movements.” For some, this hyper focus on a narrow range of interests leads to amazing accomplishments. For others, this narrow focus prevents them from participating in activities and interacting with others.
  • Impaired social interaction. This impairment might present as extreme shyness or awkwardness. Other individuals may be highly outspoken without concern for how others react to what they say. Some individuals with autism may feel extremely uncomfortable in social situations and prefer to be alone the majority of the time.

In addition to the above characteristics, many individuals with autism also experience:

  • Significant communication deficits, both functional and social communication. Some individuals may only be able to form word approximations or perhaps engage in vocal play that sounds similar to babbling. Others may be able to communicate using simple words or phrases. Many individuals who struggle to communicate through vocal verbal methods (i.e. speech) benefit from the use of Alternative and Augmentative Communication (AAC) such as PECS, speech generating devices or sign language.
  • Differences in sensory processing. Individuals with autism may recoil from too much sensory input while others seek out more and more input. For some certain types of clothing may feel unbearable. Others might crave proprioceptive input and engage in high amounts of rocking or spinning throughout the day.
  • Impairments in executive functioning skills. Executive functioning skills are the skills that help us regulate emotion, organize ourselves, control impulses, utilize working memory and think flexibly. These skills help us manage daily events and care for ourselves.
  • Other challenges including behavioral, feeding, sleeping and cognitive impairments. These challenges may be impacted by the individual’s rigidity. For example, a child who craves sameness may balk when given a different brand of chicken nuggets than he is used to. A child who reacts strongly to changes in routine might experience difficulty at bedtime with the absence of the parent who is always by his side.

What Autism Symptoms Look Like

In reality most of us display many of “autistic” traits from time to time. The difference is that for us they don’t stand out as different and they don’t interfere with our everyday lives.

Symptoms that often lead to an autism diagnosis include:

  • Stereotypies
  • Restricted interests
  • Social challenges
  • Communication challenges

In addition, there are many medical conditions that frequently co-exist with autism which can make diagnosing autism more difficult. Many of these challenges affect the quality of life of the individual or make independent living difficult, if not impossible as they get older.

Let’s look at each of these.

Stereotypies

Repetitive movements are often stereotypies, Stereotypies are repetitive behaviors that take on a variety of forms including motor movements or vocalizations. Although stereotypies are unique to the individual, common examples include:

  • Hand flapping
  • Jumping
  • Bouncing
  • Snapping fingers
  • Pushing on their eye
  • Shaking their head back and forth rapidly
  • Tapping on a table
  • Picking at their skin
  • Waving objects in front of their face
  • Marching in place

Stereotypies are not unique to people with autism. If you have ever jiggled your foot when you were nervous or tapped your fingers when you were bored then you’ve exhibited stereotypies. The difference is that you control the behaviors enough so that they aren’t noticeable to those around you.

People with autism are less aware of the impact their behavior has on others and do not attempt to control these behaviors. In fact, these behaviors often serve to soothe your child and regulate their emotions. It’s important as someone working with autistic individuals to know when you should intervene – and when you should just accept them as part of who your learner is. To better understand if and how you should intervene in a learner’s stereotypies view the section below regarding treatment of autistic symptoms.

Restricted and Focused Interests

Restricted interests is one of the defining characteristic of autism. Children with autism can be fascinated with everyday objects that most of us barely notice. They might stare intently at lights or spinning objects. It’s also common for these children to have ritualistic behaviors such as lining up objects. Similarly, children with autism generally thrive with routine.

People with autism feel most comfortable when there is order and routine in their lives. A controlled environment is often comforting for these children. When they know what to expect they feel less stress. In some cases their intense focus might help with sensory issues common in those with autism. It may also regulate their emotions in the same way stereotypies do.

Although there is nothing wrong with limited interests, it might be in a learner’s best interests to broaden them.

Social Challenges

Social deficits are the other defining criteria for autism. While many people without autism also experience social challenges, those with autism may need assistance learning critical skills. Children with autism often:

  • Have trouble recognizing emotion in themselves and others
  • Feel overwhelmed in social situations
  • Struggle taking turns, whether in play or conversation
  • Inaccurately gauging personal space
  • Lack eye contact
  • Fail to learn joint attention without guidance

These challenges make it difficult for people with autism to form relationships, especially with those who don’t understand the autism diagnosis.

Communication Challenges

Communication is a fundamental part of being human. It is how we let others know how we feel, what we need, and what we’re thinking. However, many traits common among children with autism make communication a challenge. While communication deficits are no longer considered a defining characteristic of autism, people with autism frequently struggle in this area. Issues with communication can stem from both physical and social challenges.

Physical

Childhood Apraxia of Speech (CAS) is common among children with autism (The ASHA Leader states nearly 2/3 of children diagnosed with autism). This affects the brain’s ability to direct the muscles in the mouth to form movements needed for speech, and is one of the main reasons verbal communication is difficult for people with autism.

Social

Social awareness plays a large role in communication. Being able to interpret visual and vocal cues to interpret a person’s meaning is critical to understanding a conversation. People with autism will typically take a person’s words literally, missing the meaning of idioms that others learn from a young age.

Those with autism often experience other medical conditions that aren’t directly related to their autism diagnosis. Autism Speaks provides a valuable list of Associated Medical Conditions that frequently accompany autism spectrum disorder. These include:

  • Epilepsy
  • Gastrointestinal problems
  • Feeding
  • Sleep disturbances
  • Attention-deficit/hyperactivity disorder
  • Anxiety
  • Depression
  • Obsessive compulsive disorder

Their site includes the symptoms and treatment for each. While these medical conditions aren’t indicative of autism, many autistic people will have one or more of these conditions as well.

Treatment of Autistic Symptoms

Many parents seek ABA therapy to address challenging behavior and teach their children important skills. However it’s also common for parents to want to target autistic symptoms such as stereotypies. Often this comes from fear (they’re worried their child won’t fit in) or from a lack of understanding (they don’t understand how stereotypies help their child with emotional regulation).

Before deciding whether to include autistic symptoms as part of treatment, it’s important to consider the needs of the child and whether the child will benefit from this type of intervention. If, after careful consideration, you decide that targeting these behaviors benefits the parents and not the child, it’s your responsibility to have this conversation with the parents and help them understand why they shouldn’t be targeted for change.

When to Target Stereotypies for Reduction

The early years of Applied Behavior Analysis (ABA) focused a lot of interventions on making individuals with autism appear “normal.” Clinicians attempted to mask the symptoms of autism. Children were ostracized by their peers because their stereotypes made them look “weird.” Professionals aimed to help these children be more accepted by their peers by changing these behaviors.

As we come to understand autism better, ABA professionals shift to targeting other needs for these children. The goal of making children with autism appear “normal” no longer exists. Rather, the focus directs professionals toward improving the quality of life for individuals with autism and teaching them in a way that works for them.

Before You Develop a Plan

Before deciding to intervene on a child’s stereotypies, it’s important to consider the impact they have on the child’s ability to engage in other activities. Avoid targeting stereotypies for reduction just to make him more acceptable to peers. Instead, teach other children about autism. Discuss stereotypies openly and present examples of stereotypic behavior that they also engage in (i.e. hair twirling, bouncing legs, tapping a pencil, etc.). We all engage in behaviors because they feel good. These are stereotypies. Most people are able to regulate their stereotypes so they don’t interfere with their participation in other activities.

Children with autism often engage in higher rates of stereotypies than other children for a variety of reasons. These children may engage in these behaviors in an effort to self-sooth in exciting or stressful situations. Adults with autism sometimes report that these behaviors help them regulate themselves. Keep this in mind as you decide whether or not to intervene.

Some children engage in stereotypies at such a high rate that it becomes nearly impossible for them to attend to academic, recreational, or social tasks. Some rates of vocal stereotypies prohibit vocal communication or create an environment where other children struggle to learn. Other children engage in stereotypies that pose a safety hazard such as jumping or spinning regardless of location. When these conditions occur, proceed with intervention to reduce the stereotypy or to alter it to something safer or at a more reasonable level.

Recognizing Stereotypies

Stereotypies come in many different forms, some vocal and some motor. These behaviors vary in frequency and intensity and occur at various times throughout the day. They are often unpredictable. Stereotypies fall into two categories:

  1. Vocal
  2. Motor

Vocal stereotypies may sound like babbling, humming, or a sing song sound. Any type of repetitive vocal behavior may be considered a vocal stereotypy.

People commonly think of hand flapping or repetitive jumping when referring to stereotypies in children with autism. While these behaviors are common, motor stereotypies are not limited to just these forms. Some children engage in pacing, wiggling fingers, or holding their fingers up to their eyes. Motor stereotypies may involve objects or simply be movements of the child’s own body.

Children may engage in only vocal or motor stereotypies, or both.

Defining Stereotypies

Often when defining stereotypies, using a functional definition provides more accurate and useful data than a topographical definition, unless there is one specific topography of stereotypy that is particularly disruptive or dangerous. Many children don’t engage in just one topography of stereotypy. They likely engage in several forms and if one form is unavailable, they will choose a different form.

If you want to understand exactly how often the child engages in stereotypic behavior, and you have determined that the function is likely automatic reinforcement, your definition should focus on automatically reinforced repetitive behaviors. Be sure to include many different examples and non examples, especially if you won’t be the one collecting the data.

For more help with writing a definition, read our post Operational Definitions: Clearly Define the Behavior.

Interventions for Stereotypies

Before developing an intervention plan to reduce stereotypic behavior, be very clear about your rationale and ensure that you provide the child with an alternative way to get her needs met. If the stereotypy is dangerous or prevents participation in other activities, what other ways can she self-soothe or meet her sensory needs? Can she learn to ask for time to engage in stereotypic behavior? Stereotypies should not be targeted for reduction simply because they make the child look different than other children.

Decreasing Vocal Stereotypies

Response Interruption and Redirection (RIRD) is an intervention commonly found to be effective in reducing vocal stereotypic behavior. This intervention involves several steps:

  1. Block access to the current activity
  2. Gain the child’s attention/prompt eye contact
  3. Elicit an appropriate vocalization (i.e. intraverbal, echoic, tact, etc.)
  4. Continue until the child engages in 3 consecutive correct responses without engaging in the vocal stereotypy
  5. After 3 consecutive appropriate vocalizations, provide praise and allow access to the initial activity

RIRD may have a punishing effect in that children engage in less vocal stereotypic behavior in order to avoid the procedure. Alternatively, some research suggests that the social consequence associated with appropriate vocalizations may counteract the automatic reinforcement of the stereotypy. Whatever the cause, there seems to be a correlational effect of RIRD and an increase in appropriate vocalizations.

Decreasing motor stereotypies

There appears to be less consistent research on interventions to decrease motor stereotypies. This may be due, in part, to the many different forms of these behaviors or even the possibility that they are not necessarily automatically reinforced. Some research recommends implementing differential reinforcement (for more information on implementing differential reinforcement, read the post: Differential Reinforcement: A Complete Guide). Other studies have utilized exercise to reduce stereotypic behavior.

One study found that appropriately implemented Discrete Trial Training (DTT) resulted in a decrease in motor stereotypy. It’s possible that the fast pace and rich reinforcement available during DTT influences the presence of disruptive stereotypic behavior. Read the article to learn more:

Dib, N., & Sturmey, P. (2007). Reducing Student Stereotypy by Improving Teachers’ Implementation of Discrete-trial TeachingJournal of applied behavior analysis40(2), 339-343.

A systematic review of studies that reduced stereotypic behavior suggests the importance of identifying appropriate alternative behaviors when reducing stereotypic behavior. Inevitably, when interventions have effectively reduced stereotypic behavior, other behaviors take their place. These behaviors are not always desirable. Read the article to find out more:

Lanovaz, M. J., Robertson, K. M., Soerono, K., & Watkins, N. (2013). Effects of reducing stereotypy on other behaviors: A systematic reviewResearch in Autism Spectrum Disorders7(10), 1234-1243.

Learn More

Although many stereotypies are automatically reinforced, there may also be a social component, especially if someone consistently tells them to stop, provides a reprimand, or otherwise attends to the behavior. This article discusses the possibility of stereotypies being socially reinforced and cautions against presuming the behavior is automatically reinforced:

Chao, H. T., Chen, H., Samaco, R. C., Xue, M., Chahrour, M., Yoo, J., … & Ekker, M. (2010). Dysfunction in GABA signalling mediates autism-like stereotypies and Rett syndrome phenotypesNature468(7321), 263.

Many people refer to these behaviors as “stim,” “self-stim,” or “stimming.” This assumes that the behavior is automatically reinforced and serves a sensory function. In addition, these terms conjure images of a stereotype and doesn’t reflect the true nature of the behavior. As professionals, I encourage you to choose your words carefully. Consider using the correct terminology and set an example for everyone else.

Stereotypies should be addressed carefully. Consider the function of the behavior and the impact that changing the behavior will have on the child. Is intervention necessary? Think before you intervene.

Learn about autism from individuals with autism

This list is just a peak at how autism presents in some individuals. For an interesting perspective of autism from a young man with autism, I highly recommend reading: How Can I Talk If My Lips Don’t Move?: Inside My Autistic Mind by Tito Rajarshi Mukhopadhyay. In this book, the nonverbal author tells the story of what it was like growing up with autism. This book is one of the best out there to help you understand one perspective of autism. You can find it at your local library (possibly through interlibrary exchange) or on Amazon:

Listen to parents of children with autism

All children are different and so it can be challenging to know whether behaviors or even delays in development are normal or a sign of autism. Parents of children with autism have seen the symptoms first hand and many families have shared their stories on YouTube. Compare these experiences below to see how varied the early symptoms can be.

Danny’s Autism Story – Signs of Autism:

Autism Symptoms and Behaviors – Home Video:

Home Video Footage of Our Son’s Early Autism Traits (Up to His 2nd Birthday):

10 Early Signs of Autism (UPDATED):

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Behavior and ASD

Children with autism often engage in a variety of behaviors that are contextually inappropriate for a variety of reasons. Often behavior serves as a form of communication. Many children with autism have significant challenges with verbal communication. These children may rely on behavior to communicate what they can’t express vocally.

Additionally, children with ASD may experience a powerful need for sameness and routine. This may cause them to respond dramatically to changes in their routine or their environment. Situations that are unpredictable may cause extreme stress for these children resulting in outbursts and meltdowns.

Autistic Tantrums vs Meltdowns

Both tantrums and meltdowns are common in young children with autism. When discussing tantrums it’s helpful to distinguish these from a meltdown.  While these aren’t clinical definitions, understanding the difference between the two can allow you to better help your learner. 

Tantrums are:

  • A behavior intended to elicit a response (either consciously or unconsciously)
  • Typically seen in young children
  • May come seemingly out of nowhere
  • Reinforced by attention or an audience
  • Goal-oriented or manipulative (even if the child is unaware or unintentional about it)
  • Reduced by teaching alternative behaviors

Meltdowns are:

  • A response to sensory overload and overwhelming situations
  • Timeless – they can happen at any age
  • Generally preceded by signs of distress, including increased “stimming”
  • Happen regardless of an audience or attention
  • Do not have a purpose or goal
  • Helped by reducing sensory input in an environment and teaching coping strategies

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Additionally, when a child is having a tantrum they are in control of the level of their emotions (even if they don’t appear to be), but during a meltdown they are not. 

It’s important to respond differently to a meltdown than a tantrum.  Therefore, it is necessary to understand the difference so you can respond appropriately.

Although meltdowns are common in children with autism, that doesn’t mean that they don’t also have tantrums.  Let’s look at what to do when your learner is having a tantrum and how to reduce tantrums in the future.

Understanding Tantrums

A tantrum can include whining, crying, yelling, kicking, hitting, pinching, biting, flailing, holding their breath, flopping to the ground, undressing and other similar behaviors. Knowing when a learner is most likely to have a tantrum and why allows you to both respond appropriately in the moment and help reduce the frequency of tantrums in the future.

The list of reasons children with autism have tantrums include (but are not limited to):

  • Tired
  • Hungry
  • Seeking attention
  • Frustrated
  • Not in control
  • Asked to do something they don’t want to do
  • Denied something they want

Over time, children can learn through unintentional reinforcement that tantrums get results.  Therefore this is an important behavior for you to address.

Reducing Autistic Tantrums

It’s a common belief that autistic tantrums happen more frequently than with their non-autistic counterparts due to communication challenges.  A study by the Penn State College of Medicine suggests this might not be the case (read Speech and language deficits in children with autism may not cause tantrums for the full study, Mayes, S.D., Lockridge, R. & Tierney, C.D. 2017).

Although the study did not propose the answer to why tantrums are more common in children with autism the article lists mood dysregulation and a low tolerance for frustration as two likely factors.  In the past it was believed that improving a child’s communication will help reduce tantrums, however this study seems to show that this might not always be the case.

In reality, all children are different and you should rely on ABC data to fully understand your learner’s tantrums. Once you understand the circumstances surrounding the tantrums, use whatever tools and resources you can to help your learner get what he wants, or communicate what he needs in more appropriate ways.

Understanding Meltdowns

While tantrums are a learned behavior, meltdowns are a coping mechanism or response to their environment.

Grocery stores and other public places may not seem terribly overwhelming to you, but let’s look at this from the perspective of a child with sensory issues. When she walks into a grocery store, for example, she may experience all of the following – all at once, with no way to filter out what isn’t important to process:

  • The whoosh of the door as it slides open.
  • The rattle of the AC or heater over the door.
  • The clanging of the shopping cart as other shoppers (and you) pull the carts apart.
  • The bright, almost blinding lights.
  • The smell of fried chicken from the deli, cookies from the bakery and the cleaner that was used to mop up the pickles that broke on the floor by the first aisle.
  • Music playing, then being interrupted by an announcement for the latest sale on toilet paper.
  • Someone’s cell phone ringing and dinging sounds by the registers.
  • People rushing around everywhere and there’s so much movement she doesn’t know what to look at.

And she hasn’t gotten further than the entrance before all of this hits her.

To understand what your learner might be experiencing watch What it’s Like Being Autistic (Sensory Overload ) Short Film by Thomas Gipson:

Reducing Meltdowns

It’s no wonder the grocery store and other public places are so difficult but there are ways to reduce the occurrence of meltdowns for your learner.

As with anything, begin by looking at ABC data to understand what may be causing the meltdowns. Pay particular attention to setting events and antecedents, as meltdowns are likely to occur even in the absence of other reinforcement (see our post ABC Data: The Key to Understanding Behavior for more on antecedents and setting events, including a comprehensive checklist of more than 40 common setting events).

Consider these questions:

  • Are there places where meltdowns are more common for the learner?
  • Does the learner respond by closing his eyes and/or covering his ears?
  • Are there certain sounds or smells present?
  • Does the location have more or less light than other places?
  • Are there common setting events when meltdowns occur (i.e. when the learner is hungry, tired, spent the day at school, etc)

It’s critical to keep in mind that your learner is experiencing his environment differently from you so very subtle differences can be a trigger for your client. But you can use clues from the ABC data and the questions above to provide tools for your learner. For example, if your learner squeezes his eyes shut when he walks into a brightly lit gymnasium, try using sunglasses. If your client covers his ears when you take him into a grocery store, try using headphones to drown out some of the noise.

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Treatment for Autism

Decades of studies demonstrate the benefits of ABA for children (and adults) with autism. A debate rages about the ethics of using a science to change behavior, especially among individuals with autism who were subject to rigorous, intensive, and harsh ABA treatment. While this may be the unfortunate experience of some individuals, that should not discount the field. For more information about this debate, read our post: Understanding the Debate About ABA.

ABA Therapy

ABA therapy can be highly structured, or can be used in a more natural way (known as natural environment teaching). It can take place in a clinic, at school or at home. Watch these videos for some examples of what ABA therapy might look like.

ABA Sample Session (cards and chase):

Autism Program @ Fruitville Elementary School:

ABA-therapy for 4 year old autistic son:

References

Ahearn, W. H., Clark, K. M., MacDonald, R. P., & Chung, B. I. (2007). Assessing and treating vocal stereotypy in children with autism. Journal of applied behavior analysis, 40(2), 263-275.

Dickman, S. E., Bright, C. N., Montgomery, D. H., & Miguel, C. F. (2012). The effects of response interruption and redirection (RIRD) and differential reinforcement on vocal stereotypy and appropriate vocalizations. Behavioral Interventions, 27(4), 185-192.

Huerta, M., & Lord, C. (2012). Diagnostic evaluation of autism spectrum disordersPediatric Clinics of North America59(1), 103.

Macintosh, K. and Dissanayake, C. (2006). Social Skills and Problem Behaviours in School Aged Children with High-Functioning Autism and Asperger’s Disorder. Springer Science+Business Media, Inc.

Mayes, S., Lockridge, R., Tierney, C. Tantrums are Not Associated with Speech or Language Deficits in Preschool Children with Autism. Journal of Developmental and Mayes, S.D., Lockridge, R. & Tierney, C.D. Tantrums are Not Associated with Speech or Language Deficits in Preschool Children with Autism. J Dev Phys Disabil 29, 587–596 (2017). https://doi.org/10.1007/s10882-017-9546-0

Rao, P and Beidel, D (2009). The Impact of Children With High-Functioning Autism on Parental Stress, Sibling Adjustment, and Family Functioning. Behavior Modification 33(4):437-51 .

Yu, Timothy W. (2013). Using Whole-Exome Sequencing to Identify Inherited Causes of Autism, Neuron, 77 (2), 259-273

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