Autism in the DSM 5 TR | Symptoms and Diagnosis

Hey there everybody, and welcome to today's presentation on diagnosing the autism spectrum using the DSM 5TR. I'm your host, Dr. Donnellice Snipes. In this presentation, we're very briefly going to explore the symptoms and strengths of people who have autism spectrum disorders. We'll identify co occurring issues of people with autism spectrum disorders and review differential diagnosis. Autism spectrum disorders especially now are called a spectrum because people with autism spectrum disorders can have a range of symptoms and a range of severity. They may have symptoms of, for example, Autism spectrum disorder, and some of their symptoms may be severe and other of their symptoms may be mild. And this is not uncommon. We see similar things in just about every other diagnosis. What is unique to Autism spectrum disorder, and it was of much controversy when the DSM 5 was released, was that a lot of different diagnoses were squished into Autism Spectrum Disorder when the DSM went from the DSM IV to the DSM 5. Autism spectrum disorder now includes disorders of early infantile autism, childhood autism, Kanner's autism, high functioning autism, atypical autism, pervasive developmental disorder, not otherwise specified, childhood disintegrative disorder and Asperger's disorder. Now these are not broken out as specifiers or anything in the new autism spectrum disorder diagnosis. It's just kind of all of those terms sort of disappeared and now it's just called autism spectrum disorders. And you can see how that might cause some concern and consternation. However, it is what it is. What are the symptoms of somebody with autism spectrum disorders or who is autistic? Now, I will probably vary between saying a person with autism and an autistic person in this video. I was brought up in school to use person first language. However, that is not always preferred by someone who is autistic. So it is important to ask them. If you are working with somebody who is autistic, do you prefer to be referred to as an aspie or someone with autism or somebody who is neurodivergent? There are a lot of different terms that people may prefer. It's important to ask that is very respectful of the individual. And we're going to talk a lot, I hope, in this presentation about how people with autism are neurodevelopmentally different. They're not necessarily broken, as some may think, not necessarily disordered, as some may try to categorize them. People with autism are wired differently. They have different strengths. Okay, well, let's take a look at those. The symptoms for Autism spectrum disorder. The person has to have persistent deficits in social communication and interactions across multiple contexts, evidenced currently or by history by deficits in social emotional reciprocity. This can be abnormal social approach or a failure of the normal back and forth ability to carry on a communication, reduced sharing of interest or emotions to failure to initiate or respond to social interactions. There's a lot of stuff in here, but basically it's social emotional reciprocity working with When a person who's autistic is interacting with others, there may not be that back and forth, that give and take that one might expect. They also have to have deficits in nonverbal communicative behaviors ranging from poorly integrated verbal and nonverbal communication to abnormal eye contact. A lot of times that means no eye contact at all. Sometimes it can mean excessive eye contact, abnormal body language, or even a total lack of facial expressions and nonverbal communication. This is important to recognize it's not necessarily the be all end all diagnostic criteria. A lot of times when people think autism, they think of these first two criteria first and maybe stimming later. But there are so many other different symptoms or criteria that need to be met to get a full diagnosis of autism. It is interesting to note that people with autism often think in pictures or video instead of words, which is kind of interesting. Another characteristic is deficits in developing, maintaining and understanding relationships, ranging from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or in making friends, to absence of interest in peers. Now, you can hear some other DSM diagnoses like avoidant Personality Disorder coming out here. That could be one, PTSD could be another. But what we're looking at is the whole package. We are also looking at things that are developed developmentally divergent from the person's culture. And certain cultures have different rules or different mores for eye contact and relationships and behavior in certain situations. But a person with autism, their behavior diverges markedly from what is culturally expected for someone of their age. They may also show restricted, repetitive patterns of behavior, interests, or activities as manifested by two or more of the following so the first three criteria we went over, they have to have all of those. They have to have behaviors that are representative of all of them. It's also important to recognize that when you're making a diagnosis of autism, you can't use the same behavior to meet multiple criteria. You want to have a variety of different behaviors or different behaviors for each criteria in order to really make sure that you're getting an accurate diagnosis anyhow. Moving on to restricted repetitive patterns of behavior, interests or activities, stereotyped or repetitive motor movements, use of objects or speech. This can include what a lot of people refer to as stimming, hand flapping, rocking, jumping and twirling. Stimming S t I m m I n g is basically self stimulation. And there can be a variety of reasons that the person engages in it. Let's think about. Remember, behavior is communication. What might the person with autism be accomplishing through the stimming behavior? Sometimes it's self soothing. Even people who aren't autistic, when they start to get really stressed, when they go into crisis, when they start to really dysregulate, may hug themselves and rock. This is not uncommon to see in crisis situations. So sometimes the movements, the repetitive behaviors, may be self soothing because they're feeling out of control. Other times the behaviors actually may be oriented toward helping the person feel something because they are, they have some issues with sensory integration and sensory stimulation and they're actually hypo responsive to the environment. So they may self stimulate, like wiggling their fingers in front of their eyes. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior is another characteristic. Not everybody with autism has all of these characteristics. It's very important to remember that Temple Grandin once said, when you meet a person with autism, you've met a person with autism, everybody presents a little bit differently. People with autism are unique and I really wish we could get away from the notion that it's a, that they're broken. But that's my own personal issue, I guess. But the insistence on sameness, inflexible adherence to routines or ritualized, ritualized patterns of verbal or nonverbal behavior can cause a lot of problems. In school, for example, if their normal routine is, you know, XYZ and there's a birthday party or there's a convocation or there's a pep rally, it can really throw them for a loop. Or if they're used to going out to recess at 11am but it is just thunderstorming like nobody's business, that may throw them for a loop. So that can be very difficult for a person with autism. They may display highly restricted, fixated interests that are abnormal in intensity or focus. They are interested in whales, they are interested in dinosaurs. They are interested in something, just fascinated with it. It's not a hobby, it's everything relates to this particular interest. Trains. That's another example that may be seen. But it can be anything. And one of the things that I'll talk about when we get to gender issues is many of the girls, people who are biologically female who are diagnosed with autism may go under diagnosed because they're highly fixated. Interests are what are maybe considered culturally normative, such as being fixated on a particular actor or singer or performer of some sort, and then hyper too much or hypo too little reactivity to sensory input or unusual interest in sensory aspects of the environment. People with autism may perceive the world very differently than we do. What we perceive as lukewarm in water, they may perceive as scalding hot or ice cold. Their perception is very, very different. Think about their nerve endings either being much, much more sensitive or much, much less sensitive they than ours. But that's true with sound, with touch. So let's think about this for a second. And I was going to try not to get too trauma informed in this one, but I think it is so important for us to recognize that a lot of times a person may be autistic from the time they're born. And if, especially if they are hypersensitive to sensory input than being touched, being sung to, being rocked, being swaddled, being put in a warm bath, all of that may be ultra, ultra intense and somewhat painful for that child. And the caregiver is trying to be so nurturing and so loving and those behaviors are causing sick much pain. And they don't understand. It's not that the caregiver is doing something wrong or ignoring the child. They're like, I'm doing what the book says and you just keep crying. I don't understand. It is important to recognize though that it can impact the attachment between primary caregiver and the child. Because if the child starts perceiving the caregiver as the someone who is going to cause them pain, then it's going to be very distressful and overwhelming for the child. And obviously an infant or even a young toddler may not have the verbal ability to say, ow, that hurts. Symptoms are present in early childhood but may not become fully known until demands exceed capacities and may be masked by compensatory strategies later in life. A lot of people with autism are able to live very happy, highly productive, rich, meaningful lives as they define it. And one of the things that is important for us to remember is how do they define it? We may define a rich and meaningful life this way that's full of all this social interaction and yada yada, and they may not. They may find a lot of richness and meaning in science, in nature, in logic, things in work. So it's important to not put our own expectations or our own preferences on somebody and say, well, if you can't have this, then you're not having a high quality of life. And it's important for us to ask them, how do you define your rich and meaningful life? It's also important to recognize that there is no code for in remission for autism in the dsm. Although as autistic people get older, as they develop, they often develop compensatory strategies so they learn how to function within their environment. And it may just take a little bit longer because their needs are different than the majority's needs. As a result, our environments, our stores, our airports, our doctor's offices, our schools, our playgrounds are often geared towards the majority. And the coping skills and strategies we teach are often geared toward the majority. The person with autism needs different compensatory strategies. And I believe we often fail in that aspect to recognize that and say, okay, you need this compensatory strategy. You need this tool to help you. And it takes until later in life when the person, whether child, adolescent, adult, encounters a situation and has these skills and abilities to actually say, oh, this is what works for me. This works for all these other people. This works for me. Symptoms have to cause clinically significant impairment in multiple areas of functioning and is not better explained by intellectual developmental disorder. Although intellectual developmental disorder frequently comes co occurs with autism spectrum disorders, not always. There are some people with autism spectrum disorders who are on the genius scale. The specifier we do need to look at is severity, and I grossly distilled this down. But to give you a basic idea, level one is requiring support. Without support, there's noticeable impairment and independence is hampered. Level two, substantial support. A person who needs substantial support has marked deficits that are apparent even when supports are in place. So the casual observer can see that this person may be struggling even when supports are in place. And level three, very substantial support, severe deficits in functioning and extreme difficulty with change make independence almost impossible even with supports in place. Interestingly, and I know I mentioned this earlier, what about those for whom supports and compensatory strategies actually do allow them for independence? They don't need a coach, they don't need a case manager to, to provide those supports. There are people who have autism spectrum disorders who are on the spectrum, whatever you want to say, who are very capable of independent living and very high functioning, if you want to use that term, associated features. Now, the DSM really didn't note a whole lot of associated features. People with autism may have difficulty taking perspectives of others. They have difficulty stepping out of their own head and trying to view it from someone else's perspective. It's not that they're intentionally being, quote, narcissistic. It's not that they're intentionally being mean or refusing to try to empathize. It may just not be something that's possible. Motor deficits are often present in people who are on the spectrum, whether it be walking or throwing. They may also have motor behaviors such as walking on their tiptoes instead of walking, you know, heel to toe, like the majority does. Strengths. Now, this is obviously not in the dsm. I wish they did have a section on strengths in the dsm, but I really think it's important to highlight that people with autism do have a lot of strengths that they bring to the table. They are able to memorize and learn information quickly. They think and learn in a very visual way, which is super awesome, I think, and learn in a very word sort of way. Not sure what word I'm looking for right now. Semantic sort of way. Not in so much of a visual. My visual spatial abilities really aren't that good. So working with somebody who has autism on my team might be very helpful if I'm doing something that has a visual aspect to it. Using mind maps also can be very helpful for people with autism, and I'm going to jump down. Because they have the ability to make unique connections. I mentioned earlier that sometimes they have difficulty organizing and planning. Well, one of the reasons that it's hypothesized, when they look at the brains of people with autism, when they're thinking, a whole bunch more areas in their brain light up than do in people who don't have autism. Theoretically, more connections are being made and they may be thinking of more things and they may be sort of being pulled in a whole bunch more directions, which makes it harder to focus on where was I going. But that can also be really awesome because they may see unique connections that you didn't see before. They're capable of as everybody is, but they are more able in many ways to engage in independent thought because they are less concerned, not unconcerned, but a lot of times they are less concerned about what other people think of them. So they're able to say, this is what I think. It's just very matter of fact. It's not against you. It's not that I'm trying to be all that and more. It's just this is what I thought here. It is very cognitively based. They have a strong logical thinking ability which bodes well not only in logical careers like science and math and even law, but even in medical or mental health careers where diagnosis and testing might be prominent. They may excel in technical and logical subjects that do not rely heavily on social interaction. Some of us, in the majority, really crave that social interaction, really crave the human connection. And that can make certain occupations seem less appealing to us. So that's great. There is an occupation for everybody. People with autism often have an excellent memory and are very precise and detail oriented. They have exceptional honesty. A lot of times they're not going to sugarcoat things because many times their communication is such. They think something, they see something, they state a fact, what they see is a fact. They're just very matter of fact in their communication. Therefore they may be more honest. They don't think, well, is this going to hurt somebody's feelings or do I need to hide this so I don't get in trouble? It's just, it is what it is. They are often dependable with schedules and routines and highly punctual because they don't like change. It can really be beneficial in the work environment and even in the home environment. Sometimes because they have a routine, they have a schedule. The problem happens is if there is a change, a sudden change in that routine. But largely, if you are in an environment that is structured, a person with autism will probably thrive. Interestingly, one of the articles I read said they have an excellent sense of direction, a strong adherence to rules. Autistic people are often very literal in what they read and what they see. So you may also see some traits not diagnosable, but you may see some traits in autistic people of things like obsessive compulsive personality disorder. Because of this rigidity and adherence to the rules, they are often able to concentrate for long periods of time when they're motivated, when it's something they're interested in, that intense focus serves them well. Getting people with autism motivated can be a little bit more difficult, especially if it's not something they're interested in. And I'll talk about that in the interventions video. But once you get somebody motivated, they're good to go. There's often a drive for perfection and order, direct communication and non judgmental listening. Just like they are very matter of fact in their outward communication. They are very matter of fact and non judgmental in their listening. They're not thinking, well, is this person trying to manipulate me? Are they trying to make me feel feel bad? What's good? They hear the words and they listen to what is being said. Now back to the DSM 5tr. The DSM 5tr states the prevalence at 1 to 2% in the general population. The National Institute of Mental health indicates that 3.7% of boys and 0.9% of girls will receive an autism spectrum disorder diagnosis by the age of eight. Well, that's kind of interesting that the number is so much higher in boys, which makes me wonder, are we missing cases in girls? Interestingly, the number of autism spectrum disorder diagnoses was 1 in 150 in the year 2000. That's the year my son was born. An increase to 1 in 44 by 2018 and is expected to be higher now. But the way data collection goes, they gather data and it takes two to three years to kind of get out to us. I'm wondering, is this change in numbers because we've had that marked of an increase of autism in the general population? It could be. Is that increase partly due to doctors, teachers, mental health providers becoming more aware of autism spectrum disorders and more effectively diagnosing it? That could be true too. Additionally, in 2013, when the DSM 5, the original one, was published, they squished all those disorders together. They put Asperger's in with the autism spectrum disorders, which means that more people are actually receiving that diagnosis of autism spectrum disorder. I could not find any research that broke down the different diagnoses. Pre2013 or pre20. Yeah, pre2013, before the DSM changed and then after the DSM changed. But these are things that just I find curious. Development and course, the onset of autism spectrum disorder is associated with declines in critical social communication behaviors in the first two years of life. All right, so we're going to start seeing these issues present in toddlerhood. This isn't something that has an onset in adolescence. Autism spectrum disorders are not degenerative, alright? The person is not going to. It's not like something like Alzheimer's, that is degenerative. Autism is not. Okay. So that's really comforting in some ways because learning and compensatory strategies in people who are autistic tend to develop throughout their life. So they tend to show improvement and more ability to have that high quality of life as they age. Symptoms are often most marked in early childhood and elementary school, and this is according to the DSM 5. Well, let's think about that. Early childhood, elementary school, they are developing their vocabulary, they are learning how to communicate, and that in and of itself is Difficult. They are not able to say, hey, when you play that music, that is what you find to be a reasonable volume. It really hurts my ears. They have a hard time articulating what is wrong, what's going on with them. Children are not born with coping skills. So if they've been exposed to painful stimuli throughout their life and they may have already started to develop some level of HPA axis dysregulation. And so when they are triggered, when something does hurt them or does trigger them, they may not be able to stop, use distress tolerance skills and cope. They may dysregulate, and then they're in a quandary. So it makes sense early on when they haven't been diagnosed yet. A lot of times these symptoms are diagnosed in early childhood. They've been going on for a while and they need to be addressed. So this is that early treatment period makes sense. Their symptoms are going to be most prominent. Now. Risk and prognostic factors. And I thought this was really interesting. You know me in research. Parental age is one of the strongest prognostic factors and risk factors for the development of autism. The older the age. Now let's go back to the increase from 1 in 150 to 1 in 44. We have seen over the past 20 years that the maternal age has actually gone up. Instead of having babies at 19, like my mother did, women are waiting until sometimes their late 20s, late 30s to have children. So that is one risk factor. There is no single risk factor that anybody can point to that says, this is it, this can cause autism. They suspect it's a convergence of multiple risk factors. I emphasize this because I want to make sure that we are not blaming the caregivers. We're not blaming the birth parent, we're not blaming any one particular person for the development of autism. Yes, parental age is an issue. Parental age is also a risk factor for down syndrome and a variety of other things. Prematurity is also a risk factor, especially extreme prematurity. My son was born at 29 weeks. I had a very good friend who had a child born at 24 weeks that's in the extreme prematurity range. Now, my son does not have autism. He has adhd, but he does not have autism. So it is, again, this is not something that we can say, oh, if they're premature, this is going to happen. No, we can't. However, we know, again, it's a risk factor. Teratogen exposure. This is exposure to toxic substances in utero, specifically valproic acid, otherwise known as depakote thiolates, which are chemicals in soft plastics like food packaging. All three of both of those things have been strongly associated with increases in neurodevelopmental disorders in general. Genetics is another issue. 80%. In the most recent set of studies, 80% of autism may be due to genetic heritability. And again, it's not just one gene. There's lots of genes. And when all of those genes that are wonky, go wonky together, get lined up in just the right way, then we might see the development of autism. So there is no one gene they can test for. It has to be a convergence, a bunch of modified genes, mutated genes, or genes that are turned on that aren't supposed to be not in the DSM 5tr. Now, thiolates was not in the DSM 5tr, but it is a risk factor, which is why I have it listed with a hyperlink. So you can go look at the study in the class. If you're taking this for CEUs, I do have a PDF that goes into great detail about what we currently know about the risk factors for autism spectrum disorder. It's a fascinating read, but it does take some time because they go through over 175 different studies not in the DSM 5tr perinatal physical or emotional stress. And they have a whole list, that article that I read. But we don't have the time to go into all that. Basically, physical stress, like preeclampsia, like diabetes during pregnancy, anything that may put physical stress on the mother is going to increase stress on the fetus. Emotional stress is also going to do that. And we've talked in other classes about how the body doesn't really differentiate between physical and emotional stress. Stress is stress, and it's going to trigger the HPA axis, the HPG axis, and the HPT axis. So you have your adrenals, your gonadals, and your thyroid all in overdrive when there's stress. When this happens, it increases the placental permeability of the stress hormones. So not only is the birth parent's HPA axis dysregulating, it's contributing to dysregulation of the fetus's HPA axis. In theory, fetal distress is another risk factor. And I'm not talking about the HPA axis here. I'm talking about if they end up with being deprived of oxygen because they've got the umbilical cord wrapped around their neck, or if there's a particularly difficult delivery and the heart rate starts to decelerate, there were multiple studies, and I only cited three here, multiple studies about the connection between the gut microbiome and autistic behaviors. And they found that if they alter the gut microbiome in lab rats. I wish I could say they were doing it as somebody else, but it's not ethical to actually try to cause these symptoms in humans. So they do it in lab rats, but they found by altering the gut microbiome in lab rats, that they can promote behaviors that are very common in autism. They've also found by testing the gut microbiome in people with autism and through the. Through experimentation with different antibiotics, which I don't love the idea, but that they have been able to reduce certain symptoms of autism with certain antibiotics, again, indicating a integral part of the microbiome in autism spectrum disorders. Remember? And I know I'm off on a tangent here, but I found it so fascinating. The vagus nerve that everybody knows and loves connects the gut to the brain. And when the microbiome changes, the vagus nerve communicates that to the brain. The vagus nerve can get an idea about how everything's functioning from the information it gets, in large part from the gut area. And that helps the brain decide, okay, what do I do? And then the brain decides whether to alter the microbiome in order to respond to stress. Your gut microbiome is different under stress than it is under a relaxation state. So that. That's all interesting. And childhood toxin exposure, especially aluminum and mercury. You know, I remember when I was little, way back in the day, there was this big concern because there was lead in paint. Yes. I'm that old. And children would pick at paint and put it in their mouth, and it was causing toxicity. Well, now we don't have lead in paint, so that's a really good thing. The most common toxins that children are exposed to that are associated with the development of ASDs are aluminum and mercury. Gender differences. Yeah. For my whole soapbox on biological gender, this is what we're talking about here. The DSM is still referring to biological gender. And people who are biologically female are more likely to have intellectual developmental disabilities. Thought that was interesting. Epilepsy, but also more subtle social communication issues. They hypothesized that this may be due to females mimicking other females. They may not really understand what they're doing, but they're role playing. They're mimicking other females. And that behavior is being reinforced and maintained by that reinforcement. So even though they don't understand the relationship dynamics or the reciprocity, that's going on. They know how to do it. They can fake it if you will. Now they're not faking it. It's not like they're going, I'm going to fake this. They are just doing Using a compensatory strategy and maintaining that Females, as I mentioned, also often have focused interests that are more culturally sanctioned, such as artists or horses, although still unusually intense. And these can Both of these issues can greatly contribute to the under diagnosis of females who are on the spectrum in terms of suicidal thoughts and behavior. Remember, that's a new section in the tr. Those with impaired social communication are at higher risk of suicidal ideation and planning by age 16 than those who have autism but do not have impaired social communication. So this ability to communicate needs, wants, and communicate with others is strongly related to early suicidal ideation once they get into adolescence. People with autism spectrum disorders in general tend to have a higher risk of suicidal ideation than their counterparts who do not have autism spectrum disorders. Challenges from Social Impairments Functional Impairments they may have impaired learning in social contexts, especially in the classroom. Doing group work, those sorts of things may be very, very difficult. They may have difficulty at school or work due to problems planning, organizing, and coping with change. It's important to help the person figure out strategies that work for them in their particular setting in order to help them manage that and not feel overwhelmed. Just because somebody develops compensatory strategies doesn't mean that it's easy peasy for them. They found that a lot of people who are autistic who are autistic may have these strategies may integrate pretty well. They may be more mainstreamed. However, they have significant levels of anxiety and depression because they're fearful of not being able to handle situations. And it is intensely exhausting to try to keep this up, keep up this routine, if you will. So when they're at home, they may feel extremely exhausted. Activities of daily life may also be difficult due to difficulty with changes in routine. If every Friday night you have meatloaf and this Friday night there was no meat, you know somebody forgot to get it at the grocery store, that could be very disruptive for somebody who is autistic. Now, other people who are autistic may not have an issue with that. Again, remember, one person with autism is different from every other person with autism. Some children with autism spectrum disorders do not develop a perception of themselves as active agents that can deal with novel, incongruent, disorganizing information and regularly experience emotional dysregulation, which is the very flowery Way of saying when they were younger, they were overwhelmed by life itself, and that was likely invalidated or minimized. And they weren't taught the tools that were appropriate for them to manage what was going on. Therefore, they start feeling hopeless and helpless. They start feeling fearful because they've been in so many situations where they have dysregulated that it just creates that anxiety. Social impairments in children with autism interfere with the ability for caregivers to be responsive or sensitive. This is not always remember, this is in general. But children's inability to communicate this hurts, or this is overwhelming with words, can make it more difficult for caregivers to understand what's going on and what do I need to do differently? Lack of ability to be responsive impairs a caregiver's ability to provide that support, which could provide a safe route to exploration. Children with autism are attached to their caregivers. However, the way they express this attachment can be unusual. To parents, it may seem as if their child is disconnected. Difficulty recognizing and processing the feelings of others may result in others believing that the individual with autism doesn't have empathy. Well, let's think about this. One of the main ways we are able to read people's emotions is through their micro expressions in their eyes and their mouth. And for a lot of people with autism, that direct eye contact or looking directly in somebody's face feels intrusive. And when somebody does it to them, it feels very intrusive and painful and overwhelming. So they may not have had as much practice and they may not be looking where most people look to get that information. It's important to help the caregivers evaluate how their particular child indicates their attachment and what ways that child communicates. If you want to think about it in layman's terms, what is that child's love language? About 30% of people with autism have epilepsy. Grand mal or absence seizures are very common and cause the person with autism to blank out or stare into space for a few seconds and are often triggered. The absence seizures are the ones where they blank out. Grand mal seizures we're all familiar with. Seizures in general can be triggered by hyperventilation. When a person with autism gets triggered by changes in routine, by anything that is overstimulating, it can cause hyperventilation, which can trigger a seizure. Malfunctioning fluorescent lights, intense strobe lights like visual fire alarms, Natural light, such as sunlight, especially when it shimmers off the water, flickers through the trees or through the slats of blinds that you have in your windows, especially if the clouds are coming in and out, it can trigger a seizure. Certain visual patterns, especially stripes of contrasting colors, I want you to think about if you've ever been in an office, you know, a doctor's office where they had really bold carpet, we'll use that word that had stripes of contrasting colors and you're looking at it and almost makes your eyes want to cross, or it makes your head hurt. That can trigger, in some people, that can trigger a seizure. People with autism, 46 to 85% of them have gastrointestinal problems of some sort. Well, if they've got a different microbiome than the majority that could be contributing, they could have pain caused by GI issues. Pain caused by GI issues is sometimes recognized because of a change in the child's behavior, such as increase in self soothing like rocking or outbursts of aggression or self injury. They may not be able to communicate that their tummy hurts, however their behavior changes. Behavior is communication. If they're acting out, we need to ask ourselves why? What are they trying to tell us through our behavior that they can't tell us with their words? They may also have sensory issues that make feeding difficult. Certain textures may be very offensive to them and other gastrointestinal issues like Reflux. 53% of people with autism have sleep disturbances. And we know that there's a strong correlation between HPA axis dysregulation and emotional dysregulation and sleep disturbances. Sleep is really important. So it's going to be vital to figure out what's causing those problems. If you've ever. It's summer here right now, it just started to be summer. And the air conditioner has started to kick on at night. And when the air conditioner kicks on and it blows on me, it's really, really cold. And then it kicks off and it gets really, really hot. But that change in temperature can be painful to somebody who is hypersensitive. We also want to look at the texture of the sheets and what other things might be disrupting this person's sleep. 20% of people with autism have attention deficit hyperactivity disorder, 30% have anxiety, 24% diagnosed with depression, and another percentage may also have obsessive compulsive disorder. However, it is pretty. OCD tends to be a lot less likely. So let's talk about differential diagnosis. And disappointingly, the differential diagnosis section was not as robust as I would have hoped. For example, avoidant personality disorder was not mentioned. OCPD was not mentioned. Oppositional defiant disorder was not mentioned for potential differential diagnoses. And I think it's important that we do recognize that there are other things that we may need to differentially diagnose. However, according to the dsm, ADHD differs from autism in that there's an absence of restricted repetitive behaviors and unusual interests in adhd. Now, some people with ADHD do get an intense focus on things that they're interested in, so they can focus on sometimes, which can be very confusing to caregivers. But the intensity of the interest is still less than what you would see in autism spectrum disorders. In terms of language and communication disorders, again, there's an absence of restricted repetitive behaviors and unusual interests. Their symptoms are solely around the language and communication. People with selective mutism are able to communicate appropriately in some settings, and their social reciprocity is not impaired. Rett syndrome differs because social interaction may be impaired during the regressive phase, which is often between one and four years old. However, it starts to improve after that. After the age of four, their social interaction and reciprocity tends to improve. Stereotypic movement disorder, which causes self injury and becomes a focus of treatment, can be diagnosed by itself. In autism, we know that there is the characteristic of stereotypic movement, stereotypic movements. So you would only make the diagnosis of stereotypic movement disorder if those movements rose to the level of being a focus of clinical attention and causing self injury. According to the dsm. In intellectual developmental disabilities, remember I said these often co occur. People with pure intellectual developmental disability show no discrepancy between their social and communicative skills and nonverbal and motor skills. So everything is kind of on the same level developmentally, Even if that is three years regressed from where the person is chronologically. Obsessive compulsive disorder. The main differing factor that the DSM highlights is that in autism spectrum disorders, repetitive behaviors may be pleasurable and reinforcing. In obsessive compulsive disorder, it's not. In obsessive compulsive disorder, the repetitive behaviors are merely to alleviate anxiety and they get a little bit of a breather. But they're not pleasurable and they're definitely not reinforcing schizophrenia. Hallucinations and delusions are present in schizophrenia. This we know. It's important when you're doing an evaluation on someone to differentiate childhood onset schizophrenia from autism spectrum disorders to make sure that you don't mistake literalness for hallucinations or delusions. So you may say something like, do you hear voices? And the person with autism spectrum disorders may say, yeah, and they don't follow up with the caveat when the television is on. Now there is a must watch Asperger's Disorder and other Asperger's Disorder and Other Common Misdiagnoses and Dual Diagnoses of gifted children by Dr. James Webb. I am a huge fan of this person. At this point. When this video was made, he was at the University of Wisconsin School of Medicine and Public Health and I have the link to the video here. It is a very entertaining video. If you've got a child with add, adhd, if you've got a child with autism spectrum disorders or, you know, at that point in time there was the diagnosis of Asperger's. But he makes a lot of really good and interesting points that help us understand a little bit more about what, what it might be like for our loved one or for the patient that has autism spectrum disorders. ASDs look different for every single person. Boys are more likely than girls to be diagnosed with an asd. However, a lot of people wonder whether we're just missing it in a lot of the girls because of their compensatory strategies early on and their typical areas of intense focus. Autism spectrum disorders can impact every area of life because in every area of life we have change, we have disruption of routine, we have sensory integration, smells, sight, sounds. In every area of life we have, to a certain extent, we have some sort of social interaction. Whether it's at home or at work or in recreation or even at the gym. There are issues that a person who is on the spectrum may have to find compensatory strategies in order to be able to effectively deal with if that is an environment that they want to be in. Early intervention with autism spectrum disorders can help prevent traumatization, enhanced parent child interactions, and enhanced self esteem and efficacy of both the child and the caregiver. Remember I said these symptoms start sometimes as early as 12 months or earlier they can be diagnosed. But many times it's around two that they start getting diagnosed. But that's really early and for a lot of children that's preverbal, which means you may have a caregiver who's really struggling going, you know, I love this child so much, but it seems like everything I do seems to make him madder or make him more upset. And it may contribute to the caregiver feeling very powerless and helpless. So early diagnosis is essential. Early diagnosis also allows the caregiver and anybody that the child interacts with to start providing those compensatory strategies early on so they are better able to handle situations. So there are strategies for transitioning from one activity to another, from one grade to another, starting a new school. The child feels a sense of connection with their caregiver and safety with their caregiver and is able to learn the tools and skills they need in order to handle or cope with these changes that tend to provoke anxiety in anybody, but may really be dysregulating for somebody on the spectrum.