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Lesson 1: Overview of Autism Spectrum Disorders
Language and Speech Delays and Differences
Not all children with ASD will display speech and language delays and differences. Speech and language expression in children with ASD will vary by age, by individual, and sometimes by context. Some children with ASD may not use speech, also referred to as nonspeaking, while others may use extensive vocabularies, discussing topics in great detail. Some children with ASD may display echolalia (sometimes referred to as scripting), in which they repeat words or phrases rather than engage in conversation you might engage in with someone without ASD. Echolalia can be immediate or delayed. An example of immediate echolalia would be when I say, "Good morning," and you say, "Good morning." I say, "How are you?" and you say, "How are you?" With delayed echolalia, the child can sometimes repeat a phrase verbatim that occurred some time ago. Some children, for example, can watch a movie, and can give you the entire script a few hours or even days later.
Additionally, the individual with ASD may have limited or delayed speech, such as single-word utterances or approximations of words. For example, instead of saying “ball,” the child says “ba.” The limited or delayed speech might mean that the individual with ASD has the foundations for speech but may have difficulty with forms of language expression. For example, their prepositions or use of pronouns might be different. You might also see individuals with ASD who have do not use speech at all. It is important to note that speech and language expression are just one form of communication. People with ASD may use a variety of nonspeaking communication, such as gesturing, facial expressions, pointing, and other forms of self-expression. Just because a person is not speaking does not mean they are not communicating, nor does it mean they do not have a great deal to express!
In addition, the child, youth, or adult with ASD might be using other forms of communication, such as augmentative and alternative communication (AAC). For example, they might be using sign language (e.g. ASL), a communication board with pictures, or a voice-output electronic system for communication.
Some individuals with ASD might have difficulty with what we call pragmatics. This means they might not understand some social norms related to the language of that particular context and culture. It is important to remember that many elements of a language system are culture-bound, which means what may be a common expression or familiar to one may not be familiar to everyone else. In addition, some things may be related to a particular geographical context. One example is how people with ASD may not be able to detect or interpret the meaning behind sarcasm, such as someone saying, "Oh sure, I’d love to do that!" This may present a challenge for people with ASD, who may not interpret expressions outside of their literal meaning, or even use this form of expression within their culture.
Some individuals with ASD may also use language in ways that may not reflect particular social norms that are more nuanced. Some examples may be using formal words when it is expected that one might use informal expressions or using unique intonations and emphases. These conversational differences vary by individual and context.
One common language difference among some people with ASD is the inability to interpret idioms. Idioms are expressions or figures of speech that convey a social meaning beyond their literal meaning. These often vary across global contexts, parts of the U.S., and even different areas within the same state. Idioms, such as the ones in the quote bubbles above, can be very challenging for some individuals with ASD to understand and we should be mindful of this in our communications. For example, someone might think it’s literally raining cats and dogs!
Some—not all-- individuals with ASD may also have difficulty understanding nonverbal communication, such as facial expressions, gestures, and/or physical indicators of someone’s comfort level (e.g., sound or proximity). For example, some individuals with ASD might not interpret someone stepping back as a sign that they may be standing too close for the person’s comfort. Some people with ASD may also present with a very flat affect. For example, they might not display facial expressions in response to someone telling a very animated story as someone might not expect. This should not be misinterpreted, however. This may not mean that they are not interested or engaged. We don’t always think of nonverbal communication, but they can be very important in conveying a message.
While some of the differences in communication styles (e.g., nonverbal communication) may be perceived as “deficits” many autistic people and their allies perceive these as differences, or preferred modes of communication. This is another way of looking at these differences. According to Embrace Autism, we can also perceive this as a mismatch in what we might expect:
Autistics use and value different interaction styles compared to neurotypicals. While the diagnostic criteria have identified this as a deficit in social communication, when viewed from a less neurotypical-centric lens, this deficit appears to be more of a difference or a mismatch in communication styles.
Lastly, people with ASD might have difficulty processing language when the environment has too many distractions or is overstimulating. Some examples may be a noisy environment or an environment with a lot of stimuli (which can range from a cafeteria or classroom with a lot of people talking at once, or a light bulb that needs to be changed that is flickering).
Now that you have read about speech and language difficulties that may be related to ASD, watch the following videos to get an idea of what these might look like in action.
Delayed Echolalia
In the first video, you will see an example of delayed echolalia. This young man is using what we call scripted dialogue. He's very interested in Tigger from Winnie the Pooh and uses exact lines from the movie. You’ll see that he is trying to get his mother involved in the dialogue because he wants her to recite the phrases with him.
Augmentative/Alternative Communication (AAC)
In this clip, you will see a boy named Timmy using augmentative/alternative communication (AAC). He's touching a screen that has a symbol on it. Once the symbol is pressed, there is voice output. Timmy has some behavior problems, but his communication device serves to decrease the inappropriate behaviors by allowing him to communicate more effectively.
Picture Exchange Communication System (PECS)
In this clip, you will see Andy, who is 10 years old and has cerebral palsy and ASD. He is nonverbal and uses AAC. He is learning how to use a picture exchange communication system (PECS) to communicate with people who do not know sign language. When using a PECS, he selects the picture icons, places them on the strip at the bottom of the binder, pulls off the message, and hands it to the person to indicate what he or she wants/needs.
Social Differences
Next, your text discusses social differences related to ASD. Some individuals with ASD may have difficulty being able to take the perspective of someone else and misread emotions, or cues. Much like the Greek root word auto, which relates to self, individuals with ASD might not understand what others are thinking or perceiving or that their perceptions might differ from others' perspectives. For example, for some people, if they're frustrated with something, they might assume that everyone else is frustrated with it as well. Likewise, some people with ASD who may feel okay with things might assume everyone else is as well.
This is not the only perspective, however. More recent research has highlighted the problem of double empathy. Double empathy considers the issue between the lack of understanding social interactions from the person with autism as well as the neurotypical individual (DeThorne, 2020). In the book The Reason I Jump by 13-year-old autistic author Naoki Higashida, he describes so vividly, “For people with autism, what we’re anxious about is that we’re causing trouble for the rest of you, or even getting on your nerves. This is why it’s hard for us to stay around other people. This is why we often end up being left on our own.” There is often more than we assume.
Joint Attention
Along with challenges in taking the perspective of another, another social challenge people with ASD may experience liesin joint attention. Joint attention is the ability to share an experience. For example, as you watch TV, you might say to your friend across the room, “Oh that's funny—look at that!” You may look at the other person, they look and laugh along as well. You have both just jointly shared an experience.
Below is a video segment related to joint attention. This is anl experiment that highlights the concept of joint attention. The researcher has three groups of children: individuals who are neurotypical, individuals who have intellectual disabilities (ID), and individuals who have ASD. The researchers are examining the children's reactions to various situations, such as someone getting hurt or being scared. As you'll see, the individuals with ASD don't always pay attention to others, don't always look or share the experience, and don't always understand others' points of view. It's really intriguing in this clip to watch the child with the ID. At one point, he just gets up and fixes the problem for the group, saying, "All gone." I like the way he thinks!
There also may be deficits or differences in the play of children with ASD. For example, you might observe more instances of parallel play (side by side but not together). Typically, developing young children will engage in parallel play, but eventually they'll move to cooperative play, in which they engage with each other. You see less cooperative play in children with ASD. This, of course, goes hand in hand with the issues of joint attention just discussed. There is a lot less sharing of experiences with others.
Individuals with ASD can also display social differences that are quite subtle in nature. For example, a common issue is that of personal space, with people with ASD often standing too close to another person. A good example of this can be seen in the Seinfeld episode about the “close talker.” If you stand too close to someone's face when they're talking, it can be very disconcerting. They might step back as a natural reaction. The person with ASD, though, will sometimes step up a little bit more; he or she might not understand the parameters of personal space.
Also, individuals with ASD often lack eye contact; they might not look at you when you speak. This can also be very disconcerting. Of course, lack of eye contact varies with culture, but, in the United States, not looking someone in the eyes while he or she is speaking can make you appear untruthful or uninterested in what is being said. Additionally, some individuals with ASD may appear uninterested or self-centered, wanting to talk only about their topic of choice. Another social difference is the inability to start a conversation or maintain it. For example, if you say, “How are you?” most people will say, “Fine.” You might continue and say, “What did you do last night?” Typically, the person you ask will detail the night’s activities. If you're engaging with a person with ASD, though, the conversation may just stop. The person with ASD may be unable to maintain an ongoing conversation or to engage in the typical back-and-forth exchange we have when we talk with others.
Understanding the Important Role of Culture
There also may be differences in the play of children with ASD. For example, you might observe more instances of parallel play (side by side but not together). Neurotypical young children (without ASD) usually engage in parallel play, eventually moving to cooperative play, in which they engage with each other. You may observe fewer instances of cooperative play in children with ASD. This is very much related to the issue of joint attention just discussed. There may be less sharing of experiences among people with ASD with others. This, however, is highly dependent upon social and cultural norms, as expectations, types of play, and settings may vary.
Individuals with ASD can also display social differences that may be obvious or quite subtle in nature. For example, a common issue is that of personal space, where people with ASD may sometimes stand too close to another person. This may be uncomfortable for some people, depending on cultural norms, which vary across different contexts. Some people might step back as a natural reaction to a person with ASD who is standing too close. In response, the person with ASD may even step in a bit closer, as they may not understand the cues or even the expectation for personal space.
One common criterion in identifying ASD is the lack of eye contact, where people with ASD might not look at you when you are speaking. Again, the lack of eye contact varies with culture. Check out this video by self-advocate and autistic mother, Dr. Morénike Giwa Onaiwu, who discusses some of the presentations that may be misinterpreted without specific understandings of the African American Community. In some cultures, to look someone in the eye may be interpreted as disrespectful. By contrast, in the United States, not looking someone in the eyes while they are speaking can make you appear untruthful or uninterested in what is being said.
Additionally, some individuals with ASD may appear uninterested or self-centered, wanting to talk only about their topic of choice. Another social difference may be in the inability to start a conversation or maintain it. For example, if you say, “How are you?” most people would answer, “Fine.” If you were to continue and ask, “What did you do last night?” the person you are communicating with would likely detail the night’s activities. For some people with ASD, however, the conversation may just stop after they responded to “Fine.” Some people with ASD may be unable to maintain an ongoing conversation or to engage in a back-and-forth exchange we expect when we talk with others. While this is not the presentation of every individual with ASD, we need to be mindful of this when engaging in conversations and having expectations for dialogue.
Repetitive Behaviors and Restricted Interests
Another diagnostic criterion of ASD relates to repetitive behaviors and restricted interests. Although we have already discussed that "people with ASD" is a very heterogeneous group, we need to reiterate this. This heterogeneity can manifest in both the degree to which a person with ASD engages in repetitive behaviors and restricted interests that are evidenced. Repetitive behaviors are those that are repeated over time. Some individuals with ASD engage in the self-stimulatory (sometimes called stereotypical) and repetitive behaviors of rocking and hand-flapping. You might be supporting a child who has engages in self-stimulatory behaviors, such as tugging on the bottom of his shirt and making a verbalization/sound. You should know that autistic self-advocates have described these behaviors as helping them to calm or regulate themselves or stimulate and engage themselves. Below is a great video that explains some of the functions of stimming or restrictive and repetitive behaviors, and what we are beginning to understand about people with autism. Overall, we are learning to provide supports and how we may need to differentiate between behavior that is harmful (or self-harming), and something that we may simply need to replace or place time limits upon.
There can also be an insistence on sameness. Some individuals with ASD really dislike changes in routine, as it may become really uncomfortable. If a particular person is absent one day at school, the child may have a great deal of difficulty coping that day. If gym class is cancelled due to weather, a child with ASD might express their difficulties with the change in routine in behavioral responses. It is important to monitor their behaviors to understand how they are triggered, while also providing support and preparation for changes as much as possible (e.g., social stories).
While some of these features (repetitive behaviors and restrictive interests) might be challenging in some environments and settings, some of these may be also functional for the person with ASD. Some of the behaviors (such as flapping and stimming) may serve to help a person with ASD to self-regulate, while the routines may help to ease the discomfort that comes with abrupt changes.
Self-Injurious Behavior (SIB)
Some individuals with ASD may engage in self-injurious behavior (SIB) or aggression. Self-injurious behavior can range from mild to quite severe. Some individuals with ASD, for example, may bite their hands; some may hit their heads. Other individuals with ASD may engage in extreme SIB, such as gouging their eyes and causing blindness, or gouging their ears and causing hearing problems. Extreme instances of SIB can be very difficult to address and require immediate attention if they are life-threatening. Individuals with ASD might also engage in physical aggression toward others (e.g., kicking, hitting, or scratching) or display verbal aggression (using unkind words or profanity).
Below, you will see an example of a young man who displays self-injurious behavior. You'll notice that he's wearing a helmet. He may be wearing the helmet due to seizures or for protection from his head-hitting. He wears headphones to cut down on noise, and you'll see him chewing on some rubber tubing, probably to keep him from grinding his teeth. His self-injurious behaviors are head-hitting, biting, and slapping his legs. His family has put up several videos; you will probably be able to tell that they're very frustrated, feeling that they need a lot more support in the home. This is a more extreme instance of SIB that shows that life at home may be very difficult and that additional support for the family may be needed.
Savant Skills
A relatively small portion of individuals with ASD may display savant skills. You might also hear this referred to as "splinter skills" or "islands of genius," wherein the individual can be experiencing a number of challenges in some areas of development, yet display significant strengths in others. Savant skills typically occur in areas like music, art, or mathematics. You can see an example of savant skills in the movie Rain Man, where Raymond, who has ASD, has difficulty with some functional skills but great mathematical and memorization abilities. Savant skills are often portrayed in popular media, so many think this is how individuals with ASD function; however, the condition is not very common. Savant skills occur only in about 1% of individuals with ASD.
Below is a video clip of a man named Stephen Wiltshire, who has savant skills. He has been sometimes referred to as the“the living camera.” He didn't use speech until the age of five, but at age 11 he began drawing very complex scenes from memory. In this clip, researchers took Stephen to Rome, gave him a 45-minute helicopter ride over the city, and then asked him to draw the city. The level of accuracy and detail is astounding. Again, remember that savant skills are not commonly evidenced in individuals with ASD—but they are a part of the range of autism.
It should be noted that many autistic people find the overemphasis on savant skills problematic, as it is a form of stereotyping, while also placing expectations on them to display an extraordinary talent or gift that is not true for most people. Check out this series which centers on a Korean lawyer with ASD, Extraordinary Attorney Woo (2022).
Also, subsumed under the category of repetitive behaviors and restricted interests are individuals with ASD who have very set routines, compulsions, or rituals. For example, before they are able to leave the house, they might need to do certain things each time (check the stove, touch the light switch, turn the knob three times, etc.). People with ASD who display these behaviors may have greater difficulty with change. They might have trouble problem-solving if the situation is unfamiliar. For example, if someone has the day off from work and an individual with ASD is now responsible for picking up the colleague’s part of the job for the day, it may be difficult for him or her to adjust.
Motor Skill Delays and Differences
Some individuals with ASD may have what is called dyspraxia, or difficulty with motor planning. Some individuals may have balance issues or uncoordinated movements, may walk on their toes, or may have delayed developmental milestones. Motor issues can be categorized based on fine motor skills or gross motor skills. Fine motor skills center on small muscle movements—things like buttoning a shirt or unscrewing the cap off a tube of toothpaste. Gross motor skills involve large muscle groups, typically dealing with ambulation (walking) or being able to move one’s arms in a wide circle.
Gross Motor Skills
Motor issues are addressed through occupational therapy (OT) or physical therapy (PT). Occupational therapists often work with children with ASD on handwriting issues, helping them hold the pencil or pen correctly and helping them learn the amount of pressure to use when putting the pen to paper. An OT works primarily on fine motor skills but can work with physical therapist on trunk movement. Physical therapists may help individuals with ASD with walking, exercise,and positioning. Below, you will see a video of a child engaging in toe-walking, being supported to develop a gross motor skill.
Here is another short clip from an Occupational Therapist, who offers some reasons why people with ASD may engage in toe walking.