Aspergers and Autism Spectrum Disorder

Gavin NImon: 0:28

g'day and welcome to the Aussie Med Ed, the Australian medical education broadcast, where we get to interview specialists in a variety of medical areas, asking their opinion on their certain conditions, obtaining their insight into how they diagnose and treat that condition. In these COVID times, it's a way of replacing the relaxed discussion around the hospital by allowing the listener to put forward questions to be answered, addressed on their behalf. I hope you enjoy the whole program. Welcome once again to Aussie Med Ed. And in this edition we speak to Professor Robin Young. She's a psychologist working at the School of Social Sciences at the Flinders University. Robin has a particular interest in neurodevelopmental disorders and grew an interest in autism while studying for her PhD in Savant Syndrome. Today she's going to talk to us about Asperger's Syndrome and the new nomenclature for it. Not only will this information be useful for the general practitioner seeing a patient on a regular basis, but also for the medical student revising for their exams or preparing for their OSCE examination. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide in South Australia, and I'm the host of this podcast. I'd like to begin this podcast by acknowledging the traditional custodians of the land on which this podcast has been produced, and pay my respects to the Elders both past and present. Welcome Robin Young, Professor from Flinders University. In specialising in psychology, I believe you started taking an interest in autism when you started studying Savant Syndrome, which is the high functioning autistic condition. Can you take us through what Savant Syndrome actually is and then go into what Asperger's condition involves? I look forward to actually hearing the new nomenclature for it and actually what the condition involves and the symptomatology of it is. Okay,

Robyn Young: 2:03

gosh, there was a lot there Gavin. So, to start with, savants probably aren't really the higher functioning end of the spectrum. They're people with a significant intellectual disability, but with a very specific prodigious skill. But often that's contrasted with a very low level ability in other areas. Uh, you mentioned a good point about Asperger's and autism and the nomenclature. Which has certainly changed in the last, um, revision of the Diagnostic Statistical Manual for Mental Disorders, um, in the 5th edition, which is the one we currently use. So, historically, back in 1943, a guy called Leo Canna was talking about a condition referred to as Autistic Disorder. And I think this is the stereotype view of what we perceive Autism to be. Which is the, uh, flapping, rocking, spinning, often non verbal child with significant intellectual impairment. And then, at the other end of the spectrum, you have which people, a condition people often refer to as Asperger's Syndrome, or it used to be referred to as that. And that was the more high functioning end of the spectrum. But that really came about because in 1944, a guy by the name of Hans Asperger was talking about that condition. Thank you. But really, if you look at it, he was describing a more high functioning Autism Really. So when his work translated into English, people put their heads together. Initially they were referred conditions, the DSM part of theology, and genetically similar because in, so it all got revised as an autism. So that's it in a bit of a nutshell.

Gavin NImon: 4:05

So that's the ASD conditions or ASD spectrum. And I presume there's actually a group of, or in any spectrum, there's different levels or different level of affectation to the condition. What are the main symptoms of the whole spectrum? Okay, so

Robyn Young: 4:20

it's now called Autism Spectrum Disorder and that really is part of the old pervasive developmental disorder, so it goes from people who have a very limited impairment, some of You can seek a diagnosis to those where the impairment is really quite significant and it's life becomes a bit of a battle for them. So the main areas of impairment, um, the social communication domain, and it used to be called a triad of impairment, which, which the language and the communication was separate, was, was treated separately to the social skills, whereas now we've realised that the communication can be quite impaired, even if someone doesn't have a language disorder per se. So the first area of deficit is the area of the social and communication components where in order to meet criteria, a person needs to meet three specific behavioural criteria. First one is problems with social communication. So initiating And interaction, keeping the interaction going in a reciprocal way by not monologuing and just being able to engage in general chitchat. Uh, the second area is the non verbal communication. So being able to pick up on the subtleties of Communication when someone's being sarcastic, not taking things literally, understanding metaphors, but also understanding when someone's sad or hurt, and not only just being able to recognize it, but knowing what to do with that emotion and how to respond to it. And the third criteria is developing and maintaining friendships appropriate to one's developmental level. So it's a bit of a misnomer that people on the autism spectrum are antisocial. It's often they just don't have the skills, the desire to be social. So someone needs to meet all of those three criteria in order to get a diagnosis of an autism spectrum disorder. But they also need to meet two criteria out of four criteria. in the ritualistic and repetitive behaviour domain or stereotypical behaviour. So the first one is, so stereotypical behaviour with regard to the body, so it could be flapping, rocking, spinning, pacing, it could also be pulling things apart, putting things back together, but it could also be stereotypical behaviours. With regard to one's speech, so picking up expressions, saying things over and over again, repetitive asking of questions, or idiosyncratic speech, so mispronouncing words, or using odd portmanteaus that are obviously not used in the community. Just, um. Using other things we call neologisms, which are just made up words, and that's a common feature of autistic speech. So they need to meet either that criteria or the second criteria, which is rigidity in their thinking or behaviour. So in their thinking it could be having very strict or firm beliefs about rules, or religion, or social justice, and really not open to the beliefs or understanding of other people. So being quite dogmatic. But it could also be in their behaviour, so they could have routines around getting up in the morning, having to have a cup of tea before they have breakfast, before they have their shower. And if those routines are interrupted in some way, there may be some difficulty with transitioning. So if they're exposed to new situations, that transitioning from one activity to another, particularly if they're engaged in that activity, can be quite problematic. The third criteria is obsessive interest. So that might manifest itself in researching that interest, understanding that interest, having a understanding or collecting things about that interest, and increasingly that's gone over to interest in the internet and so forth. And the final criteria, which is something that Kanna spoke about in 1943, but it didn't make it. The diagnostic manual until the recent edition is the sensory sensitivities, which for many can be quite overwhelming and disabling. And they're things like sound sensitivity, problems with touch or feel, it can be pain or adapting to the weather. So any sorts of sensory sensitivities, either sensory seeking. So, seeking out, touch, feel, playing with things, liking the feel of things, or it could be sensory avoiding, which might mean they have problems having. Showers, washing their hair, or wearing certain clothes. So in order to meet diagnostic criteria, you need to meet two of those four criteria, as well as all of the social and communication domain. And that needs to be having a significant impact upon one's life. And if it is, then you would say you'd meet criteria for an Autism Spectrum

Gavin NImon: 9:10

Disorder. Okay, so that's for the disorder. spectral traits that actually do not meet the full criteria, but actually make you think the patient or client is heading in that direction? Yeah, so

Robyn Young: 9:21

if they meet just the social and communication disorder, the three criteria in the social and communication domain, we diagnose them with the social and communication disorder. Sometimes they might meet criteria for a sensory processing disorder if they've got a lot of what we refer to as the B4 criteria, the sensory input there. Sometimes if it's more along the lines of check, if they're obsessive, interested in checking or washing hands or... Things like that. It might be more of an obsessive compulsive disorder. Sometimes, if it's texture related, they may be misdiagnosed with eating disorders because they might not eat certain foods and so forth.

Gavin NImon: 9:58

I understood that sensory processing disorder was actually a quite common diagnosis in primary schools. Yeah,

Robyn Young: 10:03

absolutely. And I think some of the problem is that a lot of the children get these diagnoses first because there might be things that stand out or they might be diagnosed with a language disorder. And it's only really when you put all of it together that you realise, okay, well they've got the language disorder. They're having problems making some friendships. There's a lot of sensory stuff going here and you sort of put it all together and think, okay, maybe we might be looking at autism spectrum disorder. But many of the children that we see, particularly in the younger years, have had other diagnoses

Gavin NImon: 10:36

first. That's interesting. So what you're really saying is, as well as the full blown spectrum of Asperger's disorder, there's a large number of students who actually have traits which actually fulfill or go close to the criteria for the autism spectrum disorder. Is that correct? Well,

Robyn Young: 10:53

I think it's like, if you think of the spectrum almost like a bell curve, when people have an intellectual disability, they've got an IQ below 70, or the criteria is a bit different, but you know, it's part of the spectrum. IQ, people above the IQ still have intelligence, if that makes sense. If you turn it the other way around, Autism Spectrum Disorder is a spectrum, so of course there are people in the community with varying levels of these autistic behaviours. Some of my clients find it quite insulting though, just when people say, oh, I'm a bit aspy or I've got a bit of autism, because it does undermine the difficulty that, um, Their condition has for them in particular, so you know, certainly it provides some strength and I think the world would be a far worse place if we didn't have people on the spectrum because often their ability to have these intense in stress or to hyper focus on things are really important for the development of life and humans in general. But people when they say, you know, I'm a bit autistic, I think that can be a little bit offensive to people on the spectrum who are really struggling with the condition.

Gavin NImon: 11:59

I certainly could understand that, especially when you consider some of the greatest inventions have come from people who may have been on the spectrum. And that brings on to the point of the fact that there's also this extra high level functioning in some of these people. Is that part of the disorder trait, the actual, or is it just part of the ultra focusing aspect to it? Look,

Robyn Young: 12:17

it's part of the ultra focusing and why this happens. We don't know, but the area that I did my PhD in was Savant Syndrome, so I interviewed around the world 50 people with prodigious skills in music or maths or clinical calculation art, and that was juxtaposed with a very low IQ. But what I actually did was I assessed family members and looked at their IQs and I think the average IQ of the parents. was well above 130, which is in the gifted range. So it sort of appears that had these persons not had autism, they would have been globally very bright people. They weren't a low intellect or, you know, wasn't more of a what we might refer to as a familial retardation. It was something very specific. Their ability for some reasons, preserved ability, or almost an innate in certain areas, allowed them to develop these skills to a prodigious level. And when I say prodigious, not just talent, really prodigious. So being able to play a piece of music that they'd heard on one hearing or represent Australia in the maps were chest olympiad and so forth.

Gavin NImon: 13:33

I understand the, the classic Savant Syndrome is the, the Rain man., Portrayed by Dustin Hoffman in the movie from the, I think, 80s or 90s, is that correct?

Robyn Young: 13:42

Yeah, I mean, but that was an eclectic, um, a combination of Kim Peake and Joseph Sullivan. And there was five different people that sort of, they combined the skills together. to form that character of Dustin Hoffman. So predominantly it was based on a gentleman by the name who recently passed away called Kim Peake, who was quite disabled but became quite famous through that film and through his skills traveling the world with his father. But he had a significant intellectual impairment, he had no corpus callosum, um, he had a significant brain impairment. Even though he might have had autism, he certainly, probably his primary diagnosis was one more of an intellectual disability than autism.

Gavin NImon: 14:26

When I've been reading about Asperger's condition, they talk about the postulation there's a different wiring of the brain, or some sort of elemental abnormality. Is that what's thought to be the case, or does anyone have any idea of what causes this at all? No,

Robyn Young: 14:38

look, I think there's no single cause or no single gene. We do know that some disorders increase the likelihood that you may have a co occurring autism spectrum disorder, even something as common. As Down syndrome, if you've got some chromosomal abnormality, you're at increased risk of having autism or any other neurodevelopmental disorder, even Williams syndrome. So, any of those conditions could increase the risk that you would also present with behaviours that were also consistent with an autism spectrum

Gavin NImon: 15:09

disorder. Okay, and it does tend to run in families too, is that correct? Yes,

Robyn Young: 15:13

certainly. So, As I've got older, my client group have got older, so initially when I was starting up back in, well, 1995 that I developed an early screening tool to pick up autism in two year olds because back then children really weren't being diagnosed until the age of six or seven, when in the age of two it was quite clear that they were presenting with an autism spectrum disorder. But the criteria required back then that there needed to be a significant language delay and how do you pick that up at the age of two. So we developed a tool at Flinders where if they weren't demonstrating all or some of these 16 behaviours, we thought they were at risk of developing an autism spectrum disorder. That was lack of eye contact, lack of joint attention, responding to their name and so forth. So that was a really nice screening tool and with that we were able to start early intervention for some of these children to maybe ameliorate some of the difficulties they may experience down the track. But as we've got older and the diagnostic criteria have broadened, a lot of the time now I'm diagnosing parents of children that I've previously diagnosed or even just adults that have struggled their whole life feeling a little bit different and watching something or learning about autism and going, hang on, actually this might be me. And even when I go out to medical groups to talk, sometimes when people are working with adults, they don't really, or they're not really primed to think about autism. in, in the psychiatric community. So clients might be misdiagnosed before with schizophrenia or a borderline personality disorder and they haven't really thought about autism. And that's particularly true for females as well because I think a lot of the medical fraternity and psychologists and allied health don't really think about autism in females because initially it was thought to be more predominantly males. But the more we learn, the more we're seeing. It occurring in the female population with a slightly different presentation.

Gavin NImon: 17:21

I believe a lot of the autistic traits can be hidden by learnt behaviours. And from my reading that the female gender is better at hiding the autistic traits than the male. And that's why it's probably made maybe more di More diagnosed than males. Would that be the case or is that just an old thought?

Robyn Young: 17:39

True. When I first started doing research, the incidence of males to females was about four to one. But in the higher functioning aspects or the higher functioning people with the spectrum, it was about 14 to one. But I think that was largely because females had to be pretty obvious before they were picked up. So it's very common for me to be diagnosing female adults now who have been diagnosed with. Either a borderline personality disorder or anxiety, depression, post traumatic stress disorder, because often they've been traumatised at school by being bullied or not fitting in. But women in particular seem to be able to camouflage it better for reasons that we don't really understand, but probably largely environmentally, because of the way we socialise girls when they're younger. We encourage more pretend play. And so it enables, and just less vocal, whereas boys tend to act out, whereas the girls tend to internalise their problems and perhaps fly under the radar because of that. One of the

Gavin NImon: 19:15

difficulties I've had understanding is why they particularly have difficulty interacting or forming social groups. Because they can't read or understand the other person's feelings. What in particular is identified in that scenario? I mean, what particular problem do they see? It's just put down as a general, oh, they can't read the other person. What is the actual reason for it, or what, what actual exact problem does occur in that scenario? I'd like to let you know that Aussie Med Ed is supported by HealthShare. HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of HealthShare's core products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, with the aim to reduce admin and free up time during a consult. And Healthshare's Specialist Referral Directory, a specialist and allied health directory integrated into GP practice management software, helping GPs find the right specialist. You can find out more from healthshare. com. au

Robyn Young: 20:24

Yeah, well, up until probably the last two or three years, it was thought to be a deficit of, we refer to it as theory of mind, and that's the ability to be able to take the perspective of somebody else. And that is if you don't understand whether someone is making fun of you or someone's genuine. Like I've had clients that are in that said they wouldn't know that someone was flirting with them until they were standing there in a wedding dress. It's difficult for them to understand the perspective of the other person. So if you don't know whether that person's bored or not or you think they're interested in you or interested in what you're saying. And you have an intense interest, you might monologue about that interest or you don't understand, they don't share your point of view and you keep going on about it. It can lead to sort of quite damaging relationships. It also leads people to be manipulated if they, I've had clients that think people are their friends and they just drive them around to parties but never get invited in. And things like that, so it, it opens up a whole can of worms for, for being manipulated and leading to damaging relationships. When can it

Gavin NImon: 21:35

become pathological or actually cause major issues apart from failure to form friendships or differently communicating? Can it cause major issues? What's the main problem that you might see with someone with, uh, on the, on the Spectral Disorder?

Robyn Young: 21:50

Yeah, one of the interesting things that we've been researching is that for the general population there's a very high correlation between IQ and adaptive ability. So to be able to function in the community and so forth, and that correlation doesn't hold up necessarily for people on the spectrum. So we have people with really high IQs but functioning quite poorly, so not being able to organise themselves, just simple things like not being able to take their garbage out because they have to recycle it, not being able to throw things out, hoarding things. So it can lead to sort of other pathologies as well. It can lead to OCD, not being able to leave the house, social anxiety and developing anxiety, depression and other co occurring conditions. It can also lead to situations where you might have a person think that someone's interested in them and they'll go around and harass that person in a way and be accused of stalking and not understanding that the relationship isn't reciprocal. So it can lead to all sorts of manners of problematic behaviours if the person has misunderstood the nature of that relationship.

Gavin NImon: 22:57

Okay, I can see how that could occur. How would you then proceed to treat someone with a disorder or a condition? Uh, so they become more functioning and more interactive in this society. Uh, what's the, what's the sort of modalities of treatment?

Robyn Young: 23:10

I think one needs to be really careful about imposing treatment. There's a real push that the community as a whole should be more tolerant and understanding of people on the spectrum. But obviously, some of the people, parts of their condition contribute significantly to impairment in them being able to engage in a neurotypical world in which they live. So the first thing would be to identify which of the behavioural characteristics are contributing to the level of impairment they're experiencing. So it might be their rigidity in thinking about strong senses of social justice. So we work on that and teach them a bit more flexibility in thought. It might be teaching someone how to engage in social chitchat or it might be if it's the sensory sensitivity that makes it overwhelming, desensitise them in some way through occupational therapy in order to be able to tolerate some of these sensory sensitivities that prevent them maybe getting on a bus or getting on a train if other kids are getting on it and so forth. So you'd have to look at the individual because... We say you've met one person with autism, you've met one person with autism and they are all very, very different. So you need to address the individual, even though the underlying cause may be autism, you have to look at the specific needs of that individual and treat them accordingly. And also recognize that there might be co occurring conditions like ADHD, obsessive compulsive disorder, anxiety or depression that may need to be medicated in addition to some sort of behavioral or cognitive therapy. Sometimes we do CBT, Cognitive Based Therapy, with our clients, it's quite hard because many of our clients are quite rigid and so if they've got some negative, trying to talk about what someone else might be thinking, so if someone's upset that their parent might be asking them. You know, every day, if they're looking for work, have you checked your emails, have you checked your emails, they will, why might they be asking you that? It's not because they're nosy, it's because they are genuinely interested in your welfare and, and trying to point out that there are sort of different points of view. But sometimes their, their beliefs are so rigid. So, say for example, someone had a belief about religion and they were an anti theist, for example, and were very anti religion. We can't have to then say and know that you're not going to change that overnight. Then a bit more about tolerance and accepting people who might have different opinions and so forth. So it's really treating the individual. One thing that can be quite problematic is that there's a fine line between accepting the condition and accommodating it. And I remember A spokesman for autism has spoken about his sister having autism and saying that once his sister was diagnosed, his family became very autistic and they didn't go out anymore. They didn't have people over. And pretty much, they accommodated a lot of the girls difficulties and I see this a lot whereby there's been so many accommodations made that the problem is that when that person then goes out into the community or they haven't got that scaffold in place, that that can be quite problematic. So, if they've been accommodated and haven't been encouraged to transition or accept other things. If things don't go to plan, then they might have some violent outbursts. Now while that's rare, it does happen. And that's something that we really want to try to avoid by trying to encourage degree of flexibility.

Gavin NImon: 26:51

The other thing I've read about when reading up about Asperger's condition is that the clients can sometimes have issues empathising with other people. I believe that can actually be the opposite scenario, they can over empathise. Is that correct?

Robyn Young: 27:04

It is. Sometimes we see that a lot in the women in particular and I'm, I'm doing this sort of binary psychotomist, I guess, idea about sexuality of male and female and a lot of our clients also experience the gender dysphoria and, and gender confusion. So, I don't want to be specific about having a male and female presentation, but there is a more of a female presentation, which we do see in people that identify as males as well. But certainly, we see these females emphasizing overly so, so they feel the emotions of other people and they get quite distressed by other people's emotions and they can't distance themselves from that. Emotion, which can be extremely challenging and draining for people, but sometimes it really varies. There was this misnomer that people on the autism spectrum couldn't show empathy or didn't didn't feel the empathy, but me and my clients say they can feel it. Some of them say they can feel it, but or see it or recognize it, but don't want to do anything about it. Others say they don't know what to do about it. Others say they don't feel the empathy at all. They don't get that. So it, it, it really varies. I have one client recently say that he feels the empathy, but really just doesn't know what to do with it. And that's actually, that's a really common thing for them to say that they feel it. And often their response won't be an emotional one, but it might be more of a physical one. So if they see that someone's sad, They'll go over and offer them a cup of tea or pat them on the back, or maybe even try to solve the problem without really understanding as to how to sit and listen and empathize. But it's varied dramatically.

Gavin NImon: 28:47

That's excellent. You've explained that really well. So moving on, what other conditions can mimic the Autistic Spectrum Disorders?

Robyn Young: 28:53

Well, I think sometimes eating disorders. So a person might be refusing food, not because of any body image or body dissatisfaction, more along the lines of that they don't like the texture or the feel of the food, or it might be they haven't tried it before, or they've got this belief that they don't like food, or they've become vegetarian because of that firm, rigid belief, so that might be, lead to food, and it might actually end up in an eating disorder, but what's underpinning it is the autism, um And similarly, Obsessive Compulsive Disorder has overlapping behaviours, as I said, anxiety and depression, we see a lot of anxiety, particularly among the females. Borderline Personality Disorder has similar features, sometimes people on the autism section are accused of being narcissists because they might appear self absorbed. So, you have people that, for example, some kids might see their parents upset and instead of feeling empathy, they're more upset that this is a change and they don't like that change. They want their parents to go back to not being upset because this is interfering with their normal routine and structure. So, difficult to disentangle the conditions. Probably one of the primary ones, which I haven't mentioned, and we see this in young children, particularly those that have been subject to trauma or attachment issues. A differential diagnosis between reactive attachment disorder and autism in the early years can be problematic if there have been attachment issues. So that's something also to look at and also language disorders as well can mimic autism because a lot of kids with language issues who are trying to get some structure or control over their lives will start to be quite rigid in their thinking. They might even line things up or become obsessive about certain things and obviously the communication and social difficulties will be there which can also affect their development of friendship. So, the only way to really disentangle it all, and I haven't really mentioned this about how people go about getting a diagnosis, is really to sit down with someone that's trained in ASC assessment, and really address all of those criteria, and then work out could there be other conditions that Them present like they have autism. Is this the underlying condition that is of interest?

Gavin NImon: 31:22

Finally, Robin, I'd like to ask you what, what would you do if you think a patient or a client's got autism? Where would they go for advice? How would they make the diagnosis? What's the next

Robyn Young: 31:31

step? The next step is probably to go on the autism website where there's a list of people who are accredited, diagnosticians. You might wanna contact either Autism SA or one of the child development units at any of the major hospitals who run diagnostics there. So if it's an older person, once again, you contact autism people who can. It can only be diagnosed by people, occupational therapists, psychologists, and psychiatrists, and they need to have had training and approved through Autism SA as being a diagnostician. The value of that is different for various people, but certainly now the value of a diagnosis rather than just simply treating the symptoms, is that this might open the door for them to be able to access services through the N and so forth, which has been really valuable. Particularly for some of our late diagnosed clients. Brilliant. Thanks, Gavin.

Gavin NImon: 32:46

Information provided to you today is designed to compliment the information provided to you in your local region and should supplement your readings and teachings in that area. Please don't take it as the only way of treating this condition or assessing a condition, but really as a one one of various ways of assessing these conditions. Please be also be aware that the information provided today is really just general medical advice and isn't designed to actually be a source of medical information regarding your particular condition. Remember to consult your specialist or medical practitioner if you have concerns about a condition raised in this podcast. Thanks once again for listening to our podcast, Aussie Med Ed or the Australian Medical Education Podcast. We really enjoy hosting this podcast. I hope you find it useful to hear a pragmatic approach to everyday conditions. If you have any questions or information you want to ask about us, Or you'd like to put a suggestion for a topic, please don't hesitate to email us at gavin@med-ed.com.au once again, I hope you've enjoyed listening to it and we look forward to hosting it next fortnight when we introduce a new topic. Thank you.