Preface

**Section 7 Aetiological Factors - Intervention in Person**

Olive Healy and Sinéad Lydon

Chapter 24 **Early Intensive Behavioural Intervention in Autism Spectrum**

Geneviève Nadon, Debbie Feldman and Erika Gisel

Rudimar Riesgo, Carmem Gottfried and Michele Becker

**Children with Autism (SCALA) with Context-Centered Design**

Fernanda Dreux Miranda Fernandes, Cibelle Albuquerque de La Higuera Amato, Danielle Azarias Defense-Netvral, Juliana Izidro

Chapter 27 **Building an Alternative Communication System for Literacy of**

Liliana Maria Passerino and Maria Rosangela Bez

Balestro and Daniela Regina Molini-Avejonas

Chapter 30 **Early Communication Intervention for Children with Autism**

**Section 8 Aetiological Factors - The Autistic Self and Creativity 747**

Chapter 31 **Atypical Sense of Self in Autism Spectrum Disorders: A Neuro-**

Chapter 32 **Critical Evaluation of the Concept of Autistic Creativity 771**

Chapter 29 **Early Intervention of Autism: A Case for Floor Time**

Chapter 28 **Addressing Communication Difficulties of Parents of Children**

Chapter 25 **Feeding Issues Associated with the Autism Spectrum**

Chapter 26 **Clinical Approach in Autism: Management and**

**of the Autism Spectrum 683**

Rubina Lal and Rakhee Chhabria

**Spectrum Disorders 719**

**Cognitive Perspective 749**

Viktoria Lyons and Michael Fitzgerald

Viktoria Lyons and Michael Fitzgerald

**with Autism 565**

**VIII** Contents

**Disorders 567**

**Disorders 599**

**Treatment 633**

**of Usage 657**

**Approach 691**

Gunilla Thunberg

The pace of research on Autism Spectrum Disorders (ASD) can only be described as extraor‐ dinary as this volume shows. It is extremely difficult for any single professional to keep abreast of all the developments in this area. This volume gathers together leading research‐ ers and expert clinicians from many different parts of the world to produce this "up-to-theminute" volume. It gives an in depth view of many areas of research which may be unfamiliar to the clinician and indeed researcher focused on their own area of interest. The volume gives an in depth overview of the field of Autism Spectrum Disorders.

The best outcome for Autism Spectrum Disorders occurs where there is an early diagnosis at around two years. Unfortunately this is only achieved in a minority of persons with ASD as described in the first section on diagnosis and prevalence. Siller et al describes the strategy for improving the situation. Information from non-English speaking countries is critical to a global understanding of Autism Spectrum Disorders. Samadi and McConkey provide this for Iran. Benjak does this for Croatia.

The brain/gut axis has a long and controversial history in autism. Sajdel-Sulkowska et al pro‐ duced some new findings in relation to the "leaky gut" during development, abnormalities in the gut microbiome and effects on the brain. This area of research remains an exciting proposi‐ tion. The non-relationship between vaccines and autism is covered in two important chapters by Bustin and De Soto. The focus on immune dysregulation in ASD by Ponzio et al is an area of increasing importance and a particularly useful method of research is the mouse model. Immune problems have been observed at a clinical level for a long time in ASDs.

Another important chapter using an animal model is by Gottfried et al who focused on Val‐ proac acid in pregnancy and associated autistic features in offspring. Romero-Munguia de‐ scribes a very interesting mnesic imbalance or hyperthymestic syndrome as a cause of autism symptoms in Shereshevskii, a man whose memory was studied by Luria. The under‐ standing of the aetiology of Autism Spectrum Disorders clearly has to pay large attention to genetic factors. This very rapidly expanding field of study is dealt with in great depth in a number of chapters by some of the foremost researchers on this topic in the world. Larsen et al discusses the genetic evaluation of individuals with ASD including genetic screening tests. Fett-Conte focuses on candidate genes, copy number variations, epigenetics and exome sequencing. Lupski and Lacario focus on mouse models in a number of conditions including autism.

Connolly et al notes the relative scarcity of causal common variants and the growing list of casual rare variants. Gill et al's chapter on the genetic architecture of autism and related dis‐ orders gives an excellent overview of genetic linkage and association. They also discuss mu‐ tation rates and models of risk in autism as well as next generation sequencing studies. Guney et al focus on genetic and environmental factors. They make reference to the intrau‐ terine environment and pre-natal stress.Alqallafet al study the genetic origins of autism.

likely to have a child with ASD. Smoking during pregnancy has been associated with ASD

There are problems in using the Autism Diagnostic Interview Revised (Lord et al 1994) in clinical practice. It ,not uncommonly, misses high functioning autism and according to Ven‐ tola et al (2006) is "under diagnosing toddlers". It is an extremely expensive instrument to train on which makes it almost impossible for under-developed countries because of the ma‐ jor cost of training on the instrument. Professor Dorothy Bishop (Feinstein 2010) points out in relation to the length of this interview that there is no evidence for such a long process - "it is more an article of faith to them". I have seen quite a few families with a person with ASD who are negative on the ADI-R come to me in tears because of the missed diagnosis. An atypical sense of self is central to understanding autism. Lyons et al explores the psycho‐ logical and neuropathological aspects of self in autism. It is important when discussing au‐ tism not to always focus on the negative and on purely the disability (Fitzgerald 2004). Lyons et al examines the positive aspects of ASD in a critical evaluation of the concept of

**Professor Michael Fitzgerald**

Trinity College, Dublin

Ireland

Preface XI

Consultant Child & Adult Psychiatrist

and intellectual disability.

autistic creativity.

There is a wide spectrum of interventions for ASD. The earlier the intervention, the better the outcome. Healy et al describes early intensive behavioural intervention (EIBI) which reduces the cost of lifelong care by as much as two thirds. It is an intervention that draws from Applied Behaviour Analysis. They also noted a study where an 'eclectic' treatment group showed sig‐ nificantly greater increase in adaptive functions than the EIBI. I have observed in my clinical practice that where behavioural interventions were applied too intensively that a number of children developed post traumatic stress disorders and of course there are also the problems with generalisation of gains made from behavioural interventions. Lal et al describes the floor time approach that focuses on unique challenges and strengths of children with ASD. The child is the director or leader of activities. It has shown positive results and of course behav‐ ioural interventions narrowly applied do not suit all children and families.

Thunberg reviews early communication intervention for children with ASD's and uses evi‐ dence/grading which is very helpful. Interventions need to be continuous and include fol‐ low ups with the possibility for booster interventions. Nadon et al examines feeding issues with persons with ASDs-a major problem. Graduated exposure food therapy and food fad‐ ing are described. Passerino et al focuses on building on alternative communication system using context-centred design. It focuses on the re-organisation of the persons with ASD's relations with the world. Developing assistive technology for alternative communication is a very important development. Riesgo et al has an important chapter on the management and treatment of ASD. They provide detailed information on psychopharmacological inter‐ ventions as well as non- medical approaches and in addition provide a commentary on their effectiveness. Urbano et al focus on the understudied area of sexuality and ASD. They pro‐ vide an overview and describe treatment in this very sensitive area. I have observed crimi‐ nal charges being brought against a number of persons with ASD because of errors of judgment in the sexuality area.

A person with Autism Spectrum Disorder places great challenges on the family. The chapter on empowering families in the treatment of autism by Elder is very pertinent. Families are the primary providers of services on the advice of professionals and support groups. This collaboration is explored by Kalyva who provides a parent/professional protocol which is very valuable in improving this relationship. The parental issue is further elaborated in the chapter on addressing communication difficulties in parents of children with Autism Spec‐ trum Disorders by Fernanda Dreux Miranda Fernandes et al.

Another overview chapter by O'Malley on Foetal Alcohol Syndrome Disorders and ASD is particularly important. This is a big global problem in terms of alcohol use during pregnan‐ cy. This topic will become of increasing importance in the years to come. De Vaan et al fo‐ cuses on another somewhat neglected area that is ASD in people with sensory issues. In my experience persons with sensory issues should always be assessed for ASD.

Russell discusses the topic of co-occurrence of developmental disorders. This is extremely common and we now realise that there is much overlap between developmental disorders (Fitzgerald 2012). The categorical approach to diagnosis has now been shown to be limited and the dimensional approach is clearly a way forward. There is also an overlap in some genetic findings between disorders. Fairthorne et al's chapter on ASD and intellectual disa‐ bility focuses on the pre-existing differences in their mothers. Immigrant mothers were more likely to have a child with ASD. Smoking during pregnancy has been associated with ASD and intellectual disability.

Guney et al focus on genetic and environmental factors. They make reference to the intrau‐ terine environment and pre-natal stress.Alqallafet al study the genetic origins of autism.

There is a wide spectrum of interventions for ASD. The earlier the intervention, the better the outcome. Healy et al describes early intensive behavioural intervention (EIBI) which reduces the cost of lifelong care by as much as two thirds. It is an intervention that draws from Applied Behaviour Analysis. They also noted a study where an 'eclectic' treatment group showed sig‐ nificantly greater increase in adaptive functions than the EIBI. I have observed in my clinical practice that where behavioural interventions were applied too intensively that a number of children developed post traumatic stress disorders and of course there are also the problems with generalisation of gains made from behavioural interventions. Lal et al describes the floor time approach that focuses on unique challenges and strengths of children with ASD. The child is the director or leader of activities. It has shown positive results and of course behav‐

Thunberg reviews early communication intervention for children with ASD's and uses evi‐ dence/grading which is very helpful. Interventions need to be continuous and include fol‐ low ups with the possibility for booster interventions. Nadon et al examines feeding issues with persons with ASDs-a major problem. Graduated exposure food therapy and food fad‐ ing are described. Passerino et al focuses on building on alternative communication system using context-centred design. It focuses on the re-organisation of the persons with ASD's relations with the world. Developing assistive technology for alternative communication is a very important development. Riesgo et al has an important chapter on the management and treatment of ASD. They provide detailed information on psychopharmacological inter‐ ventions as well as non- medical approaches and in addition provide a commentary on their effectiveness. Urbano et al focus on the understudied area of sexuality and ASD. They pro‐ vide an overview and describe treatment in this very sensitive area. I have observed crimi‐ nal charges being brought against a number of persons with ASD because of errors of

A person with Autism Spectrum Disorder places great challenges on the family. The chapter on empowering families in the treatment of autism by Elder is very pertinent. Families are the primary providers of services on the advice of professionals and support groups. This collaboration is explored by Kalyva who provides a parent/professional protocol which is very valuable in improving this relationship. The parental issue is further elaborated in the chapter on addressing communication difficulties in parents of children with Autism Spec‐

Another overview chapter by O'Malley on Foetal Alcohol Syndrome Disorders and ASD is particularly important. This is a big global problem in terms of alcohol use during pregnan‐ cy. This topic will become of increasing importance in the years to come. De Vaan et al fo‐ cuses on another somewhat neglected area that is ASD in people with sensory issues. In my

Russell discusses the topic of co-occurrence of developmental disorders. This is extremely common and we now realise that there is much overlap between developmental disorders (Fitzgerald 2012). The categorical approach to diagnosis has now been shown to be limited and the dimensional approach is clearly a way forward. There is also an overlap in some genetic findings between disorders. Fairthorne et al's chapter on ASD and intellectual disa‐ bility focuses on the pre-existing differences in their mothers. Immigrant mothers were more

ioural interventions narrowly applied do not suit all children and families.

trum Disorders by Fernanda Dreux Miranda Fernandes et al.

experience persons with sensory issues should always be assessed for ASD.

judgment in the sexuality area.

X Preface

There are problems in using the Autism Diagnostic Interview Revised (Lord et al 1994) in clinical practice. It ,not uncommonly, misses high functioning autism and according to Ven‐ tola et al (2006) is "under diagnosing toddlers". It is an extremely expensive instrument to train on which makes it almost impossible for under-developed countries because of the ma‐ jor cost of training on the instrument. Professor Dorothy Bishop (Feinstein 2010) points out in relation to the length of this interview that there is no evidence for such a long process - "it is more an article of faith to them". I have seen quite a few families with a person with ASD who are negative on the ADI-R come to me in tears because of the missed diagnosis.

An atypical sense of self is central to understanding autism. Lyons et al explores the psycho‐ logical and neuropathological aspects of self in autism. It is important when discussing au‐ tism not to always focus on the negative and on purely the disability (Fitzgerald 2004). Lyons et al examines the positive aspects of ASD in a critical evaluation of the concept of autistic creativity.

**Professor Michael Fitzgerald**

Consultant Child & Adult Psychiatrist Trinity College, Dublin Ireland

**Section 1**

**Prevalence and Diagnosis**
