Autism Spectrum Disorder refers to a broad range of conditions that involve impaired social communication, repetitive behaviors, and deficits in speech and language. It is referred to as a spectrum disorder because no two individuals with autism present the same. There are varying levels of functional levels, speech and cognitive abilities, social skills and behaviors, which may also change for the specific individual over time.
In 2013, the American Psychiatric Association merged similar diagnoses under this one umbrella of Autism Spectrum Disorder – to include autistic disorder, childhood disintegrative disorder, pervasive developmental disorder – not other specified (PDD-NOS) as well as Asperger’s Syndrome.
SO WHERE DOES HIGH FUNCTIONING AUTISM FIT IN?
A basic facet of using the term high functioning autism has to do with cognitive skills. It is estimated between 40% to 55% of individuals with autism have an intellectual disability. The term high functioning autism was created to refer to that group of individuals with autism that do not have such cognitive involvement.
In the past, people with Asperger’s were thought to have average to above-average cognitive skills but be more involved socially. Since that diagnosis isn’t used anymore, the term high functioning autism seems appropriate.
Still, high functioning autism is often referred to as Asperger’s, and vice versa, although some dispute the symptom difference between the two. Mainstream professionals use the terminology “high functioning autism” to replace the symptom group of what would previously carry the diagnosis of Asperger’s. Regardless, neither one is outlined as a separate diagnosis in the current version of the Diagnostic and Statistic Manual – version 5 (DSM-V), as they both fall under the umbrella of autism spectrum disorder (ASD).
When the DSM was rewritten between versions 4 and 5, they took out the separate diagnostic category of Asperger’s, and made it fit with the true spectrum nature that is autism. This caused a big flurry of emotions and concerns and some upheaval in the autism community at the time, but the dust is settling. Here are some specific differences between the two:
To be given the diagnosis of autism, the following diagnostic criteria must be met in all three areas.
- Persistent deficits in social interaction
- Deficits in communication, symptoms often present before age 3
- Restricted repetitive patterns of behavior, interests or activities (in 2 or more of the following)
- Repetitive or stereotyped motor movements, use of objects or speech
- Insistence on sameness, inflexibility with routines, ritualistic patterns of behavior
- Restricted, fixated interests that are abnormal in intensity or focus
- Hyper or hypo-reactivity to sensory input
SIGNS OF HIGH FUNCTIONING AUTISM
There are certain behavioral characteristics that are consistent in individuals with high functioning autism. They obviously have to meet the criteria for autism, but here are some more specific descriptions of the behavioral involvement:
- Routine based - although routines are good for all kids, those with high functioning autism can be so attached to some routines or rituals that they cannot tolerate stopping them. There is often frustration and meltdown in the individual when there is a deviation from the routine.
- Language difficulty – one of the inclusion criteria of autism is a developmental language delay by the age of 3. Most children with high functioning autism have difficulty understanding language – even as they get older and complete work in literacy around metaphors, figures of speech, irony, humor, and sarcasm. They can be very literal in their comprehension of others, black and white in their understanding.
- Social delays – those with high functioning autism have social desire, they want to interact with others but do not know how to use appropriate social skills. They might do things that are atypical or even offensive in their attempt to connect with others. They struggle reading social cues or responding from social feedback to adapt their behavior. Children with high functioning autism also struggle reading body language and can display their emotions inappropriately.
According to the current diagnostic criteria, even in high functioning autism, there must be a delay in language development by 35 months. This is different from Asperger’s, because those who were previously diagnosed with Asperger’s later in life (according to the DSM-IV), did not have language involvement as toddlers. Parents often start with speech evaluations, but a social delay must also be identified to meet the criteria for high functioning autism, as well as behavioral involvement. Such signs and symptoms of social difficulty in a toddler may include difficulty with eye contact, lack of pointing to show interest, or lack of joint attention.
Joint attention or shared attention means that the caregiver and child are paying attention to the same thing at the same time. A classic example is reading a book together, if the child can sit with the adult and look at the book, enjoying the pictures and pages together, this demonstrates joint attention.
In contrast, this is not happening if the adult is reading the book and the child is walking around the room, looking at other toys, noticing things outside instead. Granted babies and toddlers don’t always pay attention to books when the adult is ready to read to them, but when the child has the capacity to demonstrate joint attention, it's notable. Joint attention is important as it is a building block towards imitation and learning.
Often, high functioning autism can be more difficult to diagnose because of the individual’s high levels of intelligence. Sometimes intense interests in certain topics are looked for, in addition to skills for tolerating and resolving conflict. In order to diagnose high functioning autism, pediatricians will typically conduct developmental screenings, observe behavior, and interview parents and teachers who work with the child.
Additional testing in the areas of speech, occupational, and physical therapies may be requested. Consult to a neurologist, developmental pediatrician or genetic counselor is typical as well.
Some sources go on to detail two different styles of social deficits in high functioning autism:
- Active – these types of children might also meet criteria for Attention Deficit Hyperactivity Disorder, they struggle with impulse control, are very active but also socially awkward and odd. Executive function challenges are often present here as well.
- Passive – these types of children are more aloof and drawn inward. They don’t initiate social interaction much and may present with social anxiety.
WHAT ARE THE CAUSES OF ASD?
We do not know how ASD is caused. There is old, outdated information that vaccines cause autism. They do not. There are a lot of different theories and speculations- some genetics, some environmental, some biological.
Research is being conducted and the cases of autism continue to rise. What we do know is that there are differences in brain structures between those with autism and those without the developmental disorder. These differences are largely in those areas of the brain responsible for socialization: the amygdala, superior temporal sulcus, fusiform gyrus, and orbitofrontal cortex.
APPROACHES TO TREATMENT
Right now, there is no cure for autism. Developmental therapies are recommended to improve function and promote skill development, as well as alleviate some of the signs and symptoms. Early intervention is best. Each state has its own guidelines to start services before the age of three, but we know from extensive research that identifying and addressing developmental issues in young children offers the best outcomes. Typically, children will receive educational services and therapies at home and at school. While not exhaustive, this may include:
- Applied Behavioral Analysis (ABA) in general promotes positive behaviors and discourage negative ones to improve a variety of skills. Data-driven, progress is tracked and reported. ABA styles may involve Discrete Trial Training, Pivotal Response Training, or Verbal Behavioral Intervention.
- Developmental Individual Differences, Relationship-Based Approach (DIR) or “Floortime” is play-based, focuses on relationship and interaction with caregiver, emotions and coping.
- Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH) use picture cues to break down tasks into small steps to teach new skills.
- Picture Exchange Communication System (PECS) uses picture cards to teach communication
- Speech therapy works to improve communication skills, increase language development and social skills
- Occupational therapy can improve functional skills for activities of daily living. Basic self-care tasks like dressing, bathing, and eating; fine motor development for school participation, most OTs are training in sensory integration, sensory integration dysfunction is a hallmark of autism.
- Physical therapy can help children with autism have motor involvement or are clumsy, this can help improve balance, strength, and endurance; navigation of a school setting, participation in sports-related leisure activities
- Diet – in some cases parents find success in eliminating certain components from their child’s diet, like gluten or dairy, adding certain minerals and vitamins
- Medications – in some cases of severe autism, they can help with symptom management
LONG TERM OUTCOMES
The outcomes of a child with autism progressing towards adulthood are varied. Some children make progress along a continuum, are eventually mainstreamed for their education, and go on to achieve typical developmental milestones of adulthood. Others remain stagnant at their developmental level, making minimal progress towards independence. Some have specific skill attainment, like reading, writing, and self-care, but lack the judgment and safety skills to live completely independently.
Even though there is no cure for autism, with years of therapy some eventually grow “out of” their diagnoses. Surprisingly, some individuals lead fairly “typical” childhoods and receive a diagnosis of autism later on in life as adults. Every individual is different, just as this is a spectrum disorder, there is wide variation in the possible long-term outcomes.
We know that often the core symptoms of autism remain, even though the severity of their impact can improve greatly. Some studies detail that IQ and age of language attainment can be predictors of outcome. Regardless, the consensus is that early detection and intervention will offer the best outcomes. Medical interventions and educational therapies are widely recommended and acknowledged to improve quality of life.
The prevalence of autism diagnoses continues to rise, and the medical community continues to describe and refine its identification of the disorder on this spectrum. High functioning autism is commonly used to refer to the group of symptoms previously known as Asperger’s, but there are subtle differences between the two.
Generally, high functioning autism is a term that refers to individuals that have autism without an intellectual disability. They still meet the criteria for autism spectrum disorder, with deficits in communication, social interactions, and behaviors that are restricted and repetitive. If you are concerned about your child having autism, talk to your pediatrician. They can screen for and recommend further testing. Early intervention is key to long term positive outcomes.