Autism spectrum disorder

Autism spectrum disorder (ASD) appears in child and adult cases where the counselor must separate a lifelong social-communication pattern from anxiety, attention problems, or the effects of early neglect.

Criteria at exam depth. Two domains. Domain A, social communication and interaction — persistent deficits across contexts in all three areas: social-emotional reciprocity (back-and-forth conversation, sharing interests), nonverbal communication (eye contact, gestures, facial expression), and developing, maintaining and understanding relationships. Domain B, restricted and repetitive behavior — at least two of four: stereotyped or repetitive movements, speech or object use (echolalia, lining up toys); insistence on sameness and rigid routines; highly restricted, intense interests; and sensory hyper- or hyporeactivity. Symptoms are present in the early developmental period, though they may not be fully obvious until social demands exceed capacity or may be masked by learned strategies. They cause clinically significant impairment and are not better explained by intellectual developmental disorder or global developmental delay.

Severity is rated separately for each domain at Level 1 (requiring support), Level 2 (requiring substantial support), or Level 3 (requiring very substantial support). Specifiers: with or without accompanying intellectual impairment, with or without accompanying language impairment, associated with a known genetic or medical condition or environmental factor, associated with another neurodevelopmental, mental or behavioral problem, and with catatonia.

Hinge differentials.

• Social anxiety disorder: social skills and interest are intact; avoidance is fear of judgment, and there are no restricted/repetitive behaviors.
• ADHD: social missteps come from impulsivity and inattention, not a core reciprocity deficit; the two often co-occur and can both be diagnosed.
• Intellectual developmental disorder: social communication matches overall developmental level; in ASD it falls below it.
• Reactive attachment disorder: history of severe neglect; social responsiveness often improves with consistent caregiving; restricted interests and rigid routines are not characteristic.
• Social (pragmatic) communication disorder: social-communication deficits without restricted/repetitive behaviors.

On the NCMHCE. The counselor gathers a developmental history (early milestones, play, language) from caregivers and records, and refers for comprehensive evaluation (developmental pediatrics, psychology, speech-language, occupational therapy, audiology to rule out hearing loss). Interventions are strengths-based and family-centered: behavioral and skills-based approaches, social skills groups, parent training, school supports through an IEP or 504 plan, and transition planning for adolescents. In adults, explore camouflaging, anxiety, depression and burnout. Respect cultural differences in eye contact and communication norms, and honor client identity language preferences.

Clinical Pearl: ASD needs all three social-communication deficits plus two of four restricted/repetitive features. Severity is rated per domain, not once overall.