Autism Spectrum Disorder

Autism Spectrum Disorder in Children & Teens

According to a recent ‘conservative’ estimate, there are approximately 500,000 autism spectrum cases in the United States, including perhaps as many as 1 in 150 children. Autism is the fastest growing population of special needs students in the US, having grown by over 900% between 1992 and 2001, according to data from the United States Department of Education. In 1999, the Autism incidence rate in the US was generally cited at 4.5 cases per 10,000 live births. By 2005, the US Centers for Disease Control (CDC) estimates one of every 250 babies is born with Autism, or 40 cases per 10,000. As many as 1.5 million Americans may have some form of Autism, including milder variants, and the number is rising. Epidemiologists estimate the number of autistic children in the US could reach 4 million in the next decade (Autism-Help.Org, 2008).

Autism Spectrum Disorder (ASD) includes Autism, Aspergers’ Syndrome (AS) and Pervasive Developmental Disorder, (PDD). ASD involves a history of social impairment before age three. Often the child does not maintain eye contact, does not spontaneously greet or say good bye to family members is indiscriminate to familiar persons and strangers alike does not participate in reciprocal play and does not share pleasure or interests with others.

Children with ASD often demonstrate restricted repetitive and stereotyped patterns of behavior and often talk on one or two themes, regardless of suggestions from others. The child frequently amasses facts about these restrictive interests but lacks a depth of understanding about them.

Stereotypical and repetitive motor mannerisms and preoccupation with repetitive actions, such as turning things on and off are common.

ASD includes impairment in social interaction (few or no friends of in spite of a desire to have them and ample opportunities for friendships) and a lack of social and emotional reciprocity. Self-chosen activities are usually solitary in nature.

Impairments in communication are evident with difficulty in beginning and continuing a conversation, and one-sided conversations which are repetitive, without appropriate turn-taking.

Children with ASD often display a deficit in their ability to use spoken language socially and the content of their speech is often one-sided with little interest in what others wish to bring to the conversation. They may frequently have difficulty sustaining conversation with others.

One of the most frequent problems involves not coping well with change or transitions in daily routine and becoming upset if small details of the regular environment are not maintained. The child can become agitated and distressed when things do not go as anticipated or desired.

Many children with ASD are often initially diagnosed (usually around age 6) with and Attention-Deficit Hyperactive Disorder (ADHD) due to problems with impulsiveness, inattention, distractibility and sometimes hyperactivity that are seen across settings and over time. Several studies have confirmed the relationship with ASD and ADHD. However ADHD can be over diagnosed in children with ASD because there behaviors may be due to stress and anxiety.

A substantial proportion of children with ASD have one or more co-morbid anxiety disorders. Research has demonstrated that anxiety disorders exacerbate the social difficulties and other functional impairments caused by ASD. Many children receive a diagnosis of an anxiety disorder before the ASD is correctly identified or as a secondary diagnosis once ASD is identified. Research conducted by: Susan W. White, Donald Oswald, Thomas Ollendick, and Lawrence Scahill indicate that:

Anxiety and poor stress management are common concerns in clinical samples of children with autism spectrum disorders (ASD). Anxiety may worsen during adolescence, as young people face an increasingly complex social milieu and often become more aware of their differences and interpersonal difficulties.

Other researchers have identified that individuals with ASD also often have obsessive compulsive disorder (OCD). One recent study found that children with ASD showed higher frequencies of obsessive and compulsive symptoms than did typically developing children.

Children with ASD may also be observed to have Learning Disorders/Learning Disabilities (usually prior to the 4th grade). In these cases reading, mathematics or written expression ability(s) of the child measure lower than their expected potential and the child may be identified as learning disabled.

Some children with ASD have disruptive behavior disorders and present with a pattern of defiance, anger, antagonism, hostility or irritability and often blaming others for their problems or mistakes. These behaviors can be the result of punishments and consequences for something the child does not fully understand.

How Cognitive Behavioral Therapy Can Help

According to the National Institute of Health (NIH) one of the few empirically supported therapies available for ASD is cognitive behavior therapy (CBT). CBT can help with common behavioral problems associated with ASD. For younger children or children with lower functioning forms of ASD, Behavioral Therapy (BT) a component of CBT is considered the intervention of choice.

Cognitive behavior therapy is an excellent, but often underutilized form of treatment for individuals with autism. Dr. Tony Attwood

Cognitive therapy can help the child/adolescent by teaching them to identify and change thinking patterns that are associated with their mood or behavioral problems. Children with ASD frequently have associated anxiety (social anxiety, obsessive compulsive disorders, separation anxiety disorder), depressive disorders and/or disruptive behavioral disorder. CBT involves helping the child/adolescent develop skills to recognize the connection between their thinking, behavior and moods. In addition CBT helps children/adolescents identify their thoughts and teaches them skills to evaluate the accuracy of their thinking. CBT also helps children/adolescents with ASD by developing their ability to socialize in ways that are more appropriate and that will be more rewarding. CBT addresses changes in thinking and changes in behavior utilizing principles proven to work in rigorous research studies. In order to build consistency and to extend what begins in the cbt sessions treatment is ideally based on collaboration between parents, teachers and therapist.

The Diagnostic and Statistical Manual of Mental Disorders - IV -TR is being revised and DSM - V is expected to be released in 2014. The proposed changes will tighten the diagnostic criteria and in all likelihood fewer people will be diagnosed with autism. The proposed criteria, if adapted, will mean fewer children being diagnosed on the autism spectrum and fewer children and adolescents being eligible for special education services. According to the American Psychiatric Association the recommendation is for a "new category called autism spectrum disorder which would incorporate several previously separate diagnoses, including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.  The proposal asserts that symptoms of these four disorders represent a continuum from mild to severe, rather than a simple yes or no diagnosis to a specific disorder. The proposed diagnostic criteria for autism spectrum disorder specify a range of severity as well as describe the individual’s overall developmental status--in social communication and other relevant cognitive and motor behaviors."

The following link will take you to a January 19, 2012 New York Times article that addresses the changing diagnostic criteria:  New Definition of Autism Will Exclude Many, Study Suggests

If you are interested in the proposed criteria the following link may be of interest DSM -5 Proposed Autism Diagnostic Criteria.


ADHD - Coming Soon.

Oppositional Behavior - Coming Soon.

Tourette Syndrome - Coming Soon.

BDD - Body Dysmorphic Disorder

Description: AS they develop and grow our children experience tremendous changes in their bodies. It is normal for a child to experience some anxiety and concerns about their bodies at times. However an excessive focus on body appearance can be a sign of the Obsessive Compulsive related disorder of Body Dysmorphic Disorder (BDD).

BDD consists of obsessions (repetitive thoughts or images) related to body or appearance and compulsions (physical or mental behaviors or avoidance of situations), which function to reduce the anxiety, your child experiences as a result of his or her body-focused obsessions.


Symptoms of Body Dysmorphic Disorder include:

  • being preoccupied and distressed with a perceived appearance-related defect or flaw
  • frequently and negatively comparing their own appearance with peers or celebrities
  • getting “stuck” in front of mirrors or reflective surfaces
  • repeatedly asking for reassurance about their appearance
  • extreme difficulty deciding which clothes to wear
  • wearing the same clothes repeatedly and refusing to wear different clothing
  • exercising excessively
  • engaging in excessive grooming routines

Treatment & Parental Involvement: Along with the treatment provided for Obsessive Compulsive Disorder, treatment for BDD may include “perception retraining”. This involves retraining your child’s self-perception through viewing themselves in the mirror during structured exposure exercises while also narrating their appearance with neutral terms. Your child’s experienced therapist at the Anxiety and Depression Center will identify the appropriate treatment components that will help them to minimize anxiety and reduce their BDD symptoms.

Hair Pulling (Trichotillomania)

Description: Trichotillomania (also referred to as “Trich”) is an Obsessive Compulsive related disorder that involves the pulling of hair from the scalp, eyebrows, eyelashes, or from other body parts. Children who experience trichotillomania are often able to hide this disorder from family and friends until the pulling behaviors result in bald spots on the head, eye area or other parts of the body.

Trichotillomania consists of obsessions (repetitive thoughts and images) and compulsions (repetitive behaviors) typically related to desire for symmetry, perception that the hair strand “doesn’t feel right” in texture, attempts to pull the hair in a certain manner, sensation of “itchiness or tingling” in the area of the hair-pulling or examining/manipulating the hair strand extensively after it is pulled, which may include rolling it into a ball or pulling it between one’s teeth. Your child may feel extreme anxiety and distress if you attempt to prevent them from engaging in these hair-pulling actions.


Your child may suffer from Trichotillomania if you notice that your child:

  • spends extensive amounts of time alone in their bedroom or bathroom
  • leaves unexpected loose hairs on furniture, the floor, in the wastebasket
  • has bald spots on his or her scalp, eye area, or other body parts
  • complains of stomachaches or nausea (possibly due to swallowing excessive hair strands)

Treatment: Exposure therapy for Trichotillomania may include having your child spend time in the area that typically triggers hair pulling while systematically and purposely not engaging in hair pulling behavior. Treatment may also involve having your child learn and engage in alternative benign strategies (to replace the stimulating sensorial sensations they receive from hair-pulling and to provide alternative activities for the hands and fingers), such as playing with silly putty, “fidget” toys such as fidget spinner, “koosh balls”, etc. Your child may also learn a number of anxiety management coping strategies that will enable them to engage in these exposure exercises.

Skin Picking (Excoriation/Dermatillomania)

Description: Excoriation (Skin-Picking) Disorder is an Obsessive-Compulsive related disorder. Excoriation Disorder, sometimes referred to as Dermotillomania, involves recurrent skin-picking behavior and typically is focused on acne, scabs, or perceived imperfection in skin such as around the nail area. The recurrent picking behavior typically results in lesions (which may also result in infections and scarring).

Many children and adolescents engage in skin-picking due to boredom, anxiety, or a perception that the area of focus “isn’t right”. Your child may use his or her fingernail or an instrument such as tweezers or a pin to engage in the skin picking behavior.


Your child may be struggling with Excoriation Disorder if he or she:

  • spends excessive amounts of time alone in their bedroom, in the bathroom, or in front of mirrors
  • experiences significant distress related to acne or skin imperfections
  • has repeatedly attempted to cease skin-picking, but is unable to stop the behavior
  • suffers lesions, infections, or scarring related to their picking
  • refuses to attend events due to the condition of their skin
  • attempts to cover up the perceived skin imperfections and feels shame related to their perceived skin imperfections

Treatment: Exposures for Excoriation may include limiting time spent in front of mirrors, along with other exposures your child’s experienced therapist will identify. Treatment may also involve having your child learn and engage in alternative benign strategies (to replace the stimulating sensations they receive from skin-picking or to provide alternative activities to engage the hands and fingers), such as playing with silly putty, “fidget” toys such as fidget spinner, “koosh balls”, etc. Your child may also learn a number of anxiety management coping strategies that will enable them to engage in these exposure exercises.

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