┌─────────────────────────────────────────────────────────────────────────────┐
│                       ASD NEUROBIOLOGY & PROCESSING                         │
├─────────────────────────────────────────────────────────────────────────────┤
│                                                                             │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                 GENETIC & ENVIRONMENTAL FACTORS                     │   │
│   │  • Polygenic risk (hundreds of genes involved)                      │   │
│   │  • Prenatal factors (valproate, advanced parental age)              │   │
│   │  • Altered synaptic pruning & connectivity                          │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                                    ↓                                        │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                ALTERED NEURAL CONNECTIVITY                          │   │
│   │  • Local Hyper-connectivity (Detailed processing)                   │   │
│   │  • Long-range Hypo-connectivity (Integration of concepts)           │   │
│   │  • "Theory of Mind" network differences                             │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                                    ↓                                        │
│        ┌──────────────────────┬──────────────────────────────────────┐      │
│        ↓                      ↓                                      ↓      │
│   ┌─────────┐          ┌─────────────┐                    ┌─────────────┐   │
│   │ SENSORY │          │  SOCIAL     │                    │ COGNITIVE   │   │
│   │ ATYPICAL│          │  COGNITION  │                    │ FLEXIBILITY │   │
│   └─────────┘          └─────────────┘                    └─────────────┘   │
│        ↓                      ↓                                  ↓          │
│   • Hypo/Hyper         • Difficulty reading              • Preference for   │
│     sensitivity          cues                              routine          │
│   • Sensory over-      • Literal interpretation          • Special interests│
│     load               • Masking (Compensation)          • Repetitive       │
│                                                            movements        │
└─────────────────────────────────────────────────────────────────────────────┘

The "Female Phenotype"

Females with ASD are often diagnosed later or missed because they:

• Use Camouflaging/Masking (consciously imitating social behaviour).
• Have special interests that are socially acceptable (e.g., animals, literature vs trains/numbers).
• Present with internalizing symptoms (anxiety, eating disorders) rather than behavioural disruption.

A. Social Communication Deficits (All 3 required)

1. Deficits in Social-Emotional Reciprocity:
   • Failure of back-and-forth conversation.
   • Reduced sharing of interests/emotions.
2. Deficits in Non-Verbal Communication:
   • Abnormal eye contact.
   • Lack of facial expression / gestures.
3. Deficits in Developing/Maintaining Relationships:
   • Difficulty adjusting behaviour to social context.
   • Difficulty making friends or absence of interest in peers.

B. Restricted, Repetitive Patterns (At least 2 required)

1. Stereotyped movements/speech: Hand flapping, rocking, echolalia, lining up toys.
2. Insistence on sameness: Extreme distress at small changes, rigid routines.
3. Highly restricted, fixated interests: Abnormal intensity or focus.
4. Sensory anomalies: Hyper- or hypo-reactivity to sensory input (pain, sound, texture, smell).

┌─────────────────────────────────────────────────────────────────────────────┐
│                    ASD MANAGEMENT & SUPPORT FRAMEWORK                       │
├─────────────────────────────────────────────────────────────────────────────┤
│                                                                             │
│   PERSON-CENTRED APPROACH (No "one size fits all")                          │
│                          ↓                                                  │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                 ENVIRONMENTAL ADAPTATIONS (SPELL)                   │   │
│   │  • STRUCTURE: Visual timetables, clear routines                     │   │
│   │  • POSITIVE: Focus on strengths/interests                           │   │
│   │  • EMPATHY: Understand behaviour as communication                   │   │
│   │  • LOW AROUSAL: Reduce sensory noise/clutter                        │   │
│   │  • LINKS: Partnership with family/carers                            │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                          ↓                                                  │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                 TREAT CO-OCCURRING CONDITIONS                       │   │
│   │  • Anxiety/Depression: SSRIs, adapted CBT                           │   │
│   │  • ADHD: Stimulants (Methylphenidate)                               │   │
│   │  • Sleep: Melatonin                                                 │   │
│   │  • Epilepsy: Anticonvulsants                                        │   │
│   │  • GI Issues: Diet, laxatives                                       │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                          ↓                                                  │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                 SKILL DEVELOPMENT & THERAPY                         │   │
│   │  • Speech & Language: Communication aids (PECS)                     │   │
│   │  • Occupational Therapy: Sensory integration, daily living skills   │   │
│   │  • Psychoeducation: Understanding diagnosis (Post-diagnostic group) │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                          ↓                                                  │
│   ┌─────────────────────────────────────────────────────────────────────┐   │
│   │                 PHARMACOLOGY (System Based)                         │   │
│   │  • NO drug treats core ASD symptoms                                 │   │
│   │  • Risperidone/Aripiprazole: Only for severe irritability/aggres-   │   │
│   │    sion (Short term, low dose)                                      │   │
│   └─────────────────────────────────────────────────────────────────────┘   │
│                                                                             │
└─────────────────────────────────────────────────────────────────────────────┘

The SPELL Framework (National Autistic Society)

• Structure
• Positive approaches and expectations
• Empathy
• Low arousal
• Links

Adapted Psychological Therapy

CBT can be effective for anxiety in ASD but requires adaptation:

• More concrete/visual materials.
• Less reliance on abstract metaphor.
• Focus on logical rules.
• Incorporating special interests.

• Mental Health: Anxiety (40-50%), Depression (30%), ADHD (30-50%).
• Neurological: Epilepsy (10-30%), Tics/Tourette's.
• Medical: GI disorders (constipation/pain), Sleep disorders (melatonin deficiency).

Meltdowns vs Tantrums

• Tantrum: Goal-oriented (wants something), checks for audience, stops when satisfied.
• Meltdown: Response to overwhelm (sensory/emotional), loss of control, not manipulative, requires time and low arousal to recover.
• Management: Safety, reduce sensory input, space, do not punish.

Consultations with Autistic Patients

• Environment: Minimize noise/lights. Book double appointments.
• Communication: Be literal/direct. Avoid idioms ("take a seat"). Allow processing time.
• Pain: May have altered pain perception (high or low) or difficulty localizing/expressing it. Behaviour change = check for pain (teeth, ear, stuck bowel).

Exam-Focused Points

1. DSM-5 Requirements: Deficits in Social Communication (3/3) AND Repetitive Behaviours (2/4).
2. Sensory Issues: Now a core diagnostic criterion in DSM-5.
3. Medication: There is NO medication for core autism. Risperidone is for severe aggression only.
4. Heritability: Highly genetic (up to 90%).
5. Masking: Be aware of the female phenotype who may "pass" socially but suffer internally.
6. Pain rule: In non-verbal patients, new behaviour disturbance = medical pain until proven otherwise.

Common Exam Scenarios

• Child lining up cars, poor eye contact, delayed speech. (Classic presentation).
• Adult with "treatment resistant depression", rigid routines, social exhaustion. (Missed ASD).
• 4-year-old with no speech. Next step? (Audiology first, then developmental assessment).

What is Autism?

"Autism is a different way of seeing and experiencing the world. It is something you are born with, not something caused by bad parenting or vaccines.

Autistic brains are wired differently:

• Detail-focused: Great at seeing details others miss.
• Passionate: Intense focus on specific interests.
• Sensory sensitivity: Lights, sounds, or textures might feel overwhelming.
• Social logic: Social rules might feel confusing or illogical, like everyone else has a rulebook you weren't given."

Is it a Disability?

"It can be both a disability and a difference. The distinct strengths (focus, logic, detail) are valuable. However, living in a world not designed for autistic people can be disabling and exhausting."

Key Guidelines

Evidence-Based Recommendations