Social Communication Impairments All individuals with ASD exhibit social communication impairments. In the first few years of life, salient signs of autism include lack of appropriate eye contact and inability to initiate or respond to joint attention (i.e., sharing social experiences with a communication partner). Common social difficulties include: Demonstrating appropriate play skills, such as cooperative play with others. Some children with ASD may appear uninterested in playing with peers. Some may reject or ignore the social approaches of others. Responding to and initiating joint attention for social purposes. For example, many individuals with ASD are skilled at requesting items but are less likely to communicate for the purpose of sharing a social experience. Some individuals with ASD may lack interest in conversations that do not include topics of interests. Using and interpreting body language. For example, individuals with ASD may have challenges understanding tone of voice or facial expression in social situations. Staying on topic, turn-taking, and asking related or appropriate questions during conversations. Taking their communication partner’s perspective, checking for understanding, or predicting what information may already be known about a concept or situation during conversations. Speech/Language Impairments Persons with ASD may have specific difficulties in the areas of receptive and expressive language. Receptive language is the comprehension of language (e.g., following directions), while expressive language is the ability to express desires and thoughts to other persons. Some individuals with ASD express their thoughts verbally, while others may be nonverbal and require a communication device. Those who are nonverbal may demonstrate the following: Delay in, or lack of, spoken speech/language, impacting approximately 20-30% of the population. Lack of an effective way to communicate may lead to the need for the use of alternative augmentative communication (AAC), such as sign language, pictures, or a voice output device. Those who are verbal may demonstrate the following: Delayed or immediate echolalia as a means of conversation with others, for self-management, or for self-stimulation. For example, a dialogue from television programs or videos may be used as a means of conversation. Stereotyped or repetitive use of non-echolalia language routines that serve various functions such as initiating or sustaining a conversation. Use of idiosyncratic speech (e.g., inappropriate word use). Grammatical structure which may appear immature (i.e., telegraphic speech, improper tense or use of pronouns) or grammatical structure which may appear pedantic (e.g., monologue, advanced vocabulary in an area of interest). Abnormal use of pitch, intonation, rhythm or stress. For example, speech may be monotone or hypernasal, and declarative sentences may end with a rising tone to signal the asking of a question. Both verbal and nonverbal individuals may demonstrate difficulties with receptive language such as: Delayed vocabulary development; Difficulty following directions; Difficulty understanding abstract concepts; and Difficulty interpreting social language, such as sarcasm and jokes.   Restricted Repetitive and Stereotyped Patterns of Behavior, Interests, and Activities Although people with ASD may enjoy the same activities as typical same-age peers, the intensity and focus of their interests may differ. This may be due to the fact that some have a limited repertoire of alternative behaviors, or that they prefer and feel comfortable repeatedly performing certain tasks. Behavior under this category includes: Stereotyped or repetitive motor movements such as hand flapping or finger flicking, use of objects such as spinning coins or lining up toys, or use of speech such as echolalia (delayed or immediate parroting of heard words), use of “you” when referring to self or stereotyped use of words or phrases. Excessive adherences to routines and sameness such as being distressed by changes in the schedule, insisting on adherence to rules, or having inflexible thinking. Ritualized patterns of behavior such as repetitive questioning or pacing. Highly restricted, fixated interests that is abnormal in intensity or focus. A toddler may have a parent’s belt that they carry everywhere, a child may have a preoccupation with vacuums, or an adult may spend hours memorizing facts about their favorite baseball team. In the DSM-5, sensory differences are categorized under restricted repetitive behaviors. Individuals with sensory differences will be under (hypo) or over (hyper) sensitive to a variety of sensory inputs: Visual input sensitivities are staring at spinning objects, being bothered by fluorescent lights, or having trouble with keeping their place when reading. Auditory input sensitivities are covering ears during loud noises, preferring loud music or none at all in the car, or not being able to respond to verbal prompts when in a noisy area. Tactile input sensitivities dislike getting hands or feet messy, avoiding/preferring certain surfaces, textures, or fabrics, or finding specific types of touch aversive (light touch on the shoulder vs. deep pressure hug). Taste/Smell sensitivities are not eating certain foods, licking or tasting non-food items, or finding strong perfume or cologne aversive. Proprioceptive Input sensitivities are difficulties interpreting sensations from muscles, joints, ligaments, and tendons (e.g., putting too much pressure on pencil when writing or falling/crashing into things). Vestibular input sensitivities are over or under sensitivities to balance and movement sensations, such as having trouble staying seated, constantly leaning head on hands and arms, or easily losing balance. Executive Function Impairments Executive functioning refers to advanced cognitive skills, such as attention, working memory, planning, reasoning, sequencing, and flexible thinking. In typically developing people, these skills benefit not only social interactions but also academics, learning, self-regulation, and activities of daily living. Individuals with ASD may have difficulty with a wide range of executive functioning tasks, such as sequencing the order in which to dress themselves, tie their shoes, pack for a trip, or complete a homework assignment. Rigid, inflexible thinking is a common characteristic of individuals with ASD, and therefore individuals may have trouble problem-solving or generating more than one solution to a problem. Individuals with ASD may have executive functioning difficulties at more basic levels, such as sustaining prolonged attention to an activity, or dividing their attention between two activities at once.