Jacqueline van Jaarsveld Speech Therapist and Audiologist

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*Image courtesy of Hearing Tracker

“For a PDAer, even the simplest everyday instructions, like eating or getting dressed, can feel overwhelmingly impossible. It's not a matter of unwillingness or defiance but rather an intense, uncontrollable anxiety that creates an insurmountable barrier to following through with demands, no matter how trivial they may seem to others.”
- Clinical Psychologist


Pathological Demand Avoidance (PDA) is a profile seen in some autistic individuals, where everyday demands and expectations trigger extreme anxiety and an overwhelming need to avoid them. This avoidance is not due to laziness or defiance but stems from a deep-seated anxiety that makes even simple tasks, like eating or getting dressed, feel impossible to accomplish. Understanding this helps us recognize that those with PDA need patience, understanding, and tailored approaches to reduce their anxiety and help them manage daily tasks.

While we have used the term PDA (Pathological Demand Avoidance) due to its widespread recognition, we acknowledge other terms, such as Extreme Demand Avoidance (EDA) or Persistent Demand Avoidance (PDA).

Where to from here:
If you are new to PDA and wish to know more, we recommend attending our three-hour upcoming live webcast, PDA: An Introduction. On the same day, we will present a second three-hour course that assumes knowledge about PDA and explores a deeper understanding of the profile, strategies, and support: PDA Going Deeper. We hope you can join us.


https://attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-an-introduction-22-july-2024/

https://attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-going-deeper-monday-22-july-2024/

Sensory Sensitivity and Autism (Part 1)

Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment is a core diagnostic criterion for autism (APA, 2022). Sensory sensitivity is one of the earliest signs of autism and can be recognised in infancy. The sensitivity can be across all sensory modalities, life-long and affect the ability to engage in social and community activities, thus increasing loneliness and reducing quality of life (Quadt et al., 2023). Sensory sensitivity will also affect attention and concentration and contribute to anxiety, depression and meltdowns. Sensory sensitivity is not unique to autism and is recognised as a characteristic of other neurodevelopmental conditions such as ADHD and schizophrenia.

Nearly 90% of autistic children experience sensory sensitivity (Gandhi et al., 2021) and over 90% of autistic adults (Crane et al., 2009). The sensitivity does not habituate with repeated exposure, and the criticism ‘Just get used to it’ does not recognise that the experience can be extremely painful and is not easily diminished by distraction and mental effort.

There can be hyper-reactivity to external sensory experiences such as sounds, light intensity and touch (Exteroception) and hypo-reactivity to some external experiences and sensing the body’s internal states such as heart rate, breathing and hunger (Interoception). Some sensory experiences can be perceived as extremely enjoyable.

Auditory sensitivity
Acute auditory sensitivity can occur in response to specific sounds (hyperacusis), particularly sudden or ‘sharp’ noises, a specific pitch, or aspects of speech. The ‘sharp’ noises can include the sound of a dog barking, someone shouting, coughing or clapping, fireworks, loud vehicles and construction tools. Pitch sensitivity can be to small electric motors such as hand dryers and vacuum cleaners, the sound of the fan inside a computer, and someone singing off the key. There can also be a sensitivity to competing voices and sounds, such as multiple conversations or several radios playing in an office.

Temple Grandin describes her auditory sensitivity:
“ Sudden loud noises hurt my ears like a dentist’s drill hitting a nerve. High pitched continuous noises such as hair dryers and other small motors are annoying. All the behaviour modification in the world is not going to stop an autistic child from screaming when a noise hurts his ears.”

Loud, sudden noises still startle me. My reaction to them is more intense than other people’s. I still hate balloons, because I never know when one will pop and make me jump. Sustained high-pitched motor noises, such as hair dryers and bathroom vent fans, still bother me, lower frequency motor noises do not.

The auditory sensitivity can be too many everyday sounds that are difficult to avoid, and the anticipation of these aversive experiences will increase anxiety and reduce the motivation to engage in social and family events and community activities. Auditory sensitivity will also affect the ability to fall asleep with a startled reaction to nighttime sounds. However, auditory sensitivity could lead to a greater appreciation of music, learning to play an instrument, a career in the music industry and sound engineering and social connection in being a member of a band, orchestra or choir.

Tactile sensitivity
There can be acute sensitivity to specific tactile experiences, even light touch on particular parts of the body, for example, hair washing or hair or nail cutting, the sensation of rough textures, perceiving the seams and labels of clothing, food texture, unexpected touch from someone, and tight clothing. There can be tactile hyposensitivity, such that some tactile experiences are not noticed.

Tactile sensitivity will affect the experience of some expressions of affection, such as a kiss or hug. Temple Grandin describes her tactile sensitivity:
“I pulled away when people tried to hug me, because being touched sent an overwhelming tidal wave of stimulation through my body.”

“Church was a nightmare because the petticoats and other Sunday clothes itched and scratched. Many behaviour problems in church could have been avoided by a few simple clothing modifications.”

“As a baby I resisted being touched and when I became a little older I can remember stiffening, flinching, and pulling away from relatives when they hugged me”.

“As a child I wanted to feel the comfort of being held, but then I would shrink away for fear of losing control and being engulfed when people hugged me”

The sensitivity to touch could also affect aspects of sexual intimacy (Gray et al., 2021)

Tactile sensitivity can also affect the perception of surfaces, such as the fabric used for chairs and having to sit on a carpet at school, but can be associated with an enjoyable experience, such as feeling cold metal surfaces and soothing clothing, as in the comment It’s just a scarf, but it could be quite comforting to wear, I stroke the material (Kyriacou et al., 2023).

Visual sensitivity
Visual sensitivity can be due to light type, intensity, colours, and patterns. Bright and flashing lights can be aversive; fluorescent lights are perceived as flickering, bright sunlight is ‘blinding’, and some forms of lighting can trigger a headache or migraine. Supermarkets can be a source of aversive visual experiences, such as bright shop lighting, multi-colour packaging, and shiny floors. Some colours or colour combinations can be distressing, as described by an autistic teenager:

“I also remember one Christmas, when I got a new bike for a present. It was yellow. I would not look at it. Extra red was added to the colour making it look orange, and it blurred upwards making it look like it was on fire”

Some patterns can create visual distress, such as the vibrant pattern on a carpet, which is perceived as an optical illusion and “painful for my eyes”.

Visual sensitivity can lead to abilities such as drawing with attention to detail, being aware of lighting as a photographer, and noticing symmetry and patterns as an architect.


Olfactory sensitivity
The sensitivity can be to specific olfactory experiences such as perfumes and deodorants, the smell of specific food, and cleaning chemicals, as described in the following comment: “They had a new hand gel in the toilet, and I just couldn’t use it as it was so overpowering. Olfactory sensitivity can also affect the perception and acceptance of someone: “They could be the nicest person in the world, but if I don’t like how they smell, they were evil to me.

Olfactory and tactile sensitivity can combine to affect the perception of food, especially food with a fibrous texture, multiple flavours and a distinct aroma. There can also be a fear of swallowing, choking and trying new foods that contribute to Avoidant/Restrictive Food Intake Disorder (ARFID). Sean Barron described that in his childhood,

“I was supersensitive to the texture of food and I had to touch everything with my fingers to see how it felt before I could put it in my mouth. I really hated it when food had things mixed with it….I could never put any of it into my mouth. I knew if I did I would get violently sick”.

There can be a tendency to eat different foods consecutively, and some foods create excruciating pain: “Eating a pear to me felt like sharp pins being put into my throat”

Parents can be concerned that nutritional needs are not met with avoidance and anxiety due to the sensory characteristics of food. This may be one of the contributory factors to developing an eating disorder such as anorexia nervosa (Brede et al., 2020).

Interoception
Interoception is the sense of the body’s internal states, such as pain, illness, heart rate, breathing, muscle tension, hunger, satiation, thirst and the need to go to the toilet. There seems to be a mind/body division described in the comment: “Autism is being locked inside yourself, but it’s being disconnected from yourself too”. An autistic person may forget to eat or drink for long periods of time and have limited cognitive awareness of pain, injury, exhaustion and sleepiness. An example is the comment, “I had no idea I was sick and going to vomit until about 3 seconds before”, and “I’m insensitive to my body’s signals that I need to go… I’m very often extremely desperate to go once I finally realise…”

A difficulty perceiving increased heart rate, breathing and muscle tension will affect the ability to perceive increasing anxiety, agitation, imminent meltdown and the ability to regulate emotions. Problems with interoception will also affect the accuracy of medical examinations. The best way I can describe this to health professionals is that I receive a signal from somewhere I’m not exactly sure, and I have difficulties interpreting what they might mean

There can also be hypersensitivity to internal sensory experiences, such as “ I’m super sensitive to any little changes in how my body feels and I always worry that I might have some serious deadly terminal scary disease. This can lead to the autistic person being perceived as having hypochondria and experiencing anxiety associated with the internal sensations associated with digestion.


Where to From Here?
Future blog Part 2 of Sensory Sensitivity and Autism will focus on screening and measuring instruments for sensory sensitivity, the autistic sensory profile for proprioceptive and vestibular sensitivity, synaesthesia, emotional sensitivity, sensual pleasure, sensory sensitivity and anxiety, strategies for accommodating sensory sensitivity and sensory sensitivity through the life span.

We have created a brand-new half-day event on Sensory Processing and Autism that will be webcast on the afternoon of the 23rd of August:

https://attwoodandgarnettevents.com/product/webcast-event-autism-and-sensory-processing-23-august-2024/

"It feels like holding back something you need to say: Autistic and Non-Autistic Adults' accounts of sensory experiences and stimming.

By Charlton R, Entecott T, Belova R, & Nwaordu G.

Why is this research important?
This research addresses the lack of studies on restricted repetitive behaviours (RRBs) and sensory sensitivities in autistic adults. It redefines stimming, highlighting its benefits and advocating for societal acceptance while also including both diagnosed and self-identified autistic individuals to capture a wider range of experiences. Additionally, it compares stimming behaviours in autistic and non-autistic adults to understand the similarities and differences in their sensory processing.


What did the researchers do?
The researchers conducted an online survey of 340 adults (160 diagnosed autistic, 139 suspected autistic, and 41 non-autistic) recruited through social media and support groups. They examined participants' sensory experiences and stimming behaviours using both closed- and open-ended questions to explore the frequency, reasons, and effects of stimming. The data was analysed using quantitative (Chi-square, ANOVA, t-tests) and qualitative (thematic analysis) methods.

What were the findings of the study?
1. Frequency and Nature of Sensory Experiences and Stimming:

- Autistic individuals (both diagnosed and suspected) reported greater sensory sensitivity and more frequent stimming compared to non-autistic individuals.

- Stimming was also present among non-autistic adults but was less frequent.

2. Themes Identified:

- Sensory Sensitivity: Participants described negative physical, emotional, and cognitive effects due to sensory overload. These included discomfort, anxiety, confusion, and difficulties concentrating.

- Stimming as Self-Regulation: Stimming was identified as a mechanism to manage sensory overload, emotional stress, and cognitive distractions. It served both positive (pleasure, excitement) and negative (anxiety, stress) emotional regulation.

- Social Pressure and Suppression: Many participants reported suppressing stimming behaviours due to social pressure, which led to negative emotional and cognitive consequences. Suppression often required effort and resulted in less effective self-regulation.

3. Social Acceptance:

- Autistic adults described the need for societal acceptance of stimming, highlighting its positive impact on their well-being.

- Both preferred and substitute stims were used, but preferred stims were generally more effective.

4. Comparative Insights:

- Both autistic and non-autistic participants experienced social pressure to suppress stimming, though it was more prevalent among autistic individuals.

- The non-autistic group, while reporting similar types of stimming behaviours, did so less frequently and with less severity.

5. Implications:

- The study underscores the need for greater societal acceptance of stimming behaviours to improve the well-being of autistic individuals.

- Further research is needed to explore the experiences of under-represented groups within the autistic population and to better understand the relationship between sensory processing and stimming in both autistic and non-autistic adults.

This study challenges the negative connotations associated with stimming, advocating for a more nuanced understanding that recognises its role in self-regulation and emotional expression for autistic individuals.

Where to from here:
We have created a brand-new half-day event on Sensory Processing and Autism. During this training, you will learn to:
1. Understand the differences in sensory perception associated with autism.
2. Appreciate the effects of sensory sensitivity in daily life.
3. Identify adaptive coping mechanisms to support well-being in daily life.
4. Identify and address any maladaptive coping mechanisms with compassion.
5. Know strategies for managing anxiety to decrease the impact of sensory perception differences.

https://attwoodandgarnettevents.com/product/webcast-event-autism-and-sensory-processing-23-august-2024/

Reference: Charlton, R. A., Entecott, T., Belova, E., & Nwaordu, G. (2021). “It feels like holding back something you need to say”: Autistic and Non-Autistic Adults accounts of sensory experiences and stimming. Research in Autism Spectrum Disorders, 89, 101864.

Are you struggling with communication or a desire to learn? The Tomatis® Neurosensory Program can help! This innovative program uses sound to stimulate the auditory system, which plays a crucial role in how we process information, listen, and communicate effectively. ️

Here's how Tomatis can benefit you or your loved one:

Awaken the desire to communicate: Tomatis helps individuals of all ages develop a love for listening, foundational for spoken language.
Enhance learning: Improved auditory processing can improve focus, concentration, and information retention.
Unlock potential: Tomatis can support individuals with various challenges, including speech and language delays, autism spectrum disorder, ADHD, and sensory processing difficulties.

Ready to experience the Tomatis difference?

At Beltone, we understand the importance of maintaining cognitive health for healthy aging & improved hearing. That's why we're sharing tips and exercises to keep your mind sharp and your hearing at its best: https://tinyurl.com/y78m4pdb.

Incorporating cognitive exercises into daily routines is easy and can be done in a variety of ways:

✅Set aside time each day for cognitive exercises, such as jigsaw puzzles, crossword puzzles or memory games.
✅Incorporate cognitive exercises into daily activities, such as reading or learning a new skill.
✅Join a group or class that focuses on cognitive exercises, such as a language class or book club.

June is Alzheimer's & Brain Awareness Month and recent studies have highlighted a significant link between untreated hearing loss and an increased risk of cognitive decline, including dementia.

Hearing plays a vital role in keeping our brains active and engaged, and when we struggle to hear, it can lead to social isolation and reduced cognitive stimulation. By addressing hearing loss early with effective solutions like hearing aids, you're not just improving your hearing - you're taking a proactive step towards protecting your cognitive health. Learn more here: https://tinyurl.com/4k6fudm5.

Stay on top of your hearing health by scheduling your free annual hearing screening at your local Beltone. You can call us at 1-800-235-8663 or visit www.beltone.com to book your appointment today!

“Being labelled as autistic led to an overnight overhaul of my treatment and I went from getting rapidly more unwell to being given the right support to take positive steps in my treatment.”

Pooky Knightsmith, p.37, Supporting Autistic People with Eating Disorders: A Guide to Adapting Treatment and Supporting Recovery. Ed. Kate Tchanturia, 2021, JKP.



We gain the most powerful insights about autism from autistic people themselves. Pooky kindly shares seven lessons that she learned on the road to recovery from anorexia nervosa in Tchanturia (2021). Some of the insights she shares are the value of individual therapy over group therapy, treatment room and ward sensory accommodations, advance warning of changes to ingredients in food, following through with scheduled events, and many more. We share this further information as examples of modifications that were crucial for Pooky to recover. It is important to recognise that knowing autism is in the picture is helpful so that accommodations to treatment can be made that are tailormade for the autistic person.

If you want to learn more, you might find our on-demand recording from our autism and eating disorder course beneficial.

https://attwoodandgarnettevents.com/product/online-course-eating-disorders-and-autism/

Autism and Epilepsy

We know there is a link between autism and epilepsy. Studies have confirmed that up to 8% of intellectually able autistic children and over 20% of autistic children with an intellectual ability also have epilepsy (Amiet et al., 2008; Liu et al., 2022; Tuchman, 2017). There is also a correlation between the frequency of epileptic seizures and the degree of intellectual disability (Liu et al., 2022; Pacheva et al., 2019). Epilepsy can affect both speaking and non-speaking autistic individuals.
In this blog, we describe the various types of epilepsy that can be experienced by an autistic child or adult, strategies for seizure management, including medication and the behavioural and psychological effects of having epilepsy.

Onset of epilepsy

There are bimodal peaks for the onset of epilepsy, in the general and autistic population, namely infancy and puberty (Gillberg & Steffenberg, 1987). There is also an association between epilepsy and syndromic autism, which is autism associated with a medical condition such as Tuberous Sclerosis, Neurofibromatosis, mitochondrial disorders and Landau-Kleffner syndrome. We also recognise that epilepsy in childhood persists into adulthood in up to 80% of autistic individuals, with remission in about 16%.

What is epilepsy?
The term epilepsy is derived from the Greek word meaning ‘take hold’ or ‘seize’, hence the English term, seizure. During an epileptic seizure, nerve cells are caught in a reverberating cycle of repetitive firing. Excessive neuronal firing continues until excitatory neurotransmission is exhausted or the inhibitory networks extinguish it. Neurons that control muscles cause the muscles to contract, and neurons associated with other functions can lead to unusual sensations and altered levels of alertness and consciousness. We are all prone to seizures. It depends on our individual seizure threshold.

A range of circumstances can lower the seizure threshold, such as high body temperature (fever), low blood sugar, stress, lack of sleep, and antipsychotic medication. Hormonal changes during adolescence, particularly for girls, can profoundly affect seizure activity. Sometimes, seizures are triggered by specific stimuli such as flashing lights and sudden noises, and for certain types of epilepsy, seizures occur more often during sleep. Seizures may also occur in clusters.
Epilepsy is not a disease or mental illness, and a diagnosis of epilepsy requires two seizures that occur at least 24 hours apart. A seizure usually lasts seconds to minutes. An electroencephalogram, or EEG, can record excessive and abnormal neuronal activity in the cortex of the brain, which can be part of the diagnostic process for epilepsy.

Types of epilepsy:

1. Generalised Seizures affect the entire brain at once; these include tonic-clonic, myoclonic, atonic, and absences.

2. Partial seizures can be called focal or local and start from one part of the brain. Simple partial seizures (consciousness remains normal), complex partial seizures (consciousness altered), and the transition from focal to generalised seizures.

All types of seizures can occur in autistic individuals, but complex partial are the most common seizure type (Pacheva et al. (2019).

Generalised seizures:

Tonic-clonic seizure
There are three stages in a tonic-clonic seizure.
1: Aura: a preceding sensory experience which can be a particular smell, the sensation of tingling in hands, or the cognitive sensation of déjà vu (a feeling that something new has been experienced before) or jamai vu (the erroneous belief of having never experienced something that has been experienced). The recognition of experiencing an aura can be valuable in providing time to move to circumstances to avoid injury during the seizure, such as moving away from a table edge or going into the recovery position.

2: Ictal stage This is the seizure event. Usually, it starts with a loss of consciousness, followed by the Tonic stage, which involves stiffening of the extremities, and then the Clionic stage, which involves twitching movements, rhythmic jerks, clenching of teeth, and possible loss of bladder control. The person often turns blue as breathing stops in the tonic phase. The ictal stage usually lasts up to 5 minutes.

3: Postictal state includes sleepiness, muscle weakness, confusion, and difficulty speaking. Often, the person does not remember what happened during this time. There can be abnormal behaviour, including psychosis (delusions and hallucinations), after a seizure, which is relatively common, occurring in 6-10% of people (Wheless, 2009). The person is likely to feel drowsy and depressed afterwards. A non-speaking autistic young man typed, “The seizures are really exhausting, and I need to sleep for hours afterwards”.

A tonic-clonic seizure used to be called a ‘grand mal’.

Strategies for managing a tonic-clonic seizure:

1. Please remember to stay calm. This is not easy for a parent whose son or daughter has lost consciousness.
2. Then, check safety from physical injury, such as protecting the person’s head, perhaps with an item of clothing, and clearing the adjacent area.
3. Do not try to stop the movements.
4. Protect the airways, but do not put anything in the person’s mouth.
5. Ensure the person is in the recovery position.
6. Stay with the person until they recover.
7. Call for medical assistance if the seizure lasts more than ten minutes.
8. Prolonged or recurring seizures that last more than 20 minutes are called Status Epilepticus, and parents and carers may be trained in the administration of medication to end this expression of epilepsy.

Myoclonic seizures
These are brief, startle-like jerks and are often associated with drowsy states. A myoclonic seizure can occur when waking up.

Atonic seizures
They are sometimes called a ‘drop attack’ with a sudden loss of muscle tone and risk of falling and injury with no attempt to protect oneself. The person may wear a protective helmet if they frequently experience an atonic seizure.

Absence seizures
These are 3-30-second staring spells that used to be called a ‘petit mal’. There is a sudden halt in activity and appearing to ‘freeze’. The person’s eyes may roll up, stare or flicker with usually no confusion afterwards. Absence seizures are more likely in children than adults.

Partial seizures
There are simple partial seizures with abnormal sensations, such as seeing spots or feeling fear, and Complex partial seizures with a well-defined aura followed by a confused ‘trance’. Partial seizures used to be called Temporal or Frontal Lobe seizures.
A partial seizure may start with automatisms, such as involuntary movements such as eye blinking and ‘fluttering’ and actions such as lip smacking, fumbling, and finger-picking movements. These can be signs that a partial seizure is imminent.
The seizure can lead to experiencing intense feelings of fear or panic and include complicated motor automatisms, such as vigorous movements, kicking, hitting, and being aggressive to others or deliberately injuring themselves.

As clinicians, we have supported many non-speaking autistic clients who have been referred due to extremely agitated behaviour. Our analysis of the antecedents and potential function of the agitated behaviour may not show any consistent or distinct patterns of motivation or function from the individual's perspective, current and past circumstances, or quality of support. The extremely agitated behaviour appears to occur quickly and is unresponsive to behaviour management strategies. Those who know the person may say that this behaviour is out of character. When extremely agitated, they cannot be distracted or encouraged to end the agitation, which can involve the destruction of property or considerable self-harm. We have recognised that the sudden intensity and ineffectiveness of appropriate response strategies could indicate that the autistic person is experiencing a partial seizure, and we recommend an assessment by a neurologist.

Unfortunately, a partial seizure is often not recorded on an EEG. The false negative rate can be up to 70%, although a repeat EEG reduces this to 30%. Thus, an EEG recording in the normal range does not automatically rule out experiencing partial seizures. However, the neurologist will explore the nature of the agitated behaviour to identify any preceding automatisms, and it can be helpful for parents or carers to record videos of the agitated behaviour on a mobile phone to indicate the degree of consciousness. We have found that medication for epilepsy can be very effective in reducing the frequency, intensity and duration of agitated behaviour due to a partial seizure.

Medication
Anti-epileptic medication is divided into narrow-spectrum medications, such as carbamazepine, and broad-spectrum medications, such as lamotrigine, based on the seizure type. The primary effect of anticonvulsant medication is on the inhibitory neurotransmitter GABA. Medication is usually daily and has no significant effect on cognitive functioning.

A study of autistic research participants' responses to antiepileptic medication found that 58% were seizure-free on medication, and a further 27% had more than a 50% reduction of seizures. There was therapeutic resistance in 15%, and consideration may be given to prescribing more than one antiepileptic medication (Pacheva et al., 2019).
It can take up to a month for the medication to have a positive effect, and regular blood tests will need to be undertaken to confirm whether the anticonvulsant is within the therapeutic range. There is a concept of a ‘window of opportunity’—not too little or too much medication. Medication may be discontinued for children who have been seizure-free for about two years and about five years for adults.

Psychological effects of epilepsy

Having seizures witnessed by family members, friends and the general public can lead to low self-esteem, social withdrawal and internalising problems such as depression. The autistic person may need psychological support from family and perhaps a psychologist.

There is also the effect on parents, as witnessing a seizure can be frightening, being unsure when the seizure will end, and worrying about what they can do during and after the seizure. Parents need to be compassionate but not overprotective. They may also be concerned about the long-term effects of epilepsy but can be reassured that repeated seizures do not cause brain damage.

Where to from here?
On Friday, the 28th of June, Michelle and Tony will present a full-day course on Understanding and Supporting Non-speaking Autism. The course will equip participants with an understanding of life as experienced by a non-speaking autistic person, the reasons for specific behavioural and emotional reactions and the creation of an individualised plan to enhance the quality of life and well-being.
Participants in the course will learn practical strategies to encourage speech, the value of alternative and augmentative communication systems, how to acquire new abilities and coping mechanisms for accommodating changes in routines and expectations, sensory sensitivity, and social engagement, conditions that co-occur with autism including epilepsy and how to express and regulate intense emotions constructively.

https://attwoodandgarnettevents.com/product/webcast-event-understanding-and-supporting-non-speaking-autism-28-june-2024/

References
Amiet et al. (2008). Epilepsy in autism is associated with intellectual disability and gender. Biological Psychiatry 64, 577–582.
Gillberg and Steffenberg (1987). Outcomes and prognostic factors in infantile autism and similar conditions Journal of Autism and Developmental
Liu et al. (2022). Prevalence of epilepsy in autism spectrum disorders: A systematic review and meta-analysis Autism 26.
Panayiotopoulos CP (2010). A clinical guide to epileptic syndromes and their treatment based on the ILAE classifications and practice parameter guidelines (Rev. 2nd ed.). London: Springer.
Pacheva et al. (2019). Epilepsy in Children with Autism Spectrum Disorder. children 6, 15; doi: 10.3390/children6020015
Tuchman (2017) What is the relationship between Autism Spectrum Disorders and Epilepsy? Seminars in Pediatric Neurology
Tuchman and Rapin (2002). Epilepsy in Autism. Lancet Neurol. 2002;1(6)
Wheless (2009). Advanced therapy in epilepsy. Shelton, Conn.: People's Medical Pub. House. p. 443.