What is Autism?
Autism is a neurological developmental disorder that appears before age three and variably continues throughout a person’s lifetime. Children with autism often have difficulty adjusting to inconsistency in their day-to-day environment, show little interest in others, and lack social awareness. Compulsive or stereotypic behaviors may be present. Children with autism have problems with communication, poor eye contact, and difficulty expressing themselves. In addition, reciprocal social interactions are impaired.
Autism can interfere with a child forming relationships with others, which may be due to an inability to interpret facial expressions or emotions. A child with autism may play alone, resist cuddling, and/or become anxious in a changing environment. Such children exhibit repetitive body movements (such as flapping hands or rocking) and have unusual attachments to objects. However, some children may have isolated areas of cognitive and creative strengths (i.e., counting, measuring, art, music, memory).
The severity and symptoms of autism vary widely, from mild to severe. Some children may be very bright and do well in school. Others may function at a lower level, even to the degree of mental retardation.
Autism is a diagnosis in a group of developmental disorders known as the Autism Spectrum Disorders (ASDs). They are referred to as Pervasive Developmental Disorders and include Asperger’s Syndrome, Rett’s Syndrome, Pervasive Developmental Disorder–Not Otherwise Specified, and Childhood Disintegrative Disorder.
What Causes Autism?
The cause of autism is still not completely understood. Research suggests that both environmental conditions and genetic factors play a role. It is believed that several genes are involved in the development of autism. Research studies have found a variety of abnormalities in the brain structure and chemicals in the brain; however, there have been no consistent findings. Parenting behaviors are not the cause or a contributing factor to the cause of autism. Although there is no cure for autism, there are a wide variety of treatment options that can provide a positive impact on the child’s development and produce an overall reduction of disruptive behaviors and symptoms.
Who is Affected by Autism?
The rate of autism has increased exponentially around the world. Currently, it is reported that 1 in 110 children are diagnosed with autism. Autism is more prevalent in boys than girls, with four times as many boys affected. Autism is found in all socioeconomic classes.
What Are the Symptoms of Autism?
The following are the most common symptoms of autism. However, each child may experience symptoms differently. The symptoms of autism may resemble other conditions or medical problems. Always consult the child's physician for further assessment. Symptoms may include:
Deficits in Social Behavior
- Marked lack of awareness of the existence or feelings of others
- Does not notice another person’s distress;
- Has no concept of the need of others for privacy.
- No or abnormal seeking of comfort at times of distress
- Does not come for comfort even when ill, hurt, or tired.
- No or impaired imitation
- Does not wave bye-bye;
- Does not copy mother’s domestic activities;
- Mechanical imitation of others’ actions out of context.
- No or abnormal social play
- Does not actively participate in simple games;
- Prefers solitary play activities;
- Involves other children in play only as “mechanical aids.”
- Gross impairment in interpersonal relationships
- No interest in establishing friendships;
- Lack of understanding of conventions of social interaction.
Communication Problems
- Lack of communication
- Difficulty interpreting facial expressions;
- Inappropriate use of gestures;
- Lack of spoken language.
- Markedly abnormal nonverbal communication
- Does not anticipate being held, stiffens when held;
- Does not look at the person or smile when making a social approach;
- Does not greet parents or visitors, has a fixed stare in social situations.
- Absence of imaginative activity
- Lack of creativity in play activities;
- Lack of playacting adult roles.
- Marked abnormalities in the production of speech (includes volume, pitch, stress, rate, rhythm, and intonation)
- Monotonous tone, question like melody, or high pitch.
- Marked abnormalities in the form or content of speech
- Stereotyped and repetitive use of speech - immediate echolalia or mechanical repetition of television commercial;
- Use of “you” when “I” is meant – using “You want cookie” to mean “I want cookie”;
- Idiosyncratic use of words or phrases – “Go on green riding” to mean “I want to go on the swing”;
- Frequent irrelevant remarks – starts talking about train schedules during a conversation about sports.
- Marked impairment in the ability to initiate or sustain a conversation with others, despite adequate speech.
- Indulging in lengthy monologues on one subject regardless of interjections from others.
Unusual Patterns of Behavior
- Resistance to change in trivial aspects of environment
- Lines up toys or objects in a row - child may become distressed if object is moved from unusual position.
- Ritualistic or compulsive behaviors
- Insistence of eating particular foods;
- Repetitive motor acts – hand-flicking or twisting, spinning, head-banging, rocking, complex whole-body movements;
- Markedly restricted range of interests and development of preoccupations – spending a great deal of time learning facts on a particular topic and discussing this with others;
- Compulsive behaviors – touching of certain objects.
- Abnormal attachments
- Develop intense attachments to unusual objects – pipe cleaners, small plastic toys, insists on carrying around a piece of string, action figure or paper clip.
- Unusual responses to sensory experiences
- Fascination with lights, patterns, sounds, spinning objects, and tactile sensations;
- Repetitively flush toilets or turn on and off light switches;
- Preoccupation with certain features of objects - specifically their taste, smell, color, or shape;
- Oversensitivity to feel of clothing or tags;
- Avoids foods based on texture;
- Repetitive feeling of texture of materials.
How is Autism Diagnosed?
For the first time, standard guidelines have been developed to help identify autism in children before the age of 24 months. In the past, diagnosis of autism was often not made until preschool-age or later. The new guidelines can help identify children with autism early, which means more effective treatment for the disorder.
The standardized guidelines were developed with assistance from 11 different organizations and were published in Neurology, a journal of the American Academy of Neurology. According to the guidelines, all children before the age of 24 months should routinely be screened for autism and other developmental delays at their well-child check-ups. Children who show developmental delays and other behavior disorders should be further assessed for autism. According to the guidelines, less than 30 percent of children undergo age-appropriate screening at their well-child check-ups.
By screening children early for autism, children at high risk can be identified and referred for more comprehensive assessments by child and adolescent psychiatrists, developmental pediatricians, and pediatric neurologists. In association with a systematic evaluation, rating scales such as Gilliam Autism Rating Scale (GARS) and a more comprehensive assessment such as the Autism Diagnostic Observation Schedule (ADOS) can be used to detect social and communicative behavior associated with autism and related disorders. Associated assessments by speech and language pathologists, occupational therapists, and psychologists will not only add to the diagnostic understanding but help regarding early intervention recommendations both within and outside of school.
What are the Guidelines?
The standardized guidelines developed for the diagnosis of autism actually involve two levels of screening. Level one screening, which should be performed for all children coming to a physician for well-child check-ups during their first two years of life, should check for the following developmental deficits:
- difficulty interpreting sounds, tone of voice, smiles or facial expressions by age 9 months;
- no babbling, pointing, or gesturing by age 12 months;
- no single words spoken by age 18 months;
- no two-word spontaneous (non-echolalic, or not merely repeating the sounds of others) expressions by age 24 months;
- loss of any language or social skills by age 3.*
The second level of screening should be performed if a child is identified in the first level of screening as developmentally delayed. The second level of screening is a more in-depth diagnosis and evaluation that can differentiate autism from other developmental disorders. The second level of screening may include more formal diagnostic procedures by clinicians skilled in diagnosing autism, including medical history, neurological evaluation, genetic testing, metabolic testing, electrophysiologic testing (i.e. CT scan, MRI, PET scan), and psychological testing, among others.
Genetic testing involves an evaluation by a medical geneticist, particularly as there are several genetic syndromes that are associated with higher incidence of autism, including Fragile-X, untreated phenylketonuria (PKU), neurofibromatosis, tuberous sclerosis, as well as a variety of chromosomal abnormalities. A geneticist may be able to determine whether autism is associated with a genetic disorder, or has no known genetic cause. If a genetic disorder is diagnosed, there may be other health concerns. Genetic counseling may also be indicated.
In cases where no genetic cause for the autism is identified, there is still a slightly increased chance for a couple to have another child with autism. The recurrence risk for siblings is greater than the population risk, providing further evidence for a complex and strong genetic contribution. The reason for this increase over the general population is thought to be because autism may result from several genes inherited from both parents acting in combination, in addition to unknown environmental factors. There is no action/inaction known that parents could have done, or did not do, to cause autism to occur in a child.
Treatment for Autism:
Home-Based
Early intervention is the first step for parents to get the help they need to improve the overall outcome for their child. The goal of many early and intensive behavioral intervention programs is to teach preacademic skills (e.g., attending, imitation, matching), language, and social skills, in addition to reducing problem behavior (e.g., stereotypy, self-injury). Specialized behavioral and educational programs are designed to help children with autism. Individualized treatment planning for behavioral therapy is important as autistic children vary greatly in their behavioral needs.
The methods of applied behavioral analysis (ABA) have been shown to produce significant improvements in children with autism, especially when intervention is intensively implemented. Common instructional procedures include reinforcement, modeling, prompting, fading, shaping, and error correction, among others.
Floortime is a specific therapeutic technique that is based on the Developmental Individual Difference Relationship Model (DIR). Floortime is considered an alternative to and is sometimes delivered in combination with behavioral therapies that can help a child expand his circles of communication by meeting him at his developmental level and building on his strengths.
Like other therapies described in this section, Relationship Development Intervention (RDI) is a system of behavior modification through positive reinforcement. The main goal of RDI is to improve the child’s long-term quality of life by helping him/her improve his/her social skills, adaptability, and self-awareness.
Intensive behavior therapy during early childhood, home-based approach training, and involving parents are considered to produce the best results. Even when diagnosis is made later, most children with autism will improve with the right combination of treatments.
When a family has a child on the autism spectrum, unique stressors are added into the family dynamics. It may be difficult for a child with autism to express his/her basic wants or needs in a manner that parents may expect. When parents cannot determine their child's needs, both may feel frustrated. The child’s frustration can lead to aggressive or self-injurious behaviors that threaten his/her safety and the safety of other family members and siblings. Support of parents and siblings of children with autism and other PDDs is an integral part of the treatment process. Parents should be encouraged to be involved in the assessment and treatment process of their child.
School
Special education programs focus on the least restrictive environment with varying interventions from full inclusion programs to day schools and residential programs, all of which should focus on developing social skills, speech and language, occupational therapy, self-care, academics, and job skills.
Mental Health
Mental health professionals provide parent counseling, social skills training, and individual and group therapy. They also help families identify and participate in treatment programs based on an individual child's treatment needs. Medication may be helpful in treating some symptoms of autism. Specific treatment will be determined by the child's healthcare provider based on the following:
- the child's age, overall health, and medical history
- extent of the disorder
- cognition (IQ)
- the child's symptoms
- the child's tolerance for specific medications or therapies
- expectations for the course of the disorder
- the parents’ opinions or preferences
Prevention of Autism:
Preventive measures to reduce the incidence or severity of Autistic Disorders are not known at this time.
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If you have any questions or concerns about your child’s development, speak to your child’s physician about screening your child for autism. New guidelines from the American Academy of Pediatrics recommends that all children be formally screened for autism at their 18- and 24-month check-ups, whether or not they have symptoms. The earlier the diagnosis is made, the earlier treatment interventions can begin.
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*Excerpted from the American Academy of Child and Adolescent Psychiatry’s Facts for Families #11 The Child With Autism, 2008, all rights reserved ©. The American Academy of Child and Adolescent Psychiatry is a medical association representing more than 7,500 child and adolescent psychiatrists. Its members actively promote mentally health children, adolescents and families through research, training, advocacy, prevention, comprehensive diagnosis and treatment, peer support and collaboration. www.aacap.org.
For information about the sources and references used in this article, please visit the sources page.
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Child Psychology
Psychiatry