Autism

Autism is a condition now known as autism spectrum disorder (in the DSM 5) in which an affected person has difficulty with social relationships, communication, and with imagination, together with repetitive patterns of behaviour. Autism is more common in boys. The condition is, by definition, evident before the age of 30 months and is usually apparent in the first year of life. The precise causes of autism are unknown.

Symptoms and signs

Autistic children often seem normal for the first few months of life, before becoming increasingly unresponsive to parents or other stimuli. The child fails to form relationships, avoids eye contact, and has a preference for playing alone. Extreme resistance to change of any kind is an important feature of the condition, which can make it very difficult to teach the autistic child new skills. Rituals develop in play, and there is often attachment to unusual objects or obsession with one particular idea. Delay in speaking is common and most autistic children have a low IQ. Other behavioural abnormalities may include walking on tip-toe, rocking, self-injury, screaming fits, and hyperactivity. Appearance and coordination are normal. Some autistic people have an isolated special skill, such as musical ability or an outstanding rote memory.

Treatment and outlook

There is no cure for autism, which is a lifelong condition. Special schooling, support and counselling for the families, and, sometimes, behaviour therapy (such as to reduce violent self-injury) can be helpful. Medication is useful only for specific problems, such as hyperactivity. The outlook depends on the intelligence and language ability of the individual. The majority of autistic people need special care.

Autism and the pervasive developmental disorders - UK based - technical

Autism in more detail - non-technical

Definition

Autism is a complex developmental disorder distinguished by difficulties with social interaction, verbal and nonverbal communication, and behavioral problems, including repetitive behaviors and narrow focus of interest.

Demographics

Estimates from the CDC now suggest that about 1 of every 50 children in the United States are affected by autism. The prevalence has been increasing steadily according to the Centers for Disease Control (CDC) in the US. The prevalence of parent-reported cases of autism is significantly higher now than it was just five years ago, according to new Centers for Disease Control and Prevention data released in May 2013. From 2011 to 2012, 1 in 50 school-age children had a diagnosed autism spectrum disorder according to their parents -- up from 1 in 86 in 2007.

Autism is almost four times more likely to be diagnosed in males. Autism is a disorder that is found worldwide. In the United Kingdom, one out of every 100 children have autism, with over half a million total diagnosed in the United Kingdom as of 2007. In China, one in every 1,000 children is diagnosed with autism. In India, the rate of incidence is 1 in every 250 children. In Mexico, two to six in every 1,000 children are autistic. Autism is not specific to any one socio-economic, ethnic, or racial group.

Description

Classic autism is one of several disorders categorized as autism spectrum disorders (ASD). In DSM IV other ASDs included Asperger syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder. As of 2013, the classification of autism and autism spectrum disorders has been re-evaluated by the American Psychiatric Association. The American Psychiatric Association has just published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic criteria for autism spectrum disorder has been modified based on the research literature and clinical experience in the 19 years since the DSM-IV was published in 1994.

Changes include:

The diagnosis will be called Autism Spectrum Disorder (ASD), and there no longer will be subdiagnoses (Autistic Disorder, Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified (NOS), Disintegrative Disorder).

In DSM-IV, symptoms were divided into three areas (social reciprocity, communicative intent, restricted and repetitive behaviors). The new diagnostic criteria have been rearranged into two areas: 

  1. social communication/interaction, and 
  2. restricted and repetitive behaviors.

The diagnosis will be based on symptoms, currently or by history, in these two areas. for revision in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) which was published in May 2013.

Autism usually manifests before a child is three years old and it continues throughout his/her lifetime. The severity of the condition varies between individuals, ranging from the most severe (extremely unusual, repetitive, self-injurious, and aggressive behavior) to very mild. No one autistic child is alike in the manifestation of their symptoms so treatment options must be devised to treat each autistic child individually. Autism cannot be cured but is treatable. With early diagnosis and intensive therapy, autistic children may be able to lead healthy, full lives.

Risk factors

There appears to be a strong genetic basis for autism. Family studies have shown that identical twins are more likely to both be diagnosed with autism than twins who are fraternal (not genetically identical). In a family with one autistic child, the chance of having another child with autism is about one in 20 or approximately 5%, much higher than in the general population. Other risk factors associated with autism include:

  • Gender. Boys are almost four times more likely to be diagnosed with autism than girls.
  • Paternal age. Children born of fathers over age 40 have a greater chance of developing autism than children born to younger fathers. The age of the mother appears to have no effect on autism.  
  • Certain disorders and diseases. Children who have fragile X syndrome, tuberous sclerosis, Tourette syndrome, and epilepsy are more likely to have autism.

Causes and symptoms

Researchers know that autism is a complex brain disorder that affects the way the brain uses or transmits information. Studies have implicated several causes for the disorder including genetic errors and possible environmental triggers, but more investigation is needed. Studies have found abnormalities in several parts of the brain that are believed to have occurred during fetal development. The problem may be centered in the parts of the brain responsible for processing language and information from the senses.

Profound problems with social interaction are the most common symptoms of autism and the most visible. Autistic children have different ways of learning and experiencing the world around them. Often autistic children have more acute reactions to sensory stimulation such as sound and touch. This results in avoidance of eye contact, physical contact, and oftentimes an aversion to music and other sounds. It is perhaps the way autistic children experience their world that causes difficulties with social interaction, language, and nonverbal communication.

Human beings are social and social interaction is present from birth onward. Children with autism have difficulty making social connections. A developmental milestone is when an infant can follow an object or person with his/her gaze. Autistic children tend to avoid eye contact altogether. They do not actively cuddle or hug but rather they passively accept physical contact or they shy away from it. They may become rigid or flaccid when they are held, cry when picked up, and show little interest in human contact. Such a child does not lift his/her arms in anticipation of being picked up. The child may appear to have formed no attachment to his/her parents, and does not learn typical childhood games, such as ‘‘peek-a-boo.’’

Autistic children do not readily learn social cues. They do not know when or how to react to specific social situations or exchanges. Because of this, autistic children tend to look at and respond to different situations similarly. They do not understand that others have different perspectives and, therefore, autistic children seem to lack empathy.

Because of their problems socially and the inability to translate social interactions appropriately, autistic children seem to have uncontrolled emotional outbursts, expressing themselves in a manner that does not suit the specific social situation of the moment.

Language problems

Verbal communication problems vary greatly for autistic children. Some children do not speak at all. Some will only use one or two words at a time. Some autistic children may develop vocabulary only to lose it. Other autistic children may develop an extensive vocabulary; however, they have difficulty sustaining a natural, ‘‘back-and-forth’’ conversation. Autistic children tend to talk in a sing-song voice or more robotically without emotional inflections. Often autistic children do not take body language into consideration and they take what is being said quite literally. Because of their impinged language skills and the inability to express their needs, autistic children seem to act inappropriately to get what they need. They may grab something without asking or blurt out statements.

Restricted interests and activity

Language and social problems inhibit social play for autistic children. Autistic children do not engage in imaginative play and role playing. They focus on repetition, some focusing on a subject of interest very intensely.

Autistic children often stick to a rigid daily routine. Any variance to the routine may be upsetting to them and result in an extreme emotional response. Repetitive physical behaviors such as rocking, spinning, and arm flapping are also characteristic of autism. The repetitive behaviors are often self-soothing responses to sensory stimulation from the outside world.

Sensory problems

The sensory world poses a real problem to many autistic children, who seem overwhelmed by their own senses. A child with autism may ignore objects or become obsessed with them, continually watching the object or the movement of his or her fingers over it. Some children with autism may react to sounds by banging their head or flapping their fingers. Some high-functioning autistic adults who have written books about their childhood experiences report that sounds were often excruciatingly painful to them, forcing them to withdraw from their environment or try to cope by withdrawing into their own world of sensation and movement.

Diagnosis

There is no medical test for diagnosing autism. Diagnosis is made after careful observation and screening by parents, caregivers, and physicians. Early diagnosis is beneficial in treating the symptoms of autism.

Some early warning signs are:

  • avoiding eye contact
  • avoiding physical contact such as hugs
  • inability to play make-believe
  • not pointing out interesting objects
  • not responding to conversation directed at him/her
  • practicing excessively repetitive behaviors
  • repeating words or phrases
  • losing skills and/or language after learning them

Once parents feel there is a problem or their pediatrician has identified developmental problems during well-baby check-ups, they can seek out a developmental pediatrician for further diagnosis. There are several screening tests used. They are:

  • Childhood Autism Rating Scale (CARS)—a test based on a 15 point scale where specific behaviors are observed by the physician.
  • Checklist for Autism in Toddlers (CHAT)—a test to detect autismin 18-month olds that utilizes questionnaires filled out by both the parents and the pediatrician.
  • Autism Screening Questionnaire—a 40-item questionnaire for diagnosing children four and older.
  • Screening Test for Autism in Two-Year-Olds—a direct observation of three skill areas including play, motor imitation, and joint attention.

Some children have a few of the symptoms of autism, but not enough to be diagnosed with the ‘‘classical’’ form of the condition. Children who have autistic behavior but no problems with language may be diagnosed with Asperger syndrome by using the Autism Spectrum Screening Questionnaire, the Australian Scale for Asperger syndrome, or the Childhood Asperger Syndrome Test. The American Psychiatric Association has removed the diagnosis of Asperger syndrome in the DSM 5 as from May 2013. Children who have no initial symptoms but who begin to show autistic behavior as they get older might be diagnosed with childhood disintegrative disorder (CDD) - (but this has also be removed in the DSM 5), another autistic spectrum disorder. It is also important to rule out other problems that seem similar to autism.

Treatment

Because the symptoms of autism can vary greatly from one person to the next, there is not a single treatment that works for every person. A spectrum of interventions including behavioral and educational training, diet and nutrition, alternative medicine and therapies, and medication should be utilized and finetuned to treat the individual. The most strongly recommended treatment option is behavioral and educational training. Early intervention and treatment is key to helping autistic children grow into productive adults.

Educational and behavioral treatment

Several educational and behavioral treatments are:

  • Applied Behavior Analysis (ABA)
  • speech therapy
  • occupational therapy, including sensory integration therapy
  • social skills therapy, including play therapy

Typically, behavioral techniques are used to help the child respond and decrease symptoms. This might include positive reinforcement to boost language and social skills. This training includes structured, skilloriented instruction designed to improve social and language abilities. Training needs to begin as early as possible, since early intervention appears to positively influence brain development.

Most autistic children respond to intervention at home as well as at school. Schools focus on areas where the child may be delayed, such as in speech or socialization. As autistic children grow and move to different phases of childhood and adolescence, parents in collaboration with educators and physicians need to adapt the treatment to best suit the needs of their autistic child.

Medication

No single medication treats symptoms of autism; however, some medications have been used to combat specific needs in autistic children. Drugs can control epilepsy, which affects up to 20% of people with autism. Medication can also treat anxiety, depression, and hyperactivity. Medication must be individualized and adjusted as the child develops.

Five types of drugs are sometimes prescribed to help the behavior problems of people with autism are:

  1. stimulants, such as methylphenidate (Ritalin)
  2. antidepressants, such as fluvoxamine (Luvox)
  3. opiate blockers, such as naltrexone (ReVia)
  4. antipsychotics
  5. tranquilizers

In 2010, news of use of the drug memantine (used in Alzheimer’s patients for nearly a decade in the U.S.) being used in a study conducted by Dr.Michael Amen at Ohio State University involving children with autism was reported. The wisdom is, that given their similarities (a malfunction in the brain involving a chemical called glutamate which impacts the patient’s speech and interaction) the drug may help in autism, too. Most drugs for autism only focus on lessening symptoms like hyperactivity or repetitive actions. The study was designed to try and help communication, one of the core issues of autism.

Alternative treatment

Some parents report success with megavitamin therapy. Some studies have shown that vitamin B6 with magnesium improves eye contact and speech and lessens tantrum behavior. Vitamin B6 causes fewer side effects than other medications and is considered safe when used in appropriate doses. However, not many health practitioners advocate its use in the treatment of autism, citing that the studies showing its benefit were flawed.

DMG (dimethylglycine)

This compound, available in many health food stores, is legally classified as a food, not a vitamin or drug. Some researchers claim that it improves speech in children with autism. Those who respond to this treatment will usually do so within a week. Again, many doctors do not feel that the studies are adequate to promote this treatment.

Diet

Many parents have seen beneficial affects from a gluten-free and casein-free diet. Gluten is a substance found in the seeds of cereal plants such as wheat, barley, oats, and rye. Casein is a protein found in milk. Often people have sensitivities to these substances without realizing it. Many foods contain these substances as an ingredient; however, there are growing numbers of gluten-free and casein-free foods available for people that would like to eliminate them from their diets. Parents interested in using diet as a treatment should discuss with their child’s doctor how to initiate an elimination diet.

Exercise

One researcher found that vigorous exercise (20 minutes or longer, three or four days a week) seems to decrease hyperactivity, aggression, self-injury and other autistic symptoms.

Prognosis

Autism is treatable but not curable. With appropriate treatments adjusted to suit the autistic child as he/she grows up, the symptoms of autism improve. Today, parents and caregivers are focused on providing the best therapies possible in order for autistic children to develop to their highest potential. Because the incidence of autism seems to be increasing at a rapid rate worldwide, enough so that the CDC has voiced concern about its prevalence, there is more awareness of autism and more ongoing research efforts. People with autism have a normal life expectancy and with proper intervention they can lead full lives.

Prevention

Until the cause of autism is discovered, prevention is not possible.

Resources

Books 

Brock, Stephen E., Shane R. Jimerson, and Robin L. Hansen. Identifying, Assessing, and Treating Autism at School. New York: Springer, 2006.

Glasberg, Beth. Stop That Seemingly Senseless Behavior: FBA-Based Interventions for People With Autism. Bethesda, MD: Woodbine House, 2008.

Offit, Paul A. Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. New York: Columbia University Press, 2008.

Tuchman, Roberto and Isabelle Rapin, eds. Autism: A Neurological Disorder of Early Brain Development. London: MacKeith Press for the International Child Neurology Association, 2006.

Other 

Autism Resource Center. American Academy of Child and Adolescent Psychiatry, July 2009. http://www.aacap.org/cs/Autism.ResourceCenter

Organizations 

Autism Research Institute/Autism Resource Center, 4182 Adams Avenue, San Diego, CA, 92116 English: (866) 366-3361; Spanish: (877) 644-1184 ext. 5 (619) 563-6840, http://www.autism.com

Autism Society of America, 4340 East-West Hwy, Suite 350, Bethesda, MD (301) 657-0881 (800) 3-AUTISM [(800) 328-8476], http://www.autismsource.org

Autism Speaks, 2 Park Avenue, 11th Floor, New York, NY, 10016 (212) 252-8584 (212) 252-8676, email: contactus@autismspeaks.org, http://www.autismspeaks.org