Autism
Revising Medical Author: Roxanne Dryden-Edwards, MD
Revising Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
Autism: Early Screening by Pediatricians
Medical Author: David Perlstein, MD FAAP
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
It is commonplace to have a family member or close friend with a child
diagnosed with one of the autism spectrum disorders (ASDs, including autistic
disorder, Asperger disorder,
pervasive developmental disorder). These are a set
of neurodevelopmental disabilities affecting young children and adults, which
are currently not considered "curable." The goals of management include
minimizing the symptoms and maximizing both independent function and quality of
life. These are not uncommon disorders. Their prevalence has been estimated as
approximately 6.5 per 1000 children, or 1 in every 150 children. Many believe
that there is an "Autism Epidemic." However, as with many diseases and
disorders, there are many reasons for this high prevalence.
Fortunately, significant media coverage and increased research have resulted
in a better educated public and more vigilant healthcare practitioners. It is
clear that early diagnosis and intervention are associated with better outcomes.
The American Academy of Pediatrics (AAP) published an updated guide
for the "Management of Children with Autism Spectrum Disorders." In this publication, both background
information and management choices are reviewed. In addition the AAP's approved
"Surveillance and Screening Algorithm: Autism Spectrum Disorders (ASDs)" is
introduced. Currently this translates into the following: All children should be
screened for autism at 18 months and again at 2 years of age, and at any time a
parent raises a concern about autism spectrum disorders (even if they have no signs of developmental
delay). Although many healthcare practitioners were already screening, the
process has been formalized and I expect that even more children will be
referred, resulting in earlier diagnosis and intervention.
I am a community pediatrician. In my practice I have decided to adopt the
CHAT Screening Tool (Checklist for
autism in toddlers). Because early
intervention has been shown to improve outcomes, we also try to educate our
parents as early as possible to be aware of the warning signs of autism spectrum
disorders, and
encourage them to speak to our staff whenever concerned.
What is autism?
Autism is a developmental disorder that is characterized by impaired
development in communication, social interaction, and behavior. Autism is
classified as a pervasive developmental
disorder (PDD), which is part of a broad
spectrum of developmental disorders affecting young children and adults--the
autistic spectrum disorders (ASD). The range of these disorders varies from
severely impaired individuals with autism to other individuals who have
abnormalities of social interaction but normal intelligence--Asperger's
syndrome. The ways in which autism is exhibited can differ greatly.
Additionally, autism can be found in association with other disorders such as
mental retardation and certain medical conditions. The degree of autism can
range from mild to severe. Mildly affected individuals may appear very close to
normal. Severely afflicted individuals may have an extreme intellectual disability and
unable to function in almost any setting.
In the past, autism has been confused with childhood
schizophrenia or
childhood psychosis, and may have been misunderstood as schizotypal personality
disorder in some adults. As additional research information about autism becomes
available, the scope and definition of the condition continues to become more
refined. Much of the past confusion about the disorder has been resolved.
What are the symptoms of autism?
The current Diagnosis and Statistical Manual of Mental Disorders-Fourth
Edition, Treatment Revision (DSM-IV-TR) identifies three features that are
associated with autism:
Impairment in social interaction
First, patients with autism fail to develop normal personal
interactions in virtually every setting. This means that affected persons fail
to form the normal social contacts that are such an important part of human
development. This impairment may be so severe that it even affects the bonding
between a mother and an infant. It is important to note that, contrary to
popular belief, many, if not most, autistic persons are capable of showing
affection and do demonstrate affection and do bond with their mothers or other
caregivers. However, the ways in which autistic individuals demonstrate
affection and bonding may differ greatly from the ways in which others do so.
Their limited socialization may erroneously lead parents and pediatricians away
from considering the diagnosis of autism. As the child develops, interaction
with others continues to be abnormal. Affected behaviors can include eye
contact, facial expressions, and body postures. There is usually an inability to
develop normal peer and sibling relationships and the child often seems
isolated. There may be little or no joy or interest in normal age-appropriate
activities. Affected children or adults do not seek out peers for play or other
social interactions. In severe cases, they may not even be aware of the presence
of other individuals.
Communication
Communication is usually severely impaired in autistic persons. What the
individual understands (receptive language) as well as what is actually spoken
by the individual (expressive language) is significantly delayed or nonexistent.
Deficits in language comprehension include the inability to understand simple
directions, questions, or commands. There may be an absence of dramatic or
pretend play and these children may not be able to engage in simple
age-appropriate childhood games such as Simon Says or Hide-and-Go-Seek. Adults
may continue to engage in playing with games that are for young children.
Autistic individuals who do speak may be unable to initiate or participate in
a two-way conversation (reciprocal). Frequently the way in which an autistic
person speaks is perceived as unusual. Their speech may seem to lack the normal
emotion and sound flat or monotonous. The sentences are often very immature:
"want water" instead of "I want some water please." Those with autism often
repeat words or phrases that are spoken to them. For example, you might say
"look at the airplane!" and the child or adult may respond "at airplane,"
without any knowledge of what was said. This repetition is known as echolalia.
Memorization and recitation of songs, stories, commercials, or even entire
scripts is not uncommon. While many feel this is a sign of intelligence, the
autistic person usually does not appear to understand any of the content in his
or her speech.
Autistic persons often exhibit a variety of repetitive, abnormal behaviors.
There may also be a hypersensitivity to sensory input through vision, hearing,
or touch (tactile). As a result, there may be an extreme intolerance to loud
noises or crowds, visual stimulation, or things that are felt. Birthday parties
and other celebrations can be disastrous for some of these individuals. Tags on
clothing may be perceived as painful. Sticky fingers, playing with modeling
clay, eating birthday cake or other foods, or walking barefoot across the grass
can be unbearable. On the other hand, there may be an underdeveloped
(hyposensitivity) response to the same type of stimulation. This individual may
use abnormal means to experience visual, auditory, or tactile (touch) input.
This person may head bang, scratch until blood is drawn, scream instead of
speaking in a normal tone, or bring everything into close visual range. He or
she might also touch an object, image or other people thoroughly just to
experience the sensory input.
Autistic children and adults are often tied to routine and many everyday
tasks may be ritualistic. Something as simple as a bath may only be accomplished
after the precise amount of water is in the tub, the temperature is exact, the
same soap is in its assigned spot and even the same towel is in the same place.
Any break in the routine can provoke a severe reaction in the individual and
place a tremendous strain on the adult trying to work with them.
There may also
be non-purposeful repetition of actions or behaviors. Persistent rocking, teeth
grinding, hair or finger twirling, hand flapping and walking on tiptoe are not
uncommon. Frequently, there is a preoccupation with a very limited interest or a
specific plaything. A child or adult may continually play with only one type of
toy. The child may line up all the dolls or cars and the adult line up their
clothes or toiletries, for example, and repeatedly and systematically perform
the same action on each one. Any attempt to disrupt the person may result in
extreme reactions on the part of the autistic individual, including tantrums or
direct physical attack. Objects that spin, open and close, or perform some other
action can hold an extreme fascination. If left alone, an autistic person may
sit for hours turning off and on a light switch, twirling a spinning toy, or
stacking nesting objects. Some individuals can also have an inappropriate
bonding to specific objects and become hysterical without that piece of string,
paper clip, or wad of paper.
Next: What causes autism? »
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