Autism spectrum disorder

In the psychiatric community, thinking about autism, and disorders related to it, is in transition. What has been considered a set of distinct conditions described as pervasive developmental disorders—autism, Asperger’s disorder, childhood disintegrative disorder (CDD), and pervasive developmental disorder not otherwise specified (PDD-NOS)—are now considered one disorder that presents along a spectrum of symptoms and behaviors.

Autism spectrum disorder (ASD) is a condition that interferes with a child’s development of social and communication skills. Symptoms appear in early childhood and include deficits in verbal and nonverbal communication, lack of social reciprocity, and restricted, repetitive patterns of behavior and interests.

Boys are diagnosed with ASD around 3 to 4 times more often than girls. There is no cure for the disorder, though therapies have been developed to help autistic children engage more successfully with the world.

Children with autism spectrum disorder display some (or in rare cases, all) of a variety of worrying signs that experts group in a “triad of symptoms”: communication deficits, social skills deficits, and restricted or repetitive behaviors.

Social: Social signs suggesting autism include aversion to displays of affection like cuddling and hugging and a preference for solitary play. In younger kids, say under 3, failure to respond to their own name is a red flag, as is disinterest in giving, sharing, or showing objects of interest. In older children, some warning signs include what appears to be a limited understanding of others’ emotions, or even the basic meaning of social relationships, like marriage or friendship.

Communication: A child with autism often starts speaking later than the norm; you might have cause for concern if your child doesn’t make typical baby noises or gestures in the first year, hasn’t spoken a word by 18 months, or can’t string together two-word phrases by 2 years.

When a child with autism does talk, it is often in a stilted, “robotic” tone, or in an exaggerated singsong. He may also repeat certain phrases without appearing to understand their significance, or possess what an expert calls “non-functional knowledge”—information he can recite, but not use to solve problems or carry on a conversation. Young kids with autism don’t point at objects of interest, don’t make eye contact, and don’t use gestures to communicate a need or describe something. As kids with autism age and acquire language, their tone or pattern of speech can be odd; some have a habit of reversing pronouns—a youngster asking his mom for water might say “You want water” instead of “I want water.” High-functioning children with autism may monopolize conversations while showing little capacity for reciprocity, or understanding what the other party wants or feels.

Repetition: Key behavioral signs include the performance of repetitive actions and rituals, and fixation on minute details to the point of distraction. Children with autism can be deeply troubled by the slightest change in daily routine. In young kids, possibly troubling behavior includes ordering toys instead of playing with them—as one expert puts it, if your child lines up toy cars, without ever playing with them as cars, you could be concerned. In older children, the repetitive behavior can manifest as a consuming interest in a specific topic or object.

Signs of autism often manifest before 2 years, though some children with the disorder appear to develop normally and then “regress” at 1 or 2, losing language and social skills they had previously developed. Experts note that if your child displays only one of the three key signs, it is possible that autism is not the problem—or that other signs have yet to become apparent.

Researchers are unsure about the root causes of autism, but certain genetic factors have been linked to the disorder. Scientists are also exploring the possible interaction between those and environmental factors as a contributor to onset. Other explanations for autism, such as purported links between childhood vaccination and onset, are unproven and go against the consensus view.

For those still separating ASD into a series of separate disorders, the key diagnostics are as follows:

For diagnosis of autistic disorder, a child will display a certain number of specific symptoms within the triad: social impairment; communications impairment; and the presence of “restricted repetitive and stereotyped patterns of behavior, interests, and activities.” Furthermore, she must have experienced developmental delays before the age of 3 in at least one of three areas: social interaction, language, and play.

A child diagnosed with Asperger’s will have significant impairment in social interaction and the presence of stereotyped behaviors—often a fixation on a single topic or object—without attendant deficits in language acquisition or communication.

Childhood disintegrative disorder is diagnosed when symptoms of full-fledged autistic disorder present after a period of normal development; some time between ages 2 and 10 the child “regresses,” losing the social and language skills he had developed.

Pervasive developmental disorder not otherwise specified is diagnosed when clearly autistic symptoms do not specifically fit another PDD diagnosis; PDD-NOS is often diagnosed when symptoms appear after the age of 3.

Autism cannot be cured at the present time, but a structured educational program and tailored therapy have been shown to be very beneficial.

Psychotherapeutic: One effective intervention is a psychotherapeutic regimen called applied behavior analysis. This therapy seeks to maximize the child’s learning and development by systematically encouraging desired social and communication behaviors, actively teaching ways of interaction other children learn intuitively in childhood. Another approach, dubbed “developmentally-based intervention,” seeks to educate and engage with a child using the subjects, words, and stimuli appropriate to the developmental stages they have in effect been excluded from, modeling the typical progression for an atypical child. As autism and autism spectrum disorders manifest differently in every child, other therapies include occupational, physical, and speech-language.

Pharmacological: There are no drugs that target the core symptoms of autism, but medications are often prescribed to help with problems that often occur alongside the disorder, such as depression, anxiety, and hyperactivity.

Alternative: It should be noted that many alternative treatments and even “cures” have been proposed for autism spectrum disorder. None of these alternative treatments—chelation, diets, supplements, facilitated communication—have any reliable scientific evidence behind them. Some, particularly chelation—an attempt to remove heavy metals from the body via chemical injections—can be very dangerous. It’s important that parents who choose to pursue these therapies should do so in close consultation with a qualified physician.

Children with autism have certain other medical problems at a rate far above average. Epilepsy afflicts almost a third of children diagnosed with autism once they reach adulthood. Sleep disorders, allergies, and digestive problems are commonly seen, as are tic disorders like Tourette’s. Kids with autism are also more likely than others to be cognitively impaired.

Is autism brain damage?
Autistic brains are structured and function differently than normal ones, but autism has not been definitively linked to any environmental factors or trauma. Most experts agree that autistic kids are born that way.
Is my child retarded?
Autism and cognitive impairment are separate conditions, though some studies have suggested that a majority of children with autism have IQ scores that fall below the cutoff of around 70 for mental retardation. Hence it may be far more likely than the norm for a child with autism to have cognitive impairment, but it’s not a given or part of the ASD diagnosis.
Will my child grow out of it?
No. Autism is a lifelong condition—at this time, the differences in brain structure and chemistry thought to contribute to the disorder can’t be fixed. But behavioral therapy can help teach your child how to function in the world and interact with others at a higher level than he could on his own.
Will drugs help?
No drug can cure autism or treat all of the core symptoms of the disorder. But kids with autism often have other mental and behavioral problems that are treatable with medication, and that treatment can positively impact your child’s quality of life and ability to participate in therapies aimed at his autistic behavior. For instance, antidepressants could help a child suffering from depression, which affects some with autism. In other cases, medication can be used to curb aggressive behavior.
What’s the prognosis?
Children with autism can improve over time—the question isn’t really whether they will improve but to what degree the disorder will impair development. Experts agree that a young child’s language development is a good gauge of the severity of the disorder—that is, the easier language comes to the autistic child, the less severe the symptoms of the disorder will be later on. Of course, the earlier a child with autism receives treatment, the better the prognosis for his maximizing his potential.