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(Parenting) Autism - Symptoms, Causes, Assessment, and Treatment
(Parenting) Autism - Symptoms, Causes, Assessment, and Treatment
What is Autism?
Definition
Autism or Autistic Disorder is a pervasive developmental disorder that affects all of mental
development. It looks very different at different ages and certain features do not become
apparent until later. Autism is probably present at birth but is often not identified until the child
fails to develop communicative language at about 2 years of age. 70% of children with Autism
have IQ's below 70; and 11% have IQ's above 85. Those individuals who are most
developmentally delayed are usually also most autistic. As with normally developing children
no two children with Autism are alike and the differential diagnosis of such disorders as
Autism, Asperger's Syndrome, Nonverbal Learning Disability (NLD), Pervasive
Developmental Disorder (PDD), and severe communication disorder can be difficult. It is
believed by many researchers that the fundamental deficit that is seen in autistic children
is a "mind blindness" or a lack of a theory of mind or the capacity to understand that
other people think and feel the same way as they do. This deficit is believed to
contribute to the difficulty that autistic children have in imitating another person's
reactions, particularly their body movements, and particularly if the content of the
actions is affective. Several studies have also found specific deficits in autistic children's
perception and understanding of emotions.
Autism or Autistic
Disorder is a pervasive
developmental disorder
that affects all of mental
development.
Incidence
10 - 15 per 10,000 children are autistic and an additional 12 - 20 per 10,000 have autistic-like
features. Three boys to one girl have the disorder.
Diagnosis
The DSM-IV-TR (2000) has identified Autistic Disorder as one disorder under the wider category of Pervasive
Developmental Disorders. Under the broader category there are other disorders included such as Asperger's
Syndrome, Rett's Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder (Not
Otherwise Specified). DSM-IV-TR has identified the following diagnostic criteria for the Autistic Disorder.
AUTISM
Diagnostic Criteria
A.
A total of six or more items from (1), (2), and (3) with at least two from (1), and one each from (2)
and (3).
(1)
(2)
(b)
(c)
(d)
(3)
10 - 15 per 10,000
children are autistic...
B.
Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3
years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or
imaginative play
C.
The disturbance is not better accounted for by Rett's Disorder or Childhood Distintegrative
Disorder.
AUTISM
Diagnostic Criteria
It is still not clear what precise deficits underlie Autistic Disorders but researchers have got much closer
to understanding them in the last five years. This has mainly occurred because the latest research has
compared autistic children to other children with the same IQ and chronological age. Deficits appear to
be very selective and are not the same in all children with Autism.
AUTISM
Causes
Causes
Exactly what causes Autism is unknown although it is believed to be a neurological condition. Medical
conditions that could be causal are found in only about 5-10% of cases.
Genetic Component
It seems likely that a predisposition to Autism is inherited. The evidence of the heritability of
Autism comes from twin and family studies. In twin studies, unusually high rates of Autism are
found in identical twins, and very low rates in fraternal or non-identical twins. Studies of
families have indicated that 2-6% of the siblings of autistic children are also autistic, and that
8% of the extended families will include another member who is autistic. Family studies also
reveal an increased prevalence of mental retardation and cognitive difficulties in the
siblings of autistic children especially those who are mentally retarded themselves. This
suggests that what may be inherited is not an "Autism gene" but rather a nonspecific
factor which increases the likelihood of various cognitive problems including Autism.
Neurobiological Difficulties
It is believed that Autism may be related to damage to the prefrontal cortex and limbic
region of the brain and to the connections between the two regions. The most
consistent findings are of brain stem and cerebellum abnormalities. P.E.T. scans with
Autistic children show the location of problems to be in these areas of the brain. Adults
with this kind of brain damage, as a result of accident or stroke, display similar
difficulties as autistic individuals. There is some indication that the brains of children with
Autism may have increased cell density suggesting that the cells did not get pruned back
as they do in normal development. Other researchers have found that this is
particularly true within the dopamine system suggesting that there may be an excess of
dopamine which could contribute to an overactive system. Studies of glucose metabolism
and blood flow have failed to reveal consistent global or regional abnormalities, although
correlational studies do show some promise.
Developmental History
The developmental history of autistic children seldom reveals medical conditions that can be linked
to the disorder. However, certain other illnesses place children at risk for developing Autism. These
are neurofibromatosis, tuberous sclerosis, and fragile X syndrome. Many children with Autism
(approximately one fifth to one third) develop seizures. Most of these occur in lower functioning
individuals and usually develop in later childhood or adolescence. Many studies have shown that the
number of perinatal problems experienced by autistic children are exceptionally high including: difficult
delivery, infantile seizures, delayed breathing and neonatal convulsions. Some children appear to have
normal development earlier and only show the symptoms of Autism in the second year of life. There have
been two explanations given for this: (1) the child did show problems earlier but they only became obvious
when speech failed to develop and the pressure for socialization was greater, or (2) the child was born with a
vulnerability to acquiring the syndrome and it was triggered by a virus or other insult.
Environmental Factors
As mentioned previously in a very few cases of Autism a viral infection in a young child preceded the onset of
the symptoms of Autism, before which there was a period of apparently normal development. There are also
some cases where infections occurred in the mother at an early stage of pregnancy. No other links to
environmental conditions have been found.
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AUTISM
Development
Development
Infancy
In general, unless there is mental retardation, the signs of Autism may not be obvious until the second year of life when language
does not develop normally and the child does not show any interest in playing with other children. Stereotypic behaviours may also
develop at this time. However, even in early infancy some signs of difficulties may be observable. See the following chart for a list of
these signs
PERCEPTUAL
Unusually sensitive to
sensory stimuli
Auditory:
Appears deaf to voice
but jolts or panics at
environmental sounds
Tactile:
Refuses food with rough
texture
Adverse reaction to
wool fabrics and labels,
etc.
Prefers smooth surfaces
Visual:
Sensitive to light
May panic at change in
illumination
Preoccupied in
observing own hand
and finger movements
SOCIAL-E
EMOTIONAL
Unresponsive:
No social smile
Avoidance of eye
contact when held
Fleeting eye contact at a
distance
Lack of anticipatory
response to being
picked up
Seems not to like being
held or hugged
Seems content left alone
Does not visually follow
the coming and going
of primary caregiver
Does not play peek-aboo or patty-cake or
wave bye-bye
Fails to show normal 8month stranger anxiety
Does not respond to
social bids from
caregiver
LANGUAGE
MENTAL
REPRESENTATIONAL
Object permanence
develops slowly or stops
at age 2 or 3 years so
child does not develop
capacity for retaining a
memory of object or person or for searching for
them
Little communication or
use of gestures
Speech delayed or shows
precocious advances
followed by failure to use
previously learned words
Use eye contact when
interacting
Does not point to object
or hold up an object to
show it to caregiver
Early Childhood
It is usually in the second year of life that signs of Autism become most obvious and assessment is requested in order to determine
the reason or cause of the symptoms. Some of the signs that become obvious at this time are outlined below.
AUTISM
Development
PERCEPTUAL
SOCIAL-E
EMOTIONAL
Withdraws from
environmental stimulation
Echolalia or repeating
what is said
Engages in self
stimulation
Preoccupied with
spinning and shiny
objects
Socialization:
Pronoun reversals
LANGUAGE
MENTAL
REPRESENTATIONAL
Play:
No imaginative play
Little appropriate use of
toys
Does not engage in
play sequences with
toys
Does not play with dolls
Preoccupied with
impersonal, invariant
information (e.g.
television commercials)
May engage in repetitive
play activities (e.g. lining
up toys and opening or
closing cupboards)
AUTISM
Diagnosis and Assessment
Diagnosis
To meet criteria for a diagnosis of Autistic Disorder a child must meet the 3 conditions outlined in the
DSM-IV-TR. These are: 6 items in the areas of: impairment in social interaction, communication, or in
having repetitive and stereotyped patterns of behaviour; or delays in social interaction, language, and
symbolic or imaginative play which are not accounted for by Rett's Disorder or Childhood Disintegrative
Disorder. Other observation schedules and questionnaires can also be used to make the diagnosis.
Although the symptoms of Autism are evident by 2 years of age or before, the differential diagnosis
of Autism can still be difficult especially making a distinction between such other disorders as
severe communication disorder, Pervasive Developmental Disorder, and Nonverbal Learning
Disability (NLD). Testing children with Autism can be very challenging as they are usually not
interested or able to follow or imitate the examiner's instructions and demonstrations of certain
tasks. Also if children have behavioural difficulties or find strange places upsetting they may
refuse items that they could usually complete. For this reason it is critically important to
obtain information from a variety of settings and respondents.
Assessment
Assessment needs to consider the following sources of information:
If it has not been done a medical examination to rule out any other disorders.
If there are soft neurological signs an examination by a neurologist would be
important.
Use of tests which have been developed specifically to evaluate the child for autistic
symptomatology.
Parent Interview for Autism (for parents of children under 6 years of age)
Wechsler Intelligence Scales can be used if the child's level of development is high enough
Direct Assessments for Children with Autism
Psychoeducational Profile for children 1 to 12 years of age who are functioning at a preschool level
Observational Scales
AUTISM
References
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, D.C.: American Psychiatric Association.
Baron-Cohen, S., Cox, A., Baird, G., Swettenham, J., Nightingdale, N., Morgan, K., Auriol, D., &
Charman, T. (1996). Psychological markers in the detection of autism in infancy in a large
population. British Journal of Psychiatry, 168, 158-163.
Cohen, D., & Volkmar, F. (Eds.)(1997). Handbook of autism and pervasive developmental
disorder. (2nd ed.). N.Y.: John Wiley.
Kranowitz, C.S. (1998). The out-of-sync child: Recognizing and coping with sensory
integration dysfunction. New York: Perigree Book.
Lord, C., & Risi, S. (2000). Diagnosis of autism spectrum disorder in young children. In
A.M. Weterby & B.M.Prizant (Eds.). Autism spectrum disorders: A transactional
developmental perspective (pp. 11-30). Baltimore: Paul Brookes Pub. Co.
Lord, C., Rutter, M., Divare, P.C., & Risis, P. (1999). Autism Diagnosis Observation
Schedule-WPS Edition (ADOS-WPS). Los Angeles: Western Psychological Services.
Mesibov, G.B., Adams, L.W., & Klinger, L.G. (1997). Autism understanding the disorder.
New York: Plenum Press.
Rogers, S.J., & Benneto, L. (2000). Intersubjectivity in autism: The roles of imitation and
executive function. In A.M. Wetherby & B.M.Prizant (Eds.). Autism spectrum disorders: A
transactional developmental perspective (pp. 79-108). Baltimore: Paul Brookes Pub. Co.
Schopler, E., Reichler, R.J., & Renner, B. R. (1986). The Childhood Autism Rating Scale (CARS)
for diagnostic screening and classification of autism. New York: Irvington.
Siegel, B. (1996). The world of the autistic child: Understanding and treating autistic spectrum
disorders. New York: Oxford University Press.
Weatherby, A.M., & Prizant, B.M. (2000). Autism spectrum disorders: A transactional developmental
perspective. Vol. 9, Communication and Language Intervention Series. Baltimore: Paul Brookes Pub.
Co.
Wing, L. (1998). Classification and diagnosis - Looking at the complexities involved. Communication,
15-18.
ZERO TO THREE/National Center for Clinical Infant Programs (1994). Diagnostic classification 0 -3 diagnostic classification of mental health and developmental disorders of infancy and early childhood. Arlington, VA:
ZERO TO THREE.
AUTISM
TREATMENT
TREATMENT
Definition
Autism or Autistic Disorder is a pervasive developmental disorder that affects all of mental
development. For further information on the diagnosis of Autism refer to the sections on
Symptoms, Causes and Assessment. Children with Autism have three primary distinguishing
features:
Treatment for children with Autism may be one or more of the following and may vary
depending on the intellectual capacity of the child. Treatments that may be used include:
Applied Behaviour
Analysis (ABA) is based
on the view that autism
is a neurological
disorder which causes a
number of deficits in
behavioural responses.
These forms of treatment are briefly described below and comments made on their
effectiveness.
AUTISM
TREATMENT
Interactive Approaches
Stanley Greenspan and Serena Weider are the most well known advocates of using play to increase
the functioning capacity and interactions of children with Autism. Children with Autism have little
appropriate use of play objects and usually do not engage in pretend play. The treatment (called Floor
Time) can take place in a room with toys that can be used to stimulate imaginative play including cars,
animals, dolls, doll furniture, trains, etc. It can also be used throughout the day when the child is doing
something he is interested in. The child's parent is usually included in the session and is encouraged by the
therapist to carry out the following:
1.
2.
3.
Follow the lead of the child in whatever they are doing with the play and make it interactive. The
interaction should not be interrupted as long as the child is enjoying it and wants to continue.
Treat all the child's behaviour as if it is intentional and purposeful even though it may seem random
and purposeless (e.g. the child is just picking up and dropping objects or may run around aimlessly).
If the child is requesting something, indicating you do not know what he means will help extend the
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AUTISM
TREATMENT
4.
5.
6.
7.
8.
9.
Face the child and make sure that their actions are differentiated from your own and some
times put your hand over the child's to help them do something instead of encouraging the child
to lead with his hand over yours.
Use surprise and novelty to capture the child's attention and interest so the child is compelled to
respond such as using a musical box or a jack-in-the-box.
Pursue the child until he responds and keep trying new approaches to get interaction.
Use tickling, peek-a-boo, and rhymes such as This Little Piggy, Ring Around the Rosy and
help the child join in the actions. Add new meanings to stereotypic play and add pretend
human figures such as having the lined up cars or the train which is going round and
round to pick up people and talk about the people in the train or lining up waiting for
the bus or train.
If the child becomes upset empathize with the feelings but do not give up on the
interactions.
Use every opportunity to expand on pretend play such as, for example, offering
Because
pretend cups of tea or pretend keys to open doors.
Music therapy
Many children with Autism enjoy music and often enjoy dancing to it and will "sing"
along with the words. This allows the child a medium for non-verbal self-expression
and can provide a channel for communication. It can also be used to form the basis
for enjoyable interactions and a relationship.
children with
Autism enjoy music so
much it has been found
to be useful to integrate
both play and music.
AUTISM
TREATMENT
Augmentative Communication
Some children with Autism will not be learn to speak and will need to use augmentative and alternative
communication supports. Some of the common forms of augmentative communication devices are: use of
pictorial or written schedules to assist the child to understand the school schedule, teaching children manual
signs that they can use to communicate certain needs, and the use of voice-output computer programs. These
devices can all allow the child to communicate and to be communicated with.
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AUTISM
Summary and Conclusions
Treatments should start as early as possible and treatment received between 2 and 4 years
can improve a child's skills considerably.
Treatment needs to be different for different children depending on their IQ level (which
can range from below 50 to 120 and above), whether aggressive behaviour and other
stereotypic behaviour is a problem, whether the child has language, and their level
of socialization and their capacity for warm interactions with other children. It is,
therefore, important that the child has a thorough assessment in order to deter
mine the most appropriate treatment combination.
Treatment may need to be intense to begin with to get the gains that may be
As well, treatment
possible and many improvements have occurred when treatment has been
needs to be given as
intense.
All teaching in the various therapies needs to be broken down into small
early as possible and
steps, so that complex skills are acquired gradually, as a sequence of separate
be intense to be
components (see ABA and improving mind reading especially).
Teaching needs to pay attention to the child's interests and to build on them
successful.
(e.g. if a child loves trains use them as a subject to teach other words, math,
and reading).
Having a structured classroom to help contain the child's anxiety and nervous
system arousal can be very helpful.
Sensory integration therapy and use of exercise as a release is an important
component of treatment.
Using visual cues to reinforce learning as well as routines that the child follows
(e.g. have the child look at pictures of the stages of having a bath before they
have one).
Avoiding using long strings of verbal information as the child will probably not be
able to follow it.
Skills need to be reinforced by rewards but when the child finds the intervention fun and
pleasurable the influence of the rewards can be further enhanced.
Teaching needs to begin at the level the child is at and not a level that would be expected
given the child's age. However, for children with higher levels of functioning,individualized
rather than pre-packaged teaching methods need to be applied.
Family support is crucial to help parents deal with the demands of providing treatment.
to
In conclusion it is important to: use a combination of various treatment strategies including approaches
that build a relationship with the child and enhance parent's relating with their child and behavioural
approaches. As well, treatment needs to be given as early as possible and to be intense to be successful.
Author:
Sarah Landy Ph.D., Developmental Psychologist
We recognize and thank the Government of Ontario for its generous financial support of this publication.
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AUTISM
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