WHAT IS AUTISM?

- developmental - affecting social and communication skills
- life-long
- part of a range within what is termed 'the autistic spectrum'
- wide ranging - some people have accompanying learning disabilities while others have average or above average intelligence
- affecting boys more often than girls - classic autism sex ratio is four males to one female; for Asperger syndrome it is nine males to one female.






Autism and Asperger syndrome are all part of the same autistic spectrum and the differences between them relate more to degree than anything else. However, people at the more able end of the spectrum, such as those with Asperger syndrome, tend to have average or above average intelligence and generally have fewer problems with language, often speaking fluently though their words can sometimes sound formal or stilted.


Recognising the clinical features

Individuals who are considered to be on the autism spectrum are in many ways very different from each other. The range of intellectual ability extends from the severely learning disabled range right up to normal or even superior levels of intellect. Similarly, linguistic skills range from those who are mute to those who display complex, grammatically correct speech. All such individuals have difficulties in three main areas. Different authors have used slightly different terminology to describe this cluster of symptoms, but the concept of the 'triad of impairments' is widely used.

Triad of impairments

Impairment of social interaction

This refers to an impaired ability to engage in reciprocal social interactions. The most severely affected individuals seem aloof and uninterested in people. Others desire contact, but fail to understand the reciprocal nature of normal social interaction. In consequence their attempts at social interaction are clumsy, awkward and one-sided. Some passively accept the attentions of others but do not reciprocate.

Impairment of social communication

The whole range of communicative skills may be affected. A significant proportion of individuals with classical autism fail to develop useful speech. Even when the mechanics of language are mastered, the person with autism has difficulty using it for the purpose of communicating with others. Intonation is inclined to be abnormal and the non-verbal aspects of communication such as eye-to-eye gaze, use of gesture and facial expression can be impaired.


Impairment of social imagination

People with autism have great difficulty thinking imaginatively. This is demonstrated by pretend play, which will be absent or repetitive in children with autism spectrum disorders. Whether this is directly related to the development of rigid and repetitive behaviours has not been established.

Other characteristics

Repetitive and stereotyped behaviours

People may be familiar with the image of children with autism obsessively lining up toys, repeatedly spinning objects or flapping their hands in the periphery of their vision. As development proceeds, however, the focus of attention tends to shift from physical activities to the collection of information. This is particularly true of more able children who may accumulate facts about specific topics.

Characteristically, the themes of such preoccupations are unusual and the focus extremely restricted. Additionally, they do not become the currency of social exchange in the way that collecting football stickers or knowledge about computer games often does for typically developing children.

Joint attention behaviours

Joint attention behaviours are attempts to monitor or direct the attention of another person. They include gaze monitoring, pointing and showing. These behaviours are normally present by age nine to 14 months but are rare or absent in children with autism.

Screening

At present there is no suitable test for the universal screening of preschool children for autism spectrum disorders. Nevertheless identification of autism spectrum disorders can be improved by recognising those signals which might indicate further assessment is needed. These red flags include concerns around communication (eg not responding to name, not pointing or waving goodbye, delayed language), social interaction (eg seems to prefer playing alone, is very independent, does not smile socially) and behaviour (eg has unusual attachments to toys, is oversensitive to certain textures or sounds, is hyperactive, unco-operative or oppositional).

The red flags for autism

Absolute indications for immediate further evaluation:

no babbling by 12 months
no gesturing (pointing, waving, bye-bye, etc) by 12 months
no single words by 16 months
no two-word spontaneous (not just echolalic) phrases by 24 months
any loss of any language or social skills at any age.


Parents of children with autism often report dissatisfaction with the diagnostic process. On average parents first become concerned when their child is around 18 months of age and first seek help when he or she is about two years. However, it often takes years before a diagnosis is made. Not infrequently parents are reassured about their initial concerns only to discover later that their child has autism.

Behaviour problems

A tendency to engage in stereotyped, repetitive behaviours is a central feature of autism spectrum disorders. In addition, other maladaptive behaviours often develop such as temper tantrums, phobias, sleep problems, aggression or self injurious behaviours.

Behaviour management techniques have proved a valuable way of addressing these problems. It is important to remember, however, that people with autism spectrum disorders will not respond in the conventional way to standard behaviour modification techniques. They will not, for example, understand the rewards of social reinforcement. However, behavioural treatment, usually carried out by a clinical psychologist can be a useful intervention. Sometimes community psychiatric nurses or other mental health professionals may also have developed expertise in this area.

Psychotropic drugs may be indicated for the treatment of a specific mental disorder. Whilst it is preferable to avoid drugs in the treatment of longstanding maladaptive behaviours they are sometimes necessary and can prove beneficial.

Adolescence and transition to adult life

Not surprisingly, adolescence can be an especially testing time for people with autism and for their families. In addition to the developmental changes associated with puberty, some people with autism begin to develop a painful awareness of their difficulties, which can result in depression or behavioural problems. About one third of people with autism develop epilepsy with an onset of seizures in adolescence occurring in a significant proportion. Many adolescents, however, will only ever have one or two seizures and medication should not, therefore, be prescribed immediately.

Autism results in lifelong disability for those affected individuals. Follow-up studies have shown that the majority continue to suffer problems as adults and few manage to live independently.

For most, therefore, there will be a continuing need for social support and some will also require input from mental health professionals. Unfortunately, professionals working within adult services have often been unfamiliar with the problems of autism. It is hoped that this is changing as awareness of the disorder increases.