What is Autism ?

Contrary to common beliefs, autism or ASD is no longer a term or a label used to refer to individuals who act like the “Rainman”, or people who are mute, self-injurious or aggressive. They do not necessarily alienate themselves from the others or are devoid of emotions. With the advance in scientific research in the field, our knowledge about the condition has grown over the years.

At this point, autism is viewed as a spectrum or a continuum of disorders, with varying degrees of severity and levels of functioning. The term Autism spectrum disorders or Austic spectrum disorders is frequently used in replacement of the term autism. Diagnoses, such as Asperger’s Syndrome, Childhood Disintegrative Disorder, Pervasive Developmental Disorder, Autistic Disorder and Pervasive Developmental Disorders (Not Otherwise Specified) are all included within the umbrella of ASD. While the presentation of the disorder varies from individual to individual, there are 3 areas of deficits that are common among individuals with ASD: deficits in social interactions; deficits in verbal and non-verbal communication; repetitive behaviors or narrow interests. It is best viewed as social-communication learning disabilities. While some people have troubles learning to read, people with ASD have troubles learning social communication.

Tracing Its Roots

It was Dr. Leo Kanner who first coined the term “autism” in his description of the 11 patients he observed. According to his original paper, published in 1943, on “infantile autism”, he hypothesized these individuals of having inborn constitutional errors where children are born lacking motivation for social interaction. He speculated that these children have trouble in relating to others. He also described profound disturbances in communication and resistance to change. Decades of researches proved that some of Kanner’s original propositions were wrong. For instance, he observed that most of the parents of these children are successful people from a wealthier socio-economic class, from which he postulated a probable defective relationship between the mother and child; while we now understand that autism is diagnosed across all socio-economic classes and regardless of the relationship between the mother and child. 

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Diagnostic Criteria

Listed in the Diagnostic and Statistical Manual, 4th Edition: 299.00 Autistic Disorder
A total of 6 or more items from (1), (2), and (3), with at least 2 from (1), and one each from (2) and (3):

1. Qualitative impairment in social interaction, as manifested by at least 2 of the following:

• Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction;
• Failure to develop peer relationships appropriate to developmental level;
•  A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
• A lack of social or emotional reciprocity 
  

 

2. Qualitative impairments in communication as manifested by at least one of the following:

• Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
• In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
• Stereotyped and repetitive use of language or idiosyncratic language
• Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
  

 

3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

• Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
• Apparently inflexible adherence to specific, non-functional routines or rituals
• Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
• Persistent preoccupation with parts of objects
• 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
• The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorde

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Common Deficits

Social Interactions:
Not all individuals with ASD enjoy being left alone, some of them have strong social intent, yet lack the skills to accomplish age appropriate social interactions. In fact, a survey on adults with ASD reported that the presence of friendships is one of the most important determinants of good quality of life. The following symptoms are commonly reported. However, not all individuals with ASD will display all of the following symptoms and the expressions of each symptom also vary from individual to individual.

• Lack of social reciprocity: relationship is often one-sided and mostly sustained by adults or peers; social give-and-take is lacking or not age appropriate.
• Lack of initiative to share their own enjoyment, interests or achievement with others: they rarely share, show or bring things of interests to people around them.
• Not adept to use eye gaze to modulate social interactions: this does not equate to a total lack of eye contact; individuals with ASD are not skilful in using eye gaze to initiate, sustain or terminate social interactions.
• Difficulties in reading social cues, both verbal and non-verbal: including facial expressions, body postures, social distance; deciphering social dynamics from the integration of these cues, intent of the people involved and the social settings is another layer of difficulties for people with ASD.
• Difficulties in taking perspectives: some individuals with ASD find it hard to understand that others do not see what they see, think in the same way as they think or feel what they are feeling.
• Difficulties regulating emotions: some individuals become over-excited, anxious, or angry very easily, while some individuals do not seem to display much emotion during “emotional moments” for most typical individuals.

Communication: Again, communication deficits are expressed as a continuum. Some individuals never develop speech, some communicate in single words or simple phrases, and some experience a slight language delay; while people on the other end of the spectrum have adequate speech but fail to converse or express themselves appropriately with peers. It is also not uncommon to see a child with ASD moving from the end of limited speech to adequate speech of the continuum after some time of effective intervention.

Often, their deficit in the area of language is not as much as in the area of communication. While a child with born deficits in speaking will compensate their inability to speak by gesturing and using various means in the environment, children with ASD might not use gestures to compensate. Some appear passive while others get very frustrated and try to use inappropriate means to express themselves, such as tantruming, aggression or other disruptive behaviors. On the other hand, it is not uncommon to find individuals with ASD possessing a wide enough bank of vocabulary but yet, not using them spontaneously to meet their basic needs: e.g. requesting. They might be able to describe something or an event when asked, but not applying them in their daily communication: e.g. to describe something to the people around him in order to locate something. For some individuals, echolalia (parroting) is observed. For individuals with age appropriate level of language, problems with literalness and pragmatics are often reported. They might take some idioms and slang literally (e.g. they literally give you their “hands” when asked to give you a hand). They might fail to take into account the non-verbal aspect of language: tone of voice, body language, phrases of speech; and hence, fail to understand sarcasms or jokes. Conversation might be restricted to self-interests instead of shared interests. The to-and-fro of conversation is often missing. Sometimes, speech might appear awkward or out-of-place because they might inappropriately use phrases that are overly formal or overly casual. They might not modulate their volume or tone of speech, which add to their social inappropriateness.

Repetitive Behaviors:
Some individuals with ASD display odd motor or bodily mannerisms. Some examples of such include, hand flapping, tip-toeing, hand regarding, eye cornering, finger flicking, raking objects. Some spend hours focusing on parts of objects. Some examples of such include, looking at the spinning wheels of toys and real cars, putting objects close to their eyes and scanning some part of it repetitively, attending to logos on various items (e.g. clothing, cars, etc.), staring at the pilot light of electronic equipment.

Some may not have peculiar mannerisms but might be engrossed in repetitive motions with objects. Some examples include, opening and closing doors, lining up objects, stacking objects, flipping switches. Some adhere to non-functional routines or rituals: e.g. pressing certain buttons on the lift panel (instead of the functional ones), insisting to have the same place for certain activities or the same utensils without apparent reasons, insisting to go onto the same route when going somewhere. Some may have very few interests and often, they are very intense and seem to be preoccupied by these interests. Sometimes, these interests might not be common in one’s peer group or subculture: e.g. interest in bus routes, tomb stones or dinosaurs.

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Symptoms

With the advance in diagnostic tools, most children with ASD can be reliably diagnosed by the age of 3, although earlier diagnosis to as early as less than 12 months of age has also been reported. Parents are usually the first to notice the difference in their child. These children do not follow the typical patterns of child development. Some of these peculiarities are noted as early as the first few months after birth, but often they are noted between the age of 1 and 3. Some parents report a sudden regression and onset of social aloofness; while other parents report a lack of progress after the child has reached certain developmental milestones. In her paper of “practice parameter: screening & diagnosis of autism”, Dr. Filipek, et al, listed some indicators for immediate evaluation:

• No babbling, no pointing or other gesture by 12 months
• No single words by 16 months
• No 2-word spontaneous (not echolaliac) phrases by 24 months
• Any loss of any language or social skills at any age

The 6 items in the Modified Checklist for Autism in Toddlers (M-CHAT) that are found to have the best discriminability between children diagnosed with and without autism/PDD are:

• Lack of interest in other children
• Not using index finger to point, to indicate interest in anything
• Not bringing objects over to parents to show them anything
• Lack of imitation
• Failure to respond to his/her name when called
• Not following other’s pointing at a toy across the room by looking at it

Young children who are noted these symptoms are urged to seek comprehensive professional evaluations to rule out the diagnosis of ASD.

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Prevalence

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