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Autistic Spectrum Disorder

By DR KEN MYERS

Posted  March 17 2016 | 0 Shares

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Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a term used to describe people with a characteristic pattern of psychiatric dysfunction, primarily involving deficits in language and social functioning. Asperger’s syndrome, pervasive developmental disorder and autism were previously treated as separate disorders, but are now considered together as “ASD.” This updated nomenclature does not change the fact that there is an extremely broad spectrum of severity in ASD and a wide variety of long term outcomes.

Early Signs

Although the diagnosis of ASD is usually made around 4 to 5 years, parents’ first concerns usually arise much earlier, often before 18-24 months. At these early ages, parents often have concerns about behaviour and socialization, although delay in language milestones during the second year of life is another common early report. When concerns are raised between 12 and 24 months of age, these are some of the common observations:

  • When called by name, the child does not respond appropriately.
  • The child is not interested in watching or looking at other children or people, and may seem overly interested in inanimate objects (geometric shapes are a common example).
  • The child does not engage in “sharing attention.” When a typical toddler is interested in something, they try to get the attention of nearby people by pointing or showing them the object of interest. Toddlers with ASD tend not to do this and are also less likely to become engaged when someone else tries to show something to them.
  • Unusual use of objects when compared to other children the same age. Children with ASD will often rotate, arrange or spin objects in a way that is clearly unusual.
  • Abnormal temperament. Toddlers with ASD may appear to have a low mood and have difficulties regulating their emotions. Although all toddlers have tantrums, children with ASD may have frequent meltdowns that last well over 15 minutes.
  • Delayed language development. Toddlers with ASD may have fewer words and generally less developed language than other children the same age.
  • Regression. Children who seemed generally normal early on may enter a period of social withdrawal during which their development may go backward. Language skills in particular may be lost during a period of regression.

Communication and Behaviour

The core ASD features are usually very apparent by the time a child is old enough to enter school. These primarily relate to social interactions, communication and behaviour, and include the following.

  • Social and Emotional Reciprocity Difficulties: People with ASD have difficulties recognizing and responding to social cues. As a result, carrying on a back-and-forth conversation is often difficult to near impossible. Autistic people may be minimally responsive and not give out the usual cues to show their conversation partner that they are interested in what he or she is saying. Conversely, a person with ASD may talk on and on about a subject that interests them, not noticing that the listener is sighing, checking his or her watch, or giving out other indicators to show that he or she is bored. The lack of emotional reciprocity is often one of the most difficult aspects of autism for parents. While typically developing children tend to be affectionate and eager for their parents’ approval, those with ASD often show little to no desire for “cuddles” or other signs of love. Physical touch may even be unpleasant for some autistic children, leading them recoil when touched unexpectedly or in an otherwise unwanted manner. These features can compromise bonding, resulting in a weakened attachment between parent and child.

  • Poor Non-verbal Communication: The importance of non-verbal communication becomes apparent when interacting with an autistic person. Poor eye contact is a classic feature of ASD which may cause some children to give the false impression they are not paying attention when in fact they are. Even when autistic children are looking at another person’s face, they are relatively less able to recognize specific emotions, a key element of non-verbal communication.

Aside from eye contact and facial emotion, there are numerous other patterns of body language humans use to communicate, most of which we recognize and respond to subconsciously. For people with ASD these subtleties of interaction do not come naturally, and developing these skills can be difficult to impossible.

  •  Difficulties with Relationships: Children with ASD usually have difficulties making and keeping friends. Although some children with ASD appear to be quite content with minimal social interaction, others desire friendship and become frustrated when they are excluded or overlooked. The reasons for relationship difficulties in ASD presumably relate to the communication and social reciprocity issues discussed above. Forming friendships is difficult for children with ASD at all ages, but probably becomes more challenging when they reach school age and begin to observe relationships based on shared intimacy rather than mutual interests.

  • Repetitive Behaviours and Restricted Interests: As children with ASD grow older, they continue to demonstrate repetitive behaviour in many aspects of their lives. This can take a variety of forms including flipping an object over again and again, lining up blocks, and repeating words or phrases (sometimes called echolalia). They may also become obsessed with a certain television show or toy, insisting on either watching the same show or playing with the same toy, day after day. Some repetitive behaviours can be very distressing for caregivers, particularly those that involve self-injury. Head banging and self-biting are probably the two most common such behaviours, though self-scratching, self-choking, hair pulling, and many others have also been observed to be more frequent in ASD. These behaviours probably relate to the relative insensitivity to pain often seen in people with autism, however why they occur is not well understood. Some of these behaviours can be managed by having the child wear gloves or a helmet, though in many cases they become a major challenge. At older ages, people with ASD often become fixated on specific hobbies or activities. Some common examples of this include model trains, stamp collecting and video games. These fixations often seem benign, however they may have negative effects on interpersonal relationships and general day to day functioning. Physical health can be compromised if people become so focused on these interests that they neglect their basic needs for proper nutrition and exercise.

  •  Inflexibility: Strict adherence to routines is one of the classic features of autism. Children with ASD often become very upset, to the point of temper tantrums, when their usual routine is disrupted. They may also institute rituals around meals or other activities, and insist that they be followed again and again. Accommodating these ritualistic behaviours can become stressful for parents, particularly if they become time consuming.
  • Sensory Hypersensitivity and Hyposensitivity: Children with ASD do not experience the world in the same way typically developing children do. This is illustrated by their often unexpected reactions to stimuli most of us would consider benign and uninteresting. Depending on the situation, the degree of their reaction may be much more or less than we would anticipate. An example of hyporeactivity (reacting less than expected) is that children with ASD often appear to be almost insensitive to pain. In contrast, they may react violently to relatively benign stimuli such as certain pieces of clothing, crowd noise at a sporting event or unpleasant tastes. These sensory sensitivities can usually be managed once parents are able to identify the triggers and anticipate when problems are likely to arise. Sensitivity to loud noises is probably the most common sensory hypersensitivity, and can usually be pre-empted if children are given ear plugs or noise cancelling head phones to wear before going to major sporting events or other noisy crowded environments. For food sensitivities, texture is the most common reason for food refusal in ASD, so parents may be able to increase palatability by altering the consistency of the food in question. Less can be done for offensive tastes, so avoiding these foods altogether is likely the easiest route.

Sleep

Problems in sleep are common in ASD, with roughly 70% of children having sleep issues deemed “clinically significant.” The sleep issues experienced are similar to those seen in typically developing children, including refusal to go to bed, difficulty falling asleep after lights out, and nocturnal awakenings. These common childhood issues are often magnified in ASD for a number of reasons. Autistic children tend to be become extremely focused and engaged in activities, creating a challenge for parents trying to re-direct them to get ready for bed. Because of the communication issues in ASD, children may also not understand that their parents want them to go to bed and are frustrated by their resistance.

Children with ASD are also at risk for at least one medical issue which can have a negative effect on sleep. The incidence of epilepsy is considerably higher in ASD than in the general population, and nocturnal seizures can go unrecognized and wreak havoc with a child’s sleep quality. When children have seizures in their sleep they may have urinary incontinence or bite their tongue. If parents pick up on these signs, they should raise their concerns with their doctor.

Roughly a quarter of children with ASD are currently taking a medication for sleep. The most common medication is melatonin, a hormone naturally produced by the pineal gland which helps regulate sleep cycles. Melatonin is usually given 30 minutes before bed time as a way of telling the body it is time to go to sleep. Some parents have reported side effects with melatonin, but large scale studies show the frequency of side effects is the same with placebo, indicating it is a very safe. The other medications commonly used for sleep disturbance usually require a prescription and are more likely to have some side effects. In many cases the tricky part is finding a dose that helps the child sleep without making them overly drowsy during the day.

Eating

Autistic and typically developing children exhibit many of the same problematic eating habits.   Unfortunately these are more common in autistic children and are often more difficult to manage due to the behavioural features associated with ASD. Inflexibility, sensory hypersensitivity and ritualistic behaviours in a child with ASD can all lead to extreme picky eating that can put him or her at risk of malnutrition.

With inflexibility, children with ASD often display “neophobia,” a fear of trying new foods that they have not seen before. They like the routine of having the same foods again and again, and may also refuse to eat foods that deviate from this routine. Finally, an autistic child’s propensity for sensory hyper-reactivity means that they probably don’t taste foods the same way we do. A flavour that we perceive as relatively benign may be too intense for a child with ASD to tolerate.

These patterns have been shown to result in a risk for deficiencies in vitamins and other micronutrients in children with ASD. Though parents will of course do their best to encourage a healthy diet on their own, consulting with a dietary specialist may be very helpful for some families.

Diagnosis and Treatment

Diagnosis of ASD is based on primarily on the presence of the abnormalities in social interaction, behaviour and communication described above. In order to meet the criteria for diagnosis, these features must be apparent early in development and must be severe enough to cause impairment in the individual’s day to day life.

The first step in receiving a diagnosis will usually be a screening test – a questionnaire designed to identify signs that indicate possible ASD in the child in question. Some commonly used screening tests include the M-CHAT (Modified Checklist for Autism in Toddlers) and STAT (Screening Tool for Autism in Toddlers). Screening tests may be administered by a wide variety of health practitioners, including GPs, and are often a part of the routine evaluation of all children during the toddler years.

If there are serious concerns regarding possible ASD, the child will usually need a referral to a specialist, almost always one of a psychologist, psychiatrist or paediatrician. A variety of evaluative approaches may be used including more questionnaires and observation of the child in different social and play situations. The doctor will ultimately make the diagnosis based on whether the child meets the criteria defined in DSM V (Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition).

Although a diagnosis of ASD sometimes seems devastating to families, the positive aspect is that this usually quickly facilitates involvement of resources to help the child. The standard of care continues to be early intervention strategies, often with considerable parental involvement, targeting social communication in particular. The professionals involved may include psychologists, psychiatrists, occupational therapists, physiotherapists and speech therapists. Researchers continue to search for other treatment options for ASD but at this point none of these proposed interventions have sufficient supporting evidence to allow them to be widely recommended.

Reviewed by DR KEN MYERS 17 March 2016 references
  • current version

  • PEER REVIEWER

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  • next review

This document has been developed and peer reviewed by a KIDS HEALTH Advisory Board Representative and is based on expert opinion and the available published literature at the time of review. Information contained in this document is not intended to replace medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.

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Autistic Spectrum Disorder

PARENTING

Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a term used to describe people with a characteristic pattern of psychiatric dysfunction, primarily involving deficits in language and social functioning. Asperger’s syndrome, pervasive developmental disorder and autism were previously treated as separate disorders, but are now considered together as “ASD.” This updated nomenclature does not change the fact that there is an extremely broad spectrum of severity in ASD and a wide variety of long term outcomes.

Early Signs

Although the diagnosis of ASD is usually made around 4 to 5 years, parents’ first concerns usually arise much earlier, often before 18-24 months. At these early ages, parents often have concerns about behaviour and socialization, although delay in language milestones during the second year of life is another common early report. When concerns are raised between 12 and 24 months of age, these are some of the common observations:

  • When called by name, the child does not respond appropriately.
  • The child is not interested in watching or looking at other children or people, and may seem overly interested in inanimate objects (geometric shapes are a common example).
  • The child does not engage in “sharing attention.” When a typical toddler is interested in something, they try to get the attention of nearby people by pointing or showing them the object of interest. Toddlers with ASD tend not to do this and are also less likely to become engaged when someone else tries to show something to them.
  • Unusual use of objects when compared to other children the same age. Children with ASD will often rotate, arrange or spin objects in a way that is clearly unusual.
  • Abnormal temperament. Toddlers with ASD may appear to have a low mood and have difficulties regulating their emotions. Although all toddlers have tantrums, children with ASD may have frequent meltdowns that last well over 15 minutes.
  • Delayed language development. Toddlers with ASD may have fewer words and generally less developed language than other children the same age.
  • Regression. Children who seemed generally normal early on may enter a period of social withdrawal during which their development may go backward. Language skills in particular may be lost during a period of regression.

Communication and Behaviour

The core ASD features are usually very apparent by the time a child is old enough to enter school. These primarily relate to social interactions, communication and behaviour, and include the following.

  • Social and Emotional Reciprocity Difficulties: People with ASD have difficulties recognizing and responding to social cues. As a result, carrying on a back-and-forth conversation is often difficult to near impossible. Autistic people may be minimally responsive and not give out the usual cues to show their conversation partner that they are interested in what he or she is saying. Conversely, a person with ASD may talk on and on about a subject that interests them, not noticing that the listener is sighing, checking his or her watch, or giving out other indicators to show that he or she is bored. The lack of emotional reciprocity is often one of the most difficult aspects of autism for parents. While typically developing children tend to be affectionate and eager for their parents’ approval, those with ASD often show little to no desire for “cuddles” or other signs of love. Physical touch may even be unpleasant for some autistic children, leading them recoil when touched unexpectedly or in an otherwise unwanted manner. These features can compromise bonding, resulting in a weakened attachment between parent and child.

  • Poor Non-verbal Communication: The importance of non-verbal communication becomes apparent when interacting with an autistic person. Poor eye contact is a classic feature of ASD which may cause some children to give the false impression they are not paying attention when in fact they are. Even when autistic children are looking at another person’s face, they are relatively less able to recognize specific emotions, a key element of non-verbal communication.

Aside from eye contact and facial emotion, there are numerous other patterns of body language humans use to communicate, most of which we recognize and respond to subconsciously. For people with ASD these subtleties of interaction do not come naturally, and developing these skills can be difficult to impossible.

  •  Difficulties with Relationships: Children with ASD usually have difficulties making and keeping friends. Although some children with ASD appear to be quite content with minimal social interaction, others desire friendship and become frustrated when they are excluded or overlooked. The reasons for relationship difficulties in ASD presumably relate to the communication and social reciprocity issues discussed above. Forming friendships is difficult for children with ASD at all ages, but probably becomes more challenging when they reach school age and begin to observe relationships based on shared intimacy rather than mutual interests.

  • Repetitive Behaviours and Restricted Interests: As children with ASD grow older, they continue to demonstrate repetitive behaviour in many aspects of their lives. This can take a variety of forms including flipping an object over again and again, lining up blocks, and repeating words or phrases (sometimes called echolalia). They may also become obsessed with a certain television show or toy, insisting on either watching the same show or playing with the same toy, day after day. Some repetitive behaviours can be very distressing for caregivers, particularly those that involve self-injury. Head banging and self-biting are probably the two most common such behaviours, though self-scratching, self-choking, hair pulling, and many others have also been observed to be more frequent in ASD. These behaviours probably relate to the relative insensitivity to pain often seen in people with autism, however why they occur is not well understood. Some of these behaviours can be managed by having the child wear gloves or a helmet, though in many cases they become a major challenge. At older ages, people with ASD often become fixated on specific hobbies or activities. Some common examples of this include model trains, stamp collecting and video games. These fixations often seem benign, however they may have negative effects on interpersonal relationships and general day to day functioning. Physical health can be compromised if people become so focused on these interests that they neglect their basic needs for proper nutrition and exercise.

  •  Inflexibility: Strict adherence to routines is one of the classic features of autism. Children with ASD often become very upset, to the point of temper tantrums, when their usual routine is disrupted. They may also institute rituals around meals or other activities, and insist that they be followed again and again. Accommodating these ritualistic behaviours can become stressful for parents, particularly if they become time consuming.
  • Sensory Hypersensitivity and Hyposensitivity: Children with ASD do not experience the world in the same way typically developing children do. This is illustrated by their often unexpected reactions to stimuli most of us would consider benign and uninteresting. Depending on the situation, the degree of their reaction may be much more or less than we would anticipate. An example of hyporeactivity (reacting less than expected) is that children with ASD often appear to be almost insensitive to pain. In contrast, they may react violently to relatively benign stimuli such as certain pieces of clothing, crowd noise at a sporting event or unpleasant tastes. These sensory sensitivities can usually be managed once parents are able to identify the triggers and anticipate when problems are likely to arise. Sensitivity to loud noises is probably the most common sensory hypersensitivity, and can usually be pre-empted if children are given ear plugs or noise cancelling head phones to wear before going to major sporting events or other noisy crowded environments. For food sensitivities, texture is the most common reason for food refusal in ASD, so parents may be able to increase palatability by altering the consistency of the food in question. Less can be done for offensive tastes, so avoiding these foods altogether is likely the easiest route.

Sleep

Problems in sleep are common in ASD, with roughly 70% of children having sleep issues deemed “clinically significant.” The sleep issues experienced are similar to those seen in typically developing children, including refusal to go to bed, difficulty falling asleep after lights out, and nocturnal awakenings. These common childhood issues are often magnified in ASD for a number of reasons. Autistic children tend to be become extremely focused and engaged in activities, creating a challenge for parents trying to re-direct them to get ready for bed. Because of the communication issues in ASD, children may also not understand that their parents want them to go to bed and are frustrated by their resistance.

Children with ASD are also at risk for at least one medical issue which can have a negative effect on sleep. The incidence of epilepsy is considerably higher in ASD than in the general population, and nocturnal seizures can go unrecognized and wreak havoc with a child’s sleep quality. When children have seizures in their sleep they may have urinary incontinence or bite their tongue. If parents pick up on these signs, they should raise their concerns with their doctor.

Roughly a quarter of children with ASD are currently taking a medication for sleep. The most common medication is melatonin, a hormone naturally produced by the pineal gland which helps regulate sleep cycles. Melatonin is usually given 30 minutes before bed time as a way of telling the body it is time to go to sleep. Some parents have reported side effects with melatonin, but large scale studies show the frequency of side effects is the same with placebo, indicating it is a very safe. The other medications commonly used for sleep disturbance usually require a prescription and are more likely to have some side effects. In many cases the tricky part is finding a dose that helps the child sleep without making them overly drowsy during the day.

Eating

Autistic and typically developing children exhibit many of the same problematic eating habits.   Unfortunately these are more common in autistic children and are often more difficult to manage due to the behavioural features associated with ASD. Inflexibility, sensory hypersensitivity and ritualistic behaviours in a child with ASD can all lead to extreme picky eating that can put him or her at risk of malnutrition.

With inflexibility, children with ASD often display “neophobia,” a fear of trying new foods that they have not seen before. They like the routine of having the same foods again and again, and may also refuse to eat foods that deviate from this routine. Finally, an autistic child’s propensity for sensory hyper-reactivity means that they probably don’t taste foods the same way we do. A flavour that we perceive as relatively benign may be too intense for a child with ASD to tolerate.

These patterns have been shown to result in a risk for deficiencies in vitamins and other micronutrients in children with ASD. Though parents will of course do their best to encourage a healthy diet on their own, consulting with a dietary specialist may be very helpful for some families.

Diagnosis and Treatment

Diagnosis of ASD is based on primarily on the presence of the abnormalities in social interaction, behaviour and communication described above. In order to meet the criteria for diagnosis, these features must be apparent early in development and must be severe enough to cause impairment in the individual’s day to day life.

The first step in receiving a diagnosis will usually be a screening test – a questionnaire designed to identify signs that indicate possible ASD in the child in question. Some commonly used screening tests include the M-CHAT (Modified Checklist for Autism in Toddlers) and STAT (Screening Tool for Autism in Toddlers). Screening tests may be administered by a wide variety of health practitioners, including GPs, and are often a part of the routine evaluation of all children during the toddler years.

If there are serious concerns regarding possible ASD, the child will usually need a referral to a specialist, almost always one of a psychologist, psychiatrist or paediatrician. A variety of evaluative approaches may be used including more questionnaires and observation of the child in different social and play situations. The doctor will ultimately make the diagnosis based on whether the child meets the criteria defined in DSM V (Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition).

Although a diagnosis of ASD sometimes seems devastating to families, the positive aspect is that this usually quickly facilitates involvement of resources to help the child. The standard of care continues to be early intervention strategies, often with considerable parental involvement, targeting social communication in particular. The professionals involved may include psychologists, psychiatrists, occupational therapists, physiotherapists and speech therapists. Researchers continue to search for other treatment options for ASD but at this point none of these proposed interventions have sufficient supporting evidence to allow them to be widely recommended.

Reviewed by Lisa Kelly 17 March 2016
references
  • current version

  • PEER REVIEWER

  • Doc id

  • next review

This document has been developed and peer reviewed by a KIDS HEALTH Advisory Board Representative and is based on expert opinion and the available published literature at the time of review. Information contained in this document is not intended to replace medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.

make a comment

0 comments

more articles by DR KEN MYERS

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latest articles

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MEET THE EXPERTS

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